Transhepatic venous approach to permanent pacemaker placement in a patient with limited central venous access

Figure 1 Transhepatic venous approach to single-lead permanent cardiac pacemaker in a 63-year-old male with bradycardia and hypotension. A: Right upper extremity venogram demonstrating total occlusion of the right innominate vein (arrow); B: Transhepatic catheter placement terminating in the right atrium; C: Placement of the pulse generator on the lateral aspect of the thoracic wall with attached right ventricular lead; D: Adequate redundancy provided to the right ventricular lead in the right atrium (arrowhead).