A challenging image during pacemaker implantation

A 60-year-old female patient was admitted to our hospital with the complaints of syncope and palpitation. She had undergone coronary artery bypass graft surgery 2 years previously and was not taking any medications at the time of presentation. Her electrocardiography on admission was In normal sinus rhythm. Twenty-four-hour Holter monitoring revealed frequent pauses up to 5 seconds with paroxysmal bradycardia and tachycardia episodes. Coronary angiography showed thatall coronary grafts (left Internal mammarian artery-left anterior descending artery, saphenous vein-right coronary artery) were patent. In view of the Holter findings and the patient's symptoms, a dualchamber pacemaker Implantation was planned. Before the procedure, the patient was well hydrated, and the left subclavian vein was chosen for Implantation. Because multiple attempts to puncture the subclavian vein were unsuccessful, a venography was performed and revealed a challenging Image (Fig. 1, Video 1). Despite Incremental doses of nitroglycerin via the ipsilateral peripheral vein, this Image did not change (Fig. 2, Video 2). A last attempt by a lateral approach was than successful with cannulation of the subclavian vein, but there was no good flashback. However, a hydrophilic guidewire was tried, and It was successfully passed through this segment without difficulty. A dual-chamber pacemaker was Implanted with no post-procedural event.

What is the possible cause of this image?

A. Venous thrombosis

B. Subclavian vein and artery transposition

C. Venous spasm

D. Paget-Schroetter Syndrome

Video 1. Venography after Initial unsuccessful attempts

Video 2. Venography after nitroglycerin application

A challenging image during pacemaker implantation

P.75

Right answer: C. Venous spasm

This venographic appearance is compatible with venospasm. Although It Is usually known as an arterial phenomenon, severe spasm can be seen in the central veins, as In this case. Venous spasm has been reported during right heart catheterizations and central venous catheter placements for digital subtraction angiography, with an incidence of 2% and 5%, respectively (1). Because of Its strongest effect on the venous system, nitroglycerin is a reasonable approach for relieving the spasm. However, venous spasm may not resolve with nitroglycerin. As In our case and In two previously reported cases of central venous spasm during pacemaker implantation, incremental doses of Intravenous nitroglycerin failed to relieve the venospasm (2,3).

Venous spasm during pacemaker implantation is a rare clinical entity, with only a few cases reported In the literature (2-4). The exact mechanism of venous spasm remains unknown, but it may be related to the chemical effect of the contrast or a mechanical effect of multiple needle punctures and guidewire placement (2).

Paget-Schroetter syndrome Is a form of upper extremity deep vein thrombosis that can occur spontaneously or after vigorous exercise. It is also known as effort thrombosis, and the pathogenesis involves extrinsic compression and repetitive Injury of the subclavian vein between the first rib and overlying clavicle, particularly during strenuous activities Involving arm elevation or exertion (5,6).

Subclavian vein and artery transposition Is a very rare anomaly in which the subclavian vein and subclavian artery are switched in position or transposed. In this rare anatomic variation, the usual location of the subclavian artery (cephalad to the subclavian vein) is switched to caudal to the subclavian vein. In such cases, ultrasound Imaging Is necessary for understanding the anatomic relationship of the artery, vein, clavicle, and lung (7).

Lead-Induced venous thrombosis Is reported In an average of 12% (range 2%-22%) of patients, from several days to 9 years after pacemaker implantation, and only 1% to 3% of patients with upper extremity venous thrombosis develop symptoms (8). In the hospital course and control visit, our patient had no signs or symptoms attributable to venous thrombosis. Indeed, there was no evidence for venous thrombosis on the venography (presence of a collateral vessel, a visible thrombus, and/or long length of the occlusion). Therefore, venous thrombosis Is a much less likely possibility (9).

This report highlights the Importance of using venography after multiple unsuccessful attempts to puncture the subclavian vein and using hydrophilic guidewires In cases of venous spasm with successful cannulation and no good flashback. At the end of the procedure, a venography was performed again and revealed partial reversal of the venospasm (Fig. 3, Video 3).

Video 3. Partial reversal of the spasm at the end of the procedure

References

References

1. Duan X, Ling E Shen Y, Yang J, Xu HY. Venous spasm during contrast-guided axillary vein puncture for pacemaker or defibrillator lead implantation. Europace 2012; 14: 1008-11. [CrossRef]

2. Chan NY, Leung WS. Venospasm in contrast venography-guided axillary vein puncture for pacemaker lead implantation. Pacing Clin Electrophysiol 2003; 26: 112-3. [CrossRef]

3. Duan X, Ling E Shen Y, Xu HY. Venous spasm during pacemaker implantation. Anadolu Kardiyol Derg 2011; 11: E24.

4. Cooper RM, Krishnan U, Pyatt JR. Central venous spasm during pacemaker insertion. Heart 2010; 96: 1484. [CrossRef]

5. Colak MC, Kocatürk H, Bayram E. Paget-Schroetter syndrome. Anadolu Kardiyol Derg 2008; 8: 465-6.

6. Illig KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg 2010; 51: 1538-47. [CrossRef]

7. Walther ND, Auyong DB. Subclavian artery and vein transposition has implications for regional anesthesia and subclavian vein catheter insertion. Anesth Analg 2012; 115: 211-2. [CrossRef]

8. Mandal S, Pande A, Mandal D, Kumar A, Sarkar A, Kahali D, et al. Permanent pacemaker-related upper extremity deep vein thrombosis: a series of 20 cases. Pacing Clin Electrophysiol 2012; 35: 1194-8. [CrossRef]

9. Spragg DD, Marine JE. Acute subclavian vein occlusion complicating biventricular ICD implantation. J Interv Card Electrophysiol 2008; 22: 75-7. [CrossRef]