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OBJECTIVES: Complications attributed to central venous stenosis and subsequent thrombosis are increasing in frequency and are most commonly associated with neointimal fibroplasia from venous access procedures as well as neoplastic, fibrotic, and traumatic pathologies.

METHODS: We present the successful venous bypass and thoracic wall reconstruction in a patient with chronic atypical symptomatology secondary to brachiocephalic vein occlusion from congenital thoracic dystrophy.
RESULTS: A fifty-eight year-old female presented with deteriorating holocephalic retro-orbital exertional headaches associated with intermittent vertigo, neck and shoulder discomfort combined with bulging of her left sided neck veins. She had no previous venous thromboembolic disease, venous access catheters or trauma. A contrast-enhanced CT angiogram identified significant narrowing of the left brachiocephalic vein between the sternum and descending thoracic aorta. Venography confirmed a filling defect in the left brachiocephalic vein and normal patency of the other great veins. She described consistent short-term relief after multiple percutaneous brachiocepahlic vein thrombolysis, angioplasty and stenting procedures. Repeat CT imaging suggested extrinsic compression of the previously inserted brachiocephalic stent. After referral to vascular surgery, it was determined that operative decompression and venous bypass was warranted due to extrinsic pressure due to pectus excavatum. In order to expand the diameter of the upper chest, the upper manubrium, clavicle, sternum and ribs were released from scar tissue and the pectoralis muscles were elevated. Multiple transverse rib and sternal osteotomies combined with excision of the left first and second ribs were performed to elevate the chest wall. A 3-4 cm chest wall hernia was subsequently closed with XCM biologic tissue matrix^®.The right great saphenous vein was endoscopically harvested and used to construct a spiral graft to bypass the left brachiocephalic vein between the junction of the left internal jugular and brachiocephalic vein to the SVC. The chest wall was reconstructed utilizing titanium plating and FiberWire™ to reattach the ribs and manubrium to the elevated sternum. Bilateral autologous semitendinosus grafting of clavicles to manubrium was then performed. Post-operatively, the patient had an uneventful recovery and remains well seven-months later.
CONCLUSIONS: Although acute central vein obstruction warrants urgent intervention, treatment of chronic occlusions remain less descript. Despite reported equivocal results between operative intervention and repeated angioplasty, open brachiocephalic vein bypass is suggested for longer term relief in patients with any etiological anatomical compression.