Mumbai -Wockhardt Hospitals, Mira Road recently managed a rare and challenging cardiac case where “silent” venous occlusion almost prevented life-saving pacemaker implantation in a 75-year-old male patient.
The patient, a known case of coronary artery disease (double-vessel disease on medical therapy), presented with recurrent dizziness and lightheadedness. His ECG revealed trifascicular block, while echocardiography showed a reduced ejection fraction of approximately 35%. Holter monitoring further demonstrated sinus pauses of more than 2.5 seconds along with episodes of AV dissociation, clearly indicating the need for permanent pacing support.
Although a dual-chamber ICD was initially considered, financial constraints led to the decision to proceed with a dual-chamber permanent pacemaker.
However, during the procedure, attempts to access both subclavian veins were unsuccessful. A contrast venous study revealed chronic bilateral venous occlusion with collateral circulation—an unexpected finding, as the patient had no history of central venous catheters and no clinical signs such as facial puffiness or upper limb swelling, which are typically associated with venous obstruction. Well-developed collaterals had effectively masked the underlying problem.
At this critical juncture, the options appeared limited to invasive surgical epicardial pacing or significantly more expensive leadless pacemaker systems. An innovative, on-table decision was then taken by the cardiac team to perform balloon venoplasty of the right subclavian vein using a 6 × 20 mm balloon. Under careful guidance, venous patency was successfully restored, allowing two pacing leads to be introduced. A dual-chamber, MRI-compatible Biotronik pacemaker was implanted with excellent lead parameters.
ZCommenting on the case, Dr. Anup R. Taksande Consultant Interventional Cardiologist said, “This case highlights that venous occlusion can be completely silent and may only be detected during device implantation. Balloon venoplasty provided us with a safe, minimally invasive and cost-effective way to restore access and complete the pacemaker procedure without resorting to high-cost leadless systems or major surgery.”
Dr. Mayuresh Pradhan Consultant Cardiovascular & Thoracic surgeon added, “From a surgical standpoint, avoiding epicardial pacing in an elderly, high-risk patient is always detrimental. The successful venoplasty and transvenous pacemaker implantation reflect the strength of a multidisciplinary, problem-solving approach that we follow at Wockhardt Hospitals, Mira Road.”
The patient had an uneventful postoperative course and, at one-month follow-up, remains symptom-free with stable pacing parameters. This case reinforces a key message for referring physicians: in patients needing pacing, if venous obstruction is encountered, balloon venoplasty can be a valuable option to restore access and enable conventional transvenous pacemaker implantation.
