Case Report: Electrode perforation with normal pacemaker parameters leading to hemorrhagic shock: a rare case report of the “penetration-exit-re-entry” phenomenon

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Complete atrioventricular block requiring pacemaker implantation (n=1). Intervention: Permanent dual-chamber pacemaker implantation.

Q: What does this research mean for the field?

Occult pacing lead venous perforation with a 'penetration-exit-re-entry' trajectory can induce life-threatening hemothorax and hemorrhagic shock despite completely normal intraoperative pacing parameters. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Zuoan Qin; Jian Yang; Li Luo; Shi Chen; Fei Yang

doi:10.3389/fmed.2026.1943190

September 3, 2026Frontiers in MedicineOpen Access

Case Report: Electrode perforation with normal pacemaker parameters leading to hemorrhagic shock: a rare case report of the “penetration-exit-re-entry” phenomenon

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Key result

Occult pacing lead perforation causes life-threatening massive hemothorax despite normal intraoperative electrical parameters.

n=1

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Why the study?

Permanent pacemaker implantation via subclavian vein puncture may cause rare but life-threatening vascular injury with normal pacing parameters, risking missed diagnosis.

Key Points

To report an unusual and life-threatening complication where a pacemaker lead perforated the subclavian vein and re-entered the innominate vein while maintaining completely normal electrical parameters.
Clinical and surgical case review of a 70-year-old female with complete atrioventricular block undergoing permanent dual-chamber pacemaker implantation via left subclavian vein puncture.
Emergency diagnostic workup and intervention comprising diagnostic thoracentesis, closed thoracic drainage, blood transfusions, femoral artery angiography, and video-assisted thoracoscopic venous laceration repair.
All intraoperative pacing parameters of the atrial and ventricular leads remained within normal reference ranges despite the lead exiting the left subclavian vein into mediastinal tissue and re-entering the innominate vein.
The patient rapidly developed massive hemothorax with total intrathoracic blood loss exceeding 1,800 mL, severe hypoxemia, and refractory hemorrhagic shock immediately after the procedure.
Thoracoscopic surgical repair of the venous laceration at the left subclavian vein–innominate vein junction successfully stabilized the patient, who fully recovered with stable pacemaker function at 1-month follow-up.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

A 70-year-old female with complete atrioventricular block who underwent dual-chamber pacemaker implantation and developed a life-threatening procedural complication.

I

Intervention

Dual-chamber permanent pacemaker implantation via left subclavian vein puncture.

O

Outcome

Development of occult extravascular lead perforation and massive hemothorax following pacemaker implantation.safety

Normal intraoperative pacing parameters cannot rule out occult extravascular lead perforation and venous laceration during pacemaker implantation, necessitating high vigilance for unexplained perioperative hemodynamic collapse.

Limitations

Inherent limitations as a single case report whose conclusions cannot be generalized to all pacemaker implantation populations.
Lack of long-term follow-up data over a 1-year period to observe late vascular complications related to the repaired venous site.
Single case report, conclusions cannot be generalized to all pacemaker implantation populations
Lack of long-term follow-up data over a 1-year period to observe late vascular complications related to the repaired venous site

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Answers are grounded in this paper and cite their sources.

Implication

Alerts clinicians to occult perforation risk in post-implant shock despite normal parameters; single case leaves open need for enhanced surveillance protocols.

Abstract

Background: Permanent pacemaker implantation via subclavian vein puncture may induce rare but life-threatening iatrogenic vascular injury. Vascular perforation with pacing lead penetration-exit-re-entry trajectory accompanied by normal intraoperative pacing parameters is reported extremely rarely, which greatly increases the risk of missed diagnosis. Case presentation: A 70-year-old female patient with complete atrioventricular block received dual-chamber pacemaker implantation. All intraoperative lead electrical indicators were within normal range. Immediately after the operation, she rapidly developed massive hemothorax and hemorrhagic shock with severe hypoxemia. A thoracoscopic exploration verified a unique "penetration-exit-re-entry" lesion: the pacing electrode penetrated the left subclavian vein wall, exited the vascular lumen, and re-entered the innominate vein, resulting in persistent intrathoracic bleeding. After emergency thoracic drainage, surgical venous repair and blood transfusion resuscitation, the patient's vital signs gradually stabilized and fully recovered. A 1-month follow-up showed stable pacemaker function without adverse events. Conclusion: This case highlights that normal intraoperative pacing parameters cannot rule out occult extravascular lead perforation and venous laceration. Operators should maintain high vigilance for unexplained perioperative hemodynamic collapse. Combined imaging, diagnostic thoracentesis, and early thoracoscopic surgical intervention are the core rescue strategies for this fatal complication.

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Cite This Study

Qin et al. (2026) conducted a case report in Complete atrioventricular block requiring pacemaker implantation (n=1). Permanent dual-chamber pacemaker implantation was evaluated. A 70-year-old woman developed life-threatening massive hemothorax and hemorrhagic shock due to an occult pacing electrode perforation despite completely normal intraoperative pacing parameters.

synapsesocial.com/papers/6ad0fce415427f6a8404038a https://doi.org/10.3389/fmed.2026.1943190

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Case Report: Electrode perforation with normal pacemaker parameters leading to hemorrhagic shock: a rare case report of the “penetration-exit-re-entry” phenomenon

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Case Report: Electrode perforation with normal pacemaker parameters leading to hemorrhagic shock: a rare case report of the “penetration-exit-re-entry” phenomenon

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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