Myers M R, Parsonnet V, Bernstein A D
Division of Cardiac Electrophysiology, Huntington Hospital, Pasadena, CA 91105.
Am Heart J. 1991 Mar;121(3 Pt 1):881-8. doi: 10.1016/0002-8703(91)90203-t.
Within a few months of implantation, permanent pacemaker leads become ensheathed in fibrocollagenous tissue. This tissue may anchor the lead so that it is difficult, dangerous, or impossible to remove it. Leads with bulbous or finned tips are particularly resistant to extraction. The risks of applying traction to an entrapped lead include induction of bradycardia or ventricular tachycardia and fibrillation, invagination of the right ventricle, avulsion of the right ventricular myocardium or tricuspid valve, hemopericardium, and cardiac tamponade. Forceful traction may result in uncoiling of the conductor, disruption of the insulation, or complete fracture, leaving an intravascular remnant that may embolize or be a source for thrombosis. Although fixation and abandonment of an inactive chronically implanted lead is frequently appropriate and is known to pose little long-term risk, the retained inactive lead may interact adversely with a new active lead and then increase the risk of venous thrombosis, serve as a potential nidus for infection, or produce spurious electrical sensing signals that may be sensed by the pulse generator. Absolute indications for lead removal are those in which there would be a life-threatening situation if the lead were to remain in situ. In the absence of an absolute indication, the decision to proceed with extraction must be made by weighing the potential for serious morbidity or mortality against risks of the extraction technique. Techniques for lead removal include traction and open cardiotomy operations. When a portion of the lead is intravascular, forceps, snares, baskets, countertraction, or lead-transection devices may be used to retrieve the fragment.
在植入后的几个月内，永久性起搏器导线会被纤维胶原组织包裹。这种组织可能会固定导线，使其难以、危险或无法移除。带有球状或鳍状尖端的导线尤其难以拔除。对被困导线施加牵引力的风险包括诱发心动过缓、室性心动过速和颤动、右心室套叠、右心室心肌或三尖瓣撕脱、心包积血和心脏压塞。强力牵引可能导致导线导体展开、绝缘破坏或完全断裂，留下可能栓塞或成为血栓形成来源的血管内残余物。尽管固定并废弃长期植入的失活导线通常是合适的，且已知其长期风险较小，但保留的失活导线可能会与新的活性导线产生不良相互作用，进而增加静脉血栓形成的风险，成为潜在的感染病灶，或产生可能被脉冲发生器感知的虚假电传感信号。导线拔除的绝对指征是那些如果导线留在原位会危及生命的情况。在没有绝对指征的情况下，必须通过权衡严重发病或死亡的可能性与拔除技术的风险来决定是否进行拔除。导线拔除技术包括牵引和开胸心脏手术。当导线的一部分位于血管内时，可以使用钳子、圈套器、网篮、反向牵引或导线切断装置来取出碎片。
