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Background The vascularity of the nipple-areolar complex (NAC) is altered after reduction mammoplasty, increasing the risk of complications after repeat reduction or nipple-sparing mastectomy. Objectives The aim of this study was to evaluate angiogenesis of the NAC via serial analysis of magnetic resonance images. Methods Magnetic resonance images of breasts after reduction mammoplasty were analyzed for 35 patients (39 breasts) from 3-dimensional reconstructions of maximum-intensity projection images. All veins terminating at the NAC were classified as internal mammary, anterior intercostal, or lateral thoracic in origin. The vein with the largest diameter was considered the dominant vein. Images were classified based on the time since reduction: 2 years. Results The average number of veins increased over time: 1.17 (2 years). Within 6 months, the pedicle was the only vein. Veins from other sources began to appear at 6 to 12 months. In most patients, at least 2 veins were available after 1 year. After 1 year, the internal mammary vein was the most common dominant vein regardless of the pedicle used. Conclusions Repeat reduction mammoplasty or nipple-sparing mastectomy should be performed ≥1 year following the initial procedure. After 1 year, the superior or superomedial pedicle may represent the safest option when the previous pedicle is unknown.

Purpose: To describe the use of the internal mammary vein as an alternative access for central venous catheters. Methods: We performed a retrospective review of patients who underwent placement of central venous catheters via the internal mammary vein. Patient demographics, indication for venous access, technical success, catheter type, dwell time and indication for exchange or removal were recorded. Results: Placement of central venous catheters via the internal mammary vein was attempted in 11 patients including 8 children (4 males, mean age 5.7 years) and 3 adults. The most common indication was parenteral nutrition in patients with intestinal failure (7/11). Initial needle access of the vein was successful in all patients. Catheter placement was successful in 9 and unsuccessful in 2 patients due to occlusion of the superior vena cava. There were no immediate complications. A total of 20 catheters of various sizes (3–14.5 French) and lengths (8–23 cm) were either placed (n = 12) or exchanged (n = 8). The most common indications for catheter exchange were poor function and malposition (7/8). Four catheters were removed for infection and 4 were accidentally removed. The mean dwell time was 141 days (range 0–963 days) per catheter for a total of 2829 catheter days. The total mean dwell time per patient, including primarily placed and exchanged catheters, was 314 days (range 5–963 days). CONCLUSIONS: The internal mammary vein may provide a safe alternative route for patients who have lost their traditional access veins.

Malpositioning of a central venous port in the internal thoracic vein can be difficult to check based on single-plane (PA) chest radiographs only, and can be managed by interventional radiology. Teaching Point: Central venous port malposition in the internal thoracic vein must be detected on postero-anterior chest radiograph and can be repositioned via endovascular procedure.

Central venous catheter (CVC) placement is an essential component of critical care medicine. CVC malposition is a known complication of internal jugular vein (IJV) cannulation. However, catheterization of the internal thoracic vein (ITV) is much rarer. Only a handful of case reports have been documented, and guidelines for management are therefore lacking. Our case study describes this rarely occurring ITV cannulation along with the discussion of risk factors, warning signs of malpositioning, and subsequent management plans to optimize patient safety. Previous studies have used fluoroscopy and agitated saline flush tests to confirm that agents administered through an ITV-located catheter would reach the right atrium. Considering this, it would follow that a catheter in this site could theoretically be used for medication administration, especially in emergency settings. This hypothesis remains the most novel part of our case study and might prompt further exploration of management strategies in this particular situation.

Post-aortic left brachiocephalic vein (PALBV) is one of the rare congenital vessel abnormalities associated with congenital heart disease. As only a few reports of surgical treatment for thymic tumor in patients with PALBV are available, this study reports the case of a patient with PALBV who underwent surgical treatment for thymoma. In a 60-year old woman, a nodule in the anterior mediastinum was detected on chest computed tomography (CT) during examination for arrhythmia. Thymoma was suspected, and surgical resection was considered. PALBV was detected on a contrast CT scan before surgery. Video-assisted thoracoscopic surgery was used to perform thymectomy using the subxiphoid dual-port approach. This method provided an appropriate view of the operative field and made it easy to confirm the presence of PALBV and identify the thymic veins branching off from the internal thoracic vein.

Persistent left superior vena cava is a rare finding seen only in 0.3%-0.5% population. It is generally asymptomatic and is often discovered after central venous catheterization done for various indications. We present a case where we demonstrate persistent left superior vena cava/left cardinal vein remnant discovered during left-sided cuffed catheter insertion for hemodialysis in a 65-year-old chronic kidney disease patient. Findings were confirmed with computed tomography venogram. This anomaly poses iatrogenic risks to the patient if not detected early. A catheter along the left mediastinal border can be dangerously close to descending aorta and could also be indicative of its placement in the internal thoracic vein or, pericardiophrenic vein. It can also perforate the persistent/remnant vessel and enter the pleura, pericardium, or mediastinum. This case emphasizes the importance of familiarity with this entity and its role in determining the appropriate venous access for patient therapy when faced with this clinical situation.

Introduction A persistent left superior vena cava (SVC) is found in 0.3 to 0.5% of the general population. It is seen in up to 10% of the patients with a congenital cardiac anomaly, being the most common thoracic venous anomaly, and is usually asymptomatic. Being familiar with such anomaly could help clinicians avoid complications during the placement of central lines, Swan-Ganz catheters, peripherally inserted central catheter (PICC) lines, dialysis catheters, defibrillators, and pacemakers. Case Presentation We describe a case of persistent left SVC which was noted after placement of a PICC line. A 5-year-old male child was hospitalized for evaluation and management of leukemia. He required PICC line placement for chemotherapy. He was noted to have a persistent left SVC during the procedure under fluoroscopic guidance and subsequently correct placement of PICC line in right SVC. Discussion This anatomical variant can pose iatrogenic risks if the clinician does not recognize it. A central catheter that tracks down the left mediastinal border may also be in the descending aorta, internal thoracic vein, superior intercostal vein, pericardiophrenic vein, pleura, pericardium, or mediastinum. Conclusion Our case is significant because the patient was diagnosed with double SVC on table only followed by the placement of PICC line into the right SVC. This case strongly demonstrates the importance of knowing the thoracic venous anomalies.

Mice and rats are rodent specimens commonly used in multidisciplinary research. Specifically, vasculature imaging of rodents has been widely performed in preclinical studies using various techniques, such as computed tomography, magnetic resonance imaging, and ultrasound imaging. Photoacoustic CT (PACT) is a noninvasive, nonionizing optical imaging technique derived from photoacoustic tomography and benefits from using intrinsic endogenous contrast agents to produce three-dimensional volumetric data from images. In this study, a commercial PACT device was employed to assess the cervicothoracic vasculature of mouse and rat specimens, which has rarely been examined using PACT, under two conditions with depilation and skin incision. Various blood vessels, including the common carotid artery, internal/external jugular veins, cranial vena cava, internal thoracic vein, and mammary, were identified in the acquired PACT images. The difference between the depilated and skin-incised specimens also revealed the presence of branches from certain blood vessels and specific anatomical features such as the manubrium of the sternum. This study presents detailed PACT images observing the cervicothoracic vasculature of rodent specimens and is expected to be used as a reference for various preclinical experiments on mice and rats.

Summary Introduction The deep inferior epigastric perforator (DIEP) flap is a reliable and reproducible technique for autologous microsurgical breast reconstruction. Several recipient vessels sites for microvascular anastomosis have been described such as the internal thoracic vessels, the thoracodorsal vessels, and the circumflex scapular vessels. Nonetheless, the choice of the recipient site depends mainly on individual operator's experience and preferences, and currently the best recipient vessel site is under debate. This anatomical observational study aimed to determine whether anatomy could address this dilemma by determining the best vessel diameter to match the donor with these three recipient sites. Methods Our series reports 80 dissections of the three anatomical regions of interest. Forty formalin-preserved female cadavers were dissected bilaterally. Internal vessels diameter measurements were recorded with a vascular gauge ranging from 1.0 to 5.0 mm with successive half-millimeter graduations. Results The median diameter of the deep inferior epigastric (DIEA), internal thoracic (ITA), circumflex scapular (CSA), and thoracodorsal arteries (TDA) were: 2.0, 2.5, 2.5, and 1.5 mm, respectively. The median diameter of the deep inferior epigastric, internal thoracic, circumflex scapular, and thoracodorsal veins were: 3.0, 3.0, 3.0, and 2.5 mm, respectively. At the individual level, the perfect match between DIEA and ITA was significantly more frequent than between DIEA and TDA (p = 0.002), and it was more frequent between DIEA and CSA than between DIEA and TDA (p = 0.009). Conclusions This study supports the use of the internal thoracic pedicle as the first recipient vessel choice, which should be considered, at least anatomically, as the best one with the closest diameter matching with the donor pedicle.

Central venous catheters are widely used in clinical practice and are linked to many types of complications, including incorrect positioning at the time the catheter is fitted. Here, the authors describe a case in which a fully implantable catheter was inadvertently positioned in the right internal thoracic vein. The complication was identified when the nursing team attempted to use the catheter. The right internal thoracic vein is within the radiographic projection of the right brachiocephalic vein and the superior vena cava, simulating correct catheter placement on an anteroposterior radiograph. In cases of central catheter malfunction during the immediate postoperative period, work-up should include oblique and lateral views, to rule out the complication described here without a need for computed tomography.

Background: Anatomical knowledge of the facial vasculature is crucial not only for anatomists but also for oral and maxillofacial surgery, plastic surgeon, otorhinolaryngologists. Access pathways, pedicled and free flap transfer, and explantation and transplantation of total faces are based on the proper assessment and use of the facial veins and arteries. The anatomical variations reported in the present study confirms the need for preoperative vascular imaging for sure good venous outflow for the free flap survival. Aims: The aim of the present study was to describe a rare anatomical variation of the common facial vein which not been previously described. Methods and Findings: Head and neck region were carefully dissected as per standard dissection procedure, studied serially during the years 2013-2017 in 15 males and 2 females, i.e. 34 sides, embalmed adults cadavers with different age group, in the laboratory of Morphology of the University of Pamplona. In 33 sides (97 %) of the cases the anterior facial vein (FV) terminated into the internal jugular vein via the common facial vein (CFV) as per standard anatomic description. The right common facial vein in one side (3%) was found to drain into the contralateral internal thoracic vein and contralateral pericardiophrenic vein. Remarkable communications with the external jugular vein, the internal jugular vein, the anterior jugular vein, and left brachiocephalic vein. The length of the right common facial vein from the level of its formation till its termination in the contralateral pericardiophrenic and internal thoracic vein was about 22.75 cm. The venous drainage pattern on the left side of the face was found to be normal. Conclusion: The existence of this anatomical variation among others supposes a double edge sword in the medical practice with its own opportunities and risks, especially in the surgical treatment; therefore, we need to study with more strictness these possibilities with the aim of facilitate this practices, and improve the life quality of our patients.

Purpose: Video-assisted thoracic surgery (VATS) techniques have been widely used for resection of mediastinal tumors. This study investigated the usefulness of the subxiphoid approach in thoracoscopic thymectomy. Methods: In all, 36 patients with anterior mediastinal tumor underwent thymectomy using the subxiphoid approach in two Japanese institutions. These patients were retrospectively reviewed and analyzed. Results: There were 16 females and 20 males with a mean age of 57 years. Five patients underwent partial thymectomy (PT), 27 underwent total or subtotal thymectomy, and 4 underwent thymectomy with combined resection (CR) of the surrounding organs or tissues. The mean maximum tumor diameter, amount of resected tissue, and blood loss were 4.1 cm, 72.5 g, and 20.6 g, respectively. More than half of tumors were diagnosed as thymoma (n = 19). The operation time was prolonged with a greater volume of thymectomy. The duration of chest tube drainage and postoperative stay were 1.7 ± 1.0 days and 5.9 ± 7.6 days, respectively. Four patients suffered intraoperative and postoperative complications, as follows: bleeding of the innominate vein, bleeding of the internal thoracic vein, crisis of myasthenia gravis (MG), pericarditis, and phrenic nerve paralysis. There were no mortalities after surgery. Conclusion: Subxiphoid thoracoscopic thymectomy might be a safe and useful approach for mediastinal tumors.

Microsurgical reconstruction in a vessel-depleted neck is a challenge due to the lack of reliable vessels in or nearby the host site. The use of the internal thoracic pedicle (ITP) by rib section or sparring is a limited option due to the small length of the pedicle of some flaps. However, in cardiac surgery, the internal thoracic artery (ITA) is widely used for myocardial revascularization, providing a long and versatile pedicle. We aimed at determining precise anatomical bases for the use of the ITP, approached by sternotomy and rerouted in the neck, as recipient vessels for free-flap facial reconstructions. We performed a descriptive single centre anatomical study on 20 formalin-embalmed cadavers. The ITP was harvested on both sides from the emergence of the artery under the brachiocephalic vein to its terminal division. The level reached by the ITP in the cervicofacial area was described. Distal arterial and venous diameters, pedicle length and other parameters were measured. In at least 85% of the cases, the ITP reached the mandibular angle. The mean diameter at the distal extremity for the ITA was 2.36 ± 0.15, and 2.48 ± 0.19 mm for the committing vein. The mean length of the ITP was 177.3 mm. Rerouting the ITP towards the cervicofacial area could provide a reliable pedicle for free-flap reconstructions in patients with a vessel-depleted neck but it should be limited to selected patients. This novel solution for situations where current techniques are unfeasible warrants further clinical research.

The purpose of this study was to elaborate on the anastomoses between the paraumbilical and systemic veins, particularly the ensiform veins. The connections with the ensiform veins have received little attention in the anatomical and radiological literature, and remain incompletely described. Too small to be reliably traced in normal CT scans, the paraumbilical veins can dilate in response to increased blood flow from systemic veins in superior vena cava obstruction (SVCO), allowing a study of their arrangement and connections. Collateral paraumbilical veins were therefore analyzed retrospectively in 28 patients with SVCO using CT. We observed inferior and superior groups of collateral vessels in 23/28 (82%) and 17/28 (61%) patients, respectively. Inferior veins ascended towards the liver and drained into portal veins (19/28, 68%) or the umbilical vein (8/28, 29%); superior veins descended and drained into portal veins. The inferior veins (N = 27) could be traced to ensiform veins in almost all of the cases (26/27, 96%), and a little over half (14/27, 52%) were also traceable to subcutaneous and deep epigastric veins. They were opacified by ensiform (25/27, 93%), deep epigastric (4/27, 15%) and subcutaneous (4/27, 15%) veins. The superior veins (N = 17) were supplied by diaphragmatic (13/17, 76%) and ensiform veins (4/17, 24%); the diaphragmatic veins were branches of collateral internal thoracic, left pericardiacophrenic and anterior mediastinal veins. Collateral ensiform veins were observed in 22 patients and anastomosed with internal thoracic (19/22, 86%), superior epigastric (9/22, 41%), diaphragmatic (4/22, 18%), subcutaneous (3/22, 14%) and anterior mediastinal veins (1/22, 5%). These observations show that the paraumbilical veins communicate with ensiform, deep epigastric, subcutaneous and diaphragmatic veins, joining the liver to the properitoneal fat pad, anterior trunk, diaphragm and mediastinum. In SVCO, the most common sources of collateral flow to the paraumbilical veins are the ensiform and diaphragmatic branches of the internal thoracic veins.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is safe to divide the left innominate vein (LIV) in aortic arch surgery to improve access. Altogether, 228 relevant papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Following LIV division, the venous drainage takes place via multiple collateral systems such as the azygous/hemiazygous, the internal mammary veins, the lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus as well as the transverse sinus. The possible complications are mainly left upper limb swelling and neurological symptoms. In one case series of 14 patients, the LIV was divided and ligated to facilitate the exposure for aortic arch surgery. More than 2-year follow-up did not reveal upper limb oedema or neurological symptoms. In two cohorts of 52 patients, the LIV was ligated prior to the superior vena cava (SVC) resection for malignancy. During the mid-term follow-up, no neurological or upper limb symptoms were reported. Although in two studies with 72 and 70 patients undergoing SVC resection it was not specified how many of them had LIV ligation, no relevant complications were reported. In a report, LIV occlusion was observed in 4 patients undergoing left internal jagular vein catheterization for haemodialysis. The reported symptom was left arm swelling with no neurological problems. In a cohort of 18 patients undergoing SVC resection for malignancy and major vein reconstruction, 7 patients underwent ligation of the LIV with no neurological symptoms. It was also concluded that reconstruction of the LIV is not consistent with favourable patency. In a case series of 10 patients with central venous obstruction, collateral pathways to conduct efficient venous drainage were mapped. We conclude that division of the LIV is safe in selected patients and operations. Patients will initially have symptoms of central vein obstruction, but these will decrease with conservative management as collaterals form.

International audience; We report a case describing endovascular treatment of a large aneurysm of the superior vena cava involving internal thoracic vein. The goal of this case report is to highlight the contributing role of embolization with remodeling technique in such an exceptional condition.

A 35-year-old asymptomatic woman was referred for percutaneous closure of patent ductus arteriosus (PDA). Loud continuous murmur at the left and right sternal border was detected. Successful percutaneous closure of PDA with an Amplatzer 9-PDA-005 Duct Occluder was performed. The next day, however, loud continuous murmur was still present. Echo showed Amplatzer Duct Occluder in the site of PDA. CT …

The internal thoracic veins are venae comitantes of each internal thoracic artery draining the territory supplied by it and usually unite opposite the third costal cartilage. This single vein enters the corresponding brachiocephalic vein. We present a variation of right internal mammary vein draining into superior vena cava in a 45-year-old male cadaver. Likely development and clinical significance of the vein are discussed.As veias torácicas internas são veias comitantes de cada artéria torácica interna drenando o território suprido por ela e geralmente se unem em frente à terceira cartilagem costal. Esta única veia entra na veia braquicefálica correspondente. Apresentamos uma variação da veia mamária interna direita drenando para a veia cava superior em um cadáver masculino de 45 anos. O provável desenvolvimento e a significância clínica da veia são discutidos.

The arteries and veins of the left vagus (VN) and left recurrent laryngeal (RLN) nerves from the thoracic inlet to the subaortic region are described following vascular casting with red colored latex in 6 adult fresh non-embalmed cadavers. In all specimens the anterior bronchoesophageal artery supplied at least one vessel to the VN and RLN in the subaortic region. For the RLN other arterial sources were arteries arising from the aortic arch in 1 specimen, the subclavian artery in 3 specimens, the first intercostal artery in 1 specimen, and the inferior thyroid artery in all specimens. For the VN other arterial sources were arteries arising from the aortic arch in 2 specimens and the inferior thyroid artery in 1 specimen. For both the VN and RLN the veins were located under the pleura and directed towards the internal thoracic vein anteriorly and the thoracic intercostal veins posteriorly. In conclusion, the inferior thyroid artery at the thoracic inlet for the RLN and the anterior bronchoesophageal artery are the more consistent vessels supplying the VN and RLN. Vascular damage occurring during mediastinal lymph node excision to the VN and RLN, especially in the subaortic region, may explain postoperative vocal fold paralysis.

Using Color Doppler ultrasonography to trace the dilated paraumbilical vein to its connection with systemic veins in 27 patients, we have found four major pathways: In type 1 (63%), the vein connected with the external iliac vein via the inferior epigastric vein. In type 2 (3.7%), the vein connected with the saphenous vein via the superficial epigastric vein. In type 3 (22.2%), the vein connected with the internal thoracic vein via the superior epigastric vein. Type 4 (11.1%) is a combination of types 1 and 2. A frank caput medusa was not seen, but occult caput medusa were seen in two patients. Turbulent flow was seen at the junction between inferior epigastric and external iliac veins, paraumbilical and superficial epigastric veins, and superficial epigastric and saphenous veins in some patients. Color Doppler ultrasonography is a convenient, noninvasive method for determining the course and associated hemodynamic changes in the paraumbilical collateral circulation.

http://hdl.handle.net/20.500.11768/96435

The lymphatics lying along the internal thoracic artery and vein, which are termed the "internal mammary lymphatics" (IML), were minutely dissected in 134 adult cadavers (80 males and 54 females, aged 27-94 years) in order to clarify the configuration of IML in the superior mediastinum. On the right side, IML frequently terminated at the brachiocephalic angle (BA) nodes and often at the nodes situated at an intermediate position between the internal thoracic artery and vein. By way of these nodes, IML communicated with regional lymphatics of the lung and esophagus. Moreover, IML joined the right superficial bronchomediastinal trunks. On the left side, IML consistently terminated at a superficial group of aortic arch nodes, termed the "superior phrenic nodes", lying along the left phrenic nerve and lying medially to the internal thoracic vein and inferiorly to the left brachiocephalic vein. At and around these nodes, IML joined drainage routes from the so-called Botallo's nodes, which received the left lung lymphatics. The efferents of the superior phrenic nodes formed the left superior bronchomediastinal trunks, and passed deeply to the left brachiocephalic vein and on the subclavian artery toward the left venous angle region. Consequently, IML formed common drainage routes with the drainage routes from the lung and esophagus in the superior mediastinum. A transverse communicating route of IMLs via the retromanubrial nodes, lying inferior to or along the left brachiocephalic vein, was often observed. On the right side, the communicating route terminated at the BA nodes or the nodes situated at an intermediate position between the internal thoracic artery and vein. On the left side, the route consistently terminated at the superior phrenic nodes. In addition to the communicating route described above, we identified (1) a direct and superficial transverse communicating route, and (2) a deep transverse communicating route. The former route was composed of fasciculated large collecting vessels directly connecting the BA nodes to the left venous angle region, lying superficial to the left brachiocephalic vein. The latter route was composed of several large collecting vessels, crossing the brachiocephalic and left common carotid arteries superficially, and merging into the left phrenic nodes directly or occasionally via the pretracheal nodes. These results suggested that IMLs of both sides can closely communicate with each other in the superior mediastinum.

Placement of a central venous catheter into an internal thoracic vein occurs in approximately 2% of all catheterizations. A case in which a pulmonary artery catheter was trapped within the internal thoracic vein during orthotopic heart transplantation is presented.

Central venous access can be challenging in children with thrombosed central veins, particularly those who are dependent on parenteral nutrition. The present report describes a 2-year-old child with short bowel syndrome and chronically thrombosed jugular, subclavian, and femoral veins in whom a tunneled central venous catheter was successfully placed percutaneously via the internal thoracic vein.

The purpose of this study was to clarify the anatomical detail of the superior group of vessels in the falciform ligament in terms of the relationship with the internal thoracic vessels, inferior phrenic vessels, and the intrahepatic portal vein.(1) Anatomical study: we dissected eight adult human cadavers (seven normal and one cirrhotic liver) to determine the relationship between the superior group of vessels in the falciform ligament, the internal thoracic vessels, and the inferior phrenic vessels. (2) Clinical study: we determined the origin and destination of the superior group of veins demonstrated in 8 of 4,006 patients with chronic liver disease who underwent the contrast enhanced CT scans.(1) Anatomical study: the superior group of vessels anastomosed the right (n = 4), left (n = 2), and both (n = 2) internal thoracic vessels. They also anastomosed the left (n = 4), right (n = 1), and both (n = 2) inferior phrenic vessels. (2) Clinical study: the origin of the veins was identified as the left medial branch (n = 4), left lateral branch (n = 1), both the lateral and medial branches (n = 1), and the vein from the umbilical portion (n = 2) of the left portal vein. The drainage vein was identified as the left (n = 3), right (n = 2), and the both (n = 1) internal thoracic veins.We demonstrated the anastomoses between the superior group of vessels of the falciform ligament, the internal thoracic vessels, the inferior phrenic vessels, and the intrahepatic portal vein. These pre-existing anastomoses would develop as porto-systemic shunt in patients with portal hypertension.

Cannulation of the central vein for placement of the temporary dual-lumen catheter for hemodialysis can usually be safely and reliably performed under ultrasonographic guidance. Here, we report a case of aberrant catheter entry into the internal thoracic vein during an apparently smooth procedure. The value of sonographic guidance, together with fluoroscopy with or without venography, will be discussed.

Central venous catheterization is performed in the operating room, intensive care unit and emergency room for various reasons. Internal jugular vein is preferred in the operating room due to little chance of pneumothorax and straight route for catheterization to the right atrium. We experienced a case of central venous catheter malposition to cephalad in the right internal jugular vein. A 60-year-old man, 176 cm in height and 82 kg in weight, was presented for Whipple's operation due to the bile duct cancer. After completion of anesthesia induction and intubation, patient's head was turned left in Trendelenburg position. After skin disinfection, 18 guage, 2 inch thin-walled needle was inserted at the point of sternocleidomastoid (SCM) muscle apex along with medial border of lateral head of SCM muscle about angle of 45 degree to skin without using the finder needle. At the same time, anesthesiologist's left 2nd, 3rd, and 4th fingers palpated the patient's right carotid artery for avoiding arterial puncture. However, blood was not aspirated, needle was reinserted more medial direction about angle of 70 degree to skin. After aspiration of venous blood from needle, the J shape guide wire was introduced via the guiding needle using Seldinger technique. Introduction of 20 cm of J-shaped wire was done without any problem, except some resistance at 5 cm depth of the internal jugural vein. Seven Fr double lumen catheter (Prime-S®, Sungwon medical, Cheongju, Korea) was advanced to the following J-shaped wire. Blood aspiration was done to remove the air in catheter without any resistance. Catheter was sutured at the proper site and surgery was done as planned. After the operation, the patient was transferred to an intensive care unit. Head and neck antero-posterior view X-ray was checked because the central venous catheter was not seen on chest X-ray. Antero-posterior view of the head and neck showed that central venous catheter was bent sharply to the cephalad in the right internal jugular vein (Fig. 1). We removed malpositioned catheter and reinserted central venous catheter via the same side subclavian vein. The proper position of subcalvian catheter was confirmed by a chest X-ray and the patient discharged at postoperative day 13. Fig. 1 Neck anteroposterior view shows that central venous catheter is bent sharply to the cephalad in right internal jugular vein. As one of the various complications, catheter malposition via Internal jugular vein (IJV) can be associated with central venous catheterization via IJV (5.3%) [1]. There are many case reports of malpositioning central venous catheter that were positioned in the jugular venous arch via the right subclavian vein [2], in the internal thoracic vein via the internal jugular vein [3] etc. However, this is the first case of malposition of the catheter, which was bent upward. Bending the catheter is very rare because the right internal jugular vein is the straight route for catheterization to the right atrium. Although there was some resistance during introduction of the J-shaped wire, blood aspiration via catheter was normal, dripping of the fluid seemed normal and central venous pressure curve showed no other abnormal findings. We postulate that the J-shaped wire was bent in the cephalad direction at the moment of resistance. The other postulated cause is an acute angle of the introducing needle when it punctured the internal jugular vein. We cannot rule out the anatomical variation of the external jugular vein and internal jugular vein. Deslaugiers et al. [4] reported that 60% of the external jugular vein is drained to junction of the internal jugular vein and subclavian vein, drained to the subclavian vein in 36%, and drained to the internal jugular vein in 4%. However, we did not confirm the anatomical variation with venous angiogram. It seems that we should be careful when we introduce the wire with some resistance. Malpositioning of the catheter results in monitoring inaccurate central venous pressure, damage to vascular wall, and forming the thrombus. However, the chance of thrombus formation is very low since the blood flow velocity is very fast in the internal jugular vein. In addition, it is impossible that the infused drug inflows to the brain. Although, the most precise method to confirm the complications is examination of the X-ray after the catheterization, ultrasono-guided central venous catheter placement is increasing the success rate, shortening the procedure time, decreasing the complication and the easiest method for acknowledging the direction of catheter, needle and guide wire during the entire catheterization process [5]. In summary, if there is any problem during the central venous catheterization, ultrasonography can be used for optimal catheter placement, and prevention of complications. Additionally, X-ray must be examined to confirm the position of the catheter and incidental complication.

OBJECTIVE The study was designed to assess the early changes in sternal perfusion after midline sternotomy and different (skeletonized versus semiskeletonized) techniques of internal thoracic artery (ITA) harvesting. METHODS The experiments were performed in the swine model. After midline sternotomy, ITA harvesting (skeletonized technique) was performed unilaterally in Group I (6 animals). The ITA and the internal thoracic vein (ITV) were harvested (semiskeletonized technique) in Group II (5 animals). The contralateral sternal half served as a control. Using a thermographic camera with a 0.06 degrees C sensitivity, sternal perfusion was assessed 2 and 5 hours after surgery. RESULTS Midline sternotomy alone did not affect sternal blood flow. A statistically significant ( p < 0.05) reduction in perfusion of the involved sternal half in comparison to the control side was detected at 2 and 5 hours after surgery. The degree of perfusion deficit was not related to the harvesting technique. CONCLUSIONS Skeletonized and semiskeletonized ITA harvesting techniques caused a similar acute reduction in sternal perfusion during the early postoperative period and this effect lasted for at least 5 hours.

Between 1992 and 2002, 542 patients underwent a surgical treatment for hyperparathyroidism in our department. Twenty-three selective venous sampling procedures (SVS) were performed because of the failure of the other methods of diagnosis. These patients have recurrent or persistent hyperparathyroidism. Noninvasive methods of topographical diagnosis have failed or they have given contradictory results. In our experience, the surgeon needs a precise localization of the pathological glands in these difficult cases. In our series of SVS, specificity was 85.7% and sensitivity was 94.7%. Our results show that a high postoperative gradient of parathyroid hormone in the internal thoracic veins indicates an ectopic pathological gland in the thymus. A high gradient in a vertebral vein indicates a pathological superior parathyroid gland, usually in a retro-esophageal position.

A 31-year-old man presented with painless gross hematuria. His serum-creatinine level was within the normal range. Abdominopelvic CT showed an infrahepatic calcified fibrous cord, which was suggestive of inferior vena cava (IVC) remnant. Extensive venous collateralization around both kidneys and venous drainage of the extremities via the inferior epigastric and internal thoracic veins were shown. We report a case of chronic post-thrombotic obstruction of the IVC, involving both renal veins, which was believed to be the cause of painless gross hematuria from mucosal varices of the pelviureteral system in normal functioning kidney.

Ultrasound guidance is useful for venipuncture and placement of central venous access catheters; however, anatomical variants may complicate catheter insertion. A 52-yr-old female patient was admitted to the intensive care unit with acute respiratory distress due to bilateral pneumonia. Her respiratory status worsened rapidly and she required mechanical ventilation. For cardiovascular monitoring, an ultrasound-guided cannulation of her left subclavian vein was performed uneventfully using an Acuson CV70 cardiovascular ultrasound system (Siemens , Erlangen, Germany), and a central venous catheter (CVC) was inserted. A chest x-ray revealed a left-sided paramediastinal course of the CVC (Figure, Panel A), at which point, we considered the potential for arterial placement, accidental venous placement in normal structures (superior intercostal vein or internal thoracic vein), or a malformed left superior vena cava. Subsequently, the diagnosis of persistent left superior vena cava (PLSVC) was confirmed by thoracic computed tomography with contrast injection. Reconstructed computer tomography scan imaging (Figure, Panel B) showed the left subclavian vein give rise to the PLSVC, which drains into in the left atrium, and the brachiocephalic vein that forms the right superior vena cava. The CVC was then removed, and another was inserted uneventfully into the right internal jugular vein using ultrasound guidance. The patient’s respiratory status improved progressively, and her trachea was extubated 21 days later. Persistent left superior vena cava is the most common major anomaly of the systemic venous system. This anatomic variant, which is asymptomatic, results from persistence of an embryological vessel that normally involutes into the coronary sinus. Persistent left superior vena cava is not an absolute contraindication for subclavian vein cannulation if adequate drainage into the right atrium exists. Nevertheless, difficulties can arise during CVC insertion, transjugular intrahepatic portosystemic shunt insertion, and pulmonary artery catheter and pacemaker insertion. The etiology of the CVC false tracking in patients with PLSVC is usually established by chest x-ray and can be confirmed by echocardiography. This case illustrates that thoracic computed tomography is an important diagnostic imaging modality to delineate variant central venous anatomy.

Massive haemothorax and tension pneumothorax due to injury of internal thoracic vein and second rib fracture after blunt trauma is very rare. Possible mechanisms of injury to the thoracic vein include fracture of an bony structure, such as a rib, clavicle and sternum or shearing forces acting on the vessel during period of extreme acceleration or decelerations. We presented an urgent thoracotomy and ligation of the internal thoracic vein ruptured by blunt trauma immediately.

Although hot spots on hepatic scintigrams have been reported in association with superior and inferior vena caval obstruction, these studies were not clinically correlated, and are hampered by the poor resolution of earlier scintillation cameras. In this report, a modern scintillation camera was used to study the formation of hot spots associated with superior and inferior vena caval obstruction. Moreover, radionuclide cavography was performed in 70 patients with superior vena caval (SVC) obstruction and in 95 patients with inferior vena caval (IVC) obstruction. As a result, 13 cases of hot spots in the liver were observed. In cases of SVC obstruction, hot spots were seen in the quadrate lobe, the medial segment, and the bare area of the liver. In IVC obstruction, a hot spot was seen in the quadrate lobe in all cases. In rare instances, in cases of both SVC and IVC obstruction, a hot spot was seen in the wide area. For these hot spots to develop, it appears necessary to have systemic-portal venous blood flow through the internal thoracic vein and the paraumbilical vein.

Background The internal thoracic artery (ITA) is a descendant branch of the subclavian artery. The former is located bilaterally in both internal sides of the thorax near the sternum and is accompanied by two internal thoracic veins (ITV). From a practical point of view, the ITA (and the ITV) identification is important because these vessels can be injured when pericardiocentesis with the parasternal approach is used. Other advantage of the ITA recognition is to check the patency of the ITA grafts in coronary artery revascularizated patients with new onset chest pain. The purpose of this article is to introduce a simple ultrasonographic technique for recognition of the aforementioned vessels and to highlight the utility of this finding in clinical practice. Findings With linear probe and along paraesternal line, the internal thoracic vessels are recognized on grayscale imaging as an anechoic tubular structure immediately anterior to pleural line. Color Doppler identifies a pulsatile (ITA) and a non-pulsatile (ITV) flow. Spectral Doppler normally shows a high resistance velocity profile in non-grafted ITA and a phasic flow in ITV. A biphasic low resistance velocity profile is normally expected in the grafted and permeable ITA. Conclusions The ITA (non-grafted) and ITV are recognized routinely along the parasternal line. The operators should identify these vessels when the parasternal approach pericardiocentesis is required and should also consider obtaining spectral Doppler images to check permeability of grafted ITA in coronary artery bypass graft patients with chest pain.

Although aberrant locations are typical complications of central venous catheterization, the right internal thoracic vein (mammary vein) is an exceptional one. A case of this unusual aberrant location occurring after right internal jugular venous cannulation for total parenteral nutrition, is described. This aberrant position caused signs and symptoms resembling pulmonary embolism. This is the first known description of the symptoms induced by the infusion of parenteral solution into the right internal thoracic vein.

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Major tracheal reconstructive surgery requires a flap to reinforce the suture line and prevent erosion of contiguous large vessels. Omentoplasty, myoplasty, or flaps with a blood supply arising from the branches of the internal thoracic (IT) artery such as the ‘‘pericardial fat graft’’ 1,2 or the ‘‘thymus flap’’ 3 can be used. We describe the ‘‘thymopericardial fat flap’’ (TPF), which includes the IT pedicle, overlying mediastinal pleura, homolateral thymic lobe, and continuous pericardial fat tissue. In adulthood, the intrathoracic portion of the thymic lobes remains as fat and connective tissue lying on the anterosuperior pericardium. Usually, one major thymic branch per lobe comes from the IT artery. 3 The pericardial fat tissue extends up to the caudal portion of the thymus and down the cardiophrenic angles, with the blood supply arising from the IT arteries (Figure 1). During major tracheal reconstructive surgery, the right TPF is mobilized through a median sternotomy combined with a collar incision. Given the length, IT pedicle harvesting is mandatory to ensure the viability of the distal part of flap (pericardial fat tissue). The thyroid isthmus and both thymic lobes are divided medially, with preservation of the superior thymic veins. To expose the undersurface of the right half of the sternum, an externally positioned sternal retractor is used. The initial part of the IT pedicle, with its adjacent fat and parietal pleura, is dissected up to the posterior face of the first costal cartilage, with preservation of the internal thoracic vein at its junction with the innominate vein. The incision is extended along the IT pedicle, down to the sixth intercostal space. The pedicle is freed from the thoracic wall caudally. The intercostal arteries and accompanying veins are identified and divided between surgical clips. The IT pedicle is divided in the sixth intercostal space. The flap is then freed from the ascending aorta and pericardium. Finally, the anastomotic vessels from the pericardiophrenic and musculophrenic branches are divided using a transpleural approach (Figure 1), allowing ‘‘en bloc’’ mobilization of an approximately 20-cm-long 3 5-cm-wide well-vascularized flap (Figure E1).