Multicenter registry finds aspiration feasible during infected lead extraction
Percutaneous aspiration of lead-related vegetations during transvenous lead extraction was feasible across six institutions and carried a low but real procedural risk, according to a multicenter retrospective registry spanning 2016 through 2024. The experience is important because infected cardiac implantable electronic devices remain a high-risk clinical problem even when the hardware is removed successfully. Patients with device infection often arrive with bacteremia, fungemia, or large infected masses attached to chronically implanted leads, and the biology of the illness does not end when extraction begins. Septic embolization, residual infected casts, and persistent intracardiac debris can continue to drive morbidity after technically complete procedures.
Fifty-three patients underwent aspiration of 63 vegetations at the time of extraction of 114 leads. The cohort was older, with a mean age of 62 years, and 28% were female. Lead dwell time averaged 9.0 years, a reminder that extraction often takes place after long periods of endothelialization and fibrotic attachment, when infected material may be firmly anchored to the venous system, tricuspid apparatus, or right-sided cardiac structures. Mean vegetation size reached 2.8 cm, which places many of these cases in the range where embolic burden becomes a practical concern for the procedural team.
A single sentence captures the procedural tension in these cases: large infected masses were being managed at the very moment the leads were being removed.
Vegetation burden, infection phenotype, and device strategy
The dominant indication for intervention was bacteremia, present in 44 patients, or 83% of the cohort. Fungemia accounted for 4 patients, fever of unknown origin for 1 patient, and aseptic thrombus debulking for 4 patients. That mix matters clinically because the aspiration strategy was not limited to one microbial syndrome. It was used in patients with overt bloodstream infection, in those with fungal involvement, and in a small subset with noninfectious thrombotic masses. Such heterogeneity can complicate interpretation of outcomes, but it also reflects real-world electrophysiology practice, where operators confront a spectrum of lead-associated masses rather than a single disease phenotype.
Three aspiration platforms were used: Penumbra Indigo in 34% of cases, Inari FlowTriever in 30%, and AngioVac in 36%. The distribution suggests that no single device had monopolized this niche. Each system approaches clot and vegetation removal differently, but the shared intent is to reduce mass burden before or during extraction, potentially limiting pulmonary embolization and improving procedural control. In theory, lowering the volume of friable material before traction on an infected lead should reduce the showering of septic debris into the pulmonary circulation. In practice, the procedure still unfolds in complex, infected, hemodynamically fragile patients, where competing risks remain substantial.
Complete aspiration was achieved in 40 patients, or 75%. In a field where pre-procedural imaging frequently reveals bulky masses with irregular surfaces, that rate suggests the technique can remove a large proportion of visible burden. Yet complete visual clearance does not guarantee microbiologic sterilization, and it does not erase the damage already done by the infection. Vegetations are only one part of the pathophysiology; infected fibrous lead casts, native-valve involvement, bloodstream seeding, and host comorbidity continue to shape outcome after the intervention.
Extraction success remained high despite complex anatomy
Transvenous lead extraction itself remained highly effective in the registry. Complete procedural success was achieved in 49 patients, or 92%, and clinical success in 52 patients, or 98%. Those figures are reassuring, because they indicate that adding aspiration did not appear to compromise the extraction procedure in a broad multicenter setting. The registry was not designed to prove superiority over extraction alone, but it does show that aspiration can be integrated into an established extraction workflow without obvious loss of efficacy.
Major complications related to aspiration occurred in 2 patients, or 4%. That safety signal is low in absolute terms, though it is not trivial in a cohort already at elevated risk because of infection, long dwell times, and large vegetations. The clinical question at the bedside is straightforward: can aspiration reduce embolic burden without introducing new procedural hazards? This registry suggests the answer is plausibly yes, at least in experienced hands, but the data remain too limited to define the optimal patient selection threshold or the best device for each anatomy.
Mortality after device infection still tracked high
Follow-up extended for a median of 139 days, and 10 patients died, producing a mortality rate of 19% during that interval. The death rate reinforces a central problem in infected device management: successful extraction does not equal recovery. Patients who require lead removal for infection often carry a heavy burden of systemic illness, advanced cardiac disease, renal dysfunction, frailty, or resistant organisms. Large vegetations may mark a particularly severe infectious phenotype rather than merely a mechanical obstacle to extraction.
Mortality after device infection remains substantial even when extraction succeeds.
The registry cannot determine whether aspiration changed survival, because no randomized comparison or contemporaneous matched control group was included. It is also unclear whether aspiration altered pulmonary embolic events, shortened antibiotic courses, or reduced relapse rates. Those unanswered questions matter because the technique is being adopted to solve a biologically plausible problem, yet the endpoint that counts most to patients is not mass removal on imaging but survival, functional recovery, and freedom from recurrent infection.
What this experience can and cannot support
The strongest message from the multicenter experience is procedural feasibility. Aspiration devices were used across six institutions, vegetation removal was often complete, and extraction success remained high. That combination suggests the approach can be incorporated into advanced electrophysiology programs dealing with complex device infections. The study also argues for caution. The patients were sick, the follow-up mortality remained high, and the registry design leaves room for selection bias, center-specific expertise, and confounding by indication. Operators may have chosen aspiration for the largest or most concerning masses, which makes direct outcome comparisons especially difficult.
For clinicians managing cardiac device infection, the report points toward a practical but narrow conclusion: percutaneous aspiration can reduce visible vegetation burden during extraction, but it should not be mistaken for a cure-all. Persistent infection biology, embolic risk, and late mortality still define the clinical course. Future studies will need to clarify which patients benefit most, whether certain vegetation sizes or microbial syndromes justify routine aspiration, and whether adjunctive debulking changes outcomes beyond procedural imaging endpoints. Until then, the strategy remains a technically credible option rather than a proven mortality-reducing intervention.