Laser-assist during extraction of chronically implanted pacemaker and defibrillator leads

Background. Extraction of chronically implanted pacing and defibrillator leads has historically been difficult, occasionally requiring open surgical procedures. The purpose of this study was to evaluate the efficacy, safety, and potential need for percutaneous laser-assisted sheath techniques for extraction of chronically implanted leads. Methods. From January 1999 to August 2001, 128 consecutive patients underwent extraction of 229 leads (138 pacing, 91 defibrillator) in the operating room 61 +/- 44 (mean standard deviation) months after implantation. Common indications included erosion or pocket infection (41%), lead dysfunction (30%), and sepsis (13%). Results. Laser techniques were used for 56% +/- 4% (104 of 186) of long-term (implanted for more than 1 year) leads, compared with only 16% +/- 6% (7 of 43) of short-term (implanted for less than 1 year) leads (p < 0.001). For infected leads, laser was used in 53% ± 5% (49 of 92) with erosion or pocket infections, compared with only 3% ± 4% (1 of 29) with sepsis (p < 0.001). Extraction was complete in 88%, near complete (retained tip) in 10%, and incomplete in 2%. Two patients required a later percutaneous femoral venous approach to remove mobile retained segments, but no patients required cardiac surgery for extraction. Complications included sternotomy for subclavian vein injury (1), chest tube for caval perforation (1), innominate vein thrombosis (1), and partial clavicle removal for subclavian vein repair (2). There were no procedure-related deaths. Conclusions. Laser-assisted lead extraction is safe, but it is best performed in the operating room; it should be available for long-term leads, except when they are grossly infected, producing sepsis. Laser techniques have essentially eliminated the need for open surgical removal of retained leads.