Transvenous Lead Extraction with Laser Reduces Need for Femoral Approach but Not Complications or Success Rates

Background: Cardiac implantable electronic device (CIED) is technically challenging. Whether the use of a laser sheath reduces complications and improves outcomes is still in debate. We therefore aimed at comparing our experience with and without the laser in a large referral center.

Methods: Information of all patients undergoing was collected prospectively. We retrospectively compared procedural outcomes prior to the introduction of the laser sheath lead extraction technique at our institution (with use of mechanical/ powered sheaths only) to use of laser sheath.

Results: During the years 1996-2017, 1047 leads were attempted to be removed in 531 pts. Of them, 382 (72%) were extracted due to infection, vein occlusion with a need for device upgrade in 53 (10%) cases and lead malfunction in 62 (12%) cases, and other (6%). Complete removal of all leads was achieved in 995 (95%) leads, partial removal was achieved in 42 (4%) leads and failure in 10 (1%). Overall severe intra-procedural complications rate was 13 (1.3%). This included 3 (0.3 %) intra procedural deaths. Two deaths were due to superior vena cava tear with the use of laser and one due to intractable arrhythmia with the use of other sheaths. Five (0.5%) tamponades and central venous tear in 5 pts (0.5%). In 6 (1.2%) there was a need for urgent conversion to open heart surgery. Comparison of cases prior to and after laser technique introduction in the year 2012, showed that with the laser, a significantly smaller proportion of cases required conversion to femoral approach [19/238 (8%) vs. 61/340 (18%) respectively; p<0.001]. However, success rates for complete removal [223/238 (94%) vs. 319/340 (94%) respectively; p=0.83] and major complication rates [7 (3%) vs. 6 (2%) respectively; p=0.32] did not differ prior to and after laser use. Mechanical approach was an independent predictor for need of femoral station (OR= 2.38; 95% CI 1.36-4.01; p=0.002).

Conclusion: Introduction of laser lead removal resulted in lesser need to convert to femoral approach, albeit without improving success rates or preventing major complications