Pacemaker Lead-Associated Innominate Vein Thrombosis Despite Non-vitamin K Oral Anticoagulant (NOAC) Therapy: An Incidental CT Finding

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Pacemaker lead-associated innominate vein thrombosis (n=1). Intervention: Permanent pacemaker lead and apixaban therapy. Primary outcome: Incidental finding of left innominate vein thrombosis.

Q: What does this research mean for the field?

Pacemaker lead-associated venous thrombosis can occur in patients despite therapeutic NOAC (apixaban) therapy, necessitating a change in anticoagulation management such as switching to warfarin. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Neeraj Joshi; Rachel Hallam; Zaw Nyein Aye; Harriet Guthrie; Mahmud Javed Hasan

doi:10.7759/cureus.104717

March 5, 2026CureusOpen Access

Pacemaker Lead-Associated Innominate Vein Thrombosis Despite Non-vitamin K Oral Anticoagulant (NOAC) Therapy: An Incidental CT Finding

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Why the study?

Venous thrombosis occurring despite therapeutic NOAC therapy poses a diagnostic and management challenge, especially in patients with cardiac implantable electronic devices where it is often underdiagnosed.

Key Points

To describe an incidental finding of central venous thrombosis related to transvenous pacemaker leads in a patient adhering to full-dose direct oral anticoagulant therapy.
Clinical evaluation and multimodality diagnostic imaging of an older adult presenting with unexplained weight loss roughly 10 months after permanent pacemaker implantation.
Assessment included contrast-enhanced computed tomography and targeted duplex ultrasonography while the patient maintained adherence to full-dose apixaban for atrial fibrillation.
Computed tomography demonstrated poor contrast opacification of the left innominate vein alongside mediastinal and chest wall collateral vessels.
Duplex ultrasonography confirmed a thrombus adjacent to the pacing leads with partial luminal occlusion of the proximal subclavian vein without overt signs of venous obstruction.
Anticoagulation management was switched from apixaban to warfarin to allow monitoring via international normalized ratio measurements.

Study Design

Type

Case Report (n=1)

Structured PICO

P

Population

An elderly man in his early 80s with a permanent pacemaker and atrial fibrillation on therapeutic apixaban who incidentally presented with left innominate vein thrombosis.

E

Exposure

Transition from apixaban to warfarin with temporary low-molecular-weight heparin bridging.

O

Outcome

Incidental finding of left innominate vein thrombosis on CT.

Pacemaker lead-associated central venous thrombosis can occur despite therapeutic NOAC therapy, highlighting the role of local mechanical factors and the need for individualized management.

Limitations

As a single case observation, this report cannot establish causality or superiority of any particular management strategy.
Formal thrombophilia testing and tumor marker testing were not pursued during the initial evaluation.

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Implication

May warrant individualized anticoagulation in pacemaker lead thrombosis on NOAC; leaves open role of local mechanical factors.

Abstract

Venous thrombosis occurring despite therapeutic non-vitamin K oral anticoagulant (NOAC) therapy represents a diagnostic and management challenge, particularly in patients with indwelling cardiac implantable electronic devices. Pacemaker-associated central venous thrombosis is a recognized but often underdiagnosed finding due to its frequently asymptomatic presentation. We report the case of an older adult with a permanent pacemaker implanted approximately 10 months earlier who was undergoing evaluation for unexplained weight loss, in whom cross-sectional imaging incidentally revealed left innominate vein thrombosis without clinical features of venous obstruction. The patient was receiving full-dose NOAC therapy for atrial fibrillation, with good adherence and no alternative provoking factors identified. This case highlights the importance of recognizing venous thrombosis in patients with cardiac implantable electronic devices despite therapeutic anticoagulation and supports a careful, mechanism-based approach to evaluation and management in similar situations.

Discussion

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Cite This Study

Joshi et al. (2026) conducted a case report in Pacemaker lead-associated innominate vein thrombosis (n=1). Permanent pacemaker lead and apixaban therapy was evaluated on Incidental finding of left innominate vein thrombosis.

synapsesocial.com/papers/69ad122be7e9681137aa883d https://doi.org/10.7759/cureus.104717

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Pacemaker Lead-Associated Innominate Vein Thrombosis Despite Non-vitamin K Oral Anticoagulant (NOAC) Therapy: An Incidental CT Finding

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Pacemaker Lead-Associated Innominate Vein Thrombosis Despite Non-vitamin K Oral Anticoagulant (NOAC) Therapy: An Incidental CT Finding

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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