Title : Refractory axillary venous spasm during permanent pacemaker implantation due to vein wall hematoma
Abstract:
Background: The number of pacemakers and defibrillators implanted in worldwide continues to increase.Subclavian vein stenosis/occlusion following transvenous cardiac device placement is a known complication of the procedure.Central venous spasm during pacemaker implantation is uncommon with only a few cases reported from time to time. We present a case of dual chamber pacemaker implantation and subclavian vein stenosis during vein punction because of hematoma of the vein wall.
Case: A 83-year-old female patient with no prior comorbidities presented to us with recurrent dizziness on exertion and at rest. The electrocardiogram showed complete heart block. As part of the hospital protocol, a venogram was performed by giving intravenous diluted contrast (iohexol) through the left brachial vein, which showed good-sized axillary and subclavian veins. We attempted to cannulate the left axillary vein with a 16G needle using Seldinger technique, but the axillary vein could not be cannulated despite multiple attempts. We gave incremental boluses of intravenous nitroglycerine, despite that the left axillary vein could not be cannulated. Repeat intravenous contrast injection showed severe spasm of axillary and subclavian veins. Finally we decided to use ultrasonography (usg) and we observed that the lumen diameter narrows due to the hematoma on the vein wall. We can easily cannulate axillary vein with USG guidiance and implanted pacemkaer.
Conclusions: Venous spasm during device implantation although uncommon, it should be anticipated in patients with difficult cannulation to prevent inadvertent complications like pneumothorax and arterial injuries. Mild venous spasm may relieve with time but severe venous spasm may require a change of access site. If you can use ultrasonography you can learn the problem and may solve the canulation problem.
Keywords: Complete heart block, Refractory venous spasm, Ultrasonography guidiance.
