Neo-innominate vein construction in patients with bilateral superior vena cavae: Techniques, outcomes and anticoagulation considerations

Objective Neo-innominate vein creation can replace a bilateral cavopulmonary connection or simplify systemic venous reconstruction in selected patients with bilateral superior vena cavae. We reviewed outcomes and examined whether reconstructive technique was associated with venous thrombosis, anastomotic stricture, or external compression. Methods We retrospectively reviewed all patients undergoing neo-innominate reconstruction at Boston Children's Hospital from 2017 through 2022. We recorded operative context, reconstructive technique (primary end-to-side anastomosis, posterior flap with anterior patch augmentation, or interposition graft), postoperative antithrombotic therapy, and venous ultrasound findings. Associations between technique and the composite endpoint were assessed with Fisher exact tests. Results Twenty-three patients (69.6% male) underwent reconstruction at a median age of 2.7 years. Procedures accompanied single-ventricle palliation in 13 patients (56.5%), biventricular repair or conversion in 8 (34.8%), and heart transplantation in 2 (8.7%). The composite endpoint occurred in 9 patients (39.1%); 5 events occurred within 19 postoperative days. Thrombosis occurred in 5 patients (21.7%): 3 of 4 after patch augmentation and 2 of 8 after interposition grafting. No thrombosis occurred after primary anastomosis. Three patients developed anastomotic stricture. Technique was not significantly associated with the composite endpoint (p=0.09-0.66). Mean follow-up was 3.0 years (IQR, 0.7-4.9 years). Conclusions Neo-innominate vein creation is a useful reconstructive option for selected patients with bilateral SVCs, but this series does not establish a clinical hemodynamic advantage over bilateral bidirectional Glenn circulation. Early thrombosis was concentrated in patch and graft reconstructions. Close ultrasound surveillance, individualized antithrombotic treatment, and early reintervention are therefore central to postoperative management.