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A 46-year-old woman with stage 5 chronic kidney disease was unable to undergo hemodialysis treatment due to thoracic central venous obstruction (TCVO) and blockage of the tunneled cuffed catheter. This patient also presented with symptoms of TCVO. When percutaneous procedure was not possible, we resolved the obstruction with the innominate-to-right-atrial bypass grafting technique under extracorporeal circulation. There are few reports on this surgical approach. In terms of patient prognosis, this may be an effective solution to this problem. [ABSTRACT FROM AUTHOR]

We report the case of a 60-year-old woman who sought medical attention for left cervical and supraclavicular pain and swelling. Previous computed tomography, intravascular ultrasound, and venography studies were reviewed, confirming extrinsic compression of the left innominate vein by the left common carotid artery against the left clavicle head. Stenting of the lesion was performed, with good mid-term symptom relief and patency. It is, to the best of our knowledge, the first case study in the literature to report endovascular treatment of this syndrome.

Balloon rupture during angioplasty can with calcified or recalcitrant lesions. A 61-year-old woman presented with worsening arm and facial swelling. She had a history of left upper extremity thrombolysis and stenting of the innominate vein 6 years prior. Venography showed severe in-stent stenosis. After crossing the lesion, a 12-mm balloon was inflated, which ruptured at nominal pressure. The balloon became stuck and could not be moved over the wire even after retraction of the sheath. A limited surgical cutdown was performed, and the balloon and the wire were removed together. The ruptured balloon part was found to be everted and circumferentially wrapped around the wire, preventing the wire exchange. After cutting the everted portion of the balloon, the catheter was removed without losing wire access. A high-pressure balloon was subsequently used to treat the lesion successfully. Her symptoms had resolved on follow-up, and the stent remained patent after 6 months.

Objectives: Stenting of central venous stenosis to preserve upper extremity hemodialysis access is well-described, though upper extremity complications secondary to these stents are less frequently discussed. Methods: We present the case of a 43-year-old male with a right brachiocephalic fistula who developed symptoms of venous hypertension following placement of a Wallstent for central venous stenosis. Workup demonstrated venous outflow obstruction secondary to stent foreshortening into the right subclavian vein. Results: The Wallstent was removed in a piecemeal fashion using an open surgical technique and a HeRO graft was placed for dedicated fistula outflow with complete relief of the patient's symptoms. Conclusion: In situations where a stent has migrated and endovascular removal is not possible, individual Wallstent fibers can be removed through a limited venotomy. [ABSTRACT FROM AUTHOR]

The brachiocephalic vein (BCV), also known as the innominate vein, is a central vein in the upper chest formed by merging the internal jugular and subclavian veins. It plays a crucial role in venous return from the head, neck, and upper extremities and is significant in procedures such as pacemaker and implantable cardioverter-defibrillator (ICD) placement, chemotherapy ports, and central venous catheter insertions. The presence of foreign bodies and local malignancy are major risk factors for thrombosis in the BCV. As part of the deep venous system, BCV thrombosis (BCVT) is a rare condition but can lead to serious complications like superior vena cava syndrome and, rarely, pulmonary embolism. This case report presents an 82-year-old woman with a history of heart failure with reduced ejection fraction, coronary artery disease, atrial fibrillation, HIV, pulmonary embolism, systemic lupus erythematosus, and breast cancer who required an ICD placement due to persistent systolic dysfunction. During the procedure, chronic BCVT leading to the stenosis was incidentally discovered, necessitating urgent vascular intervention to establish venous patency. The patient's complex medical history, including previous chemotherapy through a central venous catheter, contributed to the risk factors for BCVT. The multidisciplinary approach led to successful ICD placement and the reinstatement of anticoagulation therapy. This case underscores the rarity and severity of BCVT and highlights the importance of pre-procedural imaging, such as CT venography, in patients with multiple risk factors. Additionally, the report suggests considering leadless ICD technology for patients with limited venous access to avoid complications. The findings emphasize the critical need for thorough evaluation and planning in complex cases to ensure successful outcomes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Stojanovic et al.)

Lung cancers and mediastinal masses can invade the veins in the upper mediastinum and neck. It can be challenging to determine management options and the feasibility of resection particularly when tumors involve the major venous junctions. Furthermore, impaired flow in these veins can have devastating complications such as Paget-Schroetter syndrome, which describes a constellation of symptoms (arm swelling, cyanosis, pain) due to stenosis of the subclavian vein. This section will provide an overview of venous drainage of the brain, which can be divided into two major systems-superficial medullary venous system and deep medullary venous system. The anatomy and function of the great veins of the neck and upper mediastinum, including the internal jugular vein, subclavian vein, and brachiocephalic (i.e., innominate) vein will be described. Also discussed will be principles of ligation of the venous structures and the importance of keeping the venous junctions intact to facilitate and maximize the development of collateral flow. This section will also discuss ensuing complications when blood flow is impaired, such as development of upper extremity deep venous thrombosis and cerebral venous thrombosis (CVT). CVT can result in a stroke and is an umbrella term that refers to problems in cerebral venous outflow due to numerous etiologies., Competing Interests: Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-23-15/coif). The series “Venous Surgery of the Mediastinum” was commissioned by the editorial office without any funding or sponsorship. A.S. served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare., (2024 Mediastinum. All rights reserved.)

Major vessels of the mediastinum such as the superior vena cava (SVC) and bilateral innominate veins can occasionally become involved with aggressive tumors or the mediastinum, including non-small cell lung cancer and thymoma. This may result in partial or complete obstruction. With presentation of these tumors symptoms can often be debilitating and would otherwise be treated with palliative therapy. A select population of patients are candidates for tumor resection. The ability to perform an adequate resection will depend on the ability to create a durable reconstruction of the SVC and bilateral innominate veins. Pre-operative and intra-operative considerations will allow for a safe surgery with few complications to the patient. Furthermore, depending on the extent of resection, there are a variety of techniques for reconstruction. These can range from a primary repair of a partial venous wall resection to a complex replacement of both the SVC and one or both innominate veins. Multiple options exist for the use of these conduits, such as polytetrafluoroethylene, homograft, autologous vein, and bovine or porcine pericardium. Depending on the type of conduit used, the post-operative outcomes will differ. In order to perform this operation safely, proper knowledge and experience is required. We review a variety of strategies used to manage these rare but complex scenarios., Competing Interests: Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-20-70/coif). The series “Venous Surgery of the Mediastinum” was commissioned by the editorial office without any funding or sponsorship. JOW is a Consultant for Intuitive, Boston Scientific, Meditronic, and Ethicon. The authors have no other conflicts of interest to declare., (2022 Mediastinum. All rights reserved.)