A Case of Bilaterally Inaccessible Subclavian Veins

We present the case of a 69-year-old female with a history of myocardial infarction, ischemic cardiomyopathy, and left bundle branch block, who was scheduled for a cardioverter-defibrillator (CRT-D) implantation. During the procedure, an unexpected left subclavian vein obstruction by a thrombus was encountered, preventing access for lead placement. Further attempts to utilize the right subclavian vein were complicated by the discovery of an acute angle near the brachiocephalic vein, which made lead placement technically unfeasible. Despite multiple attempts to navigate the venous anatomy, the procedure was halted due to the complexity of these combined vascular anomalies. This case illustrates the rare occurrence of both subclavian vein obstruction and an acute venous angle which significantly complicates proper lead placement during CRT-D implantation, emphasizing the importance of preoperative planning and the potential need for alternative strategies in challenging anatomical scenarios where standard approaches are impractical.