This is a video of 16 year old male hemophiliac patient who has had multiple central venous lines. He presented for port placement after he had his most recent port removed for infection. The patient's venous anatomy was studied and found to have thrombus in the bilateral subclavian systems and superior vena cava. He was shown to have reconstitution of the superior vena cava at the level of a large azygous vein.

The patient underwent thoracoscopic and fluroscopic guided atrial puncture through the superior vena cava using a right internal jugular approach.

Thoracoscopic atrial puncture resulted in successful port placement. He had no complications.

Thoracoscopic atrial puncture is a novel approach to patients with limited venous access.