Strategies to maximize lead tensile strength during extraction in three families of pacing leads.

BACKGROUND: Traction force that can be applied to an extraction rail is based on lead tensile strength, a product of its construction. A strong rail allows safe advancement of the extraction sheath. This study expands previous work providing strategies to optimize INGEVITY rail strength. OBJECTIVE: The purpose of this study was to measure forces that leads encounter in a simulated extraction procedure, determine lead response, and develop extraction recommendations for INGEVITY, INGEVITY+, and FINELINE II lead families. METHODS: Leads were positioned in a simulated right atrial appendage implant. Subsequent traction forces enabled evaluation of lead tensile strength and effectiveness of preparation/extraction techniques. RESULTS: Significant findings include (1) preserving the lead terminal pin did not decrease lead tensile strength and typically maximized it; (2) the weakest region is between the cathode and anode; (3) mid lead scar increases traction force tolerance until that scar is removed; and (4) optimal rail strength was observed using a multivenous approach with a femoral snare. Unique lead family findings include increased tensile strength of FINELINE II polyurethane vs silicone and INGEVITY active fixation vs passive fixation. CONCLUSION: This study teaches the implanting clinician there are specific extraction techniques available to improve the removal of leads that may be the best option for a patient's clinical needs. Bench testing demonstrates that lead construction drives lead behavior during an extraction. Preserving the lead terminal pin provides consistent and, in most cases, optimal rail strength. If clinically indicated, a multivenous approach using a femoral snare significantly increases rail strength and protects the vulnerable lead tip.

Strategies to increase the INGEVITY lead strength during lead extraction procedures based on laboratory bench testing.

BACKGROUND: The INGEVITY lead (Boston Scientific, St Paul, MN, USA) has excellent clinical performance. However, its single filar design results in decreased lead tensile strength and a possible challenging extraction. This study's goal is to evaluate techniques for extracting the INGEVITY lead. METHODS: Two- and three-dimensional models were created to simulate lead extraction from a right atrial appendage lead implant with a left subclavian approach and lead/fibrosis attachment sites. Standard and unique lead extraction preparation strategies were evaluated. Traction forces were measured from a superior approach alone or in combination with a femoral approach. RESULTS: For lead extraction via the superior approach, leaving the terminal on the lead was the only factor influencing maximum tolerated load (p-value = .0007). Scar attachment provided greater lead tensile strength by transferring traction loading forces to the polyurethane outer insulation but dependent on insulation integrity. The strongest extraction rail was seen with a simulated femoral snaring of a locking stylet within the INGEVITY lead. Deployed screw retraction was most successful by rotating a Philips LLD#2 stylet (Philips Healthcare, Amsterdam, Netherlands) within the lead. CONCLUSION: Results from in vitro simulations of INGEVITY lead extraction from an atrial location found the lead has low maximum tensile strength resulting in a poor extraction rail with common extraction tools and methods. However, the strength of the INGEVITY Lead extraction rail can be significantly increased by leaving the lead terminal intact and femoral snaring of the locking stylet within the lead. Such techniques may improve extraction of the INGEVITY lead.