Substernal implantation of a subcutaneous implantable cardioverter-defibrillator in a patient with preexisting Hemodialysis Reliable Outflow graft

Central vein stenosis is a well-documented consequence of cardiovascular implantable electronic devices. In hemodialysis patients, where preserving venous real estate is crucial, use of subcutaneous implantable cardioverter-defibrillators (S-ICDs) remains controversial. We present a novel approach for implanting an S-ICD in a patient with endstage renal disease, central venous stenosis, and precordial hemodialysis graft obstructing the normal subcutaneous implant site.