Cardiac implantable electronic device lead extraction using the lead-locking device system: keeping it simple, safe, and inexpensive with mechanical tools and local anesthesia

Abstract

Objective: We have previously reported our successful approach for percutaneous cardiac implantable electronic device (CIED) lead extraction using inexpensive tools, which we have continued over the years. Herein we report the results of the systematic use of a unique stylet, the lead-locking device (LLD), which securely locks the entire lead lumen, aided with non-powered telescoping sheaths in 54 patients to extract 98 CIED leads.

Methods: This prospective observational clinical study included 38 men and 16 women aged 68.9±13.1 years undergoing lead extraction for device infection (n=46), lead malfunction (n=5), or prior to defibrillator implant (n=3). Leads were in place for 6.7±4.3 years. Infections were more commonly due to Staphylococcus species (n=40). There were 78 pacing (31 ventricular, 37 atrial, 4 VDD, and 6 coronary sinus leads) and 20 defibrillating leads.

Results: Using simple traction (6 leads) and the LLD stylets (92 leads) aided with telescoping sheaths (15 patients), 96 (98%) leads in 52 (96.3%) patients were successfully removed, with all but one leads removed using a subclavian approach; in 1 patient, the right femoral approach was also required. In 2 patients, distal fragments from one ventricular pacing and one defibrillating lead could not be removed. Finally, lead removal was completely (52/54) (96.3%) or partially (2/54) (3.7%) successful in 54 patients for 96 of 98 leads (98%) without major complications.

Conclusion: Percutaneous lead extraction can be successful with mechanical tools using the LLD locking stylet aided with non-powered telescoping sheaths through a simplified, safe, and inexpensive procedure using local anesthesia.

Figure 1

The LLD locking stylet is depicted in this figure in its unlocked, locked state when deployed (locked) inside the lead lumen. Of note is the apparent expanded mesh appearance of the locking mechanism, allowing for a more uniform traction along several points along the lead body

Figure 2

Telescoping sheaths are an invaluable tool to dissect through the adhesions formed in various contact points along the endovenous and endocardial course of the lead and to facilitate its extraction (a) as well as to apply counter traction at the lodging point of a ventricular lead anchored at the endocardium, aiding in disengaging the lead often with a thick fibrous tissue attached to it (b), hopefully, without the feared complication of cardiac perforation and tamponade. When the above approach (subclavian access) fails, a transfemoral approach using a snare can successfully remove even grossly uncoiled and deformed leads and their fragments (c). The LLD plus telescoping sheath method is equally effective in removing multiple leads, including those in the coronary sinus (d) CS - (lead already pulled in the) coronary sinus (from a vein tributary); RA - right atrial (lead); RV - right ventricular (lead); TW - temporary wire

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