Right-sided left bundle branch area pacing with contralateral subcutaneous tunneling for lead revision in left brachiocephalic vein occlusion: a case report

Left bundle branch area pacing (LBBAP) is increasingly applied for physiological pacing but lead implantation in patients with left-sided venous anomalies or occlusion remains challenging. We report a modified sheath technique for right-sided LBBAP with contralateral subcutaneous tunneling to avoid creation of a second pocket, which may theoretically reduce pocket-related complication. A patient with pacemaker lead malfunction presented with persistent left subclavian vein stenosis and left brachiocephalic vein occlusion, precluding standard left-sided revision. Right-sided LBBAP was performed using a C315-His sheath manually bent to 90° to adapt to the right-sided venous trajectory. The newly implanted lead was tunneled subcutaneously across the anterior chest wall to the existing left pectoral pocket, obviating the need for a secondary pocket. Satisfactory pacing parameters were achieved postoperatively, and the patient remained event-free without complications at the 1-month follow-up. Contralateral pacing lead placement combined with subcutaneous tunneling provides a viable salvage option for pacemaker revision in patients with left-sided venous obstruction. This modified sheath technique facilitates right-sided lead implantation, while subcutaneous rerouting maintains the original pocket and precludes the creation of an additional pocket.