Case report: 82-year-old man was referred to our hospital with symptomatic intermittent third-degree AV block with wide QRS complex. A permanent pacemaker implantation was planned. During the formation of the surgical pocket a ventricular asystole with present P waves developed and cardiopulmonary resuscitation (CPR) was immediately started. Axillary vein puncture was attempted during the CPR, but axillary artery was inadvertently punctured, and 7F lead introducer was inserted into the same artery. Dilator and the wire were left in place and additional axillary vein puncture was performed. Permanent pacemaker leads were successfully implanted during the CPR via axillary vein. The patient recovered completely after achievement of stable ventricular pacing. After that, a 7F sheath was replaced for a 7F side-valve sheath so that axillary artery angiogram could be performed. After verifying that there were no stenoses of bifurcations at the place of axillary artery puncture, the 8F AngioSeal vascular closure device was implanted. The puncture site was successfully closed with no residual bleeding and no compromitation of ipsilateral arterial pulses.

Learning objective: The number of permanent pacemaker implantations being performed is increasing due to population aging. In third-degree AV block (complete AV block, no AV conduction), no atrial impulses reach the ventricles, and ventricular rhythm is maintained by a subsidiary pacemaker. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with bradycardia with symptoms (Class I recommendation). (1) The axillary venous approach has been associated with less frequent pneumothorax and subclavian crush syndrome. Fluoroscopic-guided, first rib approach to axillary vein access is the most effective means to access the vessel while minimizing the risk of pneumothorax. However, inadvertent punctures of axillary or subclavian artery happen an are managed by local site compression unless the sheath has been placed. In cases where the artery is cannulated with the sheath the risk of hematothorax is high and there are no guidelines how to proceed. We report on successful hemostasing using (off-label) AngioSeal closure device after inadvertent sheath placement in axillary artery.