Failure of left-sided implantable cardioverter defibrillator implantation due to absence of left brachiocephalic vein

Implantation of an implantable cardioverter defibrillator by the transvenou s approach was impossible from the left side in a patient with an absence o f the left brachiocephalic vein; the left subclavian vein was connected by a large left superior intercostal vein to the accessory hemiazygos vein tha t joined the azygos vein; then the blood flowed into the superior vena cava . Implantation was successfully attempted using the right-sided venous acce ss.