PACING
Brachiocephalic vein perforation on three-dimensional computed tomography
1 Department of Cardiovascular Medicine, Faculty of Medicine, Tottori University, 36-1 Nishimachi, Yonago 683-8504, Japan; 2 Department of Regenerative Medicine and Therapeutics, Tottori University Graduate School of Medical Science, Japan; 3 Division of Morphological Analysis, Department of Functional, Morphological, and Regulatory Science, Tottori University, Japan
Manuscript submitted 24 August 2006. Accepted after revision 3 October 2006.
* Corresponding author. Tel: +81 859 38 6517; fax: +81 859 38 6519. E-mail address: oigawa{at}grape.med.tottori-u.ac.jp
Key Words: Brachiocephalic vein, Innominate vein, Perforation, Three-dimensional computed tomography, Pacemaker lead
There have been many reports concerning difficulties with pacemaker (PM) leads. We have recorded brachiocephalic vein [(BCV) or innominate vein] perforation by a PM lead in a 78-year-old man using three-dimensional computed tomography (3DCT). The patient received a dual chamber PM system implantation in another hospital because of atrioventricular conduction block with mild sinus node dysfunction. His post-operative general condition was quite good and he did not have any complaints. Measured data showed that the amplitude of spontaneous P-waves was 2 mV. However, atrial pacing showed no capture. Chest X-ray revealed that the atrial PM lead tip was at the level of the high right atrium (RA) as shown in Figure 1A (black arrowhead). In contrast, the ventricular PM lead tip was positioned in the right ventricular apex.
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Three-dimensional computed tomography to investigate this abnormality showed that the atrial PM lead was outside the BCV and its tip was positioned just above RA in the anterior mediastinum as shown in Figure 1B and C.
Judging from these 3DCT findings, the left BCV was perforated by the atrial PM lead in the anterior mediastinum, in the space between the mediastinal pleura and the parietal pericardium.
From the anatomical point of view, the left BCV generally descends forwards from the left and turns backwards in the middle of the anterior mediastinum. This tortuosity of the BCV tends to increase with age. There was an extremely large bend in the left BCV in this case. In fact, the BCV perforation by the PM lead occurred at this bend (white arrowhead). It is very important to take these anatomical characteristics of the left BCV into consideration to avoid complications, especially in old patients. To our knowledge, this 3DCT image of BCV perforation has not previously been reported.
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