‘Inside-out’ technique to allow conduction system pacing in superior vena cava obstruction

Chronic venous occlusion is an increasingly common problem faced during transvenous cardiac device implantation or upgrade. This is attributable to the growing number of pacemakers implanted and subsequent need for an upgrade to a complex system (e.g. Biventricular pacing, conduction system pacing, implantable cardiac defibrillator). Venoplasty, with or without stenting, and lead implantation on the contralateral side with tunnelling across to the current device site are alternatives. However, venoplasty has variable success rates and lead implantation on the contralateral side is only possible in the absence of bilateral central venous occlusion or superior vena cava (SVC) occlusion. In this case report, we describe the first case of using the highly effective inside-out method to re-establish SVC access and implant a conduction system defibrillator.