The patient is a 47-year-old African-American male who presented with worsening syncope, brachiocephalic swelling, and dyspnea. Contrast computed tomography (CT) demonstrated near total obliteration of the SVC at the level of the right pulmonary artery with an area of soft tissue calcification consistent with remote granulomatous infection. (Figure 1A) The obstruction was felt unamenable to percutaneous intervention therefore SVC resection and reconstruction planned through a median sternotomy approach. Intraoperatively, large subcutaneous and mediastinal collateral veins were encountered. Circumferential dissection of both innominate veins was ultimately accomplished just proximal to the confluence and the intrapericardial SVC carefully sparing the right phrenic nerve. The azygous vein appeared chronically occluded within the area of fibrosis. Intravenous heparin (100 U/kg) was given and after 3 minutes, both innominate veins and the intrapericardial SVC were clamped one centimeter above the sino-atrial node region. The SVC was divided through the fibrotic tissue and a residual lumen of approximately 1 to 2 mm noted. The SVC and surrounding fibrotic tissue were excised proximally and distally back to normal vessel again with careful preservation of the phrenic nerve, which totaled an approximate 4 to 5 cm segment. Superior vena cava reconstruction was then accomplished using a 16 mm cryopreserved ascending aortic allograft ABO/HLA unmatched (Cryolife Inc, Atlanta, GA). The aortic valve was excised at the top of the commissures, then a proximal end-to-end anastomosis established between the conduit and the proximal SVC, just distal to the innominate confluence, using a running 5–0 polypropylene suture. The allograft was cut to appropriate length, which excised the curvature into the transverse aortic arch. A distal end-to-end anastomosis was performed from the allograft to the SVC approximately 1 cm above the SVC-right atrial junction. Clamps were removed after de-airing to reestablish flow through the homograft. (Figure 2) Subcutaneous heparin (5,000 U) three times daily for DVT prophylaxis and aspirin were begun on the second postoperative day. The patient’s initial postoperative course was uneventful with excellent relief of his symptoms. He was discharged on the seventh postoperative day on aspirin only and remains asymptomatic 12 months following surgery. Pathologic findings of the native SVC and surrounding tissue confirmed an end-stage granulomatous process including fibrosis and calcification most likely due to Histoplasmosis. A CT scan with contrast was obtained 6 months after the initial operation confirming patency of the thoracic aortic allograft (Figure 1B).