Superior vena cava reconstruction using autologous femoral vein graft

Chronic superior vena cava obstruction is a recognized complication of transvenous pacemaker and implantable cardioverter-defibrillator leads. A 39-year-old woman with genetically confirmed left ventricular non-compaction cardiomyopathy and a transvenous implantable cardioverter-defibrillator placed for primary prevention developed progressive superior vena cava syndrome. Computed tomography angiography demonstrated chronic occlusion of the superior vena cava and left brachiocephalic vein with extensive collateralization. Endovascular recanalization was attempted from femoral, bilateral internal jugular, and left brachial approaches, but no guidewire could traverse the multilevel chronic occlusion, precluding balloon angioplasty or stenting. Open reconstruction was performed. The left femoral-popliteal vein was harvested, inverted and rendered valve-free. Lead extraction was performed in two stages: the generator and extrathoracic lead were mobilized using a locking stylet and mechanical extraction sheaths, followed by intrathoracic lead removal through median sternotomy and a controlled superior vena cava venotomy. The autologous graft was anastomosed end-to-side to the right subclavian vein, tunnelled through the mediastinum, and anastomosed to the superior vena cava venotomy. Doppler ultrasound confirmed excellent flow. Follow-up imaging demonstrated a patent graft with marked symptomatic improvement.