The Tandem approach in transvenous lead extraction-experience from a tertiary center
A Breitenstein, M F Reiner, N Molitor, D HoferAbstract
Background
With the increasing prevalence of cardiac implantable electronic devices (CIEDs), the number of patients requiring transvenous lead extraction (TLE) has grown substantially. Although TLE is generally regarded as a safe and effective procedure when performed in experienced centers, it remains associated with a notable risk of major complications, particularly in cases involving leads with prolonged dwell times or extensive fibrotic adhesions. The "Tandem" approach has been introduced as a specialized technique to address such challenging extractions. In this method, the lead is extracted via a superior venous access while being simultaneously snared from the femoral at the level of the right atrium.
Purpose
To analyze the clinical characteristics of patients in whom the Tandem approach was employed during transvenous lead extraction procedures at a large tertiary center.
Methods
A retrospective analysis was conducted using data from all patients who underwent TLE at our tertiary referral center between 2013 and 2025. Demographic information, procedural characteristics, and outcomes were extracted from institutional databases. Patients were divided into two groups based on whether a Tandem approach was utilized.
Results
During the study period, 722 patients underwent TLE at our institution. The mean age was 64 ± 15 years, and 81.5% were male. The overall complete procedural success rate was 92.5%, with a major complication rate of 4.8%. A total of 76 patients (10.5%) underwent TLE using the Tandem approach. While no Tandem extractions were performed between 2013 and 2018, the adoption of this technique increased steadily thereafter, reaching approximately 25% of all procedures by 2025 (Figure 1).Compared with standard extraction cases, patients in the tandem group had significantly longer lead dwell times (121±12 months vs. 88±10 months, P<0.05) and a higher proportion of implantable cardioverter-defibrillator (ICD) leads (35.7±10.4% vs. 21.2±13.4%, P<0.05). Age and gender distribution did not differ significantly between groups. Procedure duration (143±52 vs. 112±44 minutes; P<0.05) and fluoroscopy time (16.3±3.4 versus 12.3±8.9 minutes, P<0.05) were notably longer in the Tandem group; however, complete procedural success and major complication rates were comparable between the two cohorts.
Conclusion
The Tandem approach represents a safe and effective adjunctive technique for transvenous lead extraction, particularly in patients with long lead dwell times or complex lead characteristics. Although the method is associated with increased procedure and fluoroscopy durations, it offers comparable safety and success outcomes to conventional extraction methods, suggesting it may serve as a valuable tool in the management of high-risk or technically demanding TLE cases (Figure 2).