In this article, the authors provide an updated overview on successful lead extraction methods for pacemaker and defibrillator cases.

Permanent pacemakers and automatic internal cardioverter defibrillators (AICDs) have been improving and saving lives for over 50 years.1 Unfortunately, in rare cases these devices can pose potential harm to a patient, thus indicating removal. Removal or replacement of the generator only does not pose as much risk as lead extraction. Abandoning or disabling malfunctioning leads will suffice in the majority of patients who no longer have an indication or desire for continued therapy. However, lead extraction is indicated when malfunction results in potential harm, when there is difficulty clearing a blood stream infection, when venous stenosis has ensued, or when procedures, normally contraindicated with implanted devices, are necessary.2

The risk of lead extraction increases with duration of implant. After a few weeks, endothelialization causes lead adherence to the endocardium, vessel walls, and other leads. The thinner pacemaker leads and bulkier defibrillator leads should be referred to a specialized extraction center after 1 and 2 years post implant, respectively. In the past, open-heart surgical extraction or direct traction was required to remove these leads, both of which carry significant risk to the patient. Locking stylets and telescoping sheaths have also been used with success. Other factors associated with the difficulty of extraction include the type of insulation, structural integrity, associated thrombus or vegetation, and position or number of these leads.

At the University of Toledo Medical Center, we typically use an excimer laser sheath to assist with extraction of these endothelialized leads. The excimer laser is a rigid sheath that slides over the lead, disrupting a cylinder of fibrous tissue located extremely close to the lead’s insulation surface (Figures 1 and 2). This technique allows for safer stripping and shorter extraction time of the lead encompassed by endothelialization.3,4 Upsizing the sheath can also extract thrombus surrounding the lead, which may prevent thromboembolism downstream from the lead. An endovascular approach, with emergency surgical back-up, will usually present less risk to the patient for thrombi less than 3 centimeters.5 The experience of the operator and center typically plays a major role in success. The general consensus suggests at least 30 lead extractions performed per year to maintain proficiency.6