Chapter 7 116 indication, TLE technique and peri and post-procedural care for patients undergoing TLE. In clinical practice, a wide spectrum of tools and techniques are used ranging from simple manual traction to combined approaches including powered sheaths and snare tools (11). In general, the goal of TLE is to achieve the highest clinical success rate with a low complication rate. The most important risk of lead removal includes venous or cardiac perforation requiring emergency surgery. This risk depends on multiple patient and lead related factors, including the lead dwelling time, lead properties (presence of defibrillator coils, active or passive leads), lead tip location and the presence of prior sternotomy. Although outcomes of TLE has improved as a result of technological advancements in extraction tools, experienced operators and high-volume centers are essential to achieve an optimal TLE outcome (11, 14, 15). 4.2 Role of femoral snaring Most centers perform a stepwise TLE approach where femoral snaring is used as a bail-out procedure when previous methods have failed (4, 7, 16). Several singlecenter studies have shown that adding femoral snaring to a superior approach increases clinical success by approximately 10% (5, 6, 8). Femoral snaring seems especially useful for older leads and leads with passive fixation which are more prone to fracture (5, 6). Instead of using femoral snaring as a bail-out procedure, a few single-center studies have demonstrated a high complete procedural success rate (94%) when femoral snaring is used as the primary approach (9, 10). In these experienced centers, the rate of cardiac tamponade requiring surgical intervention ranged from 0.6 to 0.9%. It is important to note that in these two studies, the proportion of extracted ICD leads was relatively low (0% to 4%) (9, 10), which may positively bias their results as ICD lead removal is known to be associated with a higher risk of major complications (15). In a European multicenter prospective registry (n = 3510), a femoral approach was associated with a higher rate of procedure-related major complications (4.1%), either as primary (9.1%) or secondary (3.5%) approach, compared with other approaches (1.4%) (11). In addition, the femoral approach was associated with a higher clinical failure rate (odds ratio 3.9) (11). The higher clinical failure rate may be biased as the femoral approach is usually used as a bail-out procedure in difficult cases. Thus, there is some discrepancy with regard to the procedural outcome of femoral snaring depending of its use as a bailout procedure or as a primary approach.
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