Stanford Cardiac Arrhythmia Service

Pacemaker or ICD Lead Extraction

In pacemakers and ICD, the leads are inserted into a lead under the collar bone and advanced into the heart.  The body tries to heal any objects that are inserted into it and gradually the leads become coated with fibrous tissue.  Over time the fibrous tissue may become attached to the heart and the blood vessels.   The longer the period that the leads have been in place there is a greater amount of fibrous tissue.  The process of removing the leads, called lead extraction, therefore, may damage the blood vessels and the heart.  While the risk of damage is generally low when the leads have been in place only a few months, this risk gradually increases.   This risk may be difficult to precisely predict since the degree of fibrosis is variable.  In general the risk is greater for ICD leads compared to pacemakers of the same age since the ICD coils increase the degree of fibrosis. 

In order to minimize the risk of removing the leads, special techniques have been developed for lead removal.  Special tools are used to anchor the lead using the narrow channel within the lead called the lumen.  Anchoring the lead from near its tip from within the lead allows the pulling forces to maximize the ability to remove the lead and minimize the ability for the lead to be pulled apart during the removal process.  In cases in which the leads cannot be removed with traction (pulling) alone, a special laser device is used to destroy the fibrous tissue surrounding the lead.  Special care is taken to only destroy the fibrous tissue needed for the removal of the lead without damaging the heart or the surrounding blood vessels.

The most serious risk of lead extraction is the damage or tear in the heart or blood vessels, which may be life-threatening because it may result in rapid collapse and may require emergency open chest heart surgery and may result in death. 

The most uniformly accepted indication for extraction of pacemaker or ICD leads is a serious infection involving the pacemaker and ICD and its leads.  In nearly all cases infection of the pacemaker and ICD and the lead system cannot be treated with antibiotics alone and requires lead extraction as well as removal of the pacemaker or ICD.  Removal of the pacemaker or ICD does not have significant risk since the they are not attached to the blood vessels.  However, as mentioned above, there may be a significant risk of removal of the leads.   Other than pacemaker or ICD infection the next most common indication for lead extraction is the presence of a damaged or malfunctioning lead with or without occlusion of the vein that contains this lead.  Unlike the presence of a pacemaker or ICD infection, there is usually an alternative of placing another lead on the opposite side or outside the heart using a surgical chest procedure.  The decision to extract a lead in the absence of a lead infection should be made by carefully balancing the risk of removal with the potential benefits.   In younger patients, placement of a new lead in the same vessel or on the opposite side of the chest may be less desirable since future lead abnormalities may occur and additional leads may be needed.  There is no absolute limit in the number of leads in the blood vessels and the heart.  The addition of more leads increases the likelihood of occlusion of the blood vessels and an increased difficulty in placing additional leads. In some cases the removal of the leads may create a channel that permits placing a new lead in the same vessel but in other cases this route cannot be used to place a new lead and another route may be needed.

Following extraction of the lead it is common that an echocardiogram may be obtained to assess whether there is any evidence of fluid surrounding the heart.  For patients that depend on pacing at all times, a temporary pacing wire may be placed.   In most cases following infection of the pacemaker or ICD system, patients will continue on antibiotics.

Following the Procedure

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