A 66-year-old woman presented 2 months after implantation of a biventricular permanent pacemaker. She had no immediate complications after the procedure. Four weeks after the procedure, she noted new varicose veins in the upper portion of her left arm and pectoral area, followed by swelling that started in her proximal upper arm and spread distally. The swelling was not reduced by arm elevation. The patient did not have pain, numbness, or weakness in the arm; swelling in other areas; increased shortness of breath; or change in systemic symptoms.

Physical examination revealed a well-healing pacemaker scar site, prominent varicose veins, and notable swelling of her left upper extremity (Figures 1 and 2).

QUESTION

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

• A. Deep vein thrombosis.

• B. Lead-related venous obstruction.

• C. Lymphedema.

• D. Superior vena cava syndrome.

DISCUSSION

The answer is B: lead-related venous obstruction. Venous occlusion secondary to pacemaker lead placement is a relatively common complication; it occurs when there is venous narrowing of 50% or more.¹ Patients can be asymptomatic, have limb swelling and venous distension on the side of the device, or, in severe cases, develop superior vena cava syndrome.² The most significant risk factor is the presence of multiple leads.³