Transvenous leadless pacemaker extraction: When, who, where, and how?

The widespread adoption of leadless pacemakers has introduced new clinical and technical challenges related to device management at end-of-service and in the setting of device-related complications. While transvenous lead extraction is an established treatment strategy for conventional pacing systems, there is currently no standardized framework for transvenous leadless pacemaker extraction (TLLE). With increasing numbers of leadless pacemakers approaching end-of-service and expanding indications for leadless pacing, a structured approach to TLLE has become clinically relevant. This review proposes a systematic concept of TLLE, including definitions, clinical indications, procedural strategies, risk assessment, and institutional requirements. Indications for TLLE including device end-of-life, dislocation, interactions, infection, or the need for upgrade to a different device are summarized. Procedural strategies, primarily based on the extraction most frequently from the femoral approach, with the use of snare-based techniques, with the choice of other tools and access tailored to device type, dwell time, fixation mechanism, and degree of encapsulation, are summarized. Literature findings reporting high success rates are presented, with potential complications such as cardiac perforation, tamponade, tricuspid valve injury, embolization, and vascular access complications also summarized. Patient selection and pre-procedural imaging are evaluated, and factors influencing decision-making, including balance of periprocedural risk against long-term implications of device abandonment, are presented.