Think Before You Pull—Not Every Lead Has to Come Out

Extraction is an infrequently performed procedure that involves meaningful risks. In the case of device infection, there are few attractive alternatives to complete the removal of all hardware, and thus, the risks are accepted because of a lack of alternatives.1 However, when extraction is performed for reasons other than infection, there are almost always attractive alternatives that should be considered.2 Performing device upgrades is a classic example. The topic of this debate is the removal of abandoned or to-be-abandoned leads at the time of pocket manipulation, which I will hence refer to as “elective extraction.” This does not include the accepted (class I) noninfectious indications for extraction listed in Table 1.3 The major factors to consider in the elective removal of cardiovascular implantable electronic device leads are listed in Table 2 and are considered in the following paragraphs. View this table: Table 1. Noninfectious Class I Indications for Lead Extraction (Adapted From Wilkoff et al3) View this table: Table 2. Factors to Consider in the Decision to Electively Extract a Pacing or Defibrillating Lead Response by Maytin and Esptein on p 412 This debate really comes down to the risks of abandoned leads versus the risks of extraction. If there are no risks to abandoned leads, then elective extraction never needs to be performed. However, if the risks of abandoned leads outweigh the risks of extraction, then the abandoned leads should be removed. So what is the data regarding the risks of abandoned leads? The data regarding the risks of abandoned leads are spotty at best. Two studies appeared in 20004 and 20015 that purport to show high rates of complications from abandoned pacing leads. In a large, retrospective series from the Mayo Clinic,4 611 abandoned leads were identified in 433 patients during a 20-year period, and the authors identified complications …