Central venous obstruction in the cardiac implantable electronic devices (CIED) population is commonly due to thrombosis and fibrosis secondary to the passage of pre-existing leads. However, vein occlusion before CIED implantation is uncommon, and one cause is retrosternal goiters. We report a case where the failure of the initial implantation of a primary CIED led to an unusual implantation route without goiter excision. The patient had an indication for cardiac resynchronization therapy (CRT) given his left ventricular (LV) function was impaired and had second-degree heart block Mobitz Type II; however, he had occluded bilateral subclavian veins due to a sizeable retrosternal goiter. This obstruction led to the implantation of a single lead pacemaker via the right femoral vein after multiple failed attempts at CRT, dual chamber pacemaker and left bundle branch area pacing (LBBaP).
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