Advanced age and anticoagulation do not increase major complications during transvenous lead extraction: insights from 797 procedures

Background/Introduction With the growing population of elderly patients with cardiac implantable electronic devices (CIEDs), transvenous lead extraction (TLE) is increasingly performed in octogenarians. While large registries such as the ExTRACT study demonstrated that chronological age alone does not increase procedural risk (1), the combined influence of advanced age and oral anticoagulation (OAC) on major complications such as bleeding events in real-world practice remains uncertain. Purpose To evaluate the impact of advanced age (≥80 years) and OAC therapy on major complications after TLE in a contemporary single-center cohort. Methods We retrospectively analyzed 797 consecutive TLE procedures performed between 2005 and 2025 at our institution. Patients were stratified into four groups according to age and OAC status: (1) <80 years without OAC, (2) <80 years with OAC, (3) ≥80 years without OAC, and (4) ≥80 years with OAC. Major complication was defined as cardiac tamponade requiring drainage or surgical repair, hemothorax, pulmonary embolization, other vascular injuries, or perioperative death. Complete procedural success, lead tear, and use of mechanical sheaths were compared among groups. Univariate and multivariate logistic regression analyses were performed to identify predictors of major complications. Results Among the cohort, 248 patients (31.1%) were aged ≥80 years and 331 (41.6%) received OAC. Overall complete procedural success was 97.0%. There were 21 major complications (2.6%), including 12 cardiac tamponades, 2 hemothoraces, 2 pulmonary embolisms, and 5 other vascular injuries, with one perioperative death (0.1%). In the ≥80-year group, infection was a more frequent indication for extraction (93.5% vs. 68.1%, p<0.001), and the proportion of shock leads was lower (10.7% vs. 44.8%, p<0.001). Major complication occurred in 2.1% in <80/OAC–, 3.7% in <80/OAC+, 2.2% in ≥80/OAC–, and 2.7% in ≥80/OAC+ (p=0.718). There were no significant differences in complete success, lead tear, or mechanical sheath use among the four groups (p=0.296, 0.103, and 0.778, respectively). In univariate analysis, the number of extracted leads (OR 1.83, 95% CI 1.09–3.09, p<0.001) and lead dwell time >20 years (OR 12.3, 95% CI 3.98–38.3, p<0.001) predicted major complications. Multivariate analysis demonstrated a similar trend. Conclusion(s) In this real-world single-center cohort, TLE in octogenarians was procedurally safe, and advanced age or oral anticoagulation did not increase major complication rates or affect procedural success. Instead, procedural complexity—particularly a longer lead dwell time and multiple extracted leads—was the main determinant of adverse events. These findings support performing TLE in elderly patients when clinically indicated, with careful attention to long-dwell leads rather than chronological age or anticoagulation status.