Background: There is an increasing number of transvenous lead extractions for cardiac implantable electronic devices (CIED) due to increased number of implanted devices. Infection and lead malfunction are the most common reasons to perform lead extraction. 

Methods: 463 consecutive patients with indication for transvenous lead extraction have been enrolled in this prospective observational study between January 2011 and August 2018.  The procedure was performed in the electrophysiology (EP) laboratory under deep sedation. Heart rate, blood pressure and oxygen saturation have been monitored continuously. For lead extraction a systematic approach with manual traction, lead locking devices, mechanical unpowered dilation sheets, mechanical controlled rotation sheets and snares was used. Patients were monitored after procedure at our intermediate care unit for at least 12 hours and transthoracic echocardiography was performed immediately after the procedure, the following day and on the day of discharge. 

Results: In 463 patients with 1025 leads it was planned to extract 780 leads with maximum lead dwelling time per patient of 56.9 ± 54.6  months. 447 (57.3%) leads were pacemaker leads, 89 (11.4%) left ventricular passive fixation leads and 244 (31.3%) ICD leads. Reasons for the procedure were infection (n=156, 33.7%), lead dysfunction (n=211, 45.6%), perforation through the skin (n=78, 16.8%) and system upgrade (n=18, 3.9%) respectively. Mean procedure time was 103.4 ± 68.8 min. Extraction with traction was successful with 458 leads (58.7%), of which 212 were successful with a lead locking device (LLD). Mechanical unpowered dilation sheaths were successful in 207 leads (26.5%). Mechanical controlled rotation sheets were used with 27 leads and successful with 25 leads (3.2%). Attempt to snare the lead was performed with 40 leads of which 36 (4.6%) were extracted successfully. Total lead extraction was successful with 726 leads (93.1%). Clinical success rate was 94.1% with a fragment <4cm left. 

Overall procedure related complication rate was 10.8%, of which 5 (1.1% overall) were major complications. In one patient (0.2%) there was a ventricle rupture with immediate cardiothoracic surgery. The patient died during surgery. Four patients (0.9%) experienced pericardial tamponade. And in one patient there was a dissection of the brachiocephalic vein, which needed surgical back-up.

Overall mortality during hospitalization was 11.4% (53). Only one death (mentioned above) was associated with the procedure. All other death were associated to sepsis. 

Pericardial effusion has been documented in 19 patients (4.1%) after procedure and needed intervention in two cases. This was significantly associated with a long lead dwelling time (R= 0.121; p=0.01). Pocket hematoma occurred in 26 patients (5.6%) and was significantly associated with dual antiplatelet therapy.  

Conclusion: A stepwise approach for transvenous lead extraction is effective and associated with few major complications.