Original Research
Cardiopulmonary Imaging
January 11, 2017

Use of Preprocedural MDCT for Cardiac Implantable Electric Device Lead Extraction: Frequency of Findings That Change Management

Abstract

OBJECTIVE. Five percent of cardiac implantable electric devices (CIEDs) are removed each year. Percutaneous extraction is preferred but can be complicated if the leads adhere to the vasculature or perforate. The goal of this study is to assess the frequency of findings on dedicated MDCT that alter preprocedural planning for percutaneous CIED extraction.
MATERIALS AND METHODS. One hundred patients with CIEDs who underwent MDCT before percutaneous lead extraction were analyzed. Major findings that could preclude percutaneous removal, including lead course and termination, were distinguished from moderately significant findings that could alter but not preclude percutaneous removal, including endofibrosis of leads to the vasculature, lead termination abnormalities, central vein stenosis, or thrombus. Incidental findings were characterized separately. Findings were correlated with preprocedural decisions, the extraction procedure performed, and procedural outcomes.
RESULTS. Twenty-six women and 74 men with 125 right ventricular leads, 84 right atrial leads, and 26 coronary venous leads were evaluated. Major findings were present in 7% of patients, including six patients with lead perforation and one with a lead coursing outside a tricuspid annuloplasty ring. Moderately significant findings of endothelial fibrosis were found in 78% of patients. The central veins were narrowed or occluded in 42% of patients, and thrombus was present in 2% of patients. Thirty-six percent of patients had incidental findings, and 4% of patients had unexpected findings requiring immediate inpatient attention.
CONCLUSION. MDCT performed before CIED lead extraction is able to identify major and moderately significant findings that can alter either percutaneous extraction or preprocedural planning. The use of dedicated preprocedural MDCT can help to stratify patient risk, guide decision making by the proceduralist, and identify non–catheter-related findings that affect patient management.
More than 350,000 cardiac implantable electric devices (CIEDs) are implanted each year in U.S. hospitals [1]. Common indications for lead removal include infection, device upgrade, lead malfunction, or thrombotic complications [24]. Despite significant advances in percutaneous lead extraction and a favorable safety profile relative to other cardiovascular procedures, lead removal is more challenging when adhesions are present between the leads and the endothelium of the veins and cardiac chambers [5] and when the lead has perforated through the heart wall [6]. Perforation frequently requires surgical intervention [7, 8].
MDCT imaging of the cardiac chambers and central veins before CIED extraction can delineate the course of the leads through the central veins and the cardiac chambers, define their relationship with the wall of the vasculature and myocardium to identify areas of vascular adhesion and myocardial perforation, and delineate venous patency, providing information for both extraction and subsequent reimplantation of CIED leads. To date, there are limited data on the use of dedicated CT for preprocedural planning for CIED removal [6, 9, 10]. The purpose of this study was to identify the frequency of findings on dedicated MDCT examinations performed before CIED lead extraction that affected preprocedural planning and patient management.

Materials and Methods

This retrospective study was HIPAA compliant and was granted a waiver of consent by the institutional review board of Duke University Medical Center.

Patient and Cardiac Implantable Electric Device Cohort

A retrospective analysis of 100 consecutive patients with an implanted CIED (pacemaker or automated implanted cardiac device) who underwent a dedicated MDCT examination as part of their routine lead extraction preprocedural care between March 2013 and May 2014 was performed. Because preprocedural CT is the standard of care at our institution, all patients undergoing planned CIED lead removal were included in this cohort. Patient-specific data, including age, sex, body mass index, and renal function, were recorded, as well as heart rate and rhythm at time of image acquisition. The type of CIED, date of placement, and indication for lead removal were recorded for all patients from the electronic medical record, as well as procedural data pertaining to lead extraction, including operative technique and success and immediate complications.

MDCT Image Acquisition

All MDCT examinations were performed on a dual-source 128-MDCT scanner (Somatom Definition Flash, Siemens Healthcare). A prospective ECG-triggered acquisition was performed in a cranial-to-caudal direction in a single breath-hold, with image acquisition at the 65% interval with 10% padding. The z-axis coverage extended from just above the venous entrance site of the pacemaker through the cardiac apex. Image acquisition was initiated 70 seconds after the IV administration of 150 mL of nonionic contrast medium containing 370 mg I/mL (iopamidol; Isovue 370, Bracco Diagnostic) injected at 4 mL/s. No preprocedural medications were administered. Volumetric datasets were reconstructed at 1.0-mm thickness at three time points in the cardiac cycle and were reviewed on an off-axis platform using TeraRecon (version 4.4.11, TeraRecon); three time points were evaluated to help with metal artifact [11].

Image Analysis

MDCT images were graded by a senior radiology resident, with correlation with clinical management and extraction procedure reports, and were reviewed for discrepancies with a senior faculty member with 15 years of cardiothoracic imaging experience. CIED, central vein, and cardiac chamber characteristics, as well as noncardiac findings, were evaluated for their effect on the percutaneous removal procedure and subsequent reimplantation of a new CIED. These findings were classified as having major significance for the CIED removal procedure with or without subsequent lead reimplantation, with the potential to preclude percutaneous extraction (category 1); as having moderate significance, with the potential to affect preprocedural planning, including directly affecting the performance of a percutaneous procedure or the degree to which the proceduralist would be prepared for thoracotomy, should it be required intraprocedurally (category 2); as being incidental findings that would not directly affect the ability to perform the percutaneous extraction procedure but would affect immediate patient management (category 3); and as being incidental findings that would not affect immediate patient management but would require follow-up or additional workup at a later date (category 4). This systematic review of findings was performed initially, before the subsequent review of the extraction procedure report.

Cardiac Implantable Electric Device Course, Termination, and Integrity

The CIED entrance site within the left or right subclavian vein and the CIED lead course through the subclavian vein, brachiocephalic vein, and superior vena cava, as well as the right atrium (RA), right ventricle (RV), or coronary sinus (CS), were all recorded, as was the integrity of each lead. The location of the lead in relation to the wall of the central vein was delineated using a 4-point scale: centrally located within the lumen, touching the wall of the central vein for less than 1 cm distance, touching the wall of the central vein for greater than or equal to 1 cm, or embedded within the wall of the vein, which was defined as the lead located outside the wall of the vein and within the surrounding fat. The latter two descriptions were defined as concerning for vascular adherence of the lead to the vessel wall and a moderately significant finding (category 2) that could affect performance of the percutaneous extraction procedure, given the implications for longer extraction times, longer fluoroscopic times, and larger sheath size requirement when lysing extensive adhesions [6].
The termination points of the leads were noted in the RA, RV, or CS. Termination points in the RA or appendage were described using a 4-point scale: mid cavity, embedded in the lateral or medial wall, termination external to the right atrial wall with extension less than 5 mm beyond the wall, or termination external to the right atrial wall with extension 5 mm or more beyond the wall. Five millimeters was used as the cutoff because of potential limitations from metal streak artifacts [11] and was considered positive for lead perforation. Termination points in the RV were described using a 4-point scale: mid cavity, embedded in the wall (free wall, apex, or interventricular septum), termination external to the RV wall with extension less than 5 mm beyond the wall, or termination external to the RV wall with extension 5 mm or more beyond the wall. A termination point in a coronary vein was described as being within the main coronary sinus, the lateral marginal vein, the great cardiac vein, or the middle vein. If the lead terminated beyond the wall of the vein, it was noted whether the extension was less than 5 mm or 5 mm or more beyond the wall. Lead termination of a lead tip greater than 5 mm distance beyond the myocardial wall was categorized as a major significant finding (category 1) that could preclude percutaneous extraction. Lead termination outside the wall but within 5 mm was categorized as a moderately significant finding (category 2) that did not preclude percutaneous extraction but could affect the extraction procedure.
The presence or absence of lead fracture and lead thrombus were recorded on a binary scale (yes or no). The presence of either was recorded as a category 2 (moderately significant) finding that could alter the percutaneous extraction procedure.

Central Vein Assessment

Central vein patency was noted on a 3-point scale: patent and normal size, defined as similar in size to adjacent venous structures or comparable contralateral venous structures; occluded; or narrowed, defined as greater than or equal to 50% luminal narrowing compared with an adjacent vein, for the internal jugular veins, subclavian veins, brachiocephalic veins, and the superior vena cava. A grade of 2 or 3 was considered a moderately significant finding (category 2) for CIED removal or reimplantation.

Non–Catheter-Related Findings Analysis

Non–catheter-related findings were categorized on a 3-point scale: urgent findings requiring immediate medical attention and immediate change in inpatient management, such as pulmonary embolism; findings that could change management in the operating room if open removal were undertaken, such as retrosternal coronary arterial bypass grafts and their potential effect on sternotomy method and surgical approach; and findings requiring follow-up at a later time, including nonurgent incidental findings such as pulmonary nodules.
Categorization of imaging findings on MDCT examinations performed before lead extraction were assessed on both a patient and CIED level and were correlated with clinical decision making and extraction procedure.

Results

Patient Cohort

The cohort included 100 consecutive subjects (26 women and 74 men) with an age range of 19–95 years who underwent MDCT examination before lead extraction (Table 1). No patients were excluded. Infection was the most common indication for lead extraction (54%). Noninfectious indications included lead malfunction (27%) and device revision (18%). One examination indication (1%) was specifically performed to assess the presence of lead perforation because of concerns raised on outside imaging. Thirty-four patients had pacemakers, and 66 patients had automatic implantable cardioverter-defibrillators. The time between implantation and removal was as follows: one patient device was present for less than 6 months, one patient device was present for 6–12 months, six patient devices were present for 12–24 months, and 92 patient devices were present for longer than 24 months.
TABLE 1: Cohort Characteristics of Patients Who Underwent MDCT Before Extraction of Cardiac Implantable Electric Device Lead
CharacteristicValue
Age (y)63 ± 15.9 (19-95)
BMI28.3 ± 7.87 (17.5-65.8)
Average heart rate (beats per minute) (93% of patients with a regular rhythm at time of acquisition)76.9 ± 13.4 (50-119)
Creatinine level (mg/dL)1.4 ± 1.3 (0.6-9.0)

Note—Data are mean ± SD (range). BMI = body mass index (weight in kilograms divided by the square of height in meters).

MDCT Imaging Technique

All patients completed the CT examination without complications. Ninety-nine patients received 150 mL of contrast agent; one patient received 125 mL, because this patient had already received 85 mL of contrast agent the same day during coronary angiography. Ninety-seven patients were injected at the standard rate of 4 mL/s; one patient was injected at a rate of 5 mL/s because of large body habitus, and two patients were injected at a rate of 3.5 mL/s, the maximum rate their power-injectable percutaneous indwelling central venous catheters could receive. Ninety-three percent of patients were in a regular heart rhythm at time of image acquisition. No datasets were excluded because of inadequate image quality.

Cardiac Implantable Electric Device Lead Course and Integrity

One hundred twenty-five RV leads were present in 100 patients; all patients had an RV lead. Eighty-four RA leads were present in 82 patients, and 26 CS leads were present in 26 patients. All leads had an intraluminal course within the central venous system. Eighty-four patients had left-sided approach systems, 10 had a right-sided approach, and six patients had both a left- and right-sided approach system in place, either bilateral long-term indwelling CIED systems or one-sided indwelling CIED with a contralateral temporary-permanent CIED lead. All leads were intact without evidence of fracture. Three patients had a history of prosthetic tricuspid valve implantation or annuloplasty; two patients had CIED leads coursing normally through the center of the valve, and one patient had a lead coursing outside the implanted valve, pinned between the valve and the annulus (Fig. 1). Two patients had findings concerning for thrombus or vegetation associated with a lead, both of which were confirmed on subsequent echocardiography (Table 2).
Fig. 1 —69-year-old woman with a history of tricuspid valve annuloplasty and prior cardiac implantable electric device (CIED) referred for imaging due to CIED infection. Contrast-enhanced MDCT image (left) and 3D rendering (right) show that two right ventricle (RV) leads are present. Superior RV lead courses through center of implanted tricuspid valve, whereas inferior lead courses outside implanted tricuspid valve (arrows), between valve and annulus.
TABLE 2: Central Vein Characteristics of Patients Who Underwent MDCT Before Extraction of Cardiac Implantable Electric Device Lead
Central Vein FindingNo. of Findings
Patency 
 Patent56
 Stenosis or occlusion42
 Thrombus2
Lead adherence 
 No evidence of adherence11
 Extension < 1 cm along venous wall11
 Extension ≥ 1 cm along venous wall67
 Lead embedded11

Cardiac Implantable Electric Device Lead Adhesion

Ten percent of patients had no evidence of vascular adherence (all leads coursing within the central lumen of the veins). Eleven percent of patients had one or more leads with a peripheral location for less than 1 cm distance along the central veins. The remaining 78% of patients had findings concerning for endofibrosis: 67% of patients had one or more leads with a peripheral location for greater than 1 cm distance along the central veins, and 11% of patients had one or more leads embedded within the wall of the vein (Fig. 2 and Table 2).
Fig. 2 —86-year-old man with device infection. Contrast-enhanced MDCT image shows that two cardiac implantable electric device leads are present. One courses through central lumen of superior vena cava (SVC) (arrowhead), and one courses along periphery of SVC embedded within wall of vein (arrow) as result of endofibrosis.

Cardiac Implantable Electric Device Lead Tip Location and Termination

Ninety-seven RV leads in 73 patients had the lead tip terminating within the RV wall without perforation (78%) (Fig. 3A). Twenty-three RV leads in 22 patients had the RV tip terminating outside the RV wall by less than 5 mm (18%), and five RV leads in five patients had the RV tip terminating outside the RV by 5 mm or greater (4%). In the five patients with leads terminating outside the RV wall by greater than or equal to 5 mm, one patient had a trace pericardial effusion. All leads extending beyond the myocardium terminated in the epicardial fat (Fig. 3B).
Fig. 3A —Two patients with right ventricle (RV) lead perforation.
A, 77-year-old woman with device infection. Contrast-enhanced MDCT image shows that RV lead (arrow) terminates normally within RV septum near apex.
Fig. 3B —Two patients with right ventricle (RV) lead perforation.
B, 58-year-old woman with device malfunction. Contrast-enhanced MDCT image shows that RV lead (arrow) terminates more than 5 mm outside RV wall, which is concerning for perforation.
Eighty-two RA lead tips in 78 patients terminated within the RA wall without perforation. In one patient, the RA lead tip terminated outside the RA wall by less than 5 mm, and in another patient, the RA lead tip terminated outside the RA wall by greater than or equal to 5 mm. For the lead terminating greater than or equal to 5 mm beyond the RA wall, there was a small pericardial effusion and local pulmonary parenchymal inflammatory changes. Twenty-six CS leads in 26 patients had the CS lead tip terminating within the lumen of the coronary vein or along its wall without evidence of venous perforation (Table 3).
TABLE 3: Cardiac Implantable Electric Device Lead Characteristics on Preprocedural MDCT
Lead TerminationTotal NumberLead CourseLead-Associated ThrombusTermination LocationTermination Point
Right atrium84Normal840Medial right atrial appendage wall26Within wall82
  Abnormal0 Lateral right atrial appendage wall30Beyond wall < 5 mm1
     Cavity right atrial appendage18Beyond ≥ 5 mm1
Right ventricle125Normal1241Free wall21Within wall or chamber79
  Abnormal1 Interventricular septum27Beyond wall < 5 mm23
     Apex69Beyond wall ≥ 5 mm5
     Cavity8  
Coronary sinus26Normal261Lateral marginal vein16Within coronary vein or wall25
  Abnormal0 Great anterior vein5Beyond wall < 5 mm0
     Coronary sinus3Beyond wall ≥ 5 mm0
     Posterior middle vein2  

Note—Data are number of leads.

Venous and Chamber Patency

Fifty-two central veins in 44 patients were narrowed or occluded. Twenty-seven patients had narrowing or occlusion of the left brachiocephalic, 15 of the left subclavian, one of the left internal jugular vein, and one of the left axillary vein (Fig. 4). Three patients had narrowing or occlusion of the right brachiocephalic, three of the right subclavian, two of the right internal jugular vein, and zero of the right axillary. The sites of narrowing or occlusion were on the same side as the CIED or prior or abandoned lead in 98% of patients and on the opposite side in 2% of patients.
Fig. 4 —63-year-old man with long-term (> 24 months) indwelling cardiac implantable electric device (CIED) and device infection. Axial (left) and coronal (right) contrast-enhanced MDCT images show that left-sided CIED lead (arrows) courses through left brachiocephalic vein, which is significantly narrowed around lead, causing central venous stenosis and endofibrosis of lead to wall of vein.
Of the 90 patients with a left-sided approach, 42% (38 patients) had narrowing or occlusion on the ipsilateral side, 2% (two patients) had narrowing or occlusion on the contralateral side, 1% (one patient) had narrowing or occlusion bilaterally, and 54% (49 patients) had no evidence of venous narrowing or occlusion. Of the patients with a right-sided approach, 25% (four patients) had narrowing or occlusion on the ipsilateral side, 0% (zero patients) had narrowing on the contralateral side, and 75% (12 patients) had no evidence of venous narrowing or occlusion. Of patients with narrowing or occlusion, two patients had visible thrombus within the veins, one in the left subclavian vein and one at the left internal jugular vein and subclavian confluence (Table 2).
One patient had partially calcified thrombus within the left ventricle with imaging evidence of prior left ventricular myocardial infarction. No patients with RV thrombus were identified. One patient had a linear low-attenuation defect in the RA, thought to be a mixing artifact; subsequent echocardiography confirmed the absence of right atrial thrombus.

Cardiac Implantable Electric Device Removal Procedure

In the cohort of 100 patients, 89 had all leads removed percutaneously, eight did not undergo percutaneous extraction, and three had unsuccessful or incomplete percutaneous extraction. For the eight patients who did not undergo percutaneous extraction, six had their leads abandoned and two underwent open thoracotomy. For the six who had their leads abandoned, five had lead tip termination beyond the myocardial wall (< 5 or ≥ 5 mm) and opted for a new lead without removal of the old lead or delay in the procedure, given the concerns for procedural risks. One patient had the generator changed and a new lead placed, with the old lead left capped. All patients who had leads abandoned had a noninfectious indication for device removal, except for one patient who was thought intraoperatively to have chronic inflammatory changes of the pacemaker pocket rather than true infection; thus, the leads were left in place. This patient did successfully undergo percutaneous extraction 1 year later. For the two patients who underwent open thoracotomy, both had concern for perforation (< 5 or ≥ 5 mm), and, because of the additional patient risk factors, the decision was made to undergo surgical extraction.
For the three patients who had unsuccessful or incomplete percutaneous extraction, one was due to an RV lead pinned outside of a tricuspid annuloplasty and two were due to lead fractures during the procedure that were unable to be completely removed percutaneously. Thirty-nine percent of the patients in the cohort required new hardware to be placed at the time of lead extraction, regardless of lead removal success; all leads were able to be placed from the same access site.
Most patients (92%) had no immediate procedural complications. Five patients had procedure-related bleeding requiring management with blood transfusion or evacuation of hematoma; this was unrelated to the presence of CIED lead perforation. One patient had significant tricuspid regurgitation postprocedurally, requiring close outpatient follow-up. There were no patient deaths during the procedure or the immediate (< 72 hours) postprocedural time.

Correlation of Cardiac Implantable Electric Device Findings and Management

Six patients had category 1 findings of lead perforation on preprocedural MDCT. Three patients in this group had their leads abandoned (50%), one patient underwent open surgical extraction (17%), and two underwent percutaneous extraction (33%). One patient had a category 1 finding of an RV lead pinned outside a prosthetic valve, between the valve and the annulus. For this patient, percutaneous removal was attempted and was successful for the right atrial lead, but it was unsuccessful for the RV lead. The patient required surgical extraction at a later date.
Ninety-one patients had category 2 CIED findings; percutaneous extraction was performed in 80 patients (88%). Findings in this cohort included tip termination less than 5 mm beyond the myocardial wall, lead fracture or lead-associated thrombus, endofibrosis, or central venous narrowing or occlusion. Twenty-four leads were identified as terminating less than 5 mm beyond the myocardial wall, and 20 leads were successfully removed percutaneously (83%). One was removed surgically (4%), one was abandoned (4%), and one had incomplete removal (4%) with lead fragments retained in the brachiocephalic or subclavian vein. Seventy-eight percent of patients had findings concerning for endofibrosis; however, clinical success of percutaneous extraction did not correlate to the MDCT grade of endofibrosis (Pearson coefficient, 0.09), because all leads were able be removed independently of the degree of endofibrosis. The two patients with lead-associated thrombus underwent successful percutaneous extraction, although both developed septic emboli intraprocedurally. No patients with venous narrowing or occlusion had preclusion of percutaneous extraction solely on the basis of venous patency. If lead reimplantation was required, all leads were able to be placed from the same access site.

Correlation of Non–Cardiac Implantable Electric Device Findings and Patient Management

Four patients had category 1 incidental findings unrelated to the CIED that immediately affected management. These included two patients with unexpected pulmonary emboli, one with discitis-osteomyelitis of the thoracic spine, and one patient with a 4.2-cm right coronary artery aneurysm, for which the patient's procedural plan was changed to a surgical approach. Ten patients had category 2 findings that could affect management if surgical extraction was performed, either planned or required emergently intraprocedurally. These included retrosternal coronary bypass grafts, complex congenital heart disease, an RV pseudoaneurysm, and fibrosis of the ascending aorta to the sternum from prior sternotomy. Thirty-six patients had category 3 findings, with additional workup or follow-up imaging recommended for 26 of these patients. Of these 26 recommendations, 20 (76%) were for pulmonary nodules; the Fleischner Society's criteria and recommendations for follow-up were used to distinguish benign from potentially clinically significant nodules [12]. Descriptions of the types of extracardiac findings are delineated in Table 4.
TABLE 4: Non–Catheter-Related Findings of MDCT Performed Before Extraction of Cardiac Implantable Electric Device Lead
Category, Type of FindingNo. of Findings
Incidental (n = 36) 
 Pulmonary nodule20
 Parenchymal infection5
 Interstitial lung disease3
 Mass in upper abdomen or breast8
Minor (n = 10) 
 Right ventricular pseudoaneurysm1
 Ascending aorta fibrosed to sternum1
 Complex congenital heart disease2
 Retrosternal coronary artery bypass grafts6
Major (n = 4) 
 Discitis-osteomyelitis1
 Pulmonary embolism2
 Right coronary artery ostium partially thrombosed pseudoaneurysm (4.2 cm)1

Note—Incidental findings are those requiring further management or follow-up at a later date. Minor findings may affect procedural planning, particularly if sternotomy is required. Major findings are those requiring immediate attention or workup or changes to procedural management.

Discussion

Major clinically significant abnormalities in CIED lead course and lead termination with the potential to preclude percutaneous remove were present in 7% of all patients. In the 6% of patients with lead tip perforation, two-thirds had their planned percutaneous extraction altered, either to open surgical removal or lead abandonment. The minority had their leads percutaneously removed under controlled circumstances because the indication (i.e., infection) was strong enough to warrant aggressive clinical management. In this scenario, given the presence of lead perforation, the degree to which the procedural team was prepared for emergent open thoracotomy was increased, including consultation with the cardiothoracic surgery department and immediate availability of equipment for cardiac bypass. Similarly, abnormalities in lead course in the setting of tricuspid annuloplasty changed the procedural approach, because leads that are pinned between the prosthetic valve and the annulus cannot be removed percutaneously and require surgical extraction. For the single patient with a pinned RV lead, percutaneous extraction failed and open surgical removal was required.
Among patients with the moderately significant finding of lead termination less than 5 mm beyond the myocardial wall, most (83%) were able to undergo successful percutaneous extraction. Although this finding does not preclude percutaneous extraction, it may raise awareness for the proceduralist as to the potential difficulty in lead removal during the procedure and allows appropriate planning for potential thoracotomy. In this group, 4% (one patient) had incomplete percutaneous extraction, and for 8% (two patients), operators elected to abandon performance of the percutaneous extraction. Correlation of imaging findings with individual patient clinical factors and operator experience should determine management of lead extraction.
The moderately significant finding of endofibrosis did not preclude percutaneous lead extraction. The degree of vascular adherence did not affect the clinical success of percutaneous extraction in this cohort. However, prior work has found a correlation between lead adherence to vascular structures and the laser times and sheath size required for percutaneous extraction [6]. As such, the presence of endofibrosis may aid in preprocedural planning by the cardiologist, such as ensuring the availability of larger sheath sizes or preparing for longer fluoroscopy times.
Venous stenosis or occlusion and the presence of chamber thrombus did not directly exclude the option for percutaneous removal. Within this cohort, regardless of central venous stenosis or thrombus, all leads were able to be extracted, and, if reimplanted, access was maintained and new leads were inserted using the ipsilateral venous course. Venous narrowing or occlusion was more frequently observed in patients with a left-sided approach (44%) as opposed to a right-sided approach (25%). This may be due to inherent differences in the vasculature or may be due to prior intervention or line placement. Regardless, the presence of venous stenosis or occlusion or the presence of thrombus, although not directly altering management, may affect pre- or postprocedural management, including discussion of anticoagulation therapy, intraprocedural venoplasty, or maintenance of the site of access.
Unexpected non–catheter-related findings directly affected immediate patient management in 4% in this cohort. This included urgent findings such as pulmonary embolism or spinal discitis-osteomyelitis. An additional minority of patients had important findings that did not necessarily preclude percutaneous extraction but could be of importance should open extraction be required, such as the presence of retrosternal bypass grafts. A larger minority of patients (36%) had incidental findings on preprocedural MDCT that required follow-up at a later date. This frequency is slightly lower than that reported for other cardiac MDCT examinations (≈ 41–43%) [13, 14]. Lee et al. [13] have previously shown that the cost of CT and the costs associated with incidental findings are outweighed by the indication for use of calcium scoring CT in the assessment of screening for coronary artery disease, and this likely holds true for this MDCT in this type of patient cohort. Of those with incidental findings, additional workup or follow-up imaging was recommended for 70%, and, of these, the most common indication was for pulmonary nodules, similar to findings in other studies [13, 14].
Our study had several limitations, including a small cohort size and retrospective study design. In addition, clinical reports varied as to reporting of the extraction procedure and decision making by a variety of interventionalists who have different levels of experience with CIED lead extraction. MDCT assessment for determining lead termination point can be challenging because of metal artifact and cardiac motion, which can be confounded with the presence of an automatic implantable cardioverter-defibrillator, compared with a pacemaker. These factors can result in variation in interpretation and confidence of findings. The evaluation of vascular adherence also can be difficult when multiple leads are present in a small vein.

Conclusion

MDCT performed before CIED lead extraction is able to identify major and moderately significant findings that can alter either percutaneous extraction or preprocedural planning. In this study, 91% of patients had moderately significant findings, including endothelial fibrosis, lead perforation less than 5 mm, venous narrowing or occlusion, and lead-associated thrombus, that did not preclude percutaneous extraction but could affect preprocedural planning. Seven percent of patients had major lead-related findings that could preclude percutaneous removal altogether. An additional 4% of patients had unexpected non–catheter-related findings that changed inpatient management. The use of dedicated preprocedural MDCT can help to stratify patient risk, guide decision making by the proceduralist, and identify non–catheter-related findings that affect patient management.

Footnote

J. P. Piccini receives research funding from Boston Scientific, Spectranetics, and St. Jude Medical and serves as a consultant to Medtronic and Spectranetics.

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 770 - 776
PubMed: 28075624

Presented at

Based on a presentation at the ARRS 2015 Annual Meeting, Toronto, ON, Canada.

History

Submitted: June 22, 2016
Accepted: September 10, 2016
Version of record online: January 11, 2017

Keywords

  1. cardiac implantable electric device
  2. MDCT
  3. percutaneous extraction
  4. preprocedural imaging

Authors

Affiliations

Wendy L. Ehieli
Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710.
Daniel T. Boll
Department of Radiology, University Hospital Basel, Basel, Switzerland.
Daniele Marin
Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710.
Robert Lewis
Department of Cardiology, Duke University Medical Center, Durham, NC.
Jonathan P. Piccini
Department of Cardiology, Duke University Medical Center, Durham, NC.
Lynne M. Hurwitz
Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710.

Notes

Address correspondence to L. M. Hurwitz ([email protected]).

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