Use of a tunneling technique to achieve a lower defibrillation threshold during implantable cardioverter defibrillator implantation via the right subclavian vein.

A 56-yr-old man with aborted sudden cardiac death underwent implantable cardioverter defibrillator (ICD) implantation. While the ICD was being implanted, a left subclavian venogram failed to visualize the left subclavian vein, which was attributed to likely prolonged indwelling of the left subclavian sheath for venous access. Accordingly, the right subclavian vein was punctured and the ICD lead was diverted from the right side area to the active Can in the left pectoral area by tunneling over the sternum for high defibrillation threshold. The approach used in this case may be considered in patients who had difficult left subclavicular venous access and it may be prudent to save the left subclavian vein for ICD implantation in patients with fatal tachyarrhythmia.