Outcomes of patients requiring emergent surgical or endovascular intervention for catastrophic complications during transvenous Lead extraction

BACKGROUND The outcomes of patients requiring emergent surgical or endovascular intervention during transvenous lead extraction (TLE) have not been well characterized. OBJECTIVES To evaluate the incidence of catastrophic complications requiring emergent surgical or endovascular intervention during TLE, to describe the injuries, and to review patient management and outcomes. METHODS Consecutive patients undergoing TLE of pacemaker and implantable cardioverter-defibrillator (ICD) leads at the Cleveland Clinic between August 1996 and September 2012 were included in the analysis. RESULTS A total of 5973 (4436 [74.3%] pacemaker and 1537 [25.7%] ICD) leads were extracted during 3258 TLE procedures (median [25th, 75th percentile] patient age 67.0 [55.0, 76.1] years; 69.2% men). The median (25th, 75th percentile) lead implant duration was 4.9 (2.4, 8.4) years, and 2.0 (1.0, 2.0) leads were extracted per procedure. Powered sheaths were used in 2369 (72.7%) procedures. Twenty-five (0.8%) patients experienced catastrophic complications requiring emergent surgical or endovascular intervention. Twenty patients (0.6%) required either sternotomy (n = 18) or thoracotomy (n = 2) for superior vena cava laceration (n = 15) and right atrial (n = 2) or ventricular (n = 3) perforation. Two patients required vascular repair at the procedural access site for either subclavian vein or artery laceration. Three patients were managed with an endovascular approach for superior vena cava laceration, left axillary artery laceration, and brachiocephalic vein and artery fistula. In-hospital mortality was 36.0% (6 procedural/operative deaths and 3 deaths during the same hospitalization). CONCLUSIONS Major vascular injury or cardiac perforation requiring emergent surgical or endovascular intervention during TLE is uncommon but carries significant in-hospital mortality. Despite high mortality, nearly two-thirds of these patients were rescued with immediate response and surgical or endovascular intervention.