Transvenous Lead Extraction Using the PISA Approach: A Decade of Experience from a National Referral Centre

Introduction and Objectives: The widespread implantation of cardiovascular implantable electronic devices (CIEDs) has led to a growing demand for safe and effective transvenous lead extraction (TLE), particularly concerning device-related infection, venous occlusions and lead dysfunction. As procedural complexity increases, so does the importance of adopting reliable and adaptable extraction strategies. We present a comprehensive, single referral centre experience using the PISA technique — a rotational sheath-based approach — to perform transvenous lead extraction over a 10-year period. Methods: This retrospective study included all patients undergoing TLE at a national referral centre between February 2013 and December 2024. Extractions were initially performed using simple traction as the first-line approach, and in all cases where simple traction was unsuccessful, the PISA approach for lead extraction was employed. Clinical and radiological success, complications, and mortality were analyzed. Results: A total of 283 patients underwent extraction of 530 leads, with a median lead dwell time of 96 months (IQR: 48–144). The majority of devices were pacemakers (62.9%), followed by cardiac resynchronisation devices (20.2%) and transvenous implanted cardioverter defibrillators (15.9%). Infection was the predominant indication (74.6%). The majority of procedures were performed via a superior approach. Clinical success was achieved in 97.5% of cases, whereas complete radiological success was achieved in 92.9% of patients. Major complications were observed in 2.8% of the procedures. In-hospital mortality rate was 3.9%, with only one death (0.4%) related to a major complication (not intra-procedure). During a median follow-up of 39 months (IQR: 17-74), all-cause mortality was 22.3%. Of these deaths, 3.9% occurred during the index hospitalization for TLE, 6.4% within the first year post-procedure, and 12.0% beyond the first year. Rehospitalisations due to cardiovascular or non-cardiovascular causes were observed in 19.8% of patients throughout the follow-up period. Conclusion: TLE extraction with the PISA technique is a high effective methodology, with favourable complication and mortality rates in patients with CIED. The implementation of structured peri-procedural protocols and a growing team experience may contribute to support a high-successfully programme.