title: Neck Pain One Week after Pacemaker Generator Replacement.
abstract: BACKGROUND
  The incidence of cardiac pacemaker implantation has risen markedly in the past three decades, making awareness of possible postprocedural complications critical to the emergency physician. This case is the first documented instance of internal jugular (IJ) deep vein thrombosis (DVT) from an uncomplicated pacemaker generator replacement.
  
  
  METHODS
  A patient presented to an Emergency Department with a 2-day history of mild left temporal headache migrating to his left neck. The patient did not volunteer this information, but review of systems revealed a temporary transvenous pacemaker inserted through the right IJ vein 1 week previously during a routine exchange of a left-sided cardiac pacemaker generator. Manipulation of the existing pacemaker wires entering the left subclavian vein was minimal. Computed tomographic angiography of the neck demonstrated near-complete thrombotic occlusion of the entire length of his left IJ vein. This required hospital admission for observation and treatment with anticoagulation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DVT, with thrombotic extension into adjacent vessels anywhere along the course of pacemaker wires, should be considered by the emergency provider in the evaluation of head, neck, or upper extremity symptoms after recent or remote implantation or manipulation of a transvenous cardiac pacemaker, including generator replacement. Failure to identify and treat appropriately could result in significant morbidity and mortality from airway edema, septic thrombophlebitis, superior vena cava syndrome, superior sagittal sinus thrombosis, or pulmonary embolism.
authors.affiliation: 99th Medical Group, Mike O'Callaghan Federal Medical Center, Nellis Air Force Base, Las Vegas, Nevada.
authors.forename: Ross F
authors.initials: RF
authors.lastname: Graham
authors.affiliation: Integrated Residency in Emergency Medicine, Boonshoft School of Medicine, Wright State University, Dayton, Ohio; 88th Medical Group, Wright-Patterson Medical Center, Wright-Patterson Air Force Base, Ohio.
authors.forename: John M
authors.initials: JM
authors.lastname: Wightman
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D004630:Emergencies; D006801:Humans; D007601:Jugular Veins; D008297:Male; D019547:Neck Pain / Q000209:etiology*; D010138:Pacemaker, Artificial; D019919:Prosthesis Implantation / Q000009:adverse effects*; D011859:Radiography; D020246:Venous Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology*
chemical_list: D000925:Anticoagulants
keywords: artificial; cardiac pacemaker; jugular veins; neck; thrombosis