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Anomalies of the thoracic venous system are rare and usually discovered incidentally, but they become clinically relevant in the case of patients requiring cardiac device implantation. Persistent left superior vena cava is considered the most common venous drainage abnormality, with several anatomical variants that generate technical difficulties during pacemaker or defibrillator lead placement. We report a case of an isolated persistent left superior vena cava with abnormal drainage into the left atrium, associated with a hypoplastic right-sided superior vena cava, in a patient scheduled for permanent pacemaker implantation. Considering the patient's anatomical characteristics, a transvenous approach proved unfeasible and the procedure was successfully accomplished via the surgical placement of a left ventricle epicardial lead. We aim to emphasize the clinical importance of such venous anomalies and to discuss the practical implications and challenges derived from these types of conditions, especially in the field of electrophysiology. [ABSTRACT FROM AUTHOR]

Persistent left superior vena cava (PLSVC) is a rare vascular anomaly that affects systemic venous circulation. PLSVC typically is asymptomatic as the return of venous blood to the right atrium occurs through the coronary sinus. It is important to possess a comprehensive understanding of drainage as it can present challenges in catheter placement on the right side of the heart, aiming to prevent potential complications. A 59-year-old female patient presented at the medical service with abdominal distention. During the examination, the presence of ascites was observed. Subsequent studies revealed peritoneal carcinomatosis of unknown origin. The patient underwent staging laparoscopy with biopsy sampling. Consequently, the placement of a catheter for chemotherapy was performed. A portable chest X-ray was obtained revealing the catheter extending along the left subclavian vein and progressing through the left paramediastinal regionThe presence of persistent left superior vena cava was confirmed after reviewing prior studies. The most common abnormality in the venous drainage system is PLSVC. Approximately 40 % of PLSVC cases have associated significant cardiovascular anomalies, with septal defects being the most common. Recognizing anomalies and anatomical variants with the involvement of a multidisciplinary team is critical to prevent vascular complications during endovascular procedures and to tailor techniques for patients in need of cardiac endovascular procedures or cardiac devices. PLSVC is often asymptomatic and discovered incidentally, it is essential to have a comprehensive understanding of this anomaly and perform meticulous imaging workup to prevent potential complications. • A 59-year-old woman with ovarian serous carcinoma had catheter placement. A chest X-ray showed the catheter extending towards the left paramediastinal area. • The discovery of PLSVC during central venous catheterization is a rare yet significant event that must be promptly recognized. • PLSVC is often discovered incidentally, and it is crucial to have an understanding to prevent potential complications. [ABSTRACT FROM AUTHOR]