Delayed left brachiocephalic vein compression following TEVAR in Marfan syndrome

Background Thoracic endovascular aortic repair (TEVAR) is widely used to treat complicated Stanford type B aortic dissection. Although complications such as endoleak, graft failure, and progressive aortic degeneration are well recognized, delayed central venous obstruction caused by extrinsic compression from a thoracic endograft is rare. Case summary A 29-year-old woman with suspected Marfan syndrome and a history of valve-sparing aortic root replacement subsequently underwent TEVAR for a multiflap Stanford type B aortic dissection. Several weeks later, she presented with progressive left-sided facial and upper-extremity swelling accompanied by pleuritic chest pain. Delayed-phase computed tomography demonstrated severe focal stenosis of the left brachiocephalic vein between the posterior sternum and the proximal thoracic stent graft. Venography and intravascular ultrasound confirmed severe extrinsic compression and central venous outflow obstruction. The patient underwent balloon venoplasty followed by placement of a 14 × 80-mm venous stent extending from the left brachiocephalic vein into the proximal left subclavian vein. Central venous flow was restored, with subsequent improvement in facial and upper-extremity swelling. She was discharged in stable condition on apixaban for treatment of provoked venous thromboembolism. Discussion The left brachiocephalic vein is susceptible to compression because of its anatomic course between the sternum and aortic arch. Altered mediastinal anatomy after serial thoracic interventions and progressive aortic remodeling may further increase this risk in patients with connective tissue disorders. Multimodality imaging, including delayed-phase computed tomography, venography, and intravascular ultrasound, is essential for diagnosis and procedural planning. Conclusion Delayed left brachiocephalic vein compression is an uncommon but clinically important complication of TEVAR that should be considered in patients presenting with unilateral facial and upper-extremity swelling. Endovascular venoplasty and stent implantation can effectively restore venous outflow and provide symptomatic relief.