COR	Recommendations for CIED Lead Management∗	LOE	References
Thrombosis/Vascular Issues
I	Lead removal is recommended for patients with clinically significant thromboembolic events attributable to thrombus on a lead or a lead fragment that cannot be treated by other means.	C-LD	[86,87]
I	Lead removal is recommended for patients with superior vena cava stenosis, baffle stenosis, or venous occlusion that prevents implantation of a necessary lead, or when deployment of a stent is planned to avoid entrapment of the lead, or as a part of a comprehensive plan for maintaining patency.	C-LD	[87]
IIa	Lead removal can be useful for patients with ipsilateral venous occlusion to allow transvenous access to the heart for required placement of an additional or replacement lead.	C-LD
Lead Upgrade or Abandonment
IIa	Lead removal can be useful for patients with an abandoned lead that interferes with the operation of a CIED system.	C-EO
IIb	Lead removal may be considered for patients requiring CIED revision, taking into account the number of leads present, patient age, size, venous capacitance, and potential for vascular occlusion.	C-LD
IIb	Lead removal may be considered for isolated upper extremity venous stenosis or thrombosis without symptoms.	C-EO
Infectious Issues
I	Lead removal is indicated for CIED-associated endocarditis, bacteremia without an alternative source (particularly Staphylococcus aureus), or bacteremia that persists or recurs despite antimicrobial therapy.	B-NR	[86,87]
I	Pre-lead removal blood cultures and transesophageal echocardiography are recommended for patients with suspected systemic CIED infection to guide antibiotic therapy and assess the potential embolic risk of identified vegetations.	B-NR
IIb	Lead removal may be considered when there is an isolated superficial CIED pocket infection with serial negative blood cultures and no evidence of endocarditis by transesophageal echocardiography.	C-LD
Other Indications
I	Lead removal is recommended for patients with life-threatening arrhythmias secondary to retained leads.	C-EO
IIa	Device and/or lead removal can be useful for patients with severe chronic pain at the device or lead insertion site or believed to be secondary to the device, for which there is no acceptable alternative.	C-EO
IIb	Lead removal may be considered for patients with leads that, due to their design or their failure, pose a potential future threat to patients if left in place.	C-LD
Epicardial Leads
I	Epicardial lead removal is recommended for patients where the lead is shown to be associated with coronary artery compression and evidence of myocardial injury.	C-LD	[90]
I	Complete removal of epicardial lead(s) and patches is recommended for all patients with confirmed infection surrounding the intrathoracic portion of the lead.	C-EO
IIb	Epicardial lead removal may be considered for patients with leads that are thought to be at risk for causing coronary artery compression, valve impingement, or cardiac strangulation.	C-EO
IIb	Epicardial lead removal may be considered at the time of epicardial lead replacement in the presence of a damaged or nonfunctional lead, taking into account the procedural risk and benefit.	C-EO

∗Recommendations based on adult lead management guidelines [[86], [87], [88]].