Direct hepatic vein puncture and transseptal access for atrial flutter and fibrillation ablation in a patient with prior ligation of the inferior vena cava

The inferior vena cava (IVC) is commonly used in procedures involving left heart instrumentation, whereby catheters are introduced through the right or left femoral vein and advanced through the IVC towards the interatrial septum.1,2 Transseptal puncture then facilitates access into the left atrium for catheter ablation or other interventional procedures. When the IVC is not available, such as in cases with congenital abnormalities or surgical ligation of the IVC,3–5 an alternate route is required to access the left atrium.