Covered Endovascular Reconstruction of the Anonymous Confluence (CERAC): a technical note describing a confluence-preserving endovascular technique.

Abstract

Introduction: Endovascular therapy is the first-line treatment for superior vena cava syndrome (SVCS), yet the optimal strategy for lesions involving the brachiocephalic vein confluence remains debated. We describe a technique for anatomical bilateral reconstruction of the anonymous confluence using covered stents, called Covered Endovascular Reconstruction of the Anonymous Confluence (CERAC).

Materials and methods: All patients treated for SVCS between September 2024 and December 2025 were reviewed. CERAC was selectively applied based on anatomical and clinical considerations. Procedural characteristics, technical success, complications, and follow-up patency were assessed.

Results: Three out of ten patients who underwent endovascular treatment for SVCS at our institution were treated using the CERAC technique. Indications included preservation of bilateral venous access in young patients with potentially treatable malignancy (n = 2) and emergency central venous decompression (n = 1). Technical success was achieved in all cases, with restoration of patency of both brachiocephalic veins and the superior vena cava. Mean fluoroscopy time was 30.6 min. No immediate complications occurred. Primary stent patency was maintained during available follow-up (29-301 days; median 149 days).

Discussion: CERAC enables confluence-preserving bilateral reconstruction while minimizing stent overlap and maintaining favourable luminal geometry. Inspired by the Covered Endovascular Reconstruction of the Aortic Bifurcation, CERAC represents, to our knowledge, the first description of a fully covered, confluence-preserving reconstruction in this anatomical setting.

Conclusion: CERAC is a feasible endovascular option for selected SVCS cases involving the brachiocephalic confluence. Further studies are needed to evaluate long-term outcomes and to better define appropriate indications.

Level of evidence: Level V.