Failure of pacemaker implantation due to occlusion of the left brachiocephalic vein

Implantation of a permanent pacemaker by the transvenous approach might fail from the left side in a patient with abnormal left brachiocephalic vein, including occlusion, or congenital absence of coexisting collateral veins. We report an 85-year-old woman with occlusion of the left brachiocephalic vein accompanied by a large and repeated up-and-down course of the collateral vein draining into the superior vena cava (SVC) along the anterior margin of the aortic arch. Such an unusual venous anomaly was revealed during the procedure of implanting a permanent pacemaker. The course of the tortuous collateral vein was clearly demonstrated by multi-slice computed tomography. Finally, implantation was successful by using the right-sided venous access.