Case Presentation: Permanent pacemaker placement is associated with venous thrombosis along the lead access tracks. Temporary pacemakers are much less frequently associated with thrombosis. We present a case of acute internal jugular deep venous thrombosis in a patient several days after temporary, followed by permanent, pacemaker insertion.A 76-year-old female with history of severe symptomatic aortic stenosis and non-obstructive coronary artery disease presented to the emergency department with neck and chest pain. She was 11 days status post TAVR, complicated by complete heart block requiring temporary, and then permanent, pacemaker implantation. She described the pain as 7/10, originating as chest pressure with radiation to her neck bilaterally, left greater than right. She denied any relationship to exertion but did note worsening with positional changes. There was no shortness of breath or arm pain. She reported compliance with aspirin and clopidogrel since surgery.In the ED, the patient’s vital signs were stable. The heart had regular rate and rhythm and there was no upper or lower extremity edema. Lungs were clear. EKG showed a ventricular-paced rhythm without acute ST-T wave changes and troponin was negative. Given her recent hospitalization for TAVR, a CTA was performed to rule out pulmonary embolism and aortic dissection. It revealed no evidence of PE, however, was unable to rule out dissection due to timing of contrast. Cardiothoracic Surgery was consulted and felt her CTA was unchanged from post-op imaging and that no further intervention was required.Due to her prominent neck pain, carotid artery ultrasound was obtained to rule out carotid dissection. This revealed an incidental finding of acute, non-occlusive deep vein thrombosis in the right proximal internal jugular vein.Given the need for anticoagulation, apixaban was started and aspirin was discontinued. As we proceeded to determine the etiology of the IJ DVT, it was confirmed that her temporary pacing wires had been placed via the right IJ vein, while her permanent pacemaker had been placed on the left.
Discussion: Over a century ago, Virchow described three critical factors for the development of venous thrombosis: venous stasis, hypercoagulability, and endothelial injury. These elements continue to be important today and prompted the team to investigate whether the patient’s IJ had been instrumented. We found that her TAVR had been performed through femoral access and permanent pacemaker was placed via the axillary vein, while temporary pacing wires had been placed via the right IJ vein. Our patient likely developed a right IJ DVT secondary to the temporary pacer wires damaging the vessel’s endothelium during instrumentation, hence creating a nidus for clot formation.
Conclusions: To our knowledge, only a few cases of IJ vein thrombosis following a permanent pacemaker have been reported and there is scarce data of any IJ DVTs following temporary pacemaker insertion. Our cardiology team was informed of the complication of the procedure, which will hopefully serve to heighten awareness and improve patient care through implementation of protocols in the long run.