Internal Mammary Arterial Injury from Lead Extraction: A Clinically Subtle yet Important Complication of Implantable Device Removal

Cesar Cruz,Michael Lloyd,Stamatios Lerakis,Ravi Veeraswamy,Jonathan Langberg

doi:10.4061/2011/408640

Abstract

Percutaneous implantable device extraction has increased in recent years and is associated with small but significant risk. Arteriovenous fistula formation is an uncommon complication of this procedure. We report two cases where lead extraction was complicated by an arteriovenous fistula between the left internal mammary artery and the left brachiocephalic vein. In both cases, the patients were asymptomatic and the presence of a continuous murmur in the left subclavicular region led to the appropriate diagnosis. These were successfully treated with coil embolization. Auscultation around prior extraction sites should be routinely done to aid in the diagnosis of this potentially harmful complication.

Highlights

Percutaneous extraction of chronic implantable devices has increased in recent years
We present the clinical manifestations and management of two cases of AV fistula formation from LIMA to left brachiocephalic vein following lead extraction
Initial angiogram (a), during coil deployment (b), and final angiogram (c) showing successful closure of the AVF. These cases of injury to the internal thoracic or mammary artery (IMA) as a result of lead extraction highlight several important points. They illustrate that smaller branch arteries such as the IMA are vulnerable to injury and fistulization

Summary

Introduction

Percutaneous extraction of chronic implantable devices has increased in recent years. Lead extraction is associated with serious complications in 1-2% of cases [1]. In a recent multicenter prospective study of 1,449 consecutive patients undergoing laser lead extraction, procedure-related major adverse events were seen in 20 patients (1.4%) including 4 deaths (0.28%) [2]. Life-threatening complications after lead extraction include myocardial perforation and venous laceration. Arterial injuries from device extraction, such as arteriovenous (AV) fistula and pseudoaneurysm formation, can occur [6,7,8]. The most common arterial injury involves the subclavian/axillary artery due to its location adjacent to the lead insertion site. We present the clinical manifestations and management of two cases of AV fistula formation from LIMA to left brachiocephalic vein following lead extraction

Case 1

Case 2

Findings

Discussion