INTRODUCTION
Cardiovascular Implantable Electronic Device (CIED) implantations have increased over the past 2 decades because of expanded indications. Following this increase there has been a parallel increase in the need to extract CIED leads for infectious and non-infectious etiologies. Nowadays, extractions of implanted leads are performed via transvenous lead extraction (TLE) procedures usually through a superior approach via the subclavian vein (SCV) 1 2.
Extraction tools can be categorized into mechanical non-powered sheaths and powered sheaths. The latter can be divided into those that deploy a source of energy in order to dissect encapsulating fibrous tissue (laser and radiofrequency (RF) energy) and those that use handled triggered rotational dissecting tip to achieve that goal. Overall, tool development has made TLE a relatively safe and successful procedure3.
The once commonly used femoral approach, which compared to the superior approach is associated with higher complication rates in the ELECTRa prospective registry 1, has now become mainly a bailout procedure in cases where superior TLE approach has failed and thus familiarity with its use has decreased as well 24 . However, albeit the inferior’s approach reduced application, each approach for TLE has its downgrades: While the femoral approach may be associated with cardiac avulsions 5, superior vena cava (SVC) tear remains a dreaded complication of the superior approach 6. A combined superior and inferior TLE approach has been suggested in order to gain the advantage of each approach and avoid the caveats of the other 7.
Elaborating and refining predictors for femoral support or bailout should help optimize the synergy between different approaches and translate into an overall reduction in complications eventually providing better procedural outcomes.
Previously, femoral TLE bailout was found to be associated with prolonged lead dwell time and number of leads extracted in two relatively large clinical cohorts, while infection as a predictor was reported in one of these studies 8,9.
In the current study, we aimed to determine the predictors and outcomes for TLE requiring a femoral bailout, including those procedures performed in the presence of occluded veins, compared to procedures performed solely by a superior approach.