Predictors of Success in Fractured Electrode Extraction: The Impact of Fracture Location and Access Strategies

ABSTRACT Introduction Fractured or sheared cardiac implantable electronic device leads presents a unique clinical challenge in transvenous lead extraction. These cases are associated with clinical failure rates of up to 40% and a greater likelihood of retained fragments. The aim of this study was to characterize fractured lead extractions performed at a referral center and identify predictors of complete removal and clinical success. Methods We conducted a retrospective single center study including all consecutive patients who underwent TLE for electrodes fractured before or during extraction between October 2011 and December 2025. Clinical, echocardiographic, and procedural data were collected. Results A total of 46 procedures were analyzed. Mean age was 62.7 years and median lead dwell time was 9.0 years. The most frequent fracture site was the electrode body (67.4%). A rotational mechanical sheath was used in 84.8% of cases (39/46), and femoral snaring was used in 60.8%. Complete extraction occurred in 32.6% whereas clinical success was achieved in 80.4% of patients. Retained fragments > 4 cm were observed in 28.3%. In multivariate analysis, the use of a 13Fr sheath was independently associated with lower odds of clinical success ( p = 0.011). Fracture location was the only consistent independent predictor of complete extraction ( p = 0.031). Femoral access showed a favorable trend but did not reach statistical significance after adjustment. Conclusions In fractured lead extraction, fracture location is the strongest predictor of complete removal, surpassing clinical and procedural variables. These findings highlight the importance of preoperative planning and suggest that femoral access may play a key role in selected complex cases.