Cardiac rhythm management devices (pacemakers) are being increasingly implanted worldwide for the management of not only bradycardia but also arrhythmia and heart failure. This increase in the frequency of device therapy is paralleled with an increase in the requirement for systemic extraction. Safe lead extraction is central to the management of several complications related to pacemakers. The most common indication for lead extraction is systemic infection. Adhesions in chronically implanted leads can become major obstacles to safe lead extraction, leading to life-threatening bleeding and cardiac perforations. Currently, several extraction tools enable safe and successful transvenous lead extraction (TLE) of pacemaker and implantable cardioverter–defibrillator leads. This article provides a comprehensive review of the indications, tools, techniques, and outcomes for TLE. Operator experience is vital in determining success, as familiarity with a wide array of techniques will increase the likelihood of uncomplicated extraction. Lead extraction should, therefore, ideally be performed in high-volume centers with experienced staff and on-site support from a cardiothoracic surgical team that is able to deal with bleeding complications from cardiovascular perforation.