Lead extraction. Indications and techniques.

Each of the extraction techniques and their ancillary tools was reported as used successfully; however, until now, no technique has been successful when used in more than a few isolated instances. The technique for intravascular countertraction and the associated tools described in this paper were devised and selected in an attempt to develop one technique to be used on all patients, with all types of leads, and with a very low complication rate. Its versatility permitted single or multiple lead extractions combined with the precision of selecting and extracting a specific lead. In our experience, as well as the experience of others, the techniques described in this paper have proved to be superior by minimizing the inherent risk and morbidity, allowing us to expand the indications for lead removal beyond septicemia and free-floating leads, to include infection, abandonment of pockets, and replacement of malfunctioning or fractured leads. Intravascular countertraction was a consistently safe and efficacious method of removing transvenous pacemaker leads regardless of the duration of the implant, thus permitting extractions in patients not considered candidates for a more extensive surgical procedure. Intravascular countertraction encompasses surgical and fluoroscopic techniques possessed by most physicians experienced in pacemaker and automatic implantable cardioverter defibrillator implants. However, there is a learning curve, predicating caution for the inexperienced physician. In addition, advanced surgical skills may be needed in handling associated conditions such as debridement and primary closure of chronically inflamed tissues, especially in submuscular pockets and sinus tracts in the neck. Although the potential for a cardiovascular complication is small, it does exist, and cardiovascular surgical backup is a recommended precaution.