Powered Rotational Sheaths in Complex Transvenous Lead Extraction: Comparative Outcomes With Telescoping Sheaths and the WARD‐10 Score

Background Transvenous lead extraction (TLE) is essential for CIED management and is generally safe with contemporary techniques, although rare cardiac or vascular complications can be life‐threatening. Comparative data between non‐powered telescoping sheaths (TS) and powered rotational sheaths remain limited. Methods After excluding simple traction cases, 308 consecutive TLE patients treated at a tertiary center (2014–2025) were analyzed (73 TS‐only; 235 TightRail). Procedural success, efficiency, and complications were compared. Major complications were defined as life‐threatening or fatal procedure‐related events, or events requiring urgent invasive or surgical intervention. Predictors of major complications were identified using multivariable logistic regression, and a pragmatic risk score (WARD‐10: Weight < 60 kg, Age ≥ 74 years, Right subclavian approach, Diabetes mellitus, lead age ≥ 10 years) was developed. Results The TightRail group included significantly older leads (oldest lead age 7.0 ± 5.3 vs. 11.4 ± 6.8 years, p < 0.001). Complete and clinical success were similar between TS‐only and TightRail (91.8% vs. 94.0%, p = 0.586; 93.2% vs. 95.3%, p = 0.545), and overall procedure and fluoroscopy times did not differ significantly. In three‐group analysis, TightRail‐only demonstrated the shortest procedural duration. Major complication rates did not differ significantly between the TS‐only and TightRail groups (1.4% vs. 4.3%, p = 0.469); these events predominantly occurred in leads ≥ 10 years, whereas complication rates were low regardless of extraction strategy in leads < 10 years. Independent predictors of major complications were weight < 60 kg, right subclavian approach, diabetes mellitus, and lead age ≥ 10 years. WARD‐10 demonstrated good discrimination (AUC 0.857); a cutoff ≥ 3 yielded 72.7% sensitivity and 85.5% specificity. Conclusion TightRail achieved comparable efficacy and efficient performance despite preferential use in more complex cases. Major complications were primarily associated with patient‐ and lead‐related risk factors rather than the extraction strategy alone. The WARD‐10 score provides a simple tool for individualized risk stratification in TLE.