Intravascular techniques were used to extract 226 leads from 124 patients. Indications for lead extraction were life-threatening septicemia (30%), complications of free-floating leads (2%), abandonment of pockets (40%), and replacement of malfunctioning leads (28%). Extraction tools included flexible, telescoping sheaths advanced over the lead to dilate scar tissue and apply countertraction, deflection catheters, and wire basket snares. Countertraction is defined as the direct force of traction on the lead countered by the circumference of an extraction sheath. One hundred sixty-four leads were extracted through the superior vena cava by advancing the sheaths over the lead to the myocardial wall. Most of these leads passed through the subclavian vein. An approach through the inferior vena cava was used for the remaining 62 leads. The countertraction sheaths were passed from the femoral vein into the right atrium. A maneuvering catheter and an extracting snare were placed inside the sheaths. The lead was positioned by the maneuvering catheter, entangled in the extracting snare, and the sheaths advanced over the snare and lead to the myocardium. An atriotomy by means of a limited surgical approach was required to free one lead. One infected lead broke 5 cm from the electrode and was removed through a median sternotomy, ventriculotomy, and retrograde extraction. All patients had unremarkable recoveries. Intravascular countertraction techniques proved to be a viable alternative, minimizing the risks and morbidity of lead removal.