Application of Excimer Laser for Percutaneous Extraction of Pacemaker and Defibrillator Leads: Experience from the Hunter Holmes McGuire Veterans Administration Medical Center and the Virginia Commonwealth University

  • Karoly Kaszala
  • Alex Tan
  • Harsimran Saini
  • Yuhning L. Hu
  • Jennifer Winfield
  • Jayanthi Koneru
  • Richard K. Shepard
  • Kenneth A. Ellenbogen
  • Jose F. Huizar


Over the last decades, the clinical need for managing the consequences of chronically implanted intravascular cardiac pacemaker or defibrillator leads has grown exponentially. Lead failure and new indications for an upgraded device therapy often requires new lead implantation in a limited central venous “real estate”. In addition, device implantation in patients with increasing comorbidities resulted in higher infection rates and cure in these cases is unlikely without complete system removal. While removal with simple traction of recently implanted leads is often sufficient, once significant fibrosis takes place around the lead (usually after 6 -12 months), use of special extraction tools often becomes necessary as traction may cause complications or incomplete lead removal. Among the numerous older and newer advanced lead management modalities, the most extensive clinical experience and supporting data from multicenter trials has come from the use of the excimer laser technology.

In this chapter, we discuss the main principles of lead extraction, including indications, perioperative management with particular focus on the laser lead removal technique and present outcome data from the Hunter Holmes McGuire VA Medical Center and the Virginia Commonwealth University.


Excimer laser lead extraction ICD lead Pacemaker lead Device infection Lead fracture 


  1. 1.
    Coe MS, Taylor KD, Lippincott RA, Sorokoumov O, Papaioannou T, editors. Proceedings of SPIE 4244, Lasers in surgery: advanced characterization, therapeutics, and systems 2001;XI:454. doi: 10.1117/12.427834;
  2. 2.
    Summary of P960042/s031 Glide Light 80Hz laser sheath (12, 14 or 16Fr), spectranetics. Department of Health and Human Services; 2012. Accessed: 25 Feb 2015. Available from:
  3. 3.
    Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley 3rd GH, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm. 2009;6(7):1085–104.CrossRefPubMedGoogle Scholar
  4. 4.
    Hauser RG, Katsiyiannis WT, Gornick CC, Almquist AK, Kallinen LM. Deaths and cardiovascular injuries due to device-assisted implantable cardioverter-defibrillator and pacemaker lead extraction. Europace. 2010;12(3):395–401.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Greenspon AJ, Patel JD, Lau E, Ochoa JA, Frisch DR, Ho RT, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol. 2011;58(10):1001–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Turk KT, Reeves R, et al. Intravascular extraction of problematic or infected permanent pacemaker leads: 1994–1996. U.S. Extraction Database, MED Institute. Pacing Clin Electrophysiol. 1999;22(9):1348–57.CrossRefPubMedGoogle Scholar
  7. 7.
    Wilkoff BL, Byrd CL, Love CJ, Hayes DL, Sellers TD, Schaerf R, et al. Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the excimer sheath (PLEXES) trial1. J Am Coll Cardiol. 1999;33(6):1671–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Bongiorni MG, Blomström-Lundqvist C, Kennergren C, Dagres N, Pison L, Svendsen JH, et al. Current practice in transvenous lead extraction: a European Heart Rhythm Association EP Network Survey. Europace. 2012;14(6):783–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Van Erven L, Morgan JM. Attitude towards redundant leads and the practice of lead extractions: a European survey. Europace. 2010;12(2):275–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Henrikson CA, Zhang K, Brinker JA. A survey of the practice of lead extraction in the United States. Pacing Clin Electrophysiol. 2010;33(6):721–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Reiser C. Clinical study of the laser sheath for lead extraction: the total experience in the United States. Pacing Clin Electrophysiol. 2002;25(5):804–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Wilkoff BL, Byrd CL, Love CJ, Sellers TD, Van Zandt HJ. Trends in intravascular lead extraction: analysis of data from 5339 procedures in 10 years (XIth World Symposium on Cardiac Pacing and Electrophysiology: Berlin). Pacing Clin Electrophysiol. 1999;22(6 (pt. II)):A207.Google Scholar
  13. 13.
    Di Monaco A, Pelargonio G, Narducci ML, Manzoli L, Boccia S, Flacco ME, et al. Safety of transvenous lead extraction according to centre volume: a systematic review and meta-analysis. Europace. 2014;16(10):1496–507.CrossRefPubMedGoogle Scholar
  14. 14.
    Mendenhall GS, Saba S. Prophylactic lead extraction at implantable cardioverter-defibrillator generator change. Circ Arrhythm Electrophysiol. 2014;7(2):330–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Ghosh N, Yee R, Klein GJ, Quantz M, Novick RJ, Skanes AC, et al. Laser lead extraction: is there a learning curve? Pacing Clin Electrophysiol. 2005;28(3):180–4.CrossRefPubMedGoogle Scholar
  16. 16.
    Sood N, Martin D, Clancy J, Curtis J, Parzynski CS, Lampert R. Incidence and predictors of peri-procedure complications with transvenous lead extractions in the real world: data from NCDR ICD registry. Circulation. 2014;130 Suppl 2:A19603.Google Scholar
  17. 17.
    Kennergren C, Schaerf RH, Sellers TD, Wilkoff BL, Byrd CL, Tyres GF, et al. Cardiac lead extraction with a novel locking stylet. J Interv Card Electrophysiol. 2000;4(4):591–3.CrossRefPubMedGoogle Scholar
  18. 18.
    Vlay SC. Concerns about the Riata ST (St. Jude Medical) ICD lead. Pacing Clin Electrophysiol. 2008;31(1):1–2. [Comment Editorial].PubMedGoogle Scholar
  19. 19.
    Kay GN, Brinker JA, Kawanishi DT, Love CJ, Lloyd MA, Reeves RC, et al. Risks of spontaneous injury and extraction of an active fixation pacemaker lead: report of the Accufix Multicenter Clinical Study and worldwide registry. Circulation. 1999;100(23):2344–52.CrossRefPubMedGoogle Scholar
  20. 20.
    Theuns DA, Elvan A, de Voogt W, de Cock CC, van Erven L, Meine M. Prevalence and presentation of externalized conductors and electrical abnormalities in Riata defibrillator leads after fluoroscopic screening: report from the Netherlands Heart Rhythm Association Device Advisory Committee. Circ Arrhythm Electrophysiol. 2012;5(6):1059–63.CrossRefPubMedGoogle Scholar
  21. 21.
    Parvathaneni SV, Ellis CR, Rottman JN. High prevalence of insulation failure with externalized cables in St. Jude Medical Riata family ICD leads: fluoroscopic grading scale and correlation to extracted leads. Heart Rhythm. 2012;9(8):1218–24.CrossRefPubMedGoogle Scholar
  22. 22.
    Goyal SK, Ellis CR, Rottman JN, Whalen SP. Lead thrombi associated with externalized cables on Riata ICD leads: a case series. J Cardiovasc Electrophysiol. 2013;24(9):1047–50.CrossRefPubMedGoogle Scholar
  23. 23.
    Bongiorni MG, Di Cori A, Segreti L, Zucchelli G, Viani S, Paperini L, et al. Transvenous extraction profile of Riata leads: procedural outcomes and technical complexity of mechanical removal. Heart Rhythm. 2015;12(3):580–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Birgersdotter-Green UM, Pretorius VG. Lead extractions: indications, procedural aspects, and outcomes. Cardiol Clin. 2014;32(2):201–10. [Review].CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • Karoly Kaszala
    • 1
  • Alex Tan
    • 1
  • Harsimran Saini
    • 2
  • Yuhning L. Hu
    • 2
  • Jennifer Winfield
    • 3
  • Jayanthi Koneru
    • 2
  • Richard K. Shepard
    • 4
  • Kenneth A. Ellenbogen
    • 2
  • Jose F. Huizar
    • 1
  1. 1.Cardiac Electrophysiology LaboratoryHunter Holmes McGuire VA Medical Center and Division of Cardiology, VCU Pauley Heart Center, Medical College of Virginia and VCU School of MedicineRichmondUSA
  2. 2.Division of CardiologyVCU Pauley Heart Center, Medical College of Virginia and VCU School of MedicineRichmondUSA
  3. 3.Cardiac Electrophysiology LaboratoryHunter Holmes McGuirevVA Medical CenterRichmondUSA
  4. 4.VCU Pauley Heart Center, Medical College of Virginia and VCU School of MedicineRichmondUSA

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