Background
The first implantable pacemaker was placed in the 1958, ushering in a
new frontier of cardiovascular medicine. Since that time, implantation
of cardiovascular implantable electronic devices (CIED) has exploded.
The growth in CIED implants has been accompanied by a similar growth in
the need to remove them. With the development of specialized tools and
advancement of our understanding of transvenous lead extraction (TLE),
success rates are excellent, typically reported around 98%. There are,
however, challenges. Over time an ingrowth of fibrous tissue binds the
leads of these devices to surrounding vascular and cardiac structures
and to other leads. This tissue creates most of the challenges faced
during transvenous lead extraction. The spectrum of ingrowth and
adhesion of the leads is quite variable, and we have a long way to go in
our understanding of how to predict these adhesions.
Multiple modalities have been shown to be effective in detecting
adherence between the leads and other structures. CT, transesophageal
echo (TLE), intravascular ultrasound (IVUS), and intracardiac echo (ICE)
have all be studied. Patel et al detected some degree of adherence in
86% of subjects and severe adherence with the lead outside the contrast
lumen in 19%1 In another study evaluating CT in TLE,
Svenberg et al reported severe lead adhesion in about 45% of
subjects.2 TEE has also been evaluated to detect
adherence to the SVC and cardiac structures. Nowosielecka reported
binding to the SVC and right heart structures in 34% of
patients.3 IVUS and ICE may also be used to assess
lead binding to cardiac and venous structures. Using IVUS, Beaser et al
reported high grade adherence in 25% of patients.4Sadek et al used ICE to look for lead binding to the SVC or myocardium
and detected significant binding in 36% of patients.5 While, the modalities differ in how they detect these adhesions and, to
some degree, the structures being assessed, together, the studies tell
us that adhesions binding leads to other structures is common.