# Pocket Perforation Using 3-0 Nylon Suture for Device Fixation

## TL;DR

An 83-year-old man experienced a pacemaker suture perforating his skin after four years, highlighting risks in thin elderly patients and suggesting preventive measures.

## Contribution

Reports a novel case of suture perforation and proposes practical preventive strategies for device fixation in thin elderly patients.

## Key findings

- A 3-0 nylon suture perforated the skin of an elderly patient four years after pacemaker implantation.
- BMI reduction over time contributed to subcutaneous tissue thinning, increasing perforation risk.
- Silk sutures and leadless pacemakers are suggested to reduce such complications in thin elderly patients.

## Abstract

Device infection occurs at a rate of 1.5%, and age over 65 years is considered a risk factor. If a pacemaker infection occurs, it is recommended that both the generator and pacing lead be removed, which is a highly invasive complication that should be avoided.

We report the case of an 83-year-old man whose 3-0 nylon suture used to fix the generator had perforated the body surface four years after pacemaker implantation. Fortunately, there was no evidence of infection, and thus we were able to repair the perforated portion of the nylon suture and replace the generator without removing the pacing lead. The patient had a body mass index (BMI) of 20.4 kg/m2 at the time of pacemaker implantation, but over the course of four years, the patient's BMI had progressively decreased to 18.4. The tip of the nylon suture was sharp, and the thinning of the subcutaneous tissue caused the tip of the nylon suture to perforate the skin. In this case, only the nylon suture protruded through the skin, reminding us of the strong penetrating power of the nylon tip. Preventive measures that are easy for physicians to implement include the use of thin nylon sutures with low penetration force for fixation. It is recommended to use silk sutures when fixing the generator, as the cut ends of the silk sutures are not sharp, and to fix the generator so that a knot is formed at the back. Also, implant a leadless pacemaker. We need to be careful because the number of pacemakers implanted in thin elderly patients is expected to increase in the future.