Axillary Vein Spasm During Permanent Pacemaker Implantation

J INVASIVE CARDIOL 2022;34(11):E824.

Key words: axillary vein spasm, permanent pacemaker implantation, venogram

A woman in her 60s presented with symptomatic complete heart block and was advised permanent pacemaker implantation. During the procedure, left axillary vein access was attempted using fluoroscopic landmarks but was not successful. A venogram was taken subsequently, which showed severe spasm of the axillary vein (Figure 1A and Video 1). Normal saline was infused from the ipsilateral peripheral venous access but venous spasm persisted. Intravenous nitroglycerin was administered from the ipsilateral access. A repeat venogram performed after 10 minutes showed resolution of the spasm (Figure 1B and Video 2). Successful venous puncture could be performed using the venogram as reference.

The axillary vein is the preferred puncture site for insertion of transvenous leads during cardiac implantable electronic device implantation. Axillary vein spasm is an important cause of failed venous cannulation and should be suspected when access cannot be obtained despite multiple attempts. It can be diagnosed by performing a venogram from ipsilateral peripheral cannula. The features include marked reduction in lumen and contrast opacification of the axillary vein. The cephalic vein may or may not be visualized during the spasm. The etiopathogenesis is not well understood. Implicated factors include chemical irritation caused by intravenous contrast, administered during initial venogram prior to puncture, and vessel trauma by repeated puncture attempts.

Management of axillary vein spasm is challenging. Once axillary vein spasm has been diagnosed, unnecessary attempts at venous puncture should be avoided as this can result in worsening of the spasm. Intravenous fluids should be infused from the ipsilateral venous access. Intravenous nitroglycerin from the ipsilateral access in incremental doses of 100-200 µg can help in relieving the spasm. It is imperative to wait for 5-10 minutes before reattempting puncture. A repeat venogram should be performed to demonstrate resolution of spasm and guide the puncture. If spasm persists, puncture may be attempted in the medial part of the axillary vein or the subclavian vein. In refractory cases where the above measures fail, contralateral venous access may be required.

Affiliations and Disclosures

From the ¹Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; and ²Department of Anesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted August 4, 2022.

Address for correspondence: Dr Dinkar Bhasin, Assistant Professor, Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh-160012 India. Email: dinkarbhasin@gmail.com

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