A case of pacing lead induced clinical superior vena cava syndrome: a case report

Pacemaker lead thrombosis - a rare cause of breathlessness

As the number of pacemaker insertions increases to manage numerous cardiac arrhythmias, the number of complications is also increasing as a result. More common complications such as infection and lead displacement are routinely discussed with patients before they undergo the procedure. However rare complications such as superior vena cava syndrome are not discussed during the consenting period. But they do occur, as seen in this case of a 69-year-old male. This fit and active man had a right-sided dual-chamber pacemaker inserted due to sinus node disease and presented 5 years later with symptoms suggestive of superior vena cava obstruction (SVCO). Despite anticoagulation and before surgical intervention could be performed, the patient developed a right-sided chylothorax which was drained. An autologous pericardial patch repair of the SVC and a thrombectomy of SVC clots was subsequently performed. This was only partially successful and the SVCO recurred. A low fatty chain diet was initiated to manage the chylothorax, which remains stable. This rare complication has left the patient with a small pleural effusion and chronic pleural thickening. They can still exercise with mild breathlessness. The management of such a complication, which requires the input of many specialists, is challenging and often does not completely resolve all symptoms. For this reason, superior vena cava obstruction should be considered as a risk during the consenting procedure for a pacemaker insertion.

Recurrent Transient Ischemic Attacks in a Patient with Multiple Pacemaker Leads

Venous complications-specifically, stenosis and thrombosis-are both well-known complications of transvenous implantation of pacemakers and defibrillators. Although they are a well-recognized phenomenon, these complications are rarely of clinical significance. One of the most concerning complications is the development of superior vena cava (SVC) syndrome. Studies have found that the incidence of SVC syndrome varies from 1 in 3,100 to 1 in 650 patients. The azygos-hemiazygos venous system is the most commonly observed collateral. We report a case of a 71-year-old female patient who presented with stroke-like symptoms during the injection of agitated saline bubbles while performing an echo and was found to have an unusual venous collateral circulation formed as a result of brachiocephalic and SVC obstruction from multiple pacemaker leads. Our patient's clinical presentation was extremely unique, and we did not find any cases during our literature search reporting a similar presentation. Multiple collaterals formed between the brachiocephalic and subclavian veins, and bilateral pulmonary veins in our patient allowed the injected air bubbles from the venous system to reach the left side of the heart and eventually the cerebrovascular system, resulting in these transient ischemic attacks. These attacks eventually resolved as the air bubbles were dissolved and washed away by the continuous blood flow. It is advisable to monitor the patient for possible venous stenosis and SVC syndrome after any device insertion during regular device follow-up appointments.