E-page Original Images: Venous spasm during pacemaker implantation

A 75-years-old female presented with dyspnea and syncope. Electrocardiogram revealed atrial fibrillation and complete atrioventricular block. She was therefore listed for pacemaker implantation on the next day. Initial attempt at venous access was left axillary vein. A venogram showed good venous anatomy (Fig. 1a). Several attempts to puncture axillary vein were made. However, there was no good flashback, and the attempts to pass guidewire were unsuccessful. The selection of venous access was changed to left subclavian vein. But, the puncture was still unsuccessful. Venogram was taken once again and revealed significant venous spasm (Fig. 1b). Application of nitroglycerin was taken but without significant effect (Fig. 1c). More than half an hour later, the implantation was changed to right side for the spasm of the vessel had not relieved. A single-chamber pacemaker system was implanted (Fig. 1d).