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 but carries a risk of life-threatening cardiac or vascular injury. 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. 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. Although major complications were numerically higher with TightRail (4.3% vs 1.4%, p=0.469), these events were largely confined to long-dwell (≥10-year) leads, whereas complication rates were similarly low in leads <10 years. Independent predictors of major complications were right subclavian approach, lead age ≥10 years, weight <60 kg, and diabetes mellitus. 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 extraction strategy alone. The WARD-10 score provides a simple tool for individualized risk stratification in TLE.Figure 1Figure 2