We present a challenging case of a 75-year-old female with a history of paroxysmal atrial fibrillation (PAF) and symptomatic sick sinus syndrome (SSS) who presented for a dual chamber pacemaker implantation and was found to have persistent left superior vena cava and absent right superior vena cava with stenosis of the left subclavian vein. In this report, we discuss the implant technique in this group of patients.