*2.1.3 Mediastinal bleed*

Any mediastinal bleed during CIED implantation could produce acute chest pain. This pain is typically very diffuse and radiates toward the posterior aspect of the chest secondary to mediastinal reflection [23, 24]. Patients may manifest tachycardia secondary to sympathetic stimulation and hypotension, depending upon the extent of the blood loss. This is one of the dangerous conditions, which needs to be identified and addressed as soon as possible. Inadvertent access of the subclavian artery could produce mediastinal bleed. Hence, accessing the axillary vein at the

**Figure 1.** *Chest X-ray showing right sided pneumothorax.*

level of the first rib is a preferred approach as it allows for manual compression in this situation [25, 26]. After getting access into the central system, it is very important to advance the guide wire below the diaphragm to confirm placement within the inferior vena cava and not in the arterial side prior to introduction of the sheath. This way, even if there is any inadvertent arterial access, the chances of mediastinal bleeding will be minimized. In the elderly patients, the venous system could be very tortuous especially at the level of the brachiocephalic system [27–29]. Hence, the wire and the sheath have to be advanced very carefully. If there is any resistance noted during advancement of the sheath, further advancement has to be done under fluoroscopic guidance.
