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Proposed treatment algorithm for cardiac device-related subclavian vein stenosis: a case series. Background: Subclavian vein obstruction may occur in patients with pacemaker leads, which may make the implantation of new pacemaker leads difficult. Case summary: We report two cases in which upgrading to cardiac resynchronization therapy pacemaker was challenging due to total central vein occlusion. In the first case, a 78-year-old woman with permanent pacemaker implantation, 5 years ago, was successfully treated by balloon venoplasty. In the second case, balloon venoplasty was unsuccessful in a 46-year-old woman who has received twice single-chamber implantable cardioverter-defibrillator, 12 years and 5 years ago, due to vessel crowding, so a contralateral side puncture, along with a tunnel technique, was performed to solve this problem. Discussion: Cardiac implantable electronic device-related subclavian vein stenosis can present a challenge to common cardiac resynchronization therapy device upgrades in the absence of appropriate techniques.