Permanent pacemaker implantation complicated by anchoring sleeve embolization through cephalic vein: case report and discussion of management strategies.

Background: Anchoring sleeve embolization is a rare complication of first-time permanent pacemaker (PPM) implantation, and there is little guidance on how to manage such an eventuality. Case summary: An 82-year-old lady underwent PPM implantation for symptomatic 9-second sinus pause. During procedure, the anchoring sleeve from the atrial lead embolized through cephalic vein to the left superior lingular artery. The patient remained haemodynamically stable and multimodality imaging demonstrated only a small affected area of lung with patent pulmonary blood flow distal to the sleeve. Therefore, the patient was managed with anticoagulation alone and has remained well at 26-month follow-up. Discussion: Most case reports dealing with embolization of pacing apparatus to the pulmonary vasculature document endovascular retrieval. We lay down a framework of considerations for assessing management strategies to help guide practitioners to the most efficacious treatment plan. This includes factors affecting the risks of leaving the foreign body in place and outlines the rationale for no active treatment, through anticoagulation, and towards endovascular and surgical retrieval.