Abstract
Abnormal central venous anatomy can obstruct cardiac-device implantation. We report a 54-year-old patient found to be in complete heart-block after identification of profound bradycardia, requiring cardiac-pacing. Echocardiography revealed systolic dysfunction, prompting a plan for cardiac resynchronization therapy. Conventional lead placement was impossible due to failed guide-wire advancement bilaterally. Peri-procedural venography demonstrated attenuation of both brachiocephalic veins and contrast-enhanced computed tomography confirmed complete central venous occlusion (CVO). Further history identified previous chemotherapy delivered via central venous catheters, as the likely aetiology for the CVO and systolic dysfunction. Alternative pacing options were considered. Ultimately the leadless Micra-AV-pacemaker was successfully implanted via the femoral vein with good clinical recovery. This unique case highlights CVO as an obstacle to cardiac-device implantation, with specific patients at increased risk. Pre-procedural imaging in those at-risk may reduce procedure failure and facilitate appropriate device strategy choice. Leadless pacing provides a safe, effective alternative in cases of CVO.