The challenges of cardiac pacing: an illustrative case.

The history of transvenous pacing encompasses the past five decades. Multiple lead complications have been described, including problems related to central venous access, venous thrombosis, extravascular bleeding, lead and pacemaker pocket infections, lead fractures, lead dislodgment, lead perforation, diaphragmatic pacing, and chronic lead threshold changes. Potential solutions to these problems have included: improvements in lead composition and tip technology, multiple pacemaker lead and generator insertions, alternative lead sites, pacemaker lead extenders, extraction of infected leads, multiprogrammable pacemaker generators, high output generators, antibiotics and anticoagulants, and venous reconstruction. This case illustrates complications and solutions over a 20-year period. The indications for temporary transfemoral and permanent iliac vein transvenous pacing are reviewed, including a new indication for the iliac venous approach.