Abstract 4140358: Predictors Of The Need For Powered Extraction Sheaths During Transvenous Lead Extraction

Introduction: The need for powered sheaths, either laser or mechanically-powered, may increase risk during transvenous lead extraction (TLE). Tools to better predict the need for powered sheaths may facilitate procedural risk stratification. Methods: We identified all TLE procedures at Emory Healthcare from 2007-2023. Clinical characteristics and procedural details were collected from medical records. Although the specific details of the extraction procedure were at the discretion of the operator, extraction of targeted leads typically followed a stepwise approach of simple traction, with or without a locking stylet, followed by use of powered sheaths, if needed. Results: Out of 1,717 TLE procedures, 849 (49.4%) used powered sheaths. The dwell time of the oldest lead targeted for extraction was significantly longer in cases requiring powered sheaths: 8.7 ± 5.6 vs. 2.3 ± 2.6 years, p<0.001. Powered sheath use as a function of lead dwell time is presented in Figure 1A. Even among leads with dwell times of <1 year, 6% of pacing and 7% of defibrillator leads necessitated powered sheaths. The number of leads targeted for extraction was also higher in cases requiring powered sheaths: 1.8 ± 0.9 vs. 1.6 ± 0.7 leads, p<0.001. In a multivariate model (Figure 1B), increased lead dwell time, increased number of leads, presence of a defibrillator and renal dysfunction were associated with increased likelihood of needing powered sheaths. In contrast, infectious indication for extraction and the presence of a coronary sinus lead were associated with lower likelihood of needing powered sheaths. Major procedural complications (1.8 vs. 0.9%, p=0.13) and procedural deaths (0.8 vs. 0.2%, p=0.09) were numerically higher with powered sheaths. Conclusion: A significant minority of leads with dwell time <1 year require powered sheaths for extraction. Longer lead dwell time, increased lead number, presence of a defibrillator and renal dysfunction are associated with increased likelihood of needing powered sheaths. These data may guide pre-operative risk stratification and facilitate tailored use of resources for TLE, such as cardiac surgical back-up.