Placement of coronary sinus (CS) leads is predominantly accomplished via the left cephalic-axillary-subclavian (CAS) venous system. However, vein stenosis or occlusion from long-term chronic hemodialysis in patients with end-stage renal failure can pose a challenge. Cannulation of the CS via the left Internal jugular vein is technically difficult but often feasible. We report a case in which a patient with ESRD had extensive left venous system occlusion from prior in dwelling hemodialysis catheters, and an AV fistula contralaterally, who underwent biventricular- implantable cardioverter defibrillator (BiV-ICD) placement with lead insertion through the left internal jugular vein (IJV).