Cerebral air embolism after implantation of a leadless pacemaker via the right internal jugular vein: a case report

Abstract Background Leadless pacemaker (LP) implantation is associated with fewer device-related complications than conventional transvenous pacing systems. While traditionally performed via the femoral vein, the right internal jugular (RIJ) approach has recently emerged as an alternative strategy, potentially improving catheter control. However, safety data for this approach remain limited. Case summary A 77-year-old man with precapillary pulmonary hypertension, diabetes mellitus, and recurrent traumatic syncope underwent LP implantation via the RIJ vein following documentation of infra-Hissian conduction delay (HV interval 80 ms). The procedure was uneventful, with satisfactory electrical parameters. Immediately after repositioning the patient in a 30° head-up position, he developed acute neurological deterioration (Glasgow Coma Scale 6/15). Transthoracic echocardiography excluded pericardial effusion but revealed air bubbles in the right ventricle. Cerebral computed tomography demonstrated multiple air bubbles within the right intracerebral venous system, consistent with retrograde cerebral venous air embolism. Emergency management included Trendelenburg positioning, 100% oxygen administration, and hyperbaric oxygen therapy. Neurological status improved, although a persistent left-sided motor deficit remained. At 15-month follow-up, no further syncope occurred, and the LP functioned normally, but residual left limbs hypokinesia persisted. Discussion This case illustrates a rare but severe complication of RIJ LP implantation. Large-bore sheath use, low venous pressure in the jugular system, relative dehydration, severe pulmonary vascular disease, and early head-up positioning likely contributed to retrograde cerebral venous air migration. Strict preventive measures—including meticulous system flushing, adequate hydration, maintenance of slight Trendelenburg positioning, and post-procedural echocardiographic screening—may help mitigate this risk.