IMAGES IN ELECTROPHYSIOLOGY AND PACING
Occlusion of the proximal subclavian vein complicating pacemaker lead implantation
Department of Cardiology Sint Lucas Andreas Ziekenhuis, Jan Tooropstraat 164, 1006 AE, Amsterdam The Netherlands
Manuscript submitted 29 September 2004. Accepted after revision 1 June 2005.
Corresponding author. E-mail address: r.k.riezebos{at}xs4all.nl
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A set of images in which a pacemaker lead replacement procedure was complicated by occlusion of the proximal subclavian vein is presented. However, this was not detected on venography performed before the procedure. Physicians should be aware of a more proximal occlusion of the subclavian vein while replacing pacemaker leads, even in cases with seemingly normal venography.
Key Words: Subclavian vein occlusion, Venography, Pacemaker complication
A 69-year-old male was admitted because of dysfunction of his DDDR pacemaker. Six years ago he received the device because of symptomatic 2° atrioventricular block. The chest X-ray revealed a fracture of the atrial lead just below the clavicle (Figure 1).1
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Before the lead replacement, cineangiography of the left subclavian vein was performed to visualize any venous obstruction.2
Normal diameter and flow were observed (Figure 2).
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However, no passage of the new atrial lead through the subclavian vein at the site of the junction with the innominate vein was possible. In addition, more proximal venography showed a total occlusion of the innominate vein with extensive collateral flow through the jugular veins (Figure 3).
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At this point, the procedure was terminated. The old pacemaker was removed and both old atrial and ventricular leads were insulated, while a new pacemaker and leads were implanted on the contralateral side. No further complications occurred, and the patient was discharged on the next day.
Venous thrombosis and stenosis at the implantation site are common complications after pacemaker placement, with the incidence varying between 30 and 45% (Figure 4).3–5 Therefore, in pacemaker lead replacement procedures, evaluation of the patency of the subclavian and innominate veins by venography is recommended. Furthermore, in this manner, the optimal site of puncture can be assessed and possible damage to the already implanted leads could be avoided. However, although uncommon, physicians should be aware of a more proximal occlusion of the subclavian and innominate veins while replacing pacemaker leads, even in cases with seemingly normal venography.
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[1] Weiner S, Patel J, Jadonath RL, Goldner BG, Gross JN. Lead failure due to the subclavian crush syndrome in a patient implanted with both standard and thin bipolar spiral wound leads. Pacing Clin Electrophysiol 1999; 6: 975–976.
[2] Spencer WH III, Zhu DW, Kirkpatrick C, Killip D, Durand JB. Subclavian venogram as a guide to lead implantation. Pacing Clin Electrophysiol 1998; 3: 499–502.
[3] Splittell PC and Hayes DL. Venous complications after insertion of a transvenous pacemaker. Mayo Clin Proc 1992; 67: 258–265.[Web of Science][Medline]
[4] Sharma S, Kaul U, Rajani M. Digital subtraction venography for assessment of deep venous thrombosis in the arms following pacemaker implantation. Int J Cardiol 1989; 23: 135–136.[Medline]
[5] Costa DCD. Incidence and risk factors of upper deep vein lesions after permanent transvenous pacemaker implant: a 6 month follow-up prospective study. Pacing Clin Electrophysiol 2002; 25: 1301–1306.[Medline]
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