An Extremely Rare Reason for Failure of Left Sided Pacemaker
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Anomalies of the great thoracic veins are uncommon. Vast majority of anomalies of these veins are diagnosed on routine radiologic examinations incidentally. Persistent left superior vena cava (LPSVC) is the most common systemic venous anomaly of thorax with the incidence of 0,5% . However isolated anomaly of the left brachiocephalic vein (LBCV) is extremely rare Anomalies of the LBCV are clinically silent unless accompanying cardiac defects, but the anomalies of the LBCV might pose a challenge if invasive procedures are scheduled to be driven through this route. Herein we report a failed left sided pacemaker implantation attempt due to isolated anomaly of the LBCV.

Case Presentation
A 77-year-old woman with the diagnosis of sick sinus syndrome was referred to our institution for permanent pacemaker implantation. Left pectoral site was prepared for implantation according to routine practice. Left subclavian puncture was performed successfully. But we could not advance the guidewire into the LBCV. Instead of getting into LBCV, the guidewire made a sharp turn and propagates downwards after subclavian vein. The repetitive attempts showed the same result. On cine venography, an accessory hemiazygos vein was seen which takes blood from LBCV and drains into azygos vein. Because of the challenging anatomy, we decided to make the implantation from the right side. And at the same session, we implanted DDD-R permanent pacemaker by using the right subclavian vein, without difficulty....
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