A 55 year old man complained of signs and symptoms typical of the superior vena cava (SVC) syndrome. In 1977 he underwent surgical implantation of an AAI mode permanent pacemaker through the left subclavian approach for sick sinus syndrome (type I). Because of the repeated pacing lead breakage, VVI mode pacemakers were implanted through the right subclavian approach in 1985 and 1999. Two months after the last operation, he noticed his face was progressively swelling.

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A chest x ray showed that the three pacemaker wires (arrows) were entangled with one another in the SVC (panel A). The right internal jugular venogram revealed that the SVC was occluded at the site (arrow) just caudal to the bifurcation of the inominate veins (RIV, right inominate vein; LIV, left inominate vein) and well developed collateral veins (arrowheads) from the inominate veins were observed returning to the inferior vena caval and azygos systems (panel B). Simultaneous venograms from the right internal jugular vein and the right atrium revealed that the SVC obstruction was found at the portion where the pacing leads were entangled. It was suggested that the entangled leads caused the venous flow stagnation, resulting in the thrombotic SVC occlusion. Attention has to be given to the development of the SVC syndrome as a possible complication of multiple pacing lead implantation.