Left ventricular lead placement with over-the-wire technique for right ventricular pacing in a patient with distorted vessels.

Vascular access can present a clinical challenge in the implantation of permanent pacemaker leads. We describe the case of an 81-year-old man with complete heart block in whom it was difficult to find a suitable vein for advancing a pacemaker lead. The left cephalic vein was selected for lead implantation; however, because of a 90° angle between the cephalic and axillary veins, the lead failed to advance. Because the patient was elderly and at high risk, we decided to place a left ventricular pacing lead in the right ventricle by means of an over-the-wire technique. After 1 month, the patient's pacing threshold was good, and the lead remained in the right ventricular apex. When patients have distorted vessels and lead placement seems difficult or impossible, we think that the over-the-wire placement technique can be effective.