VIENNA, AUSTRIA — Routine extraction of transvenous leads that are no longer needed isn’t necessary; usually they can be safely abandoned, because their removal doesn’t lower the risk of future major complications should lead extraction be needed due to infection, suggests a small observational study[1].
Of the 468 consecutive patients with any old, abandoned leads present when it came time for the extraction of a combined 1103 leads due to infection related to cardiac implantable electronic devices (CIEDs), three-fourths had only one abandoned lead and 95% had only one or two.
It’s in such cases, especially, that routine removal of the abandoned leads isn’t justified in order to improve the outcomes of future extractions, Dr Frank Bracke (Catharina Hospital, Eindhoven, the Netherlands) told theheart.org|Medscape Cardiology.
No Guidelines, No Consensus
“Most patients only have one abandoned lead,” he said, noting that in lead-extraction cases presented at meetings and courses, “you always see five, six, or seven abandoned leads.”
On the other hand, the current small study found no significant difference in the procedural success rate for lead extraction due to CIED-related infection between patients with one vs two or more abandoned leads present.
Bracke reported the analysis here at the European Heart Rhythm Association (EHRA) EUROPACE-CARDIOSTIM 2017 sessions. Interestingly, a study presented at last year’s EHRA sessions came to opposite conclusions.
There are no guidelines to help decisions on whether to extract such leads, and there is little consensus among different centers; some will abandon most nonfunctional leads and some will extract most, observed Prof Jean-Claude Deharo (Hôpital de la Timone, Marseille, France), who isn’t connected with the analysis.
Therefore, he said when interviewed, clinicians may feel reassured by the current findings based mostly on patients with one abandoned lead, if they choose not to extract them.
If the current study is accurate, the implications of abandoning a single lead aren’t high “because you’ll have only one lead to extract if you decide to do it later,” Deharo said. “But if you have two, three, or four abandoned leads, of course it might be much more of an issue.”
Certainly some nonfunctional leads should always be extracted, including those associated with CIED infection and in unusual cases, if there is thrombus on the lead, according to Deharo.
The current analysis of patients requiring extraction of transvenous leads due to CIED infection compared 130 patients with a mean age of 72, each with one to four abandoned leads (total 436 leads), with 338 patients with a mean age of 70.5, each with only active leads (total 667) available for extraction.
The median dwell time was 9.9 years for the abandoned leads in the former group, dubbed group 1, and 5.7 years for the active leads in the latter patients, group 2.
Success Rates for Endovascular Lead Extraction in Patients with Abandoned vs Active Leads
| End points | Group 1 | Group 2 | P |
|---|---|---|---|
| Procedural success | 84.6 | 93.2 | <0.01 |
| Clinical success | 93.8 | 97.3 | 0.09 |
| Elective surgical bailout | 5.4 | 2.1 | 0.07 |
Group 1= only abandoned leads present
Group 2=only active leads present
In the group with abandoned leads, extraction success rates were 86.7% for those with one abandoned lead vs 84.3% for those with two or more abandoned leads (P=0.77).
Serious complications included one superficial vena cava tear in group 1, and in group 2, one such tear in three patients and tamponade in two patients.
What About Younger Patients?
There is controversy about whether unused leads in younger patients should always be extracted. Younger patients can accumulate a lot of abandoned leads over the years, and leads can become much harder to extract the longer they are in place. The risk of serious complications from later extraction procedures goes up accordingly, Deharo noted.
“To leave a lead in a young patient is to expose this patient to a very long dwelling time. Then when you may have to explant the lead, for any reason like infection, there will be a high number of leads with a higher dwelling time. So young patients might be one of the indications for systematic lead removal.”
Brache had a different take. The younger the patient with abandoned leads, the more life-years lost in the event of a serious complication related to an extraction procedure, he said. “So, even with a young patient, we leave them inside. If you look at the literature, complication rates in young patients, when you extract the nonfunctional leads, even for relatively young leads, are not negligible.”
Neither Bracke nor Deharo had relevant financial relationships.
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