CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
AFRICA
201
Subclavian crush syndrome: a cause of pacemaker lead
fracture
F FEMENIA, JCL DIEZ, M ARCE, A BARANCHUK
Abstract
A 48-year-old male with a symptomatic 2:1 atrio-ventric-
ular block and a dual-chamber pacemaker, implanted one
year previously, was admitted due to a syncopal episode.
Pacemaker malfunction was identified as the cause of
syncope. Subclavian crush syndrome was the cause of the
pacemaker malfunction. Its incidence, consequences and
management are discussed in this report.
Keywords:
Subclavian crush syndrome, pacemaker lead, lead
fracture
Submitted 17/2/10, accepted 1/7/10
Cardiovasc J Afr
2011;
22
: 201–202
DOI: 10.5830/CVJA–2010–052
Various techniques for pacemaker implantation are universally
used. A number of different methods for venous access are used
for permanent pacemaker implantation, of which subclavian
vein puncture using Seldinger’s technique is the most frequent.
1
Subclavian crush syndrome is a well-described cause of pace-
maker lead failure. It usually occurs after medial intrathoracic
puncture of the subclavian vein and results in damage to the
pacemaker lead body by entrapment within the costoclavicular
ligament and/or the subclavian muscle.
2
We present a case of a subclavian crush syndrome that
occurred one year after dual-chamber pacemaker insertion using
the subclavian puncture technique.
Case report
A 48-year-old male with a prior history of positive serology for
Chagas’ disease, symptomatic 2:1 atrio-ventricular block and a
dual-chamber pacemaker (Identity DR 5386, St Jude Medical,
atrial lead: Tendril 1688 TC, ventricular lead: Isoflex 1646 T),
implanted one year ago, was admitted due to a syncopal episode.
Cardiac monitoring evidenced pacemaker dysfunction and fail-
ure of capture (Fig. 1A).
Fluoroscopy revealed ventricular lead fracture below the clav-
icle (Fig. 1B, white arrow). A venography ruled out subclavian
vein obstruction (Fig. 1B). The fractured lead was abandoned
and a new ventricular lead was implanted with no complications,
Unidad de Arritmias, Departamento de Cardiología, Hospital
Español de Mendoza, Argentina
F FEMENIA, MD,
M ARCE, MD
Arrhythmia Service, Kingston General Hospital, Queen’s
University Kingston, Ontario, Canada
JCL DIEZ, MD
A BARANCHUK, MD, FACC
using the same vein and puncturing more distally. The patient
was discharged the following day.
Discussion
Subclavian vein puncture is usually performed for pacemaker
implantation. Although this approach offers high success rates
and low incidence of major complications, it has been associated
with lead fracture (coil fracture or insulation damage) at stress
points in the costoclavicular region.
1
Subclavian crush syndrome
is a well-described cause of lead fracture, resulting from lead (or
leads) entrapment between the clavicle and the first rib following
subclavian vein puncture.
2-4
Its prevalence is up to 7% depending
on the series.
1
Injuries are more frequent if both leads are intro-
duced via a single venous puncture. Cephalic vein dissection has
been demonstrated to reduce the prevalence of complications
associated with subclavian vein puncture.
Magney
et al
. have described a modification of the usual tech-
nique in order to avoid entrapment of the leads in the subclavius
muscle, the costocoracoid ligament, or the costoclavicular
ligament (the catheters could be stressed with the movement
of the ipsilateral upper extremity).
5
This approach consists of
introducing the lead or catheter into the subclavian vein near the
lateral border of the first rib (extrathoracic segment). This type
of placement avoids soft-tissue entrapment. Three years after this
report, the same group reported a follow up on 461 patients who
underwent pacemaker implantation using the described approach
without having a single crush syndrome.
6
In the presented case, there was not only compression of the
electrodes between the clavicle and the rib, but also compression
of the electrodes against each other, causing further erosion.
Conclusion
Subclavian crush syndrome is a well-known cause of lead
damage. Subclavian punctures performed too medially may
increase the risk of this complication. Proper pacemaker follow
up should be done in order to minimise the consequences of lead
failure, particularly in the setting of pacemaker dependency.
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