EP attitudes toward lead extraction have changed in the past decade

Kroman stressed the importance of early intervention, citing extensive research that supports improved patient outcomes when timely action is taken. She also said extraction is needed if there are potential lead issues like fractures for improved, proactive care.

EP devices are also being implanted in younger patients, which means the patient will require multiple devices replacements as batteries are depleted. In the past, the old leads were left in place, but multiple leads and scar tissue overtime can occlude the vessel. 

Extraction in the past was seen as risky, but safety has improved greatly with experience and newer devices. The introduction of an emergency occlusion balloon to seal any potential tears in the vessel increased the safety net for EPs performing these procedures. 

Many EP centers even have established lead management programs now.

"I think it's crucial to educate our community and offer these services. At our program at MUSC, our numbers have gone from where historically there were maybe 15 or 20 extractions done per year. Now we're up to 150 cases a year and many more leads per case. I think part of that is really being a champion and offering that service and trying to make sure patients get taken care of appropriately," Kroman explained. 

When do EP leads need to be removed?

EP implantable device pocket infections are very serious and can lead to poor outcomes if the leads are not removed along with the device. 

Kroman emphasized the imperative nature of complete lead removal in cases of pocket infections or exposed hardware. Merely treating the pocket, or resorting to rounds of antibiotics is deemed ineffective, she explained. 

"We need to be aggressive and be active with our treatment. All our data and our studies have shown through all the big centers that the earliest we can intervene on these patients, the earliest we can get their hardware out, improve patient outcomes overall," Kroman said. 

She added that early recognition and treatment of any potential lead problems may also require extraction such as lead fractures. A third area of concern is understanding patients that need to undergo upgrades. 

"Rather than just leaving abandoned hardware on multiple sides, we need to really have a sense of lead stewardship and think about getting leads out that aren't going to be used, or if patient is occluded, rather than just implanting a whole new system on the contralateral side," she explained.

Tools for removing EP leads

Kroman said there is an array of tools and techniques employed. There are laser energy catheters, for example, that fit over the leads, dissolving the scar tissue as it is slowly pushed over the lead. There are also mechanical tools using a trigger action to rotate small, circular blades over the lead. These have recently had the additional of powered rotary cutters because of the difficulty to the EP of needing to pull a trigger for long periods of time. She emphasized the need for flexibility and adaptability during these procedures, often employing various tools and methodologies to troubleshoot and achieve successful extractions.

Need for training EPs in lead extraction

Kroman highlighted the challenges faced in training new medical professionals in the nuances of lead management, especially those who might not have received specialized training during their earlier education. However, she emphasizes the significance of collaborative efforts within a dedicated EP team and mentorship to build a successful lead management program.

"To run a successful lead management and extraction program, it really takes a huge team and I'm incredibly fortunate in that my surgical partners are just fantastic. They're an integral part of the team. Our cardiac anesthesia team, our device clinic team, everybody is crucial to that for people starting out. I think, important to find kind of a mentor in a high volume extractor and really learn from there," she said. 

Kroman also said it is good to have clear safety protocols in place and it should not be something that is taken lightly or casually. 

Using community outreach to build lead management referrals

Clinicians outside of EP may not clearly recognize the signs of device or lead infections, faulty leads or vessel occlusion caused by abandoned leads. This is where outreach can be used to help clinicians better identify these patients and send them to the experts.

"Part of what our center has worked on doing is a lot of community outreach and education, not just to referring cardiologists, but even to our ER centers that may see these patients so they know that recognition is key, and then they need to send them to someplace where we will treat them and be able to get everything out. Otherwise, they're just going to end up in a spiral of getting worse and worse," Kroman explained. 

Related content: Kroman shares how she uses PaceMate’s real-time integration with Epic for early recognition of lead health issues and long-term lead management.