Safety and Outcomes of Percutaneous Vegetation Aspiration During Transvenous Lead Extraction: A Multicenter Experience

BACKGROUND: Transvenous lead extraction (TLE) for cardiac implantable electronic device infection has high procedural success, but with a 1-year mortality approaching 25%. Potential mechanisms include septic embolization and persistent infected lead casts or "ghosts." Percutaneous mechanical aspiration of lead-related vegetations during TLE is a potential strategy to reduce vegetation burden, but safety and outcomes data are limited. OBJECTIVES: To describe a multicenter experience utilizing percutaneous vegetation aspiration during TLE, including vegetation characteristics, procedural techniques, complications, and outcomes. METHODS: A retrospective multicenter registry included patients undergoing aspiration of lead-related masses at the time of TLE between 2016 and 2024 across six institutions. Clinical, microbiologic, and procedural data were collected. Vegetation size and outcomes were assessed using transesophageal or intracardiac echocardiography. RESULTS: Fifty-three patients (62 ± 14 years, 28% female) underwent aspiration of 63 vegetations during extraction of 114 leads (mean dwell time 9.0 ± 8.2 years). Indications included bacteremia in 44 (83%), fungemia in 4 (8%), fever of unknown origin in 1 (2%), and aseptic thrombus debulking in 4 (8%). Mean vegetation size was 2.8 ± 1.8 cm. Aspiration devices included Penumbra Indigo (34%), Inari FlowTriever (30%), and AngioVac (36%). Complete aspiration occurred in 40 patients (75%). TLE achieved complete success in 49 (92%) and clinical success in 52 (98%). Major complications related to aspiration occurred in 2 patients (4%). After a median follow-up of 139 days, 10 patients (19%) died. CONCLUSIONS: Percutaneous vegetation aspiration during TLE appears feasible and generally safe. However, mortality following extraction for device-related infection remains substantial, and the impact of adjunctive aspiration on outcomes requires further study.