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Lateral epicondylitis, also known as tennis elbow, is characterized by a low-grade inflammatory process in the lateral aspect of the elbow. Symptoms are typically treated conservatively, and most patients show resolution or improvement of symptoms within a few months. For those with refractory symptoms, treatment options are limited with questionable benefit. Embolization of the arteries supplying the elbow decreases the neo-vascularity seen in epicondylitis. The procedure may result in marked improvement in pain and function, which has shown to be durable., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the hemodynamics of percutaneous arteriovenous fistulae (pAVF) created between the proximal radial artery and the deep communicating vein of the elbow., Methods: Consecutive patients with a percutaneously created proximal radial artery to perforating vein arteriovenous fistulae were evaluated and compared with control patients with clinically well-functioning surgical wrist radiocephalic arteriovenous fistulae (sWRC-AVF)., Results: Thirty-one patients with a pAVF (21 males - 68%, mean age: 62 years, range: 53-81), with mean follow-up of 254 days (range: 60-443) and 32 patients with a surgical fistula (20 males - 62%, mean age of 63 years, range: 30-84) were evaluated. Mean access flow and distribution range were similar in the two study groups, with a mean flow of 859 mL/min vs 919 mL/min, respectively. There was no significant difference in the mean radial artery diameter (4 mm vs 4.3 mm, p  = 0.2). Statistically significant trends were observed for resistive index (0.57 pAVF vs 0.52 (0.07) and brachial vein cross-sectional area (13 pAVF vs 33 mm 2 , p  = 0.06). The arteriovenous anastomosis area was significantly smaller with pAVFs (13 vs 43 mm 2 , p  = 0.002) and the pressure difference between extremities was less for the pAVF group vs sWRC-AVF (19 vs 27 mm Hg, respectively, p  = 0.03). Existence of single cephalic or basilic versus cephalic and basilic outflow did not affect vein maturation or overall flow., Conclusions: pAVF have a favourable hemodynamic profile with many similarities when compared with surgically created wrist fistulae. Cephalic and/or basilic vein matured with only minor outflow shunted to the deep venous system.

Purpose: To report our 13 years of experience with the 'primary extension technique' for the prevention of dialysis-associated steal syndrome., Methods: All diabetic patients undergoing upper arm autogenous elbow fistula formation using the primary extension technique between September 2001 and September 2014 at a single centre were included. At follow-up all patients were evaluated for patency, adequacy of needling and the presence or absence of steal symptoms. In primary extension technique, the fistula is formed by anastomosing the median cubital vein with the proximal radial or ulnar artery just below the brachial artery bifurcation., Results: In total, 64 operations of the primary extension technique were included in this study. All patients were diabetic. Primary failure was 5%, follow-up 23-84 months. Nine patients (14%) developed cephalic vein thrombosis. In these cases, the basilic vein was successfully transposed to the existing fistula. In eight patients (12.5%), the cephalic vein required superficialisation. In three patients, the flow was preferentially into the basilic vein with poor maturation of cephalic vein. Of these three patients, there was a small proximal cephalic vein in one patient and stenosis in the other two patients. One patient who developed dialysis-associated steal syndrome is included in the results as they were listed for primary extension technique fistula formation but in fact did not have their fistula formed using primary extension technique. Instead, the anastomosis was formed proximal to the bifurcation of the brachial artery. Symptoms improved with revision of the fistula., Conclusion: Our 13-year experience demonstrates that the primary extension technique is a safe and effective procedure for fistula formation. Patency rates are comparable to brachio-cephalic and brachio-basilic fistulas and primary extension technique is effective in the prevention of dialysis-associated steal syndrome.

The posterior approach is a commonly employed exposure of the elbow that provides excellent visualization and efficacy for various orthopedic procedures, including total elbow arthroplasty (TEA) and fracture care. The posterior approach to the elbow has been associated with an increased rate of wound complications, including infection, skin necrosis, and wound dehiscence. Despite an association between these complications and decreased elbow perfusion, data regarding the intrinsic anatomic etiology for preferential complications in this area has been scarcely reported in the literature. This study characterizes the subdermal and cutaneous vascular perfusion about the elbow by describing the predominant direction of circulation, subdermal anastomoses, and volume of perfusion through cadaveric modeling using computed tomography angiography (CTA). Fifteen upper extremity cadaver specimens were prepared with injection of radiographic contrast directly into the axillary artery immediately preceding CTA imaging of each specimen. Sectra IDS7 software for Windows was used for analysis of all images to produce superimposed axial and 3-D reconstructions of each CTA series. From these images it was discerned that the predominant direction of flow in the posterior elbow integument is anterior medial to posterior lateral. Both the posterior medial and posterior lateral subdermal vascular networks emanate from proximally derived medial arterial sources with few anastomoses and minimal collateral perfusion from the anterolateral location. Consequently, it is important to preserve medial subdermal vascular structures to prevent ischemic wound complications. This is especially true in previously incised elbow integuments. Clin. Anat. 32:509-514, 2019. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

Venous punctures are among the most common procedures performed by healthcare professionals. In particular, the cubital fossa is the site where the venous accesses are frequently made due to the number of superficial veins and the numerous anastomoses in this region. The arrangement of these venous connections is of particular interest for clinical application in several areas, thus, the healthcare professional must possess knowledge about these vessels and their anatomical relationships. The present study aims to analyze the venous pattern of the cubital fossa among individuals from Brazil. This study was approved by a Research Ethics Committee. The sample had 100 healthy individuals (50 men and 50 women). The superficial veins of the cubital fossa were analyzed with the aid of a sphygmomanometer. When inflated, the pressure in the forearm increased and the veins became prominent. It was observed that in the selected sample the types with the highest prevalence were the Type I and Type VII, both with 22% in 200 limbs studied. The chi 2 test showed a significant statistical difference between the anastomosis pattern and the sex of the studied sample. The anastomotic pattern of the superficial veins of the studies sample is similar to African, European and Asian populations. The study of these variations is necessary to provide scientific basis for the healthcare professional during a venipuncture in order to avoid iatrogenic errors and damages in cutaneous nerves or neighboring arteries., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA., Methods: We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique., Results: The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs., Conclusions: Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Abnormal vessels and accompanying nerves are possible sources of pain with lateral epicondylitis. The purpose of this study was to describe the safety and efficacy of transcatheter arterial embolization (TAE) for lateral epicondylitis resistant to conservative treatment., Methods: This prospective study was conducted in 24 patients with lateral epicondylitis resistant to conservative treatments for more than 3 months, with a symptom duration longer than 6 months, and with moderate to severe pain who were treated with TAE between March 2013 and October 2014. Two patients were lost to follow-up, and the remaining 22 patients were followed up for 2 years after TAE., Results: Abnormal vessels were identified in all of the patients. No major adverse events were observed. The Quick Disabilities of the Arm, Shoulder and Hand scores at baseline significantly decreased at 1, 3, 6, and 24 months after treatment (50.8 vs 23.4, 8.3, 5.3, and 2.7, respectively; all P < .001). There was a statistically significant (P < .001) change from baseline to the last observed value in all of the clinical parameters, including visual analog scale pain score, Patient-Rated Tennis Elbow Evaluation score, and pain-free grip strength. Magnetic resonance images obtained 2 years after TAE showed an improvement in tendinosis and tear scores compared with baseline, and no patients showed bone marrow necrosis, obvious cartilage loss, or muscle atrophy., Conclusion: TAE could be one possible treatment option for patients with lateral epicondylitis that fails to improve with conservative treatments., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The exhaustion of superficial venous patrimony or reduced diameter of superficial veins usually prevents patients from having an arteriovenous fistula created. In such cases, using deep vessels can be a more viable option as opposed to an arteriovenous graft. We describe a new approach for the brachio-brachial arteriovenous fistula creation technique. It consists of 3 small incisions, thus causing minimal surgical damage. We have found it to be better tolerated by the patients and well received by dialysis nurses. This procedure also allows improved access for cannulation and more available puncture sites., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Brescia-Cimino radiocephalic arteriovenous fistula (AVF) remains the first-choice vascular access procedure for patients in need of long-term hemodialysis. The average life expectancy of patients receiving hemodialysis has increased in recent years and many patients now live longer and require secondary or tertiary procedures. Elbow fistulas should only rarely be constructed as primary fistulas. The aim of the surgeon must be not only to achieve a functioning fistula, but to avoid possible complications other than failure to mature (FTM), like distal ischemia and cardiac failure and to save the vessels as much as possible for future procedures., Background: Both arterial and venous anatomy of the elbow and upper arm have significant variations. The surgeon must be aware of these variations during the operation, and try not to harm the vasculature of the extremity while trying to construct a functioning fistula. The main advantages of elbow fistulas are the opportunity to have multiple outflows, preservation of the major veins in their original place with no dissection and giving no harm to them, and having a longer outflow tract for cannulation., Conclusions: In the elbow, beginning to construct an AVF with the perforating vein is the most advantageous. If the perforating vein is not available or has been used before, median cubital vein, its branches, median antecubital vein or other available nearby veins may be used depending on the anatomy. Perforating vein should be ligated if any other elbow vein is used to prevent flow to deep veins.

Differentiation between psoriatic arthritis (PsA) sine psoriasis and rheumatoid arthritis (RA) may be a challenge, especially in the early stages, hence the need for new instrumental markers to assist their diagnosis. In this study, we investigated possible dermoscopic differences in vascular appearance of nail fold and elbow (a classic site of repeated trauma) in these two conditions. Fifteen patients with PsA sine psoriasis, 12 patients with RA and 12 controls were included in the study. Regarding the nail fold vascular appearance in PsA sine psoriasis and RA cohorts, the presence of diffuse reddish background with or without sparse dotted vessels was significant in the former, whereas the evidence of parallel dotted/short linear vessels ("fish school-like" pattern) or irregular/ramified, blurry, purple vessels were significant in the latter; none of these patterns were detected in the control group. Regarding the elbow, the pattern significantly associated with PsA sine psoriasis consisted of diffusely distributed, red, dotted vessels. On the other hand, RA patients and controls displayed similar dermoscopic findings, with three possible vascular patterns being observed: (i) irregular, blurry, purple vessels; (ii) avascular appearance; and (iii) sparse, dotted, purple vessels. In conclusion, dermoscopy may be a useful supportive tool for differentiating early PsA sine psoriasis from RA., (© 2016 Japanese Dermatological Association.)

Background: The purpose of the study was to find a relationship between the configuration of autogenous upper arm arteriovenous fistulas (AVFs) at the elbow and high access flow rates., Methods: Forty-seven patients with well-functioning autogenous upper arm AVFs at the elbow were included. The configuration of the AVF and access flow rate was determined by duplex scanning., Results: Hemodialysis access-induced distal ischemia scores and access flow rates were comparable in AVFs with 1 or 2 efferent veins (1829.9 ± 1121.3 mL/min, range [400-5000] vs. 1988.5 ± 1324.5 mL/min, range [130-5000]; P = 0.61). The basilic vein had statistically significant larger diameters than the cephalic vein (8.1 ± 2.7 mm, range [2.7-11.0] vs. 5.8 ± 2.5 mm, range [3.8-13.0]; P = 0.02), but no statistically significant difference in flow rates were observed (1884.5 ± 889.0 mL/min, range [824-3600] vs. 1130.0 ± 1258.4 mL/min, range [400-5000]; P = 0.53). Access flow rates were higher in AVFs with the brachial artery as afferent artery than when the radial artery was used (1909.5 ± 1273.2 mL/min, range [550-5000] vs. 1188.6 ± 642.7 mL/min, range [130-2800]; P = 0.02)., Conclusions: There is no difference in access flow rates in autogenous AVFs at the elbow with 1 or 2 efferent veins. Autogenous AVFs at the elbow on the radial artery have lower access flow rates than AVFs on the brachial artery., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Interscapulothoracic amputation (ISTA) encompasses the removal of the upper limb, scapula and clavicle. As the reconstructive and oncologic limb-saving techniques improved, the indications for this formidable procedure decreased. However, it is still the appropriate procedure in cases with extensive oncologic or traumatic involvement of the shoulder girdle. Following ISTA, the surgeon is not only faced with a large defect but also with severe functional and aesthetic impairments. A solution to these problems is the immediate reconstruction with a free composite transfer from the amputated extremity. We successfully treated three oncologic cases and one traumatic case using this technique. The recipient vessels included the subclavian artery and vein in three cases and the internal thoracic vessels in one case. After a mean follow-up time of 4.5 years, two of the three tumour patients were free of recurrent disease. In all cases stable wound closure was achieved. Three out of four patients would opt for surgery again, in spite of the high occurrence of complications. One patient died after a 14-year event-free postoperative course. We conclude that the defect following ISTA can be successfully covered using a free composite tissue transfer of the amputated disease-free elbow and forearm, while simultaneously reconstructing the shoulder silhouette and axilla. This procedure reduces functional and aesthetic impairments and improves the quality of life., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Multiple superficial veins in different anatomical configurations exist in the elbow. The resulting variety of elbow arteriovenous fistulae (AVFs) is described in this paper. A classification of elbow AVF in nontransposed AVF, transposed AVF and multiple outflow AVF is proposed. The nontransposed brachiocephalic AVF has the lowest primary failure rate and a good medium-term survival particularly in the elderly. The simplest technique is an end-to-side anastomosis of the median cubital vein to the brachial artery. In cases of small upper arm veins, a perforating vein AVF, using multiple outflow tracts, may be helpful to lower primary failure risk. In the era of vein mapping with portable ultrasound elbow AVF should be made when forearm veins are exhausted or too small. A side-to-side AVF in order to enhance retrograde flow in the median forearm vein seems rarely indicated, in particular considering the greater risk of steal and venous hypertension. A transposed brachiobasilic AVF is a tertiary access procedure after the simpler alternatives have been exhausted. There is conflicting evidence of the benefits of one-stage versus two-stage procedures. Therefore, the type of operation should be tailored to the individual patient.

Introduction: The elbow defects can raise problem to plastic surgeon. Indeed, this region is characterized by thin and mobile tissues; its reconstruction must be long-lasting, resistant to movements, to shear forces and to external support. Perforator propeller flaps beings appear an interesting option in the reconstruction of elbow defects. In this report, we describe a patient having benefited from the excision of a melanoma of the region of the elbow. After multidisciplinary meeting and resection of new margins, a reconstruction by perforator propeller flap was realized. A perforator pedicle of the lateral brachial region was located and used. The postoperative result in term of cover and function was considered very satisfactory. The perforator propeller flaps appear a reliable and interesting solution in the coverage of elbow defect., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: The superficial vein of the resting limb constricts sympathetically during exercise. Central command is the one of the neural mechanisms that controls the cardiovascular response to exercise. However, it is not clear whether central command contributes to venous vessel response during exercise. Tendon vibration during static elbow flexion causes primary muscle spindle afferents, such that a lower central command is required to achieve a given force without altering muscle force. The purpose of this study was therefore to investigate whether a reduction in central command during static exercise with tendon vibration influences the superficial venous vessel response in the resting limb., Methods: Eleven subjects performed static elbow flexion at 35% of maximal voluntary contraction with (EX + VIB) and without (EX) vibration of the biceps brachii tendon. The heart rate, mean arterial pressure, and rating of perceived exertion (RPE) in overall and exercising muscle were measured. The cross-sectional area (CSAvein) and blood velocity of the basilic vein in the resting upper arm were assessed by ultrasound, and blood flow (BFvein) was calculated using both variables., Results: Muscle tension during exercise was similar between EX and EX + VIB. However, RPEs at EX + VIB were lower than those at EX (P <0.05). Increases in heart rate and mean arterial pressure during exercise at EX + VIB were also lower than those at EX (P <0.05). CSAvein in the resting limb at EX decreased during exercise from baseline (P <0.05), but CSAvein at EX + VIB did not change during exercise. CSAvein during exercise at EX was smaller than that at EX + VIB (P <0.05). However, BFvein did not change during the protocol under either condition. The decreases in circulatory response and RPEs during EX + VIB, despite identical muscle tension, showed that activation of central command was less during EX + VIB than during EX. Abolishment of the decrease in CSAvein during exercise at EX + VIB may thus have been caused by a lower level of central command at EX + VIB rather than EX., Conclusion: Diminished central command induced by tendon vibration may attenuate the superficial venous vessel response of the resting limb during sustained static arm exercise.

This study investigated the adjustments in muscle activation and oxygenation in biceps and triceps brachii during two tasks sustained to failure at 20 and 60% of the maximal voluntary contraction (MVC) force. The tasks required participants either to push against a rigid restraint (force task) or to support an inertial load (position task) with the elbow flexor muscles. The surface EMG was recorded for biceps brachii, brachioradialis, triceps brachii and trapezius superior muscles. Muscle oxygenation of biceps and triceps brachii was measured by near-infrared spectroscopy. The position task was briefer (404 ± 159 s) than the force task (533 ± 194 s) when performed at 20% MVC (P = 0.011), but endurance time did not differ at 60% MVC (54 ± 19 versus 64 ± 16 s, respectively; P = 0.13). Biceps brachii oxygenation decreased slightly (by ~7%) during tasks performed at 20% MVC, whereas it dropped (-40%) for tasks sustained at 60% MVC. However, the decrease in muscle oxygenation was not a significant predictor of time to failure at the two target forces, although its contribution to muscle fatigue cannot be completely ruled out at 60% MVC. In contrast, time to failure was predicted by the increase in EMG of biceps brachii for both tasks at 20% MVC, and EMG of brachioradialis and trapezius for both tasks at 60% MVC. These results suggest that neural adjustments rather than muscle oxygenation limited the time to failure for the force and position tasks at low and high target forces.

Permanent nerve palsy is an extremely rare but critical complication after embolotherapy of arteriovenous malformations of the extremities. The authors present a case of permanent ulnar nerve palsy after embolotherapy of an arteriovenous malformation around the elbow, and caution that transcatheter embolotherapy of arteriovenous malformations located close to major neurovascular structures must be carefully planned and individualized.

To assess the effect of regional anesthesia on the outcome of elbow arteriovenous fistula (AVF), prospectively studied consecutive patients with end-stage renal disease referred for permanent vascular access to the Vascular Unit of King Fahd University Hospital between September 2004 and September 2007. The patients were divided into 2 groups: Group 1: patients who underwent the construction of the AVF under regional anesthesia and Group 2: patients who were operated under general anesthesia, indicated by their preferences or failure of regional anesthesia. Data including patient characteristics and type of AVF were recorded. The internal diameter of the vein and the artery and intra-operative blood flow were measured. The complications of both types of anesthesia were recorded. The patients were followed up for three months. Eighty four cases were recruited in this study. Complete brachial plexus block was achieved in 57 (68%) patients. Seven patients were converted to general anesthesia and 20 patients had AVF under general anesthesia from the start. There were no significant differences between the 2 groups with regard to basic characteristics or operative data. There were no instances of systemic toxicity, hematomas, or nerve injury from the regional block. No major complications were reported from the general anesthesia. There was no significant difference between both groups regarding early failure of AVF (Group 1, 14% vs. Group2; 11%. P= 0.80). No significant advantage of regional over general anesthesia in terms of early outcome of AVF was seen in this study.

We hypothesized that interrupting the connection between superficial and deep veins of the upper extremity at the elbow for creation of hemodialysis arteriovenous fistulas (AVFs), in addition to adequate dilation of the elbow veins, will reduce the risk of steal syndrome and venous hypertension. In this prospective study over a period of one year, patients who were candidates for creation of elbow AVFs based on Doppler ultrasound findings and physical examination, were enrolled into the study. For creation of AVFs, based on the anatomy of the vessels, side-to-side or end-to-side anastomosis between the brachial artery and either cephalic or median antecubital or basilic veins was performed. In some cases, Gracz AVF was created. For interrupting the connection between superficial and deep veins, the perforating vein was either ligated or used for anastomosis. The patients were then followed-up regarding patency rate of the AVF and complications. AVFs were created in 50 patients and the duration of follow-up varied from one to eight months. About 56% (n = 28) of the patients had history of failed AVF or arteriovenous graft and 48% (n = 24) of them had history of insertion of a dual-lumen catheter for hemodialysis. Neuromuscular problem (n=1) and infection (n=1) were the observed complications. None of the patients developed steal syndrome or venous hypertension. At the end of the study, 47 AVFs (94%) were patent and adequate. Our study suggests that interrupting the connection between the superficial and deep venous systems of the upper extremity can reduce the risk of development of steal syndrome and venous hypertension despite side-to-side anastomosis. These techniques provided acceptable patency rate for elbow AVFs.

The perforating veins, as the name suggests, are the veins that perforate the muscular aponeuroses ensuring communication between the superficial and the deep veins. Located at the bend of the elbow, almost constantly, there is a vein, named perforating vein of the elbow, which is of great interest to the nephrologist who is responsible for the management of vascular access for hemodialysis (HD). It represents, in fact, because of its intrinsic characteristics and topographical reasons, a valuable resource for the creation of a vascular access for HD, especially in obese patients, elderly patients, diabetics, and patients affected by peripheral vasculopathy. Arterio-venous fistulae (AVF) constructed with the perforating vein of the elbow are relatively easy to perform, have an excellent patency rate, a low incidence of early thrombosis, adequate flows, and a low incidence of the steal syndrome. In other types of AVFs, the perforating vein of the elbow subtracts flow to the superficial veins slowing or preventing their full maturation, and can become a problem in measuring the blood flow of the AVF. But still, its presence can maintain patent a fistula in case of poor compliance of the superficial veins, while awaiting for interventional procedures able to accelerate a subsequent maturation. This review intends to explore the role that the perforating vein of the elbow plays in the physiology and pathology of the AVF, in relation to the issues that most frequently occur in clinical practice.

Upper extremity contractures still happen and constitute one of the most trying challenges in burn patients. This series comprised of 4 radial forearm flaps, 14 dorsoulnar artery flaps, and 4 medial arm flaps, all of which were used in a reverse pattern for upper extremity postburn contractures. The reverse flow radial forearm flap (RRFF) was chosen for reconstruction of extensive palmar contractures after burn. The reverse flow dorsoulnar flap (RDUF) was used particularly for reconstruction of the hypothenar aspect of the hand which requires moderate size tissue transfer. The reverse medial arm flap (RMAF) was used for elbow contractures after burn. In the first RMAF, venous congestion occurred and was finaly resolved with minimal flap loss, which was managed with STSG later. In the following 3 cases the flap was supercharged with anastomosis of the brachial vein into the antebrachial vein. Both RRFF and RDUF may provide a smooth and efficient solution. However, RMAF has a significant venous problem, which may result in flap loss, therefore, this flap should not be considered as a first option in the elbow area.

Objective: We postulated that ligation of a consistent perforating venous branch at the elbow would improve distention and flow in the superficial veins about the elbow. This would also lesson the likelihood of arterial steal enabling a favorable outcome following a brachial artery medial antecubital or cephalic vein arterio-venous fistula (AVF)., Methods: Pressure measurements were made from the radial artery after side-to-side brachial artery antecubital or cephalic vein AVF in 20 patients. Clamping of the perforating vein increased radial artery pressure significantly indicating that a considerable amount of flow from the side-to-side AVF was diverted into the deep system and away from the accessible superficial veins. Encouraged by this finding, we studied the outcome of brachial cephalic or brachial antecubital AVF with ligation of the deep branch in 134 patients who were not candidates for radio-cephalic AVF. The end point of the study was successful hemodialysis using the fistula., Results: Of the 134 patients treated, 24 died, and 11 were lost to follow-up and were censored from analysis of fistula performance at that time point. The primary fistula success rate was 89.7% +/- 2.66% and 83.7% +/- 3.5% at 1 and 2 years by life table analysis. No patient developed significant arterial steal or venous hypertension., Conclusion: We recommend this simple one-stage procedure for patients requiring hemodialysis whose cephalic vein at the wrist is unsuitable.

Venipuncture is a routine procedure performed at medical institutions for blood collection and blood donation, as well as for health screening and testing. Venipuncture is invasive and usually mildly painful, but it occasionally causes internal bleeding and chronic persistent pain, which is referred to as complex regional pain syndrome. The most common site of venipuncture is the upper arm. The present study macroscopically and anatomically ascertained positional relationships between cutaneous nerves and veins in the cubital (aka antecubital) fossa in many cadaveric dissections to determine the risk of peripheral nerve injury during venipuncture. We identified the most suitable venipuncture site in the upper arm. The medial cutaneous nerve of the forearm (MCNF) passed above the median cubital vein (MCBV) in 27 of 128 cases (21.1%), and was located inferior to the MCBV in 37 of 128 cases (28.9%). The MCBV also passed above the lateral cutaneous nerve forearm (LCNF) in 8 of 128 cases (6.2%). The LCNF was located deeper than the MCBV in 56 of 128 cases (43.8%). The distribution of cutaneous veins and nerves widely varies, and while no single area suitable for all individuals was identified, puncture of the MCBV near the cephalic vein is the least likely to cause nerve damage., ((c) 2008 Wiley-Liss, Inc.)

This case report describes a patient with elbow contracture due to phlebosclerosis induced by anti-cancer drug infusion. Limitation of elbow extension was completely relieved by surgical excision of the sclerotic vein.

We report the case of a venous pseudoaneurysm that developed after a venipuncture made during a blood donation in an otherwise healthy 43-year-old man. The patient presented 3 years later with a mass in the antecubital fossa that was successfully treated with surgical resection. The clinical features of this exceptionally rare lesion are discussed.

Background: Modeling of pharmacokinetic parameters and pharmacodynamic actions requires knowledge of the arterial blood concentration. In most cases, experimental measurements are only available for a peripheral vein (usually antecubital) whose concentration may differ significantly from both arterial and central vein concentration., Methods: A physiologically based pharmacokinetic (PBPK) model for the tissues drained by the antecubital vein (referred to as "arm") is developed. It is assumed that the "arm" is composed of tissues with identical properties (partition coefficient, blood flow/gm) as the whole body tissues plus a new "tissue" representing skin arteriovenous shunts. The antecubital vein concentration depends on the following parameters: the fraction of "arm" blood flow contributed by muscle, skin, adipose, connective tissue and arteriovenous shunts, and the flow per gram of the arteriovenous shunt. The value of these parameters was investigated using simultaneous experimental measurements of arterial and antecubital concentrations for eight solutes: ethanol, thiopental, 99Tcm-diethylene triamine pentaacetate (DTPA), ketamine, D2O, acetone, methylene chloride and toluene. A new procedure is described that can be used to determine the arterial concentration for an arbitrary solute by deconvolution of the antecubital concentration. These procedures are implemented in PKQuest, a general PBPK program that is freely distributed http://www.pkquest.com., Results: One set of "standard arm" parameters provides an adequate description of the arterial/antecubital vein concentration for ethanol, DTPA, thiopental and ketamine. A significantly different set of "arm" parameters was required to describe the data for D2O, acetone, methylene chloride and toluene - probably because the "arm" is in a different physiological state., Conclusions: Using the set of "standard arm" parameters, the antecubital vein concentration can be used to determine the whole body PBPK model parameters for an arbitrary solute without any additional adjustable parameters. Also, the antecubital vein concentration can be used to estimate the arterial concentration for an arbitrary input for solutes for which no arterial concentration data is available.

After the bidirectional cavopulmonary or Fontan operation, the physiologic consequence is passive flow of the systemic venous return to the pulmonary arteries. Knowledge of pulmonary artery pressure (PA) is valuable in the management of these patients, and obtaining this information without the need for a central line or cardiac catheterization would be advantageous. The aim of this study was to evaluate the correlation between upper extremity peripheral venous (PV) pressures and PA or superior vena cava (SVC) pressures in patients who have undergone cavopulmonary or Fontan connections. During cardiac catheterization, 19 patients with complex cyanotic heart disease who had undergone a cavopulmonary shunt or Fontan procedure were studied. Simultaneous pressure measurements were obtained from the peripheral intravenous line placed prior to the procedure and the SVC or PA. The mean pressures were compared. The mean PV pressure was 17.5 +/- 5.6 mmHg. The mean SVC or PA pressure was 16.1 +/- 5.4 mmHg. The mean difference was 1.5 +/- 1.5 mmHg ( p < 0.001). The correlation coefficient PV to SVC or PA pressure was 0.97 ( p < 0.001). PV pressure measurements taken from an upper extremity accurately reflect PA pressures in patients who have undergone a cavopulmonary shunt or Fontan procedure.

We report on an undefined tumor of the right ulnar side of the elbow in a 15-year-old boy. The clinical examination showed painful swelling in the area of the ulnar nerve at the right elbow as well as sensory and motor deficits of the right hand corresponding to distribution of the ulnar nerve. Ultrasound examination and magnetic resonance imaging showed a tumor along the nerve. Subsequent surgical therapy included tumor decompression by division of the fascia. The histological examination demonstrated a capillary hemangioma that infiltrated the ulnar nerve.After surgery, oral glucocorticoid therapy with cortisone (5 mg/kg per day) was administered over a period of 4 weeks, alternating between 1 week of therapy and 1 week without medication. The result of this combined therapy was a rapid diminution of the tumor and an almost complete restitution of the neural function.

The frequent use of veins in surgery, especially in the replacement of clogged arteries in the lower extremities, persuaded the authors to conduct research concerning the morphology of superficial veins in the human upper extremity. In a post-mortem study a group of 40 male subjects of 22-92 years of age was examined. The preparation of the region of the elbow fossa was performed in order to establish the architecture of superficial veins in the extremity. Many detailed anthropometrical measurements were also carried out, enabling a typological evaluation to be made of the deceased under study. Two characteristic pictures of venous anastomosis were tested, one with symmetrical tributaries to the vena basilica et cephalica and the second characterised by a rich set of tributaries to the vena basilica. The characteristics, calibre and structure of both these suggest a fruitful application of them in vessel surgery. The vena cephalica in particular, taken with efficient valves, may successfully play the role of vessel implant.

Perforator flaps allow an individual flap design on the basis of a preoperative ultrasound examination. Aim of the present study is a preliminary evaluation of results and technical pitfalls of this new technique in the use for flap coverage on the dorsum of the hand and the elbow region. Since 1999, seven individually designed pedicled perforator flaps were prepared on the upper extremity. In four cases, defects on the dorsum of the hand and in a further three defects in the elbow region were treated. In the latter cases the flaps were harvested in a mainly epifascial plane, without dissecting the perforating vessels down to their origin. Five flaps were based on perforating vessels of the interosseous arteries, a further two from the lateral collateral humeral artery. Three out of four pedicled perforator flaps used on the dorsum of the hand healed completely. One flap was lost because of venous insufficiency due to the lack of wrist immobilisation. In the elbow region, two out of three defects were successfully covered with an individual perforator flap. One flap was lost due to venous insufficiency, a further needed an additional split-skin graft with a partial flap loss. The main advantage of the presented technique remains the possibility of individual flap design. However, the donor-site defect is almost negligible since in most cases a primary closure of the donor site was possible. The main arteries remained untouched leaving the blood supply to the hand unchanged. Nevertheless, the mainly epifascial harvest of the perforating vessels in the elbow region has the disadvantage of a short pedicle together with a high degree of torsion which leads to an increased risk of flap loss due to venous insufficiency.

The macroscopic arterial vascularization of the extensor carpi radialis brevis tendon was investigated in 12 elbows from cadavers to provide fundamental anatomic information of this tendon which has been associated with lateral epicondylitis. The arterial blood supply of the extensor carpi radialis brevis tendon was highly consistent. The radial recurrent artery vascularized the entire proximal tendon through direct branches to the medial and lateral border of the tendon forming a network of small vessels on the surface of the tendon. Important contributions were provided by the posterior branch of the radial collateral artery, and minor contributions were provided by the interosseous recurrent artery. The undersurface of the tendon seemed almost avascular. This observation suggests that potential hypovascular zones might be located at the undersurface of the tendon causing degeneration and partial tear of the tendon, and that this might be an etiologic factor in the pathogenesis of lateral epicondylitis. Additional microvascular studies are necessary to investigate this hypothesis.

Objectives: diabetes mellitus is an increasingly common cause of end stage renal failure (ESRF) and the establishment of adequate permanent vascular access for dialysis is a major cause of morbidity and mortality in these patients. The aim of this study was to compare the availability of suitable vein, maturation rates, patency and complication rates of autogeneous elbow fistulas in diabetics and non-diabetics at a single centre where an autogeneous vein only policy is employed., Design: retrospective series., Patients and Methods: two hundred and ninety-three elbow fistulas were attempted in 232 patients over a seven year period, [median age 60 years (range 14-94 years)], of which 210 were in non-diabetic and 83 were in diabetic patients. The diabetic group had a significantly higher proportion of male patients (p < 0.05), peripheral vascular disease and established ESRF., Results: there was a trend towards a higher technical success rate in the non-diabetic group (98% versus 93% p = 0.057). There was no significant difference between the primary failure rate, fistula maturation rate, revision rate or incidence of complications between the two groups. Diabetes had no effect on cumulative secondary fistula patency even when stratified for Type 1/Type 2 diabetes, female sex, old age or primary versus subsequent procedures., Conclusion: diabetes mellitus has no significant detrimental effect on outcome following formation of autogeneous elbow fistulas for haemodialysis., (Copyright 2002 Elsevier Science Ltd.)

We present the case of a large venous aneurysm in the upper extremity of a 71-year-old male. The patient presented with acute thrombosis of the aneurysm, which was only diagnosed at operation. Aetiology, diagnosis and treatment of this uncommon lesion are discussed.

The antecubital flap is a fasciocutaneous strip that has its blood supply provided by the first proximal collateral of the radial artery. This flap was described for the first time in 1983 by Lamberty and Cormack, but it has not been widely used and there have been only a few reports in the literature concerning this procedure. The aim of the present investigation was to demonstrate via an anatomical study and a report on five cases the viability of the various anatomical features of this cutaneous flap, and also its positive contribution to elbow reconstruction. The anatomical study involved eight fresh cadavers (eight upper limbs). An injection of colored prevulcanized latex was made in the humeral artery in the lower third of the arm. The aim was to determine which artery provided blood supply to the flap, its anatomical location, and also to look for possible distal anastomoses which would permit a distal pedicled flap to be removed. Contrary to the findings of other authors, in the present study it was found that the vessel providing blood to the antecubital flap always branched off from the radial artery. However, no anastomoses with distal vascularization were detected, which would have permitted a distal pedicled flap to be obtained. The use of the antecubital flap for elbow coverage was then illustrated by five clinical cases of soft tissue defects of the elbow. This method was found to be reliable, practical, and the flap could be rapidly dissected. Moreover, this particular technique is sensitive, and has an interesting rotational arc. The distal cutaneous island flap has the advantage of limiting scar tissue. A comparison between the antecubital flap and other pedicled flaps has then been made. In conclusion, it appears that this little-known procedure has definite advantages, and that it should be included in the range of surgical techniques that are available for soft tissue reconstruction in the case of elbow defects.

This article details a 7- to 12-year follow-up of seven young male baseball players with osteochondritis dissecans of the capitellum that we treated using closed-wedge osteotomy. This procedure was established by Yoshizu in 1986 for the treatment of "Little League elbow." The bone of the capitellum was revascularized and remodeled within 6 months in all seven patients. Six of the patients were able to return to full athletic activity and continued to play baseball. Radiographic assessment during the follow-up study revealed minimal osteoarthritic change and suggests that the treatment is useful for such an injury.

The forearm extension of the lateral arm flap was introduced on the basis of the vascular territory of the posterior radial collateral artery extending beyond the elbow into the forearm. However, there is controversy as to whether the posterior radial collateral artery extends as a single trunk below the elbow or if it terminates more proximally with only a rich vascular plexus extending beyond the elbow. The purpose of this study was to revisit the artery's anatomy in the region of the elbow and to study its distribution in the forearm. Using latex and barium-gelatin injections of the posterior radial collateral artery in ten cadaveric upper limbs, it was observed that terminal branching of the artery occurred 4.5 cm proximal to the lateral epicondyle of the humerus. Distal to the epicondyle, the terminal branches of the posterior radial collateral artery were seen to fan out as finely arborized branches supplying the lateral forearm skin. No single, constant vascular trunk to the forearm skin could be identified. Furthermore, in its distribution toward the periphery, the terminal branches of the posterior radial collateral artery took an increasingly superficial course. Proximal to the epicondyle, the vessels lay deep within the subcutaneous fat, whereas distal to the epicondyle, they were very close to skin. These findings suggest that lateral forearm skin cannot be islanded without risk of vascular disruption and that the distally sited flap should include skin proximal to the epicondyle for safety.