Pre-procedural computed tomography predicts procedural complexity and complications in bidirectional rotational mechanical transvenous lead extraction

Aims: Despite technical advances, transvenous lead extraction (TLE) remains a challenging procedure. Cardiac computed tomography (CT) has emerged as a valuable tool for pre-procedural assessment, but its role in predicting outcomes in rotational mechanical TLE as a first-line strategy is not well defined. The aim was to determine whether pre-procedural CT can predict complications and procedural complexity in patients undergoing rotational mechanical TLE. Methods and results: This retrospective study included 115 patients. All had pre-procedural contrast-enhanced CT with a dedicated lead extraction protocol. Two procedural outcomes were evaluated: (i) complicated procedure, defined as major complication, incomplete lead removal, or snare use, and (ii) complex procedure, defined as requiring either a snare or a tissue stabilization sheath. Logistic regression and receiver operating characteristic analyses were used to identify predictors. A total of 215 leads were extracted (mean dwelling time 95 ± 73 months). Complicated procedures occurred in 20.9% and were independently associated with longest fibrosis length on CT (odds ratio 1.1; P < 0.001); a fibrosis length of >40 mm predicted complicated procedures [area under the curve (AUC) 0.92; 95% confidence interval (CI) 0.88-0.97]. Complex procedures occurred in 37.4% and were associated with longest fibrosis length, lead calcification, dwelling time, and systolic heart failure. A fibrosis length of >30 mm predicted complex procedures (AUC 0.72; 95% CI 0.64-0.81). Conclusion: Pre-procedural CT allows accurate identification of high-risk anatomical features, particularly fibrosis length and calcifications, which independently predict both complicated and complex rotational mechanical TLE. These findings support the integration of CT imaging into procedural planning and individualized risk stratification.