Resection and a rare type of reconstruction of the superior vena cava with the left brachiocephalic vein.

Resection and reconstruction of the superior vena cava (SVC) are required in a selected group of patients with anterior mediastinal tumors and lung neoplasms. We present the case of a 63-year-old woman who underwent invasive type B2 thymoma resection and a rare type of reconstruction of the superior vena cava using a patch of the left brachiocephalic vein (LBV). The various types of reconstruction of the superior vena cava are discussed.

Complex aortic-arch pseudoaneurysm with aorto-innominate vein fistula in a case of traumatic chest injury.

A patient in his late 30s presented with issues of retrosternal chest pain and palpitations. He had sustained a splinter injury to the left hemithorax a year ago for which he had been managed with a tube thoracostomy. During subsequent evaluations, he was found to have atrial fibrillations and a CT angiography revealed an arch of the aorta pseudoaneurysm with a fistulous communication with the innominate vein, which being a rare condition has no established treatment protocols. Endovascular salvage of the condition required an aortic Ishimaru zone 2 deployment of the thoracic endovascular aortic repair stent graft to provide an adequate landing zone. The elective left subclavian artery revascularisation was obtained by a left carotid artery to left subclavian artery bypass. Post procedure there was complete exclusion of the pseudoaneurysm sac, and the fistulous aorto-venous communication inflow tract. The patient recuperated well and has returned to full active duties.

Tetralogy of Fallot with an Anomalous Course of the Brachiocephalic Vein.

CLINICAL DATA: Infant, 11-month-old, male, diagnosis of Tetralogy of Fallot with retrotracheoesophageal course of the brachiocephalic vein. Usual findings of Tetralogy of Fallot on physical examination. Technical description: Chest radiography showed slightly reduced pulmonary vascular markings and no cardiomegaly. Normal preoperative electrocardiogram with postoperative right bundle branch block. Usual findings of Tetralogy of Fallot on echocardiogram. Postoperative computed tomography angiography confirmed left brachiocephalic vein with anomalous retrotracheoesophageal course, configuring a U-shaped garland vein, in addition to postoperative findings of total correction of Tetralogy of Fallot. OPERATION: Complete surgical repair was performed with pulmonary valve commissurotomy and placement of bovine pericardial patch to solve right ventricular outflow tract obstruction, pulmonary trunk enlargement, and ventricular septal defect closure. COMMENTS: Systemic venous drainage may show variations in patients with Tetralogy of Fallot. These abnormalities are usually of little clinical relevance, as they are asymptomatic. We presented a rare case of retrotracheoesophageal course of an anomalous left brachiocephalic vein with intraoperative diagnosis, confirmed by imaging during postoperative follow-up, without compromising clinical management or surgical approach.

Most complex brachiocephalic vein occlusion in hemodialysis patients can be treated with simple endovascular techniques in an office-based angiosuite.

OBJECTIVE: Brachiocephalic vein (BCV) obstruction can cause dialysis access dysfunction and failure. Central vein stenosis involving the BCV may require advanced endovascular procedures. We report that most BCV occlusions can be treated using simple endovascular techniques on an outpatient basis. METHODS: From January 2009 to January 2022, 115 hemodialysis patients underwent BCV endovascular revascularization. Seventy-three of the initial procedures were performed in an office-based angiosuite. Indications for the procedure were BCV occlusion endangering the performance of a previous arm access or making the creation of a new arm access unadvisable. We recorded and analyzed risk factors and procedural results, patency rates, complications, and mortality. RESULTS: The median age was 62 years (range, 23-91 years); 56% were female. Most prevalent associated conditions were diabetes mellitus (61%) and hypertension (68%). Fifty-six patients (48.7%) presented with severe upper extremity edema ipsilateral to the side of pre-existing functioning access. Obstruction recanalization was effective using standard catheter and wire in 106 cases (92.1%) and transseptal needle in nine cases (7.8%), that included seven using inside-out procedure. Initial management of the BCV stenosis was percutaneous transluminal balloon angioplasty alone in 74 patients (64.3%), stenting in 33 (28.7%), and HeRO conduit in eight cases (7%). Treatment of other central venous lesions included 49 cases (42.6%). The procedure was successful in 99.1% of patients. No intraoperative complications occurred. All 92 patients with previous arm access maintained adequate performance (100%). In 22 of 23 patients (95.6%), new upper extremity access creation was effectively performed after the venous intervention. Overall clinical success rate was 92%. The mean postoperative monitoring was 23 months, the median was 12 months, and the range was 1 to 84 months. During this monitoring period, 266 endovascular procedures, 91% in the office and 9% in the hospital, were required to preserve access performance. Eventually, 49 patients (42.6%) were stented. Eleven patients (9.56%) had infections, and six required complete access removal. Other causes of access failure included two patients with central vein thrombosis and one with massive pulmonary embolus. At the end, nine patients (7.8%) had access failure. Thirty-two patients (27.8%) died of unrelated causes during the follow-up period. Seventy-six patients (66%) have maintained functional access. Kaplan-Meier curves determined median primary patency of 9.6 months, median primary assisted patency of 56.2 months, and secondary patency of 75% at 80 months. CONCLUSIONS: Successful endovascular revascularization of BCV obstruction can be treated safely, with simple endovascular techniques in an office-based context with minor complication rates and durable results.

Ultrasound-guided supraclavicular cannulation of left brachiocephalic versus right internal jugular vein: Comparative analysis of central venous catheter-associated complications.

AIMS: Central venous catheters are essential for the management of pediatric cardiac surgery patients. Recently, an ultrasound-guided access via a supraclavicular approach to the brachiocephalic vein has been described. Central venous catheters are associated with a relevant number of complications in pediatric patients. In this study, we evaluated the frequency of complications of left brachiocephalic vein access compared with right internal jugular vein standard access in children undergoing cardiac surgery. METHODS: Retrospective analysis of all pediatric cases at our tertiary care university hospital over a two-year period receiving central venous catheters for cardiac surgery. PRIMARY ENDPOINT: Frequency of complications associated with central venous catheters inserted via the left brachiocephalic vein vs. right internal jugular vein. Complications were defined as: chylothorax, deep vein thrombosis, sepsis, or delayed chest closure. Secondary endpoints: Evaluation of the insertion depth of the catheter using a height-based formula without adjustment for side used. RESULTS: Initially, 504 placed catheters were identified. Following inclusion and exclusion criteria, 480 placed catheters remained for final analysis. Overall complications were reported in 68/480 (14.2%) cases. There was no difference in the frequency of all complications in the left brachiocephalic vein vs. the right internal jugular vein group (15.49% vs. 13.65%; OR = 1.16 [0.64; 2.07]), nor was there any difference considering the most relevant complications chylothorax (7.7% vs. 8.6%; OR = 0.89 [0.39; 1.91]) and thrombosis (5.6% vs. 4.5%; OR = 1.28 [0.46; 3.31]). The mean deviation from the optimal insertion depth was left brachiocephalic vein vs. right internal jugular vein 5.38 ± 13.6 mm and 4.94 ± 15.1 mm, respectively. CONCLUSIONS: Among children undergoing cardiac surgery, there is no significant difference between the supraclavicular approach to the left brachiocephalic vein and the right internal jugular vein regarding complications. For both approaches, a universal formula can be used to determine the correct insertion depth.

Surgical Resection of an Intravascular Lipoma of the Superior Vena Cava.

Intravascular lipomas (IVL) located in the superior vena cava (SVS) are rare benign primary venous tumors with less than 15 cases reported in the literature. We report a case of a 64-year-old woman with IVL of the SVC extending to the right brachiocephalic vein. She was treated successfully using a hybrid procedure which involved endovascular control of the right subclavian vein and surgical approach via median sternotomy followed by mass resection and use of pericardial patch for vein defect closure.

Comparison of the needle tip location with the operator's position during ultrasound-guided internal jugular vein catheterization: A randomized controlled study.

OBJECTIVE: We hypothesized that when a right-handed operator catheterizes the left internal jugular vein (IJV), the tip of the needle might be positioned closer to the center of the vessel after puncture if the operator is standing in the patient's left axillary line, rather than standing cephalad to the patient. METHODS: The study randomly allocated 44 patients undergoing elective surgery under general anesthesia with planned left central venous catheterization to either conventional (operator stood cephalad to the patient) or intervention (operator stood in the patient's axillary line) groups. The left IJV was catheterized by 18 anesthesiologists. The distance between the center of the vessel and the needle tip, first-attempt success rate, and procedure time were compared. RESULTS: The distance from the needle tip to the center of the IJV after needle puncture was 3.5 (1.9-5.5) and 3.2 (1.7-4.9) cm in the conventional and intervention groups, respectively (P = .47). The first-attempt success rate was significantly higher in the intervention group (100% vs 68.2%, P = .01). Overall time to successful guidewire insertion was faster in the intervention group (P = .007). CONCLUSIONS: There was no significant difference in needle tip position when the right-handed operator was standing in the patient's left axillary line compared to standing cephalad to the patient during left IJV catheterization. However, it increased the first-attempt success rate and reduced the overall time for guidewire insertion.

Case report of double superior vena cava and double odd vein with hypoplastic left brachiocephalic vein.

Persistent left superior vena cava (PLSVC) is a common venous variation that is usually accompanied by an absence of the left brachiocephalic vein, and displays a higher incidence in patients with congenital heart disease. Here, the case of a 57-year-old male patient who was found to have PLSVC on chest computed tomography (CT) during screening for gastric cancer metastasis at the Affiliated Hospital of Qinghai University, is described. Further coronal CT and three-dimensional reconstruction of the chest revealed the patient's double superior vena cava (DSVC), double odd veins, and left brachiocephalic vein dysplasia. The patient did not have congenital heart disease and the case was associated with dysplasia of the left brachiocephalic vein, indicating an unusual and rare venous abnormality. At the time of writing, the patient was receiving antitumour therapy.

Edoxaban: front-line treatment for brachiocephalic vein thrombosis in primitive mediastinal seminoma: A case report and literature review.

RATIONALE: Venous thromboembolism is a feared frequent complication of cancer with a 2-way relationship. Low molecular weight heparin is the mainstay of treatment. The use of direct oral anticoagulants is supported by established evidence for the treatment of deep vein thrombosis also in active cancer and they are prioritized over low molecular weight heparin for cancer-associated thrombosis according to current guidelines. However, upper limb deep vein thrombosis is poorly studied with scant data on the use of direct oral anticoagulants in noncatheter-related deep vein thrombosis. We report the case of a patient with noncatheter-related deep vein thrombosis and a rare tumor site effectively and safely treated with a direct oral anticoagulant, edoxaban, after lack of efficacy with low molecular weight heparin. PATIENT CONCERNS: A 35-year-old man with primitive mediastinal seminoma presented at our Cardio-Oncology Unit for prechemotherapy assessment. DIAGNOSIS: Persistent brachiocephalic deep vein thrombosis, despite full-dose enoxaparin, was detected at ultrasonography. INTERVENTION: We decided to switch the anticoagulant treatment from enoxaparin to edoxaban. OUTCOME: The 3-month ultrasonography showed almost total regression of the deep vein thrombosis without any adverse effects and a good patient compliance. LESSONS: We conducted a literature review on upper limb deep vein thrombosis, since its management is challenging due to inconsistency of evidence. This report highlights the benefits of direct oral anticoagulants compared to low molecular weight heparins in cancer-associated thrombosis therapy in terms of efficacy, safety and ease of use.

Ultrasound-guided totally implantable venous access ports placement via right brachiocephalic vein in pediatric population: A clinical debut.

BACKGROUND AND OBJECTIVES: To investigate the feasibility and safety of ultrasound-guided totally implantable venous access ports (TIVAPs) via the right brachiocephalic vein (BCV) in pediatric patients. METHODS: A single-institute retrospective review was performed on 35 pediatric patients with predominantly hematological malignancies (88.6%) who underwent TIVAP implantation via ultrasound-guided right BCV approach from July 2018 to June 2021. The catheter tip was adjusted to be positioned at the cavoatrial junction under pulsed fluoroscopic guidance. Technical success rate, procedural information, and TIVAP-related complications were evaluated. RESULTS: All the pediatric TIVAP devices were successfully implanted via right BCV access. Venous access was successful by first attempt in 32 children (91%), two cases (5.7%) required a second attempt, and one patient (2.9%) required a third attempt. The mean procedural time was 44.6 ± 6.4 minutes (range: 34-62 minutes). No intraoperative complications occurred. The average TIVAP indwelling time was 564 ± 208 days (range: 193-1014 days), with a cumulative 19,723 catheter-days. Overall, three patients (8.6%) experienced four postoperative complications (two cases of local hematoma and two catheter dysfunctions) at a rate of 0.2 per 1000 catheter-days. No other complications such as wound dehiscence, delayed incision healing, catheter-related thrombosis (CRT), catheter malposition/fracture, surgical site infection, catheter-related bloodstream infection (CRBSI), pinch-off syndrome, and drug extravasation were observed during follow-up. CONCLUSIONS: Ultrasound-guided right BCV access for TIVAP placement in pediatric patients appears to be technically feasible, safe, and effective. Further large-sample, prospective studies are warranted.

Rare case of epithelioid hemangioendothelioma in the right innominate vein-An innovative diagnostic approach.

BACKGROUND AND AIMS: Epithelioid hemangioendothelioma is a rare malignant vascular tumor with limited literature. AIMS: We reported an innovative endovascular biopsy of the right innominate vein tumor. MATERIALS AND METHODS: Endovascular suction thrombectomy was performed with multipurpose catheter and constant negative pressure under fluoroscopic guidance. RESULTS: Epithelioid hemangioendothelioma was diagnosed preoperatively and a complete margin-free tumor resection with patch repair of the right innominate vein was achieved via sternotomy. DISCUSSION: Preoperatively diagnosis is usually not available due to lesions' location. Identifying malignant vascular tumors becomes valuable to guide the surgical treatment. CONCLUSIONS: In this case report, this innovative endovascular approach led to a rare preoperative diagnosis of EHE and subsequent margin-free resection.

[Hemangioendothelioma of the right innominate vein]. / Gemangioendotelioma pravoi plechegolovnoi veny.

The authors report a rare case of hemangioendothelioma of the right innominate vein complicated by superior vena cava syndrome. Considering development of enlarged venous collaterals, we performed circular resection of superior vena cava together with the right and left innominate veins without replacement. There were no postoperative complications. The use of vascular prosthesis in patients with long-standing superior vena cava compression and enlarged collaterals is associated with high risk of thrombosis and subsequent pulmonary embolism. Safe circular resection of superior vena cava without replacement is possible after intraoperative test clamping.

Extremely tortuous vertical vein in supracardiac totally anomalous pulmonary venous connection.

We present a case of a 2-month-old boy with supracardiac totally anomalous pulmonary venous connection where computed tomography angiography demonstrated an extremely tortuous course of the vertical vein before its drainage into the left brachiocephalic vein.

Intrathymic course of left brachiocephalic vein: A hitherto undescribed anatomical variant in tetralogy of Fallot.

We hereby present a case of a unique intrathymic course of left brachiocephalic vein in a patient with Tetralogy of Fallot and aberrant right subclavian artery deciphered on computed tomography angiography.

Abnormal drainage pathway of a supracardiac total anomalous pulmonary venous drainage in a neonate: a case report.

Supracardiac total anomalous pulmonary venous drainage is commonly associated with a left-sided ascending vein draining into innominate vein. We present a case of a newborn with a right-sided ascending vein, draining into the right superior caval vein with stenosis at the SVC-ascending vein junction, posing a surgical dilemma in corrective surgery. Usage of three-dimensional computed tomographic scan was essential in delineating the anatomy and aiding surgery. The case demonstrates the rarity of this type of cardiac disease and the complications that develop.

Ultrasound-guided percutaneous right brachiocephalic vein cannulation in a 5-year-old patient with bilaterally occluded internal jugular veins due to previous access by venous cut-down: A case report.

The open surgical venous cut-down technique is widely performed in cases of long-term treatment including administration of chemotherapy, parenteral nutrition, or replacement therapies. However, it has been recommended to avoid this technique considering the resultant unpredictable alterations in the veins draining the relevant site, especially in patients who may need central venous cannulation (CVC) during disease progression. We aimed to report on CVC in a 5-year-old child who had previously undergone bilateral internal jugular venous access by the open venous cut-down technique, in order to highlight the importance of performing the Rapid Central Vein Assessment protocol prior to any intervention and considering to abandon the use of the open surgical venous cut-down technique by gaining experience with ultrasound-guided percutaneous techniques.

Brachiocephalic Vein and Superior Vena Cava Reconstruction with a Superficial Femoral Vein Graft.

Superior vena cava syndrome (SVCS) is an entity that has become more frequent due to the increasing use of indwelling central venous catheters. Surgical management is considered in patients with extensive venous thrombosis and when endovascular therapy is not feasible. The use of superficial femoral vein is an excellent technique for reconstruction of the brachiocephalic vein and superior vena cava (SVC) in cases with benign and malignant etiologies. We describe two cases of SVCS that were managed surgically at our institution with replacement of the SVC and brachiocephalic veins with a superficial femoral vein graft technique.