Key result
Jugular leadless pacemaker repositioning causes severe retrograde cerebral venous air embolism with persistent motor deficit.
Why the study?
While leadless pacemaker implantation via the right internal jugular vein has emerged as an alternative approach that may improve catheter control, safety data remain limited.
Case Report (n=1)
No
Leadless pacemaker implantation via the right internal jugular vein carries a rare but severe risk of retrograde cerebral venous air embolism, highlighting the need for preventive measures like adequate hydration and maintaining a slight Trendelenburg position post-procedure.
May cause severe retrograde cerebral air embolism with persistent deficit via jugular access; leaves open optimal preventive protocols for leadless pacemaker implantation.
Background Leadless pacemaker (LP) implantation is associated with fewer device-related complications than conventional transvenous pacing systems. While traditionally performed via the femoral vein, the right internal jugular (RIJ) approach has recently emerged as an alternative strategy, potentially improving catheter control. However, safety data for this approach remain limited. Case summary A 77-year-old man with precapillary pulmonary hypertension, diabetes mellitus, and recurrent traumatic syncope underwent LP implantation via the RIJ vein following documentation of infra-Hissian conduction delay (HV interval 80 ms). The procedure was uneventful, with satisfactory electrical parameters. Immediately after repositioning the patient in a 30° head-up position, he developed acute neurological deterioration (Glasgow Coma Scale 6/15). Transthoracic echocardiography excluded pericardial effusion but revealed air bubbles in the right ventricle. Cerebral computed tomography demonstrated multiple air bubbles within the right intracerebral venous system, consistent with retrograde cerebral venous air embolism. Emergency management included Trendelenburg positioning, 100% oxygen administration, and hyperbaric oxygen therapy. Neurological status improved, although a persistent left-sided motor deficit remained. At 15-month follow-up, no further syncope occurred, and the LP functioned normally, but residual left limbs hypokinesia persisted. Discussion This case illustrates a rare but severe complication of RIJ LP implantation. Large-bore sheath use, low venous pressure in the jugular system, relative dehydration, severe pulmonary vascular disease, and early head-up positioning likely contributed to retrograde cerebral venous air migration. Strict preventive measures—including meticulous system flushing, adequate hydration, maintenance of slight Trendelenburg positioning, and post-procedural echocardiographic screening—may help mitigate this risk.
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Ollitrault et al. (2026) conducted a case report in Recurrent traumatic syncope with infra-Hissian conduction delay (n=1). Leadless pacemaker implantation via right internal jugular vein was evaluated on Retrograde cerebral venous air embolism (safety event). Leadless pacemaker implantation via the right internal jugular vein resulted in a severe retrograde cerebral venous air embolism upon repositioning, leaving the patient with a persistent left-sided motor deficit.
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