Surgical patch venoplasty after unsuccessful percutaneous balloon venoplasty for pacemaker lead-related superior vena cava stenosis.

Key Teaching Points•Pacing leads can lead to asymptomatic superior vena cava (SVC) stenosis in up to 33%–60% of patients and symptomatic SVC stenosis in up to 1%–3% of patients. Over time, pacemaker lead–induced mechanical stress of the venous endothelium can lead to inflammation, modeling, fibrosis, and, ultimately, stenosis.•Bulging of the superficial abdominal veins, groin, and upper extremity in the setting of SVC stenosis is characteristic of stenosis below the level of the azygos vein.•Treatment of pacemaker lead–mediated SVC stenosis includes anticoagulation, angioplasty with or without stent, and surgery. Treatment is usually individualized. Angioplasty and surgery show good short-term patency rates, but recurrent venous obstruction can occur in a small percentage of patients.•Prevention of SVC stenosis is key. The number of pacemaker leads and the sum of the diameters of the implanted leads are associated with an increased risk of SVC stenosis. Therefore, the number of leads placed and procedures involving lead exchanges should be avoided. •Pacing leads can lead to asymptomatic superior vena cava (SVC) stenosis in up to 33%–60% of patients and symptomatic SVC stenosis in up to 1%–3% of patients. Over time, pacemaker lead–induced mechanical stress of the venous endothelium can lead to inflammation, modeling, fibrosis, and, ultimately, stenosis.•Bulging of the superficial abdominal veins, groin, and upper extremity in the setting of SVC stenosis is characteristic of stenosis below the level of the azygos vein.•Treatment of pacemaker lead–mediated SVC stenosis includes anticoagulation, angioplasty with or without stent, and surgery. Treatment is usually individualized. Angioplasty and surgery show good short-term patency rates, but recurrent venous obstruction can occur in a small percentage of patients.•Prevention of SVC stenosis is key. The number of pacemaker leads and the sum of the diameters of the implanted leads are associated with an increased risk of SVC stenosis. Therefore, the number of leads placed and procedures involving lead exchanges should be avoided.