Brachiocephalic venous tumors often display no specific clinical symptoms. They are often found by further examinations after physical examination of abnormal mediastinum [5]. In this case, the patient had an irritating cough due to the large tumor and compression. The chest CT scan only detected abnormal mediastinal masses, which requires enhanced CT or MRI to identify. When thrombosis occurs, it is manifested as a localized filling defect in the lumen. If blind biopsy is performed, serious or even fatal complications may occur [6]. MRI of the chest shows abnormal blood flow at the base of the venous tumor, which shows better imaging than CT.
The reports of brachiocephalic vein tumors are often based on individual cases, lacking of unified treatment guidelines. Conservative treatment includes: for fusiform and small cystic brachiocephalic vein tumors, which rarely cause tumor enlargement, compression, rupture, etc., therefore, long-term antiplatelet conservative treatment and regular review are sufficient if there is no significant change in the size and shape of the tumor [7]. But if the symptoms are aggravated, the tumor is enlarged, or imaging suggests that related complications occur, surgical intervention should be applied.
Scholars are constantly exploring that endovascular treatment is less traumatic for patients, and recovery is quicker after surgery. Gaopo Cai [8] reported that the use of an endovascular stent to treat a case of left brachiocephalic vein tumor have achieved satisfactory early results, but during the 12-18 months follow-up stent thrombosis gradually appeared, and its long-term effect needs further checked. In 2014, Jargiello [9] reported percutaneous transcatheter thrombin injection for the treatment of cystic venous tumors. After intraoperative injection of thrombin, balloon expansion is used to seal the entrance of the tumor to achieve the therapeutic effect. It is suitable for patients with narrow and long tumor necks, or small tumors, but their allergic reactions and intraoperative and postoperative embolization complications need to be vigilant. For this case, because of our insufficient experience in endovascular treatment and the patient was unwilling to try this new technique, surgery was therefore used.
We believe that although the surgical path of median thoracotomy is more traumatic, it gives the surgeon a full view during the operation and facilitates the observation of the anatomical relationship between the venous tumor and the surrounding tissues, and can provide help for the extracorporeal circulation surgery when necessary. This method is safe and effective. After blocking the blood flow on both sides of the tumor, we clamped the neck of the tumor, excised the tumor, and did double-layer continuous suture with 5-0 prolene thread for angioplasty. During the process, we paid attention to the diameter of the venous lumen, to prevent excessive sutures from causing stenosis. The results of the postoperative follow-up visit were satisfactory. The patient’s symptoms were significantly improved after the operation. Cheng Fang [10] also reported a case of left brachiocephalic vein tumor with accumulated superior vena cava. They used autologous pericardium tissue from the patient to reconstruct venous blood vessels, and also achieved a good therapeutic effect. In addition, autologous pericardium has the advantages of strong plasticity, easy access, and better immunocompatibility [11], so that patients do not need anticoagulant treatment after surgery. This method is beneficial when the tumor is large and other blood vessels are dilated.