Medical Mystery of the Week

       You are asked to evaluate a short video of an 80-year old man. You are given no other information. 
      What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, do you recommend?
      DIAGNOSIS: Pacemaker lead-related obstruction of the external jugular vein.
      Access to the right heart for permanent pacing has been achieved by introducting leads into the subclavian, cephalic, internal or external jugular, and ileofemoral veins.
    Veinous obstruction is a well-documented complication of pacemaker implantation and is thought to be due to lead-associated endothelial cell damage and the consequent release/activation of various procoagulants. In rare cases, pacemaker leads can cause partial or complete obstruction of the superior vena cava. In all circumstances, the pacemaker should be removed and, where necessary, the involved vein stented.

In this video one can see the pacemaker in the right clavicular area. The pacemaker leads were inserted into the right heart via the right external jugular vein. Lead-related obstruction of this vein is evidenced by it's marked dilation and the presence of collaterals.