Reasons for Lead Extraction

Leads sometimes need to be removed. The most common reason for removal is infection at the site of the lead or the device. If there is infection around the device, it must also be removed. Leads and devices may also need to be removed when heart valves become infected. Lead extraction is needed if scar tissue forms at the tip of the lead (this is called exit block), or the vein becomes blocked by scarring or a clot. 

Damage to the lead itself (fracturing) may require extraction.  Surgeons may sometimes leave the broken lead where it is and place new ones beside it. This is not always possible, since there is only so much space in the vein. 

Less common reasons for lead extraction include recall of leads, protruding wires, or leads triggering abnormal heart rhythms.

Types of Lead Extraction Surgery

There are 2 approaches to lead extraction. The most commonly used is subclavian, in which the lead or leads are removed through an incision in the upper chest over the subclavian vein (under the collarbone). Sometimes this is not feasible, and in the femoral approach, leads are extracted via a small puncture in the groin over the femoral vein.

Preparing for Lead Extraction

Your doctor will tell you how to prepare. Pay close attention to instructions about stopping some medications like blood thinners and aspirin a few days before your procedure. You will also be instructed about when to stop eating and drinking, and about taking your other medications before the surgery. 

Before the procedure, you may need to have some tests such as an EKG, echocardiogram, venogram, or blood tests. Let your doctor know if you are pregnant. 

The lead extraction procedure

Subclavian approach:

Your doctors will give you a general anesthetic. An incision will be made and leads will be removed from the heart using a sheath (tube). After the procedure is complete, the sheath will be removed through the blood vessel. New leads might also be placed at this time. After everything is removed, the surgical team will close and bandage the sheath insertion site.

Femoral approach: 

You will likely be given general anesthesia. Some doctors will instead use a sedative that will keep you semi-conscious. You may feel some pulling as the leads are removed. But you should not feel pain. If leads are being removed because of an infection, you will be first treated for the infection before the new leads are placed. If they are removed for another reason, you may have new leads implanted during this procedure.

Risks

As with any surgery, there are risks involved with lead extraction. Risks include pulmonary embolism, anesthesia complication, fluid accumulation, subcutaneous bleeding, swelling of the arm, infection, damage to the heart valve, and death in rare cases. There is also a chance of puncturing the heart or a surrounding blood vessel which could cause major bleeding. This may require you to undergo immediate open-heart surgery or blood transfusion. Certain factors like being female, being younger, having calcified leads, or needing multiple leads removed makes complication more likely. 

Your doctor will discuss these risks with you before you go in for the procedure.

Recovery

After the procedure you will be transferred to an inpatient room. Expect to stay in the hospital at least overnight and possibly for several days. If the femoral approach is used to remove the leads, you will need to lie flat in bed for several hours. If new leads are implanted after the old ones are removed, you may be able to go home the morning after your procedure. Your doctor should be able to provide you with a personalized timeline. 

While in the hospital, your heart rate and rhythm will be monitored by telemetry (radio transmission of measurement data). 

If the lead extraction was due to an infection, you will most likely get antibiotics after the procedure. If new leads were placed, you will probably be x-rayed the following day to check your lungs and the positions of the new leads. Some patients may have stitches that will be removed 10-14 days after the procedure. 

Your doctor will talk with you about activity limits, medications, and follow-up visits. You should check your incisions every day. Call your doctor if you notice swelling at the incision site or extremities, increased bleeding or drainage, or a fever.