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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.

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.

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.

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 …

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

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.

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.

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.