Introduction: To report the case of a patient with a total atrioventricular block with significant ventricular dysfunction whose pacemaker implantation and physiological stimulation occurred through the iliac vein due to tortuosities in other vessels that prevented the procedure. 

Method: Information was obtained by reviewing the medical records, interviewing the patient, photographing the diagnostic methods to which the patient was submitted, and reviewing the literature. 

Conclusion: The reported case and published publications bring to light the discussion of pacemaker implantation sites and physiological stimulation in a complex situation that, although it occurs in a minority of cases, when well it is capable of obtaining satisfactory results.