Left subclavian access for pentaspline pulsed field ablation system: A feasible option in bilateral femoral vein thrombosis.

BACKGROUND: Standard femoral venous access may not be feasible in patients with inferior vena cava (IVC) obstruction or bilateral deep vein thrombosis (DVT), necessitating alternative venous routes. CASE SUMMARY: We report the case of a 73-year-old man with paroxysmal AF, antithrombin III deficiency, and chronic bilateral femoral and iliac vein thrombosis. After a failed prior attempt at PVI due to inaccessible femoral veins, a left subclavian approach was selected based on favorable ultrasound imaging. Under deep sedation, subclavian venous access was obtained and a Pentaspline PFA system (FaraWave™) was used via a steerable sheath. Transseptal puncture was performed using the VersaCross™ RF pigtail system under fluoroscopic and transesophageal echocardiographic guidance. Ablation was successfully delivered to all pulmonary veins, including a left common trunk, using standard electroporation protocols. Total procedure time was 117 minutes. No complications occurred, and the patient was discharged the following day in stable condition. CONCLUSION: This case demonstrates the technical feasibility and safety of using the Pentaspline PFA system via left subclavian venous access in a patient with extensive lower extremity venous thrombosis. The approach enabled successful PVI in a complex clinical scenario where traditional femoral access was precluded. While alternative access routes for PFA are rarely reported, this case expands the potential use of superior venous access and may serve as a reference for similar high-risk patients. Such procedures should be reserved for experienced centers with advanced imaging and transseptal expertise.