An irregular approach of right atrial lead placement in a patient with persistent left superior vena cava and concomitant agenesis of the right-sided superior vena cava.

Persistent left superior vena cava (PLSVC) is the most common venous anomaly of the thorax. It could lead to catheter malplacement and even vascular injuries. We describe an unusual way to deliver a right atrial (RA) endocardial pacing lead in a 61-year-old female with a PLSVC concomitant agenesis of the right-sided SVC. After failed attempts with the standard procedure, we placed the RA lead tip in the PLSVC near the right auricle. The pacemaker worked well after one and 17 months of follow-up. We conclude that when placement of the RA lead fails, the PLSVC near the right auricle could be a next choice in the RA lead placement in patients with PLSVC concomitant agenesis of the right-sided SVC.