Removal of spontaneously fractured leads with their proximal ends in the heart and vasculature -experience among 3847 lead extraction procedures

Abstract

Abstract Background Spontaneous fractures and insulation breaks of the intracardiac leads near their entry into the venous system cause the proximal end of the fractured lead slide into the veins, with potential subsequent looping in the heart and secondary complications. So far, this topic has not been extensively studied. As it is a relatively uncommon finding, it has been described in a few number of case studies only. The aim of the study was to describe the phenomenon of leads migrated proximal end (LMPEs) into the cardiovascular system and techniques for such leads removal. Methods Retrospective analysis of 3847 transvenous lead extractions (TLE). Results Over a 17-year period 72 (1.87%) leads with migrated proximal ends (LMPEs) (mean dwell time 148.0 months) were extracted, mainly ventricular leads (56.94%). Overall, 68.06% of MPLEs had their cut proximal ends located in the venous system. Most of them were pacing (95.83%) and passive fixation (98.61%) leads. Independent risk factors for LMPEs included abandoned leads (OR=8.473; p<0.001) and leads on both sides of the chest (2.981; p=0.045). Higher NYHA class lowered the probability of leads with migrated proximal ends (LMPEs) (OR=0.380; p<0.001). Extraction complexity was higher in the MPLE group than in remained patients. Femoral approach was most often used (62.50%), contrary to superior (23.61%) and combined approach (11.11%). Lead dilatation was necessary in 80.56%, and grasping and traction was effective in 18.06%. In 66.7%, the proximal end was strongly attached to the wall and a pulling loop had to be applied. In 15.28% of procedures the lead was wrapped around a pig-tail catheter ("spaghetti twisting technique"), which was sometimes sufficient to free the lead end. This manoeuvre was especially helpful in releasing the leads with their tip in the distal branch of the pulmonary artery. All these manoeuvres were performed from the femoral or superior approach, depending on the anatomical conditions. Extraction of MPLEs did not influence long-term survival. The rate of major complications was 2.78% but it may be attributed to long implant duration (152.2 months) and were not the result of extraction of LMPEs. Conclusions 1. Extraction of leads with migrated proximal ends (LMPEs) is rare among other TLE procedures (1.9%), 2. Risk factors include abandoned leads and presence of leads on both sides of the chest. 3. Complexity of LMPEs extraction is higher as regards procedure duration, unexpected procedure difficulties, use of advanced tools and techniques but rates of major complications are comparable to other leads but in spite of a high level of procedure complexity its effectiveness is also high (procedural success rate 93.06%) with an acceptable rate of major complications. 4. Extraction of LMPEs did not influence long-term survival.