Transvenous lead extraction is a treatment for patients with Cardiac implantable electronic devices like pacemakers or implantable cardioverter-defibrillator (ICD). These devices are crucial for these patients to live who have abnormal heart rhythms-arrhythmias.
An insulated wire called the ‘lead’ is an essential component of an implantable cardioverter-defibrillator or pacemaker to deliver the energy from them to the heart. They help maintain the stability of the heartbeat. Removing the lead from the heart becomes essential in the incidence of infection or malfunction.
Upon implantation of the electronic devices, scar tissues secure the lead. However, the scar tissues can accumulate, leading to an ‘exit block.’ Exit block is when the buildup of scar tissues deters the device’s performance by restraining the energy delivered to the lead, making it unable to function correctly.
It makes the tedious task of freeing the lead by navigating through this buildup without harming the blood vessels inevitable.
Causes of Transvenous Lead Extraction:
The common reasons for lead extraction are the following:
- Scar tissue or blood clots disrupting blood flow
- Blood infections like bacteremia spread to the device
- Infected heart valves-infective endocarditis extending to the device
- Malfunctioning lead
- Improper positioning of the lead
- Lead fracture
- The lead breaking, either from the inside or from the outside
- The lead triggered an arrhythmia
- The manufacturer recalled the lead for some reason
The need to upgrade the device with a newer model.
Symptoms of Transvenous Lead Extraction:
Symptoms in patients with such devices can be detected during regular checkups. Patients should consult the doctor if they experience symptoms, which may include:
- Pain in the chest or near the insertion site
- Tightness around the chest
- Warmth or bleeding sensation in the device area
Diagnosis of Transvenous Lead Extraction:
The cardiac provider in charge will conduct a few diagnostic tests and procedures to confirm the condition and its severity.
- Blood tests
- ECHO
- EKG/ECG
- Interrogation of pacemaker or defibrillator to check for issues
Treatment of Transvenous Lead Extraction:
Lead extraction is a surgical procedure. General anesthesia will be delivered to the patient, while small incisions of 2 to 3 inches will be made. There are several approaches that healthcare providers can adopt depending on the factors.
The Subclavian approach is most commonly adopted. It involves an incision in the subclavian vein under the clavicle to extract the desired lead. If this approach is not possible, the incision will be made in the femoral artery along the groin.
The main lead extraction procedure is performed in the cardiothoracic operating room (OR) and can take at least two to six hours. After administering anesthesia and other medical fluids, the surgeon in charge makes incisions in the subclavian or the femoral vein and places a tube into it.
This tube advances with the help of fluoroscopy to help the surgeon visualize its path until it reaches the lead. The lead is then detached from the accumulated scar tissue using the instruments, a laser device, at the tip of the tube and then removed.
The extraction is followed by the closure of the incisions and bandaging. Other cases involve the placement of a new tube before the closing-up process.
Benefits of Transvenous Lead Extraction:
A successful lead extraction can help to fix and improve the patient’s health. The malfunctioning or fractured cardiac implantable electronic device can resume functioning stably and to its full potential. Resultantly, any arrhythmias caused due to the lead will stop. The blood flow restricted by the blockage around the lead will be restored to its natural pace.
Risk of Transvenous Lead Extraction:
Though the procedure is minimally invasive, there are still a few risks which may include the following:
- A tear in a blood vessel
- Excessive bleeding, maybe to the point where blood transfusion becomes a requirement
- The tip of the lead piercing-perforating the heart
- Leakage of blood around the heart
- The lead breaking
- Anesthesia complications
Complications of Transvenous Lead Extraction:
Due to the minimally invasive nature of the Transvenous Lead Extraction process, the patient is usually required to only stay for a night. So the healthcare providers can monitor them for any side effects like swelling, soreness, pain, or bruising around the site of the device and the leads and tend to them appropriately, overseeing their prompt and proper recovery. The recovery period is, on average, a week.
References:
- https://my.clevelandclinic.org/health/treatments/17165-lead-extraction
- https://www.rwjbh.org/treatment-care/heart-and-vascular-care/tests-procedures/transvenous-lead-extraction/
- https://www.brighamandwomens.org/heart-and-vascular-center/procedures/transvenous-lead-extraction
- https://www.aerjournal.com/articles/transvenous-lead-extractions-current-approaches-and-future-trends
- https://www.e-arrhythmia.org/journal/view.php?number=344
