Transvenous Lead Extraction: Differences and Similarities Between Pacemakers and ICDs

For cardiac device leads in place for more than 20 years, transvenous extraction is more likely to be successful with implantable cardioverter-defibrillator (ICD) leads than with pacemaker leads, despite the need for more specialized tools to complete the procedure with ICD leads.

So finds a comparative analysis of Cleveland Clinic’s experience with the two types of cardiovascular implantable electronic devices (CIEDs) over a recent nine-year period. The study was published in the Journal of Cardiovascular Electrophysiology (2024;35:1382-1392).

“We found that the success rate with transvenous lead extraction was higher for ICDs than for pacemakers when the leads had a dwell time of more than two decades, but not when the dwell time was shorter,” says corresponding author and Cleveland Clinic electrophysiologist Thomas Callahan, MD. “Major complication rates were similar between the two device types regardless of dwell time.”

Understanding lead extraction

Transvenous lead extraction (TLE) is integral to CIED management, and leads for ICDs and pacemakers differ in structure and diameter, as do their tensile strengths. Previous reports have suggested that these variations may affect TLE success and complications. The biggest obstacle to the procedure is fibrotic tissue growth and calcification, particularly if device dwell time is lengthy.

While experience with TLE for CIEDs has been explored in single-center and multicenter registry-based studies, few comparisons have been done of TLE for implantable ICDs and pacemakers, and none are recent. To fill that knowledge gap, Cleveland Clinic researchers performed a detailed analysis of ICD and pacemaker TLE in patients with long-duration CIEDs at their high-volume center to assess efficacy, safety and procedure characteristics such as lead age and type of extraction device used.

Analysis of a large experience base

The researchers evaluated data from consecutive patients in the Cleveland Clinic Prospective TLE Registry who underwent TLE between February 2013 and April 2022, defined as removal of a lead that had been in place for more than a year or that required specialized extraction tools.

Overall, 1,617 patients met the inclusion criteria, consisting of 810 patients who underwent ICD lead extraction (885 ICD leads extracted) and 807 patients who underwent pacemaker lead extraction (1,352 pacemaker leads extracted).

Procedural success was categorized in alignment with a 2017 consensus statement from the Heart Rhythm Society and a 2018 consensus statement from the European Heart Rhythm Association:

• Removal of the entire lead system constituted “complete success.”
• Success was “partial” when most of the lead tip was removed but < 4 cm of coil, insulation and/or lead tip remained.
• Extraction “failed” if ≥ 4 cm of the tip remained.

The researchers also analyzed major complications, defined as those related to the TLE procedure that were life-threatening or resulted in death, as well as unexpected events that resulted in persistent or significant disability and/or required surgical intervention.

Outcomes and observations

Compared with patients in the pacemaker group, those in the ICD group were significantly younger and more likely to be male and had a significantly lower median left ventricular ejection fraction. Median lead age was greater in the ICD group than in the pacemaker group (8 vs. 7 years; P = .001).

Key outcome findings included the following:

• Rates of TLE procedural success were higher in the ICD group than in the pacemaker group among patients with leads > 20 years old (P = .005), but success rates were similar between the groups for leads ≤ 20 years old. “We were consistently able to achieve complete extraction of ICD leads that were more than 20 years old,” Dr. Callahan notes.
• Rates of complete success declined significantly with increasing lead age in the pacemaker group but not in the ICD group.
• More extraction tools were required for TLE in the ICD group than in the pacemaker group, but in both groups older leads necessitated non-laser sheath extraction devices more often.
• In both groups, major complications generally increased with lead age, but not significantly so, and rates of major complications were comparable between the ICD and pacemaker groups.
• Among cases with complications, the most common injury site was the superior vena cava in the ICD group, whereas it was the right atrium (including the superior vena cava/right atrial junction) in the pacemaker group.

Multivariable analysis revealed the following as independent predictors of incomplete lead removal:

• Lead age
• Combined lead age
• Passive fixation leads
• Differences in lead manufacturer

“The finding that the manufacturer is an independent predictor of incomplete removal for both ICD and pacemaker leads suggests that lead design characteristics, which differ across manufacturers, influence extractability independent of lead age,” Dr. Callahan observes.

“This analysis of prospectively collected data from our high-volume center can help guide practice around transvenous lead extraction regardless of device type,” notes Oussama Wazni, MD, MBA, Section Head of Clinical Electrophysiology and Pacing. “One of the key insights it provides is the pattern of differences in likely injury sites between extraction of ICD and pacemaker leads. Recognition of these differences can improve the safety of lead extraction moving forward.”

“This study demonstrates Cleveland Clinic’s excellent outcomes in extraction of both ICD and pacemaker leads with high procedural success and low complication rates in a complex patient population,” adds Tarek Malas, MD, a cardiac surgeon who provides backup in TLE cases. “At our center, electrophysiology and surgery collaborate closely in a multidisciplinary approach to share our collective expertise and ensure optimal patient care for lead extraction.”