Superior vena cava obstruction due to pacemaker leads

A 45-year-old woman was referred for a pulse generator change with insertion of a new ventricular lead. Given a wire would not advance into the right atrium, a venogram was performed. Injection of contrast demonstrated complete occlusion of the distal superior vena cava with extensive dilation of the hemiazygous system and collateralization into the inferior vena cava. The patient had no symptoms indicative of obstruction. In the coming years, this ‘silent’ complication will gain increasing attention as the number of patients requiring new leads will increase with ageing of the population, expansion of implant guidelines, and ongoing recalls.