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Brachial Plexus Injury Caused by Indwelling Axillary Venous Pacing Leads.

Kim SY, Park JS, Bang JH, Kang EJ - Korean Circ J (2015)

Bottom Line: Brachial plexus irritation by the angulated CRT leads was strongly suspected.To relieve the acute angulation, we had to adjust the entry site of the LV and RA leads from the distal to the proximal axillary vein using the cut-down method.After successful lead repositioning, the neuropathic pain improved rapidly.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Dong-A University Medical Center, Busan, Korea.

ABSTRACT
A 64-year-old male patient underwent cardiac resynchronization therapy (CRT) device implantation via the axillary venous approach. Two weeks later, the patient started complaining of "electric shock-like" pain in the left axillary area. During physical examination, typical pain in the left axillary area was reproduced whenever his left shoulder was passively abducted more than 60 degrees. Fluoroscopic examination showed that the left ventricle (LV) and right atrium (RA) leads were positioned at an acute angle directing towards the left brachial plexus whenever the patient's shoulder was passively abducted. Brachial plexus irritation by the angulated CRT leads was strongly suspected. To relieve the acute angulation, we had to adjust the entry site of the LV and RA leads from the distal to the proximal axillary vein using the cut-down method. After successful lead repositioning, the neuropathic pain improved rapidly. Although transvenous pacing lead-induced nerve injury is not a frequent complication, this possibility should be kept in mind by the operators.

No MeSH data available.


Related in: MedlinePlus

Chest computed tomography images. A, B, and C: axial images showing an RV lead (arrows) running into the left subclavian vein at the medial side of the pectoralis minor muscle (asterisks). The LV and RA leads (arrowheads) were running together along the lateral side of the pectoralis minor muscle into the left axillary vein at the outer border of the first rib (D). A three-dimensional volume-rendered image showing overall directions of each lead. The LV and RA leads were forming a curvature with an acute angle (empty arrow) before insertion into the left axillary vein. There were no specific findings of vascular complication or local infection. RV: right ventricle, LV: left ventricle, RA: right atrium.
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Figure 1: Chest computed tomography images. A, B, and C: axial images showing an RV lead (arrows) running into the left subclavian vein at the medial side of the pectoralis minor muscle (asterisks). The LV and RA leads (arrowheads) were running together along the lateral side of the pectoralis minor muscle into the left axillary vein at the outer border of the first rib (D). A three-dimensional volume-rendered image showing overall directions of each lead. The LV and RA leads were forming a curvature with an acute angle (empty arrow) before insertion into the left axillary vein. There were no specific findings of vascular complication or local infection. RV: right ventricle, LV: left ventricle, RA: right atrium.

Mentions: However, two weeks after the implantation of the CRT device, the patient started complaining of "electric shock-like" pain in the left axillary area radiating to the medial border of the left arm. The patient described the pain as being usually triggered by active shoulder movements, especially when pulling up his pants. During physical examination, typical pain in the left axillary area was reproduced whenever his left shoulder was passively abducted more than 60 degrees. However, there were no objective sensory changes or motor weakness. The patient's symptoms and signs suggested irritation of the left brachial plexus. Chest computed tomography scans showed the LV and RA leads running together into the lateral axillary vein along the lateral side of the pectoralis minor muscle causing a curvature with an acute angle (Fig. 1). Fluoroscopic examination in the supine position showed that the LV and RA leads were positioned at an acute angle directing towards the left brachial plexus whenever the patient's shoulder was passively abducted more than 60 degrees (Fig. 2; Video in the online-only Data Supplement). Severe left axillary and radiating arm pain recurred whenever the LV and RA leads formed such an acute angulation on fluoroscopic examination. Brachial plexus irritation by the angulated CRT device leads was strongly suspected. Analgesics and antibiotics were prescribed to control the pain and to treat the possible subclinical device-related infection. However, the patient complained of gradual worsening of the pain despite continued administration of high-dose pain killers. Six months after implantation of the CRT device, the patient was readmitted for adjustment of lead angulation due to worsening of the left axillary and radiating arm pain which impeded the patient's daily physical activities.


Brachial Plexus Injury Caused by Indwelling Axillary Venous Pacing Leads.

Kim SY, Park JS, Bang JH, Kang EJ - Korean Circ J (2015)

Chest computed tomography images. A, B, and C: axial images showing an RV lead (arrows) running into the left subclavian vein at the medial side of the pectoralis minor muscle (asterisks). The LV and RA leads (arrowheads) were running together along the lateral side of the pectoralis minor muscle into the left axillary vein at the outer border of the first rib (D). A three-dimensional volume-rendered image showing overall directions of each lead. The LV and RA leads were forming a curvature with an acute angle (empty arrow) before insertion into the left axillary vein. There were no specific findings of vascular complication or local infection. RV: right ventricle, LV: left ventricle, RA: right atrium.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4580703&req=5

Figure 1: Chest computed tomography images. A, B, and C: axial images showing an RV lead (arrows) running into the left subclavian vein at the medial side of the pectoralis minor muscle (asterisks). The LV and RA leads (arrowheads) were running together along the lateral side of the pectoralis minor muscle into the left axillary vein at the outer border of the first rib (D). A three-dimensional volume-rendered image showing overall directions of each lead. The LV and RA leads were forming a curvature with an acute angle (empty arrow) before insertion into the left axillary vein. There were no specific findings of vascular complication or local infection. RV: right ventricle, LV: left ventricle, RA: right atrium.
Mentions: However, two weeks after the implantation of the CRT device, the patient started complaining of "electric shock-like" pain in the left axillary area radiating to the medial border of the left arm. The patient described the pain as being usually triggered by active shoulder movements, especially when pulling up his pants. During physical examination, typical pain in the left axillary area was reproduced whenever his left shoulder was passively abducted more than 60 degrees. However, there were no objective sensory changes or motor weakness. The patient's symptoms and signs suggested irritation of the left brachial plexus. Chest computed tomography scans showed the LV and RA leads running together into the lateral axillary vein along the lateral side of the pectoralis minor muscle causing a curvature with an acute angle (Fig. 1). Fluoroscopic examination in the supine position showed that the LV and RA leads were positioned at an acute angle directing towards the left brachial plexus whenever the patient's shoulder was passively abducted more than 60 degrees (Fig. 2; Video in the online-only Data Supplement). Severe left axillary and radiating arm pain recurred whenever the LV and RA leads formed such an acute angulation on fluoroscopic examination. Brachial plexus irritation by the angulated CRT device leads was strongly suspected. Analgesics and antibiotics were prescribed to control the pain and to treat the possible subclinical device-related infection. However, the patient complained of gradual worsening of the pain despite continued administration of high-dose pain killers. Six months after implantation of the CRT device, the patient was readmitted for adjustment of lead angulation due to worsening of the left axillary and radiating arm pain which impeded the patient's daily physical activities.

Bottom Line: Brachial plexus irritation by the angulated CRT leads was strongly suspected.To relieve the acute angulation, we had to adjust the entry site of the LV and RA leads from the distal to the proximal axillary vein using the cut-down method.After successful lead repositioning, the neuropathic pain improved rapidly.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Dong-A University Medical Center, Busan, Korea.

ABSTRACT
A 64-year-old male patient underwent cardiac resynchronization therapy (CRT) device implantation via the axillary venous approach. Two weeks later, the patient started complaining of "electric shock-like" pain in the left axillary area. During physical examination, typical pain in the left axillary area was reproduced whenever his left shoulder was passively abducted more than 60 degrees. Fluoroscopic examination showed that the left ventricle (LV) and right atrium (RA) leads were positioned at an acute angle directing towards the left brachial plexus whenever the patient's shoulder was passively abducted. Brachial plexus irritation by the angulated CRT leads was strongly suspected. To relieve the acute angulation, we had to adjust the entry site of the LV and RA leads from the distal to the proximal axillary vein using the cut-down method. After successful lead repositioning, the neuropathic pain improved rapidly. Although transvenous pacing lead-induced nerve injury is not a frequent complication, this possibility should be kept in mind by the operators.

No MeSH data available.


Related in: MedlinePlus