Advances in device lead extraction.

The removal of chronically implanted pacemaker and defibrillator leads has evolved over the past 20 years into an integral part of the medical and surgical practice of electrophysiology. It is the basis for management of device-related complications. Lead removal has progressed from just pulling, to a sophisticated procedure based on telescoping sheaths, counterpressure, and countertraction. Current telescoping sheaths have a powered tip (laser or electrosurgical) for more efficient extirpation of leads from encapsulating fibrous tissue. The management of a device infection exemplifies the spectrum of procedures ranging from debridement of inflammatory tissue to transvenous, transatrial, or epicardial lead reimplantation (care must be given to the consequences of chronic implant complications such as superior vein occlusion). The magnitude of these lead removal procedures ranges from a transvenous procedure to cardiopulmonary bypass removing a pannus of infected material. Current procedure related mortality is less than 0.2% at experienced centers.