All roads lead to the heart, but not always. A complex case of a hemodialysis patient requiring permanent cardiac pacing, with no vascular access for either conventional or leadless pacemaker implantation

Abstract The use of leadless pacemakers, like the Micra device, has become more common, especially in patients on hemodialysis or those at high infection risk. These devices are typically implanted via the femoral vein, but this is not always possible due to venous obstructions. This case report describes a 58-year-old male with multiple complex medical conditions, including chronic hemodialysis and prior aortic valve endocarditis, who presented with a complete AV block and required urgent pacing. Imaging revealed severe cardiac abnormalities and extensive vascular issues, including occlusions and stenoses in both the superior and inferior vena cava. A fractured dialysis catheter fragment further complicated access. Due to the lack of viable venous routes, traditional and alternative access points for leadless pacemaker implantation were not usable. As a result, epicardial pacing was determined to be the most appropriate option.