Abstract

Background and Aims The need for transvenous lead extraction (TLE) is rising due to increased cardiovascular device implantation and an aging population. While the superior access is standard, complex cases may benefit from the Tandem approach, combining femoral and superior access to improve efficacy and safety. This study evaluates outcomes and predictors associated with the Tandem approach as a primary strategy. Methods A retrospective analysis was conducted on 148 patients who underwent Tandem TLE at a high‐volume UK center between September 2020 and December 2024. Data on procedural success, complete lead removal, complications, and outcome predictors were collected. The Needle's eye snare (NES) learning curve was assessed via fluoroscopy time. Results Median patient age was 72.4 years, with 42.6% considered high‐risk (EROS 3). 319 leads were targeted, with 81.2% extracted via the Tandem approach. Clinical procedural success was 97.3%, and complete lead removal 93%. Use of Medtronic leads was the sole independent predictor of complete lead removal. Major complications occurred in 3.4% of cases, with no procedural mortality. BMI < 25 kg/m² and extraction of ≥ 3 leads were predictors of complications and 30‐day mortality. NES proficiency improved significantly after 40 leads (p < 0.001), confirming a learning curve. Conclusion The Tandem approach is a safe and effective primary strategy for complex TLE, particularly in cases involving passive fixation, shock, and long dwell times leads. However, widespread use may be limited by resource intensity, increased fluoroscopy exposure, and the need for experienced operators.