Arteriovenous fistulae complicating cardiac pacemaker lead extraction: Recognition, evaluation, and management

Transvenous pacemaker lead extraction has become a commonly performed proce dure that is associated with a small but significant risk. We report two ca ses where lead extraction was complicated by arteriovenous fistulae between branches of the aortic arch and the left brachiocephalic vein. Presenting signs and symptoms included severe chest or back pain, persistent or copiou s bleeding from the venous puncture site, unexplained hypotension or anemia , superior vena cava syndrome, and signs of central venous hypertension or acute heart failure. One patient whose injury was not recognized immediatel y and who did not undergo repair died rapidly, whereas the other patient wh o was diagnosed quickly underwent successful repair. Immediate diagnosis wi th arteriography and rapid intervention with surgery or percutaneous techni ques are indicated and may prevent mortality.