LEFT RETRO-AORTIC BRACHIOCEPHALIC VEIN WITH AORTO-PULMONARY WINDOW: SURGICAL DIFFICULTIES IN AN EXTREMELY RARE ENTITY
Authors: RAJA JAVID , santoki nishit , Bansal Vidur , Kumar Nitish , Mittal Apeksha , Mandal Meenakshi , R Irshad , Mishra Anand 
Published: April 2022

DISCUSSION – Left brachiocephalic vein is 6 cm long; it begins behind
the sternal end of the clavicle, anterior to the cervical pleura by
union of the left internal jugular vein and the left subclavian vein. It
descends obliquely to the right, behind the upper half of the manubrium
sterni, up to the sternal end of the first right costal cartilage,
uniting here with right brachiocephalic vein to form SVC. The aortic
arch is inferior to this vein. The left retro-aortic bracheocephalic
vein is rare entity which was first described by
Kerschner.[(1)](#ref-0001) Incidence of left retro-aortic
bracheocephalic vein is noted between 0.2 to 1%.[(2)](#ref-0002)
Aorto-pulmonary window is a rare cardiac condition, first described by
Eliotson in 1830[(3)](#ref-0003) with an incidence of 0.2% - 0.3%
of all congenital cardiac lesions.[(4,5)](#ref-0004) Three standard
approaches for surgical closure of aorto-pulmonary window have been
described in literature include: trans-aortic approach, trans-window
approach, trans-pulmonary approach. Trans-window approach is also known
as sandwich repair of aorto-pulmonary window.[(6)](#ref-0006) The
left retro-aortic brachiocephalic vein with tetralogy of fallot and
coarctation of aorta are noted. The left retro-aortic brachiocephalic
vein with aorto-pulmonary window is very rare case and has not been
reported previously. In our case the patient was admitted for AP window
closure after complete pre-operative evaluation. Cardiac computed
tomography reported 2.2cm aorto-pulmonary window with the left
retro-aortic brachiocephalic vein. After obtaining parental consent for
surgery, median sternotomy was performed. Thymus was excised and
pericardium was opened longitudinally. By careful dissection, the left
brachiocephalic vein was identified behind the distal ascending aorta
adjacent to the AP window. Aorta was dissected off the brachiocephalic
vein meticulously. Due to left retro-aortic brachiocephalic vein, aortic
cannulation had to be done more caudally to avoid obstruction of vein.
Aorta was cannulated and clamped without injury to the brachiocephalic
vein. Attention was paid to avoid injury of the brachiocephalic vein
during encircling the SVC for snaring. Aorto-pulmonary window was closed
with PTFE patch through trans-window approach under mild
hypothermia.[(6)](#ref-0006) Clinical implication of retro-aortic
brachiocephalic vein is very important. More caudal cannulation of SVC
is required in left brachiocephalic vein; but in AP window setting, this
is more difficult as work space for closure of the defect is also
required. Injury may occur to the vein during clamping of aorta. Left
retro-aortic brachiocephalic vein may cause technical difficulty during
central venous line placement through left arm approach. CONCLUSION-
Being the rarest combination of left retro-aortic brachiocephalic vein
and aorto-pulmonary window, certain things have to be taken care of like
clamping of aorta, SVC cannulation, central vein catheter insertion,
snaring of SVC. Pre-operative CT scan is also important to avoid
intra-operative surprises.