The most common indication for ICD removal or lead extraction is system infection. Other indications include lead malfunction (fracture or failure), lead or device erosion, lead upgrade, retained lead or lead fragment causing potentially life-threatening arrhythmias, or thromboembolic complications or venous obstruction.
There are several methods for lead extraction. Traction is the most simple technique, employing graded traction and rotational forces to free the lead. This has limited success when removing older leads and can cause invagination of the myocardium, myocardial rupture, arrhythmia, hypotension or acute severe tricuspid regurgitation secondary to valve leaflet avulsion.
Sheaths can be used, in which a sheath is passed over the wire to mechanically disrupt fibrosis. Upon reaching the myocardium the larger bore sheath may help reduce the risk of invagination as the lead is removed, but myocardial perforation is still possible. Electrosurgical sheaths have the ability to dissect as they are passed over the lead using, e.g. radiofrequency ablation or lasers.
Major complications from lead extraction may include cardiac or vascular avulsion or tearing (requiring thoracotomy, pericardiocentesis, chest tube, or surgical repair), pulmonary embolism, stroke, and pacing system related infection of a previously non-infected site.
Analysis of data from a registry of 5339 lead extractions over 10 years revealed a major complication rate of 1.6%.
Long implantation time, lack of operator experience, ICD lead removal, number of leads being extracted, laser lead extraction technique, and female gender are risk factors for life-threatening complications.
Leads that have been in place for more than 1 year may develop adhesions, which can cause life-threatening bleeding or cardiac perforations. ICD leads are more difficult to extract than standard leads because the diameter of ICD leads is larger and defibrillator coils stimulate more fibrosis.
F M Farooqi, S Talsania, S Hamid, C A Rinaldi Extraction of cardiac rhythm devices: indications, techniques and outcomes for the removal of pacemaker and defibrillator leads. Int. J. Clin. Pract.: 2010, 64(8);1140-7