E-Science Station

Lead extraction is a specializied procedure with well-defined indications, excellent results, few possible complications as described in several guidelines and scientific documents on the pathway for training and accreditation. It is indicated in infection (pocket infection, lead endocarditis and valvular endocarditis ), chronic pain, venous thrombosis and stenosis and lead malfunction. Different techniques and tools are used for lead extraction including simple extraction tools, traction with locking stylets and snare, countertraction, counterpressure and tissue disruption using manual telescoping sheaths, powered sheaths (laser, electrosurgical and evolution sheaths). It requires team approach with an experienced electrophysiologists with an adequate cardiothoracic surgery team on standby to cope with any complications in a well-equipped catheter room or operation theatre. It may have undesirable complication ranging from minor complication that requires no or only medical intervention to major complications which causes persistent or life threatening or results in death. The clinical outcomes may include Removal of all targeted leads (complete success) or retention of a small portion of the lead (clinical success) or failure.

This study aims to present and analyse the experience of Ain Shams University Hospitals in the field of percutaneous lead extraction among 30 patients who were referred for percutaneous lead extraction in the period between April 2011 till April 2014. All enrolled patients were subjected to full history taking, clinical examination, investigations and then the procedure of extraction which was achieved according to specific protocol involving proper environment, personnel and techniques.

The mean age of patients was 53.3±16.8 years with 18 males (60%) and 12 females(40%). The indications for lead extraction were pocket infection in 26 patients (86.7%), chronic pain in two patients (6.7 %), subclavian thrombosis complicated by upper limb oedema in one patient (3.3 %), lead malfunction in one patient (3.3%). The extracted devises included 15 VVI/R devices (50%), ten DDD/R devices(33.3%), three ICDs devices (10%), one Cardiac resynchronization therapy(CRT-P) (3.3%) and one Cardiac resynchronization therapy with defibrillator(CRT-D) (3.3 %) of devices. Forty seven leads were planned to be extracted, including 14 atrial leads (all were active fixation) (28.9%), 27 right ventricular pacing leads (57.8 %), (21passive fixation, six active fixation), (26 bipolar and one unipolar), four shock leads (8.9%), all with active fixation (two single coil and two dua lcoil), and two coronary sinus leads (4.4 %). Average lead implantation duration was 64.1 months with range of 8-240 months. Manual traction was successful in 17 leads (35.6 %), addition of locking styletalone was successful in one lead (4.4%), while further addition of manual telescoping sheaths were successful in 14 leads (33.3 %), addition of evolution to locking stylets was successful in 11 leads (26.7%), evolution shortie was used in one case (2%), bulldog was used in one case (2%). Snares were used in four cases (13 %), jugular snare was used only in one case (3.3%) while femoral snares were used in three cases. The mean procedure time was 136.5± 52.7 minutes. Complete procedure success rate was 91.5%, while lead failure rate was (8.5 %). Major complications in the form of death occurred in two patients (6.7 %), with no other major complication, while minor complication occurred in 6 cases (20%). The results show no effect of sex, risk factors, lead polarity, fixation or duration of implantation on any method of extraction while simple traction was the dominant method in old age patients.

There was no effect of age, sex, risk factors, method of extraction or duration of implantation on complication incidence while anticoagulation was associated with increasing complications. The longer the duration of implantation of the lead, the longer the procedure time needed.