Feasibility and Outcomes of Intravenous Lithotripsy as an Adjunct in Complex Transvenous Lead Extraction

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BACKGROUND: Transvenous lead extraction (TLE) of old leads is associated with increased procedural complexity and risk due to the development of calcified vascular adhesions. This may necessitate additional tools to free the leads. Shockwave intravenous lithotripsy (IVL), which employs acoustic pressure waves to fracture calcified lesions, has emerged as an adjunctive tool in this setting. However, data on its feasibility in TLE remains limited. OBJECTIVE: To evaluate the feasibility of IVL as an adjunctive tool in complex TLE cases, focusing on the extraction tools utilized, fluoroscopy duration, success rates, and associated complications. METHODS: From a prospectively maintained registry, we analyzed all patients undergoing IVL-assisted TLE at our institution. These patients were matched to controls without IVL using propensity scores derived from baseline and procedural characteristics, including age, sex, infection indication, age of the oldest explanted lead, number of extracted leads, and number of extracted ICD leads. A matching ratio of 1:3 was applied to increase statistical power while maintaining covariate balance. RESULTS: A total of 27 IVL-assisted cases were matched to 81 controls. Baseline demographics and comorbidities were well balanced between groups. The mean number of extracted leads and mean age of the oldest extracted lead were comparable (2.44 ± 0.98 vs. 2.49 ± 0.90, p = 0.81; 15.35 ± 5.80 vs. 15.78 ± 8.24 years, p = 0.80). IVL patients demonstrated significantly higher utilization of laser sheaths, either alone (100% vs. 77.7%, p = 0.006) or combined with mechanical tools (44.4% vs. 18.5%, p = 0.008). Median fluoroscopy time was significantly longer in the IVL group (50.2 vs. 15.7 min, p < 0.001). Complete IVL application from the brachiocephalic vein to the superior vena cava was achieved in 20 patients, while 7 were limited by proximal venous stenosis. Procedural and clinical success rates, as well as major and minor complications, were not significantly different between groups. CONCLUSION: We report the largest series on the use of shockwave IVL during complex TLE cases, with significantly higher fluoroscopy and procedure durations. Despite favorable safety and efficacy outcomes, adjunctive IVL did not confer clear clinical benefit, and the complexity of lead removal remained evident.

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