Internal jugular vein perforation due to blind temporary pacing lead insertion: Pitfall of a blind procedure

Najeeb Ullah Sofi; Santosh Kumar Sinha; Mohit Sachan

doi:10.4103/jicc.jicc_18_22

CASE REPORT

Year : 2022 | Volume : 12 | Issue : 4 | Page : 189-191

Internal jugular vein perforation due to blind temporary pacing lead insertion: Pitfall of a blind procedure

Najeeb Ullah Sofi, Santosh Kumar Sinha, Mohit Sachan
Department of Cardiology, LPS Institute of Cardiology, GSVM, Kanpur, Uttar Pradesh, India

Date of Submission	25-Jun-2022
Date of Decision	21-Jul-2022
Date of Acceptance	23-Jul-2022
Date of Web Publication	19-Dec-2022

Correspondence Address:
Dr. Najeeb Ullah Sofi
Department of Cardiology, LPS Institute of Cardiology, GSVM, Kanpur
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicc.jicc_18_22

Abstract

Temporary pacing lead is placed through the internal jugular, subclavian or femoral vein under fluoroscopic, echocardiographic, or electrocardiographic guidance. However, in most of the developing world, this procedure is done without fluoroscopic guidance. Blind procedures are known to be associated with more complications as compared to guided procedures. Here, we report a case of the right internal jugular vein perforation while placing the temporary pacing lead in an 80-year-old male patient who had permanent pacemaker implantation done 10 years back and had developed right subclavian and brachiocephalic vein stenosis. Clinicians need to be aware of this rare complication and preferably do these procedures under fluoroscopic guidance and avoid an overzealous approach if the pacing lead does not pass through easily. Patients who had undergone any procedure through their central venous system, especially with retained catheters and pacing leads in situ in the past should undergo a venogram before planning any reintervention from the ipsilateral side to avoid such complications.

Keywords: Blind procedure, brachiocephalic vein stenosis, internal jugular vein perforation, subclavian vein stenosis, temporary pacing

How to cite this article:
Sofi NU, Sinha SK, Sachan M. Internal jugular vein perforation due to blind temporary pacing lead insertion: Pitfall of a blind procedure. J Indian coll cardiol 2022;12:189-91

How to cite this URL:
Sofi NU, Sinha SK, Sachan M. Internal jugular vein perforation due to blind temporary pacing lead insertion: Pitfall of a blind procedure. J Indian coll cardiol [serial online] 2022 [cited 2023 Feb 8];12:189-91. Available from: https://www.joicc.org/text.asp?2022/12/4/189/364211

Introduction

In certain emergency situations, temporary pacing lead insertion helps in restoration of rhythm, preserving cardiac output, and life-saving measures till either reversible cause is resolved or permanent lead is implanted.^[1] In certain situations, sometimes, especially in developing countries, temporary lead is also implanted blindly without fluoroscopic guidance. Blind procedures are known to be associated with more complications as compared to guided ones. These complications are lead dislodgement, cardiac perforation, pneumothorax, cardiac tamponade, central vein stenosis, and rarely internal jugular vein (IJV) perforation. The complication rate of implanting such devices varies between 3% and 7.5% depending on the types of devices, hemodynamic status, age, venous access site, and operator experience.^[2] Subclavian and brachiocephalic vein stenosis have been reported after indwelling devices such as central venous catheters, pacemakers, or defibrillator leads. Any blind procedure in the same vessel in such patients can cause catastrophic complications.

Case Report

An 80-year-old male, with a single chamber pacemaker, implanted 10 years back, presented with recurrent syncope for the past 1 day with hemodynamic compromise. An electrocardiogram revealed a loss of pacing spike. Pacemaker interrogation revealed the end of life of the pacemaker generator. The right IJV was cannulated with a 6°F sheath under aseptic condition. 6°F temporary pacing wire (PACEL; St Jude Medical; Germany) was advanced through the jugular sheath, however, resistance was felt while advancing it and hence manipulated accordingly. After connecting with the pulse generator, pacing potentials were recorded on the surface electrocardiogram but myocardial depolarization did not happen. Chest X-ray revealed lead crossing the right mediastinal border [Figure 1].

Figure 1: Chest X-ray showing temporary pacing lead (Red arrow) crossing the right mediastinal border

Click here to view

The patient was shifted to the catheterization laboratory. Venogram revealed the obstruction of the right subclavian and brachiocephalic vein and perforation of the right IJV with contrast spilling out of it [Figure 2]a and [Figure 2]b. The left brachiocephalic vein and superior vena cava were patent [Figure 3]. Finally, the right femoral vein was accessed and a temporary pacing wire was placed in the right ventricle. The patient was managed conservatively. A serial chest X-ray indicated mild right-sided pleural effusion which gradually resolved [Figure 4]. Subsequently, the pulse generator was replaced and the patient was discharged after 5 days.

Figure 2: (a and b) Perforation of right IJV due to Temporary pacing wire (red arrow) in a patient with stenosis of right subclavian and brachiocephalic vein (Arrowheads). IJV: Internal jugular vein

Click here to view

Figure 3: Patent left brachiocephalic vein and SVC (Red arrows) with right IJV perforation. IJV: Internal jugular vein

Click here to view

Figure 4: Chest X-ray posteroanterior view on 2^nd day showing minimal effusion on the right side (horizontal arrow)

Click here to view

Discussion

Central vein (subclavian and innominate) stenosis after indwelling devices such as central venous catheters, pacemaker or defibrillator leads, and hemodialysis catheters has been reported in 30%–50% of patients.^{[3],[4],[5],[6]} One study found that 9% of patients who had implantable cardioverter-defibrillator implanted had developed total occlusion of the brachiocephalic, subclavian, axillary vein, or superior vena cava.^[7] It has been attributed to thrombus formation acutely or fibrosis caused due to chronic irritation of the endothelium.^[8] Different authors have quantified the stenosis of <50%, 50%–70%, and more than 70% as mild, moderate, or severe, respectively. These obstructions are mostly asymptomatic and are usually identified when repeat interventions are needed from the ipsilateral side such as upgradation of device or lead replacement. The asymptomatic nature of these stenotic lesions is attributed to the collateral venous circulation that develops as the stenosis gradually worsens. When required these lesions can be circumvented by balloon venoplasty and sometimes stenting in selected situations.^[8],[9] One should be aware of this complication and be prepared to intervene from the contralateral side if the ipsilateral approach does not work. Few of the predictors of cardiac or vessel perforation while placing pacing wire are low body mass index, advanced age (>80 years), increased right ventricular pressure, temporary lead, active fixation lead, dilated and thinned cardiac chamber, emergency situation, and concomitant use of steroids.^[10],[11]

In our case, the patient was frail and elderly and a temporary lead was being put in an emergency situation in the background of central vein stenosis which led to the catastrophe. Increased risk of perforation with temporary lead may be attributed to the increased number of leads, its stiffness, and vigorous manipulation in emergent situations. One must do these procedures preferably under imaging guidance and a venogram must be obtained in all patients who had undergone any procedure through their central venous route, especially with retained catheters and leads in the past, before any reintervention is planned from the same venous side, to look for any stenosis and to avoid any vascular injury.

Conclusions

Patients who had undergone any procedure through their central venous system, especially with retained catheters and pacing leads in the past are predisposed to stenosis of those veins. Inserting a temporary pacing lead without imaging guidance in those patients may cause vascular injury.

Temporary pacing procedure should be done under fluoroscopic guidance, especially in those who have retained catheter or pacing leads. A venogram should be done before planning any reintervention from the ipsilateral side to avoid complications.

Learning objectives

One must insert a temporary pacing lead preferably under imaging guidance.

To look for any stenosis and to avoid any vascular injury, a venogram must be obtained in all patients who had undergone any procedure through their central venous route, especially with retained catheters and leads in the past, before any reintervention is planned from the same venous site.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Laborderie J, Barandon L, Ploux S, Deplagne A, Mokrani B, Reuter S, et al. Management of subacute and delayed right ventricular perforation with a pacing or an implantable cardioverter-defibrillator lead. Am J Cardiol 2008;102:1352-5.
2.	Bradshaw PJ, Stobie P, Knuiman MW, Briffa TG, Hobbs MS. Trends in the incidence and prevalence of cardiac pacemaker insertions in an aging population. Open Heart 2014;1:e000177.
3.	Lee JA, Zierler BK, Zierler RE. The risk factors and clinical outcomes of upper extremity deep vein thrombosis. Vasc Endovascular Surg 2012;46:139-44.
4.	Winters JP, Callas PW, Cushman M, Repp AB, Zakai NA. Central venous catheters and upper extremity deep vein thrombosis in medical inpatients: The Medical Inpatients and Thrombosis (MITH) Study. J Thromb Haemost 2015;13:2155-60.
5.	Verso M, Agnelli G. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol 2003;21:3665-75.
6.	Haghjoo M, Nikoo MH, Fazelifar AF, Alizadeh A, Emkanjoo Z, Sadr-Ameli MA. Predictors of venous obstruction following pacemaker or implantable cardioverter-defibrillator implantation: A contrast venographic study on 100 patients admitted for generator change, lead revision, or device upgrade. Europace 2007;9:328-32.
7.	Lickfett L, Bitzen A, Arepally A, Nasir K, Wolpert C, Jeong KM, et al. Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography on patients presenting for their first elective ICD generator replacement. Europace 2004;6:25-31.
8.	O'Leary B, Allaqaband S. Subclavian vein stenosis/occlusion following transvenous cardiac pacemaker and defibrillator implantation: Incidence, pathophysiology and current management. J Patient Cent Res Rev 2015;2:112-7.
9.	Sudhakar BG. Left subclavian and innominate vein balloon venoplasty followed by permanent pacemaker implantation: A case report. J Innov Cardiac Rhythm Manage 2019;10:3738-42.
10.	Mahapatra S, Bybee KA, Bunch TJ, Espinosa RE, Sinak LJ, McGoon MD, et al. Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm 2005;2:907-11.
11.	Hirschl DA, Jain VR, Spindola-Franco H, Gross JN, Haramati LB. Prevalence and characterization of asymptomatic pacemaker and ICD lead perforation on CT. Pacing Clin Electrophysiol 2007;30:28-32.