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Lead Management
The Evolution of Lead Extraction
Melanie Maytin, MD
1
and Laurence M Epstein, MD
2
1. Clinical Electrophysiology Fellow; 2. Chief, Arrhythmia Service, and Director, Electrophysiology Laboratory, Brigham and Women’s Hospital
Abstract
Before the introduction of successful intravascular countertraction techniques, options for lead extraction were limited and dedicated tools
were non-existent. The significant morbidity and mortality associated with these early extraction techniques limited their application to life-
threatening situations such as infection and sepsis. The past 30 years have witnessed significant advances in lead extraction technology,
resulting in safer and more efficacious techniques and tools. This evolution occurred out of necessity, similar to the pressure of natural selection
weeding out the ineffective and highly morbid techniques while fostering the development of safe, successful, and more simple methods. Future
developments in lead extraction are likely to focus on new tools that will allow us to provide comprehensive device management and the design
of new leads conceived to facilitate future extraction. With the development of these new methods and novel tools, the technique of lead
extraction will continue to require operators who are well versed in several methods of extraction. Garnering new skills while remembering the
lessons of the past will enable extraction technologies to advance without repeating previous mistakes.
Keywords
Lead extraction, device management, pacemaker, defibrillator
Disclosure: Melanie Maytin, MD, has no conflicts of interest to declare. Laurence M Epstein, MD, provides research and consulting services for Boston Scientific, Spectranetics
Corporation Medtronic Inc., St Jude Medical, and GE Healthcare.
Received: May 26, 2009 Accepted: June 5, 2009
Correspondence: Laurence M Epstein, MD, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02215. E: lmepstein@partners.org
Early Techniques with tools and technology frequently borrowed from other
Lead extraction has undergone an explosive evolution since its inception disciplines.
10–12
Byrd utilized the lessons of these early experiences and
as a rudimentary skill with limited technology and therapeutic options created a femoral retrieval system that consisted of a 16Fr sheath with
(see Figure 1). Early techniques involved simple manual traction, which a hemostatic valve in combination with various snares.
13
To this day,
frequently proved ineffective for chronically implanted leads and carried transfemoral foreign body retrieval with the Byrd Femoral Work Station
®
a high risk for myocardial avulsion, tamponade, and death.
1–3
Bilgutay and (Cook Medical) remains a necessary skill for successful lead extraction,
colleagues attempted to improve the success rate of simple traction by particularly in cases where the lead is not accessible from the implant
creating a graded weight and pulley system to deliver sustained gentle vein. The recent description of a novel technology to facilitate extraction
traction on the externalized portion of a lead.
4
This method failed to and the maintenance of vascular access proposed a hybrid superior and
significantly improve outcomes and suffered from similar limitations. In inferior approach, with femoral snaring of the lead to stabilize the lead
addition, weighted traction typically required prolonged bed rest and while countertraction and counterpressure are used to free the lead,
heightened the risk for infection. In the event that transvenous extraction reiterates the clinical importance of femoral retrieval.
14
proved unsuccessful, cardiotomy via median sternotomy, thoracotomy,
or limited atriotomy remained a definitive solution, but at the expense of Mechanical Extraction
significant morbidity.
5–7
The significant morbidity and mortality associated Telescoping Sheaths
with these early extraction techniques limited their application to life- Telescoping mechanical sheaths were developed in the 1980s to aid in
threatening situations such as infection and sepsis and, thus, stymied the the extraction of chronically implanted leads utilizing the principles of
development of the field. counterpressure and countertraction. Counterpressure is the pressure
applied by the telescoping sheath as it dilates adherent fibrous tissue.
Femoral Tools Countertraction is the traction applied to the lead that is opposed by the
Percutaneous catheter retrieval and removal of foreign bodies has been force of the overlying sheath delivered to the myocardium.
15
Applying
described since 1967.
8,9
Early techniques of transvenous foreign body countertraction limits the traction forces on an entrapped electrode to
removal utilized catheters, wire snares, forceps, and basket retrievers the circumference of the sheath. Once the lead is released from the
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