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Lead extraction for a subcutaneous implantable cardioverter-defibrillator (S-ICD) was associated with no major complications, though the procedure wasn't always easy, according to operators in France.

Complete lead removal failed in only one of 32 patients in a multicenter experience, which was attributed to lead entrapment in sternal wires after a sternotomy for heart transplantation, reported the group led by Nathalie Behar, MD, of CHU de Rennes in France.

"Such patients should be carefully managed by cardiac surgeons and the parasternal lead removed at the time of heart transplant," the authors recommended in their report in the July 2020 issue of .

No procedural complications were reported during subcutaneous ICD lead extraction.

"S-ICD lead extraction is an efficient and safe procedure when using a stepwise strategy," they concluded. "A simple traction of the lead through the xiphoidal incision is sufficient to remove the lead in up to 60% of the cases, but may require some specific tools like mechanical sheath when fibrotic adhesions are present around the parasternal coil."

An accompanying editorial agreed that the study confirmed the safety of S-ICD lead extraction.

"However, with time, more chronic leads will need to be extracted and more studies will have to confirm their results. A more systematic approach and adapted tools may have to be developed," wrote François Philippon, MD, and Frédéric Jacques, MD, both of Laval University in Québec.

"More challenges will come in the future with new ICD systems, such as substernal lead implantations. This all-new world of 'extravascular ICDs' will add complexity for the extraction procedure and will still require a lead extraction heart team approach that is so important for quality of care and safety for our patients," they wrote.

Behar and colleagues performed a retrospective review of the records of people who underwent subcutaneous ICD lead extraction (with or without generator removal) in 2014-2019. Participants had a mean age of 45.7 years and three-quarters were men.

A median 9.3 months passed from device placement and lead extraction.

Indications for lead removal were as follows: device infection (n=9), heart transplantation (n=7), sensing vectors issue (n=5), need for conventional cardiac resynchronization therapy or ICD (n=5), lead dislodgement (n=4), and technical issue (n=2).

Simple traction of the lead did the job in most cases. Nine people required a mechanical sheath to remove lead adhesions around the coil, and three an additional incision.

Those whose leads were removed by a simple traction tended to have been implanted more recently (7.1 vs 16.5 months prior, P=0.04). "Indeed, fibrotic adhesions may increase with the age of the S-ICD lead," Behar's team noted.

"Furthermore, more than one-third of the patients requiring mechanical tools for lead extraction had a history of median sternotomy, which may represent a potential factor increasing local fibrosis due to scar tissue formation and hampering an easy extraction of the lead," the group suggested.

Limitations of the report include the relatively limited sample size and the limited age of the ICD leads.

"Further studies are needed to prospectively assess the factors resulting in more challenging procedures and the efficacy of such a stepwise strategy in older S-ICD leads," according to study authors.

Subcutaneous ICDs were developed in part to limit compared to traditional devices.

"Despite all of the benefits from S-ICDs, some patients will require a system revision and eventually a system extraction for many reasons such as lead failure, system infection, heart transplantation, need for cardiac resynchronization therapy or pacing (upgrades), cardiac surgery, and so on," Philippon and Jacques wrote.

Subcutaneous ICD lead extraction may be associated with "the absence of all major vascular complications" but should still be performed by a dedicated team when the "dwell time is more than 1 year and in many patients with previous sternotomy," the editorialists suggested.

"The complete 'toolbox' of an extraction team will prevent in most cases unnecessary incisions, lead remnants, bleeding, and so on," they wrote.

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