Cardiovascular Implantable Electronic Device Lead Management and Extraction

Publication Date: September 14, 2017
Last Updated: December 16, 2022

Treatment

Lead Survival

A lead model and clinical scenario-specific strategy of increased surveillance and management is recommended for CIED leads that have been identified with higher-than-expected failure rates. (IIa, C-EO)
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Existing CIED Lead Management

Leaving the lead in a condition that will permit future extraction and prevents retraction into the vessel is recommended for any abandoned lead. (I, C-EO)
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Careful consideration with the patient on the decision to abandon or remove a lead is recommended before starting the procedure. The risks and benefits of each course of action should be discussed, and any decision should take the patient's preference, comorbidities, future vascular access, and available programming options into account. (I, C-EO)
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Lead abandonment or removal can be a useful treatment strategy if a lead becomes clinically unnecessary or nonfunctional. (IIa, B-NR)
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CIED Infection

If antibiotics are going to be prescribed, drawing at least two sets of blood cultures before starting antibiotic therapy is recommended for all patients with suspected CIED infection to improve the precision and minimize the duration of antibiotic therapy. (I, C-LD)
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Gram stain and culture of generator pocket tissue and the explanted lead(s) are recommended at the time of CIED removal to improve the precision and minimize the duration of antibiotic therapy. (I, C-LD)
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Preprocedural transesophageal echocardiography is recommended for patients with suspected systemic CIED infection to evaluate the absence or size, character, and potential embolic risk of identified vegetations. (I, B-NR)
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Evaluation by physicians with specific expertise in CIED infection and lead extraction is recommended for patients with documented CIED infection. (I, C-EO)
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Transesophageal echocardiography can be useful for patients with CIED pocket infection with and without positive blood cultures to evaluate the absence or size, character, and potential embolic risk of identified vegetations. (IIa, B-NR)
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Evaluation by physicians with specific expertise in CIED infection and lead extraction can be useful for patients with suspected CIED infection. (IIa, C-EO)
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Additional imaging may be considered to facilitate the diagnosis of CIED pocket or lead infection when it cannot be confirmed by other methods. (IIb, C-LD)
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A complete course of antibiotics based on identification and in vitro susceptibility testing results after CIED removal is recommended for all patients with definite CIED system infection. (I, B-NR)
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Complete device and lead removal is recommended for all patients with definite CIED system infection. (I, B-NR)
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Complete removal of epicardial leads and patches is recommended for all patients with confirmed infected fluid (purulence) surrounding the intrathoracic portion of the lead. (I, C-EO)
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Complete device and lead removal is recommended for all patients with valvular endocarditis without definite involvement of the lead(s) and/or device. (I, B-NR)
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Complete device and lead removal is recommended for patients with persistent or recurrent bacteremia or fungemia despite appropriate antibiotic therapy and no other identifiable source for relapse or continued infection. (I, B-NR)
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Careful consideration of the implications of other implanted devices and hardware is recommended when deciding on the appropriateness of CIED removal and for planning treatment strategy and goals. (I, C-EO)
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Indications for Lead Extraction (Noninfectious)

Device and/or lead removal can be useful for patients with severe chronic pain at the device or lead insertion site or believed to be secondary to the device, which causes significant patient discomfort, is not manageable by medical or surgical techniques, and for which there is no acceptable alternative. (IIa, C-EO)
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Lead removal is recommended for patients with clinically significant thromboembolic events attributable to thrombus on a lead or a lead fragment that cannot be treated by other means. (I, C-EO)
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Lead removal is recommended for patients with SVC stenosis or occlusion that prevents implantation of a necessary lead. (I, C-EO)
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Lead removal is recommended for patients with planned stent deployment in a vein already containing a transvenous lead, to avoid entrapment of the lead. (I, C-EO)
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Lead removal as part of a comprehensive plan for maintaining patency is recommended for patients with SVC stenosis or occlusion with limiting symptoms. (I, C-EO)
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Lead removal can be useful for patients with ipsilateral venous occlusion preventing access to the venous circulation for required placement of an additional lead. (IIa, C-LD)
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Lead removal is recommended for patients with life-threatening arrhythmias secondary to retained leads. (I, C-EO)
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Lead removal can be useful for patients with a CIED location that interferes with the treatment of a malignancy. (IIa, C-EO)
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Lead removal can be useful for patients if a CIED implantation would require more than 4 leads on one side or more than 5 leads through the SVC. (IIa, C-LD)
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Lead removal can be useful for patients with an abandoned lead that interferes with the operation of a CIED system. (IIa, C-EO)
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Lead removal may be considered for patients with leads that due to their design or their failure pose a potential future threat to the patient if left in place. (IIb, C-LD)
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Lead removal may be considered for patients to facilitate access to MRI.* (IIb, C-EO)

* Removal of leads to prevent their abandonment, removal of broken or abandoned leads, or removal of leads to allow implantation of an MRI conditional system.

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Lead removal may be considered in the setting of normally functioning nonrecalled pacing or defibrillation leads for selected patients after a shared decision-making process. (IIb, C-EO)
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Outcomes and Follow-up

Extraction programs and operator-specific information on volume, clinical success rates, and complication rates for lead removal and extraction should be available and discussed with the patient prior to any lead removal procedure. (I, C-EO)
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Recommendation Grading

Overview

Title

Cardiovascular Implantable Electronic Device Lead Management and Extraction

Authoring Organization

Heart Rhythm Society

Publication Month/Year

September 14, 2017

Last Updated Month/Year

March 19, 2024

Supplemental Implementation Tools

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Document Objectives

To provide practical clinicalguidance in the broad field of lead management, including extraction.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D001424 - Bacterial Infections, D017147 - Defibrillators, Implantable, D010138 - Pacemaker, Artificial

Keywords

lead management, extraction, defibrillator, pacemaker