Powered Rotational Sheaths in Complex Transvenous Lead Extraction: Comparative Outcomes With Telescoping Sheaths and the WARD-10 Score.

BACKGROUND: Transvenous lead extraction (TLE) is essential for CIED management and is generally safe with contemporary techniques, although rare cardiac or vascular complications can be life-threatening. Comparative data between non-powered telescoping sheaths (TS) and powered rotational sheaths remain limited. METHODS: After excluding simple traction cases, 308 consecutive TLE patients treated at a tertiary center (2014-2025) were analyzed (73 TS-only; 235 TightRail). Procedural success, efficiency, and complications were compared. Major complications were defined as life-threatening or fatal procedure-related events, or events requiring urgent invasive or surgical intervention. Predictors of major complications were identified using multivariable logistic regression, and a pragmatic risk score (WARD-10: Weight < 60 kg, Age ≥ 74 years, Right subclavian approach, Diabetes mellitus, lead age ≥ 10 years) was developed. RESULTS: The TightRail group included significantly older leads (oldest lead age 7.0 ± 5.3 vs. 11.4 ± 6.8 years, p < 0.001). Complete and clinical success were similar between TS-only and TightRail (91.8% vs. 94.0%, p = 0.586; 93.2% vs. 95.3%, p = 0.545), and overall procedure and fluoroscopy times did not differ significantly. In three-group analysis, TightRail-only demonstrated the shortest procedural duration. Major complication rates did not differ significantly between the TS-only and TightRail groups (1.4% vs. 4.3%, p = 0.469); these events predominantly occurred in leads ≥ 10 years, whereas complication rates were low regardless of extraction strategy in leads < 10 years. Independent predictors of major complications were weight < 60 kg, right subclavian approach, diabetes mellitus, and lead age ≥ 10 years. WARD-10 demonstrated good discrimination (AUC 0.857); a cutoff ≥ 3 yielded 72.7% sensitivity and 85.5% specificity. CONCLUSION: TightRail achieved comparable efficacy and efficient performance despite preferential use in more complex cases. Major complications were primarily associated with patient- and lead-related risk factors rather than the extraction strategy alone. The WARD-10 score provides a simple tool for individualized risk stratification in TLE.