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Central vein stenosis is not uncommon in hemodialysis-dependent patients as a result of mechanical damage to the vessel walls from prior cannulation. It can cause ipsilateral upper limb swelling and pain, resulting in suboptimal hemodialysis. It is unfortunate for bilateral central vein stenosis to develop concomitantly, and rare in the setting of an in-situ pacemaker. This case illustrates the successful ligation of a nondependent left arteriovenous fistula and stenting of the right subclavian vein with functioning ipsilateral arteriovenous fistula, to overcome the problem of symptomatic bilateral upper limb swelling.

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A 59-year-old man presented with giddiness, shortness of breath and lethargy in 2011. ECG showed complete heart block, which necessitated temporary pacing. Echocardiography revealed no regional wall motion abnormality and normal systolic ejection fraction. His cardiovascular risk factors were type 2 diabetes mellitus and hypertension. Subsequently, a dualchamber pacemaker was implanted with direct puncture of the left subclavian vein for placement of two 6.1 F silicone-coated leads (figure 1). The pacing parameters were acceptable. About 19 months post implantation, his 2-year-old grandson bumped into him. The toddler's head hit his left upper chest wall. There was pain and swelling of the left pulse generator (PG) pocket site. Two days later, he noticed protrusion of the PG edge through the eroded skin. Inflammatory blood markers were not raised. There was no evidence of pus at the pocket site. The affected area was thoroughly cleaned and debrided. The PG was wiped with povidone iodine solution before being placed back into a deeper subcutaneous pocket. He completed 1 week course of cloxacillin. His wound healed nicely and remained afebrile during the following month clinic review. This case highlights the occurrence of PG extrusion from an innocuous direct impact force to the chest wall, possibly affected by the superficially placed PG in the thin subcutaneous skin layer. The exposed PG could still be salvaged by meticulous debridement and cleaning with antiseptic and a course of prophylactic antibiotic. Surveillance should be continued for occult or late-onset cardiovascular implantable electronic device infection.