Background <p>Locally advanced thymic epithelial tumors (TETs) may extend into the adjacent brachiocephalic vein (BCV), creating major technical challenges for resection. While BCV reconstruction is traditionally considered after tumor removal, its true clinical value compared with simple transection remains unclear.</p> Patients and Methods <p>Consecutive patients with TETs involving the BCV who underwent surgical resection at Shanghai Pulmonary Hospital between January 2013 and March 2023 were retrospectively analyzed. Perioperative details, 30-day morbidity, and long-term outcomes were systematically assessed. Inverse probability of treatment weighting (IPTW) was applied to improve baseline comparability between groups.</p> Results <p>A total of 51 patients were enrolled in the final cohort and were categorized into the transection group (<i>n</i> = 22) or the reconstruction group (<i>n</i> = 29), according to the surgical management of BCV. Compared with the reconstruction group, the transection group had a significantly lower transfusion rate (9.1% versus 37.9%, <i>P</i> = 0.025). However, both 30-day morbidity (40.9% versus 48.3%, <i>P</i> = 0.601) and long-term morbidity (22.7% versus 27.6%, <i>P</i> = 0.693) showed no significant differences. Similarly, recurrence-free survival and overall survival did not differ significantly between the two groups (<i>P</i> = 0.731 and <i>P</i> = 0.882, respectively). After IPTW adjustment, transfusion rates remained significantly higher in the reconstruction group (37.3% versus 5.9%, <i>P</i> = 0.005), whereas no other short- or long-term outcomes differed significantly between the groups.</p> Conclusions <p>Despite its technical complexity, BCV reconstruction did not confer additional short- or long-term benefits compared with transection. Therefore, BCV transection may be a more practical surgical approach for selected patients with locally advanced TETs.</p>