Case 2
An 84-year-old woman underwent implantation of a single lead atrioventricular (VDD) pacemaker via an axillary approach. Pectoral swelling with an associated reduction in her hemoglobin from 12.2 g/dl to 5.0 g/dl was noted. After 2 units of packed red blood cells were transfused the patient was urgently taken to the operating room for exploration of her device pocket. A hematoma was not identified during this procedure but minor oozing from the initial puncture site was noted and subsequently cauterized. She continued to have declining hemoglobin, ongoing expansion of her device pocket and experienced an acute kidney injury with creatinine increased to 202 umol/L. CT angiography was performed which identified a chest wall hematoma with active bleeding from a ruptured pseudoaneurysm of the left superior thoracic artery at the site of the pacemaker lead insertion (Figure 2A). The patient underwent emergent coil embolization of the pseudoaneurysm (Figure 2B, C). Antiplatelet therapy was reinitiated and the patient remained stable for the duration of their hospitalization.