catheter systems are safe and effective at removing vegetations [25,26]. The decision to debulk a vegetation prior to extraction is made on a case-by-case basis [5], but the risk of clinically relevant acute PE was rare in several cohort studies: In a retrospective study of 53 cases of pacemaker-lead endocarditis, 29 patients with 49 leads bearing vegetations with a mean size of 17.8 mm underwent successful transvenous removal using locking stylets and sheaths with no clinically apparent PEs [80]. Pacemaker leads with larger vegetations (mean size 22.4 mm) were removed by open cardiac surgery in 24 patients, three of whom died. https://www.uptodate.com/contents/cardiac-implantable-electronic-device-lead-removal/print 12/21 7/6/23, 10:48 AM Cardiac implantable electronic device lead removal - UpToDate In a single-center study of percutaneous lead removal (215 leads in 100 patients) in the setting of intracardiac vegetations, either on the leads or on the valves and ranging in size from 0.2 to 4.0 cm (mean 1.6 cm) in diameter, embolization of vegetation material, which measured >2 cm before extraction, was witnessed in only two cases with a third case that was presumed to have embolized (97 percent overall success rate for removal without embolization) [82]. In spite of the apparent embolization, all three patients recovered completely. [82] Paradoxical embolization of vegetation or thrombus into the systemic circulation at the time of lead extraction is possible, albeit rare, in patients with a patent foramen ovale (PFO). Among a cohort of 774 patients undergoing transvenous CIED lead extraction in the Mayo Clinic system over 17.5 years, postprocedural stroke occurred in 1 percent of patients and was significantly more likely among patients with PFO and right-to-left shunting [85]. SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cardiac implantable electronic devices".) SUMMARY AND RECOMMENDATIONS Lead removal is a general term that encompasses removal of a cardiac implantable electronic device (CIED) lead using any technique, while lead explantation and lead extraction are terms with more specific definitions. (See 'Definitions' above.) The most common indications for lead removal are infection, venous occlusion, mechanical lead failure (often resulting in improper pacemaker function or inappropriate implantable cardioverter-defibrillator [ICD] shocks), or advisory or recall as a result of (potential) lead malfunction. As a result of the complex nature of these cases, recommendations for lead extraction apply only to those patients in whom the benefits outweigh the risks when assessed on individual patient factors and operator-specific experience and outcomes. (See 'Indications' above.) Relative contraindications to percutaneous transvenous lead removal include unavailability of required personnel or equipment, the patient not being a candidate for emergency https://www.uptodate.com/contents/cardiac-implantable-electronic-device-lead-removal/print 13/21 7/6/23, 10:48 AM Cardiac implantable electronic device lead removal - UpToDate thoracotomy, or anomalous lead placement. (See 'Contraindications' above.) Lead removal generally requires a significant amount of advance preparation. Knowledge of the patient's comorbidities, prior invasive/surgical history (eg, prior cardiac surgery or presence of an inferior vena cava filter), and lead characteristics such as lead length, diameter, and adapter information are required. The need for pacemaker support (ie, in a pacemaker-dependent patient) and ongoing device therapy must be assessed. Due to the risk of endovascular injury, lead extraction procedures should be performed with cardiothoracic surgical backup available. (See 'Lead removal procedure' above.) On occasion, previously placed leads may be capped and abandoned during CIED upgrade. Abandoned leads, however, pose a risk of interference with the placement or operation of another CIED and may need to be removed. In the absence of contraindications, we suggest removal of abandoned leads at the time of an indicated CIED procedure if implantation of the new device would result in greater than four unilateral leads or greater than five leads through the superior vena cava (Grade 2C). (See 'Lead upgrade and abandonment' above.) There are a variety of techniques and equipment used for lead removal, including direct (manual) traction, locking stylets, nonpowered "mechanical" sheaths, excimer laser powered sheaths, rotational cutting blade sheaths, and endovascular snares. (See 'Techniques' above.) Success rates for lead removal are variable and often reported in terms of complete versus partial removal. Large series of patients who have undergone lead extraction have reported high success rates (95 to 99 percent). Most of the complications are traumatic and related to the lead itself (eg, vascular injury, cardiac perforation resulting in cardiac tamponade, tricuspid regurgitation), although embolization of thrombus or vegetation from the lead is also a concern. When performed by experienced operators, mortality is usually less than 1 percent of patients, with major complications seen in 2 to 4 percent of patients. (See 'Outcomes' above and 'Complications' above.) ACKNOWLEDGMENTS The UpToDate editorial staff acknowledges Brian Olshansky, MD, and Jonathan Weinstock, MD, FACC, FHRS, who contributed to earlier versions of this topic review. Use of UpToDate is subject to the Terms of Use. https://www.uptodate.com/contents/cardiac-implantable-electronic-device-lead-removal/print 14/21 7/6/23, 10:48 AM Cardiac implantable electronic device lead removal - UpToDate REFERENCES 1. 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Stroke in patients with cardiovascular implantable electronic device infection undergoing transvenous lead removal. Heart Rhythm 2018; 15:1593. Topic 971 Version 40.0 Contributor Disclosures Jay A Montgomery, MD No relevant financial relationship(s) with ineligible companies to disclose. Jonathan Piccini, MD, MHS, FACC, FAHA, FHRS Grant/Research/Clinical Trial Support: Abbott [Atrial fibrillation, catheter ablation]; AHA [Atrial fibrillation, cardiovascular disease]; Bayer [Atrial fibrillation]; Boston Scientific [Cardiac mapping, pacemaker/ICD, atrial fibrillation care]; iRhythm [Atrial fibrillation]; NIA [Atrial fibrillation]; Philips [Lead management]. Consultant/Advisory Boards: Abbott [Atrial fibrillation, catheter ablation]; Abbvie [Atrial fibrillation]; Bayer [Atrial fibrillation]; Boston Scientific [Cardiac mapping, atrial fibrillation, pacemaker/ICD]; ElectroPhysiology Frontiers [Atrial fibrillation, catheter ablation]; Element Science [DSMB]; Medtronic [Atrial fibrillation, pacemaker/ICDs]; Milestone [Supraventricular tachycardia]; Pacira [Atrial fibrillation]; Philips [Lead extraction]; ReCor [Cardiac arrhythmias]; Sanofi [Atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. Todd F Dardas, MD, MS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/cardiac-implantable-electronic-device-lead-removal/print 21/21