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Objective To study the clinical characteristics of ultrasound-guided central venous catheterization at various sites in infants with shock, and to explore how to quickly select the site for central venous puncture in infants with shock. Methods The medical data of 112 infants who were diagnosed with shock and underwent central venous catheterization in the Pediatric Intensive Care Unit, Dongguan Children's Hospital Affiliated to Guangdong Medical University, from January 2016 to December 2020 were reviewed retrospectively. The patients were divided into an ultrasound group (n=70) and a body surface location group (n=42) according to whether the catheterization was carried out under ultrasound guidance. The application of ultrasound-guided catheterization at various sites in infants was summarized and analyzed, and the success rate of one-time puncture, overall success rate, catheterization time, and complications were compared between these sites. Results Compared with the body surface location group, the ultrasound group had a significantly higher success rate of one-time puncture, a significantly shorter catheterization time, and a significantly reduced incidence rate of complications in internal jugular vein and femoral vein catheterizations (P<0.05). In the ultrasound group, the proportion of internal jugular vein catheterization was the highest (51%, 36/70), followed by femoral vein catheterization (33%, 23/70), and subclavian vein catheterization (16%, 11/70). For the comparison between different puncture sites under ultrasound guidance, internal jugular vein catheterization showed the shortest time of a successful catheterization [5.5 (5.0, 6.5) minutes] (P<0.05). There was no significant difference in the incidence rate of complications among the different puncture sites groups (P>0.05). Conclusions In infants with shock, ultrasoundguided internal jugular vein catheterization can be used as the preferred catheterization method for clinicians. [ABSTRACT FROM AUTHOR]

Background: Pediatric hemato-oncologic patients require central catheters for chemotherapy, and the junction of the superior vena cava and right atrium is considered the ideal location for catheter tips. Skin landmarks or fluoroscopic supports have been applied to identify the cavoatrial junction; however, none has been recognized as the gold standard. Therefore, we aim to develop a safe and accurate technique using augmented reality technology for the location of the cavoatrial junction in pediatric hemato-oncologic patients. Methods: Fifteen oncology patients who underwent chest computed tomography were enrolled for Hickman catheter or chemoport insertion. With the aid of augmented reality technology, three-dimensional models of the internal jugular veins, external jugular veins, subclavian veins, superior vena cava, and right atrium were constructed. On inserting the central vein catheters, the cavoatrial junction identified using the three-dimensional models were marked on the body surface, the tip was positioned at the corresponding location, and the actual insertion location was confirmed using a portable x-ray machine. The proposed method was evaluated by comparing the distance from the cavoatrial junction to the augmented reality location with that to the conventional location on x-ray. Results: The mean distance between the cavoatrial junction and augmented reality location on x-ray was 1.2 cm, which was significantly shorter than that between the cavoatrial junction and conventional location (1.9 cm; P = 0.027). Conclusions: Central catheter insertion using augmented reality technology is more safe and accurate than that using conventional methods and can be performed at no additional cost in oncology patients. [ABSTRACT FROM AUTHOR]

The distance from the skin surface to the cephalic vein may be measured to assess the need for a subsequent superficialization procedure.12,13 If the cephalic vein in the forearm is found to be inadequate for fistula creation, other veins in the forearm may be examined in a similar fashion to determine whether they are adequate. The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. Note that in case of more central cephalic vein thrombosis or hypoplasia, the forearm portion of the cephalic vein may drain preferentially via a large antecubital vein into the basilic or brachial veins. [Extracted from the article]

Background: If mechanical complications associated with a central venous port (CVP) system are suspected, evaluation with a flow confirmation study (FCS) using fluorescence fluoroscopy or digital subtraction angiography should be performed. Evaluations of mechanical complications related to CVP of the chest wall using FCS performed via the subclavian vein have been reported. However, the delayed complications of a CVP placed in the upper arm have not been sufficiently evaluated in a large population. We evaluated the effectiveness of FCS of CVPs implanted following percutaneous cannulation of the subclavian (chest wall group) or brachial (upper arm group) vein. Methods: A CVP was implanted in patients with advanced cancer requiring chemotherapy. FCS was performed if there were complaints suggestive of CVP dysfunction when initiating chemotherapy. Results: CVPs were placed in the brachial vein in 390 patients and in the subclavian vein in 800 patients. FCS was performed in 26/390 (6.7%) patients in the upper arm group and 40/800 (5.0%) patients in the chest wall group. The clinical characteristics of the patients were similar in both groups. The duration of CVP implantation until FCS was significantly shorter in the upper arm group (136 ± 96.6 vs. 284 ± 260, p = 0.022). After FCS, the incidence of CVP removal/reimplantation being deemed unnecessary was higher in the upper arm group (21/26 [80.8%] vs. 26/40 [65.0%], p = 0.27). In the upper arm group, no cases of catheter kinking or catheter-related injury were observed, and the incidence of temporary obstruction because of blood clots that could be continued using CVP was significantly higher than that in the chest wall group (10/26 [38.5%] vs. 4/40 [10.0%], p = 0.012). Conclusions: FCS was effective in evaluating CVP system-related mechanical complications and deciding whether removal and reimplantation were required in both groups. [ABSTRACT FROM AUTHOR]

Background: Axillary vein/subclavian vein (AxV/SCV) and Internal jugular vein (IJV) are commonly used for implantable venous access port (IVAP) implantation in breast cancer patients for chemotherapy. Previous research focused on comparison of complications while patient comfort was ignored. This study aims to compare patient comfort, surgery duration and complications of IVAP implantation between IJV and AxV/SCV approaches.Methods: Two hundred forty-eight breast cancer patients were enrolled in this randomized controlled study from August 2020 to June 2021. Patients scheduled to undergo IVAP implantation were randomly and equally assigned to receive central venous catheters with either AxV /SCV or IJV approaches. All patients received comfort assessment using a comfort scale table at day 1, day 2 and day 7 after implantation. Patient comfort, procedure time of operation as well as early complications were compared.Results: Patient comfort was significantly better in the AxV/SCV group than that of IJV group in day 1 (P < 0.001), day 2 (P < 0.001) and day 7(P = 0.023). Procedure duration in AxV/SCV group was slightly but significantly shorter than IJV group (27.14 ± 3.29 mins vs 28.92 ± 2.54 mins, P < 0.001). More early complications occurred in AxV/SCV group than IJV group (11/124 vs 2/124, P = 0.019). No difference of complications of artery puncture, pneumothorax or subcutaneous hematoma between these two groups but significantly more catheter misplacement in AxV/SCV group than IJV group (6/124 vs 0/124, P = 0.029). Absolutely total risk of complications was rather low in both groups (8.87% in AxV/SCV group and 1.61% in IJV group).Conclusions: Our study indicates that patients with AxV/SCV puncture have higher comfort levels than IJV puncture. AxV/SCV puncture has shorter procedure duration but higher risk of early complications, especially catheter misplacement. Both these two approaches have rather low risk of complications. Consequently, our study provides an alternative choice for breast cancer patients to reach better comfort. [ABSTRACT FROM AUTHOR]

Tumour thrombus is the presence of tumour cells in great vessels. The reported incidence of tumour thrombus in thyroid carcinoma is about 0.2-3.8%. Being asymptomatic, detection of tumour thrombosis clinically is difficult. We present the report of internal jugular vein (IJV) tumour thrombosis in a known follicular thyroid carcinoma patient, detected with multimodality imaging. Grayscale ultrasound scan of the neck showed a well-defined, bi-lobed (2.4 x 1.5) cm, intraluminal solid lesion with homogeneous echotexture within the distal left IJV close to its confluence with the ipsilateral subclavian vein. The lesion showed significant internal vascularity on colour Doppler assessment. The sonographic findings confirmed further imaging with computed tomography (CT) and radioisotope scans. We conclude that patients with thyroid cancer should be evaluated for tumour thrombosis both clinically and with imaging, particularly with ultrasound and CT/MRI or nuclear medicine, as it has prognostic implications. [ABSTRACT FROM AUTHOR]

Background/Aim: To compare the outcomes of totally implantable central venous access device (TIVAD) insertions by surgical residents (SRs) with those by experienced surgeons (ESs) and establish the safety of percutaneous TIVAD insertion by SRs. Patients and Methods: A total of 700 insertions were successfully performed between January 2015 and December 2019 in our Department. The puncture site conversion and complication rates were compared, and risk factors related to complications were analysed. Results: In total, 84 and 616 insertions were performed in the SR and ES groups, respectively. SRs mainly punctured the internal jugular vein (IJV), and ESs punctured the subclavian vein (SV). The conversion rate from the IJV to SV was similar, whereas that from the SV to IJV was higher by SRs than ESs. Overall, early, and delayed complications were similar between the two groups. Conclusion: Percutaneous TIVAD inserted into the IJV by an SR was demonstrated to be safe. [ABSTRACT FROM AUTHOR]

Central venous catheterization is a widely used venous vascular access intervention and is often used in patients receiving treatment in intensive care units, in various surgeries and for hemodialysis. For this, the vena jugularis interna, femoral vein and subclavian vein, and more rarely the vena jugularis externa, basilic, and cephalic veins are used. Complications are encountered in central venous catheterization applications. Morbidity and mortality can be significantly reduced by rapid detection and treatment of complications in the early period. In this article, a patient with renal failure who was inserted into the right vena jugularis interna ruptured and migrated to the inferior venacava is presented. [ABSTRACT FROM AUTHOR]

Variations of external jugular vein are common. Here, we present a rare terminal bifurcation of the left external jugular vein. The left external jugular vein was formed by the union of entire retromandibular vein and posterior auricular vein. One inch above the clavicle, it bifurcated into medial and lateral divisions. The medial division terminated into the internal jugular vein and the lateral division terminated into the subclavian vein. Medial division received a common vein formed by the union of anterior jugular vein and an anonymous vein lying under the sternocleidomastoid muscle. The lateral division received a common vein formed by the union of suprascapular and transverse cervical veins. The knowledge about this variation could be useful to head and neck surgeons, radiologists and plastic surgeons. [ABSTRACT FROM AUTHOR]

The computed tomography (CT) image-guided needle biopsy was applied in the diagnosis of lung malignant tumors based on artificial intelligence (AI) algorithm under convolutional neural network (CNN) to explore the effect of artificial intelligence algorithms segmentation in needle biopsy surgery and to guide the diagnosis of lung malignant tumors. The subjects of the study were 100 patients with lung malignant tumors admitted to the hospital. The cases were diagnosed as lung cancers by CT, and they were divided into two groups with 50 people in each group. Among them, 50 people in the control group did not use algorithms for guidance and 50 people in the experimental group used algorithms for guidance. The 50 patients who received needle biopsy without guidance of any algorithm were included in the control group. The results showed that the average coincidence rate of automatic segmentation and manual segmentation by the artificial intelligence algorithm was 97.46%, and the average false positive rate (FPR) and false negative rate (FNR) were 0.07% and 0.08%, respectively. The segmentation time of the algorithm group was 12.5 s, which was significantly shorter than the 36.11 s of the control group, and the segmentation speed was significantly faster. The positive rate of pathology in the control group was 78%, and the pathological positive rate of the algorithm group was 80%. The difference in the pathological positive rate between the two groups was 2%, and the detection effect of the pathological positive rate in the algorithm group was close to that in the control group, which was of positive significance in pathological detection. The satisfaction rate of patients in the algorithm group with the detection effect was 88%, and that of the patients in the control group was 94%. The difference in the detection satisfaction rate between the two groups was 6%. The number of patients with pneumothorax in the algorithm group was 22, the number of patients with bleeding was 21, and the number of patients with infection was 2. The number of patients with pneumothorax in the control group was 17, the number of patients with bleeding was 19, and the number of patients with infection was 3. The patients had a higher probability of pneumothorax and bleeding and a lower probability of infection; there was no significant difference in the incidence of complications between the two groups of patients. In summary, the intelligent algorithm was effective and feasible in segmenting lesions, and the accuracy of segmentation could meet the clinical needs, which can be used as a reference for surgery. CT images based on artificial intelligence algorithms were a good way to guide the needle biopsy in the diagnosis of lung malignant tumors, improving the accuracy and sensitivity of the diagnosis of lung malignant tumors. [ABSTRACT FROM AUTHOR]

The subclavian venous puncture catheter has been widely used in treatment of critically ill patients. However, the lack of a mechanical model for subclavian vein puncture and selection of puncture parameters lead to procedure failures. This paper develops a puncture force model, and explores the factors affecting puncture force through a series of experiments. The puncture process is divided into four stages, and a mechanical model is established for each stage. The parameters of the puncture model, including the needle insertion angle and diameter, and venous pressure, are analyzed experimentally using biological tissues. The Box–Behnken experiment design is chosen to account for the cross-interactions of the various factors considered. [ABSTRACT FROM AUTHOR]

This study was to explore the application value for central venous stenosis and occlusion in hemodialysis patients under the CT angiography based on intelligent segmentation algorithm, so that patients can survive better. Spiral CT was used to examine upper limb swelling in 62 uremic hemodialysis patients at a speed of 3.8 mL/s. Nonionic iodine contrast agent was injected around the contralateral limb. The total dosage of 90-102 mL, it was scanned by intelligent trigger technology. The trigger scanning threshold was set. The monitoring point was located in the superior vena cava. CT with convolutional neural network intelligent segmentation algorithm was used to process image data. Finally, the quality of life and related biochemical levels of patients before and after hemodialysis were detected. Under the CT angiography of intelligent segmentation algorithm, 77 stenoses were found in 62 uremic patients, including 48 stenoses of the brachial vein and 17 stenoses of the superior vena cava. The correlation coefficient between CT angiography and digital subtraction angiography (DSA) imaging results of intelligent segmentation algorithm was 0.411. Segmentation effect of the algorithm in this study: automatic segmentation accuracy was greater than 79%. After hemodialysis treatment, the scores of physical fitness, pain, social function, and energy status of patients were significantly increased compared with those before treatment, and the levels of albumin, serum phosphorus, and parathyroid hormone were significantly decreased (P < 0.05). In summary, CT angiography with intelligent segmentation algorithm can obtain clear, intuitive, and complete vascular walking images, and better display subclavian vein, brachiocephalic vein, and superior vena cava. It can provide more valuable support for surgical intervention and has certain application value for better survival of hemodialysis patients. [ABSTRACT FROM AUTHOR]

Background: Malignant peripheral nerve sheath tumor (MPNST) is a rare soft tissue sarcoma mainly treated via surgical resection. Herein, we report a case of MPNST wherein a massive tumor thrombus extended to the major veins and heart. Case presentation: A 39-year-old female with a history of neurofibromatosis type 1 developed MPNST from the right radial nerve. In addition to adjuvant chemotherapy, she underwent wide tumor resection and concomitant radial nerve resection, followed by postoperative radiotherapy. Histological evaluation revealed marked venous invasion. The 2-year follow-up CT revealed an asymptomatic recurrent tumor thrombus extending from the right subclavian vein to the heart. An urgent life-saving operation was performed to ligate the base of the right subclavian vein and remove the entire intravenous thrombus that extended to the right ventricle. The remaining tumor in the right subclavian vein increased in size 3 months after thrombectomy. After confirming the absence of any metastatic lesions, the patient underwent extended forequarter amputation to achieve surgical remission. One year later, a new metastasis to the right diaphragm was safely resected. The patient remains alive without any evidence of disease 2 years after the extended forequarter amputation. Conclusions: In cases of a previous history of microscopic venous invasion, recurrence can occur as a massive tumor thrombus that extends to the great vessels. [ABSTRACT FROM AUTHOR]

Objectives: Central venous catheter (CVC) placement is a common procedure performed in thoracic surgery practice and in the early postoperative period, a chest X-ray is a routine procedure. The aim of this study was to investigate the prevalence of CVC tip malpositions in thoracic surgery patients. Methods: Chest radiographs of patients who were operated on by thoracic surgeons for 5 years were examined. The region between the lower superior vena cava and the atriocaval junction was assigned as “Position 1,” the middle-upper superior vena cava region was assigned as “Position 2,” the right atrium was assigned as “Position 3,” and the regions outside of these were assigned as “Position 4.” Position 1 was evaluated as “no malposition.” Positions 2, 3, and 4 were evaluated as “there is malposition.” Results: The data of 392 patients were evaluated. Catheters inserted in the left internal jugular vein had the most malposition (73.9%), followed by the catheters inserted in the left subclavian vein (62.2%). A number of 50.2% of catheters were evaluated to be in the right positions. According to the CVC tip positions, there was a statistically significant difference between CVC insertion sites (p<0.001). Malpositions of catheters placed from the left were found to be in Position 2, whereas malpositions of catheters placed from the right were found to be in Position 3. Conclusion: The prevalence of CVC tips outside of the recommended location is a common that is often overlooked. Understanding the factors that may lead to malposition and implementing appropriate measures, we believe and will lessen the risk of malposition. [ABSTRACT FROM AUTHOR]

Introduction: Induction of general anesthesia is often associated with hypotension and is a common scenario faced by anesthesiologists. Intraoperative hypotension can have detrimental effects and cause various adverse effects leading to an extended hospital stay. Patients' preinduction volume status can have an effect on postinduction blood pressure. Ultrasonography is a useful tool for measuring intravascular volume status. We studied the ability of ultrasonographic measurement of subclavian vein (SCV) and inferior vena cava (IVC) diameter, collapsibility index (CI) to predict hypotension after induction of general anesthesia. Materials and Methods: We included 120 patients in our study. SCV measurements during spontaneous and deep inspiration and IVC measurements were taken before induction and postinduction blood pressure was monitored. Patients with mean arterial blood pressure <60 mmHg or with a 30% decrease from baseline were considered to be having hypotension. Results: The CI of IVC with a cutoff 37% showed sensitivity of 94% and specificity of 84% which was statistically significant. The CI of 36% of SCV during deep breathing was found to have high sensitivity and specificity of 90% and 87%. Conclusion: Our study in spontaneously breathing preoperative patients shows that SCV CI in deep breathing and IVC CI is very sensitive and reliable in predicting postinduction hypotension. Bedside ultrasound measurements can be easily done to obtain valuable information to recognize patients who could be at risk from postinduction hypotension. [ABSTRACT FROM AUTHOR]

Summary: Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound‐guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One ‐hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J‐tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real‐time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J‐tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J‐tip to a correct position in the lower superior vena cava. All ultrasound‐determined final guidewire J‐tip positions were consistent with the central venous catheter tip positions on chest X‐ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6–8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real‐time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation. [ABSTRACT FROM AUTHOR]

Background and objectives: Muscular variations of the ventral thoracic wall are generally common and of great clinical interest. Materials and methods: An unusual muscular variation of the ventral thoracic wall was observed and dissected in a West-European female body donor. Results: An interclavicularis anticus digastricus muscle was observed and studied. It originated from the manubrium sterni and inserted bilaterally to the clavicles. Both muscle bellies were interconnected by a tendon on the ventral surface of the manubrium sterni. The muscle was innervated by branches of the lateral pectoral nerve. Conclusions: The interclavicularis anticus digastricus muscle is a muscular variation of the ventral thoracic wall of unknown prevalence. This variation might be of clinical interest in orthopaedics and thoracic surgery. It is also a vulnerable structure during infraclavicular insertion of a subclavian vein catheter or fractures of the clavicle. [ABSTRACT FROM AUTHOR]

Acupuncture is practiced as a complementary medicine worldwide. Although it is considered a safe practice, pneumothorax is one of its most common serious complications. However, there have been few reports of deaths due to pneumothorax after acupuncture treatment, especially focused on electroacupuncture. We report an autopsy case of a man in his 60s who went into cardiopulmonary arrest and died immediately after receiving electroacupuncture. Postmortem computed tomography (PMCT) showed bilateral pneumothoraces, as well as the presence of numerous gold threads embedded subcutaneously. An autopsy revealed two ecchymoses in the right thoracic cavity and a pinhole injury on the lower lobe of the right lung, suggesting that the needles had penetrated the lung. There were marked emphysematous changes in the lung, suggesting that rupture of bullae might also have contributed to bilateral pneumothoraces and fatal outcome. The acupuncture needles may have been drawn deeper into the body than at the time of insertion due to electrical pulses and muscle contraction, indicating the need for careful determination of treatment indications and technical safety measures, such as fail‐safe mechanisms. This is the first case report of fatal bilateral pneumothoraces after electroacupuncture reported in the English literature. This case sheds light on the safety of electroacupuncture and the need for special care when administering it to patients with pulmonary disease who may be at a higher risk of pneumothorax. This is also the first report of three‐dimensional reconstructed PMCT images showing the whole‐body distribution of embedded gold acupuncture threads, which is unusual. [ABSTRACT FROM AUTHOR]

Background: Management of acute decompensated heart failure (ADHF) requires accurate assessment of relative intravascular volume, which may be technically challenging. Inferior vena cava (IVC) collapsibility with respiration reflects intravascular volume and right atrial pressure (RAP). Subclavian vein (SCV) collapsibility may provide an alternative. Hypothesis: The purpose of this study was to examine the relationship between SCV collapsibility index (CI) and IVC CI in ADHF. Methods: This was a prospective study of non‐ventilated patients with ADHF who had paired IVC and SCV ultrasound assessments. As SCV CI is highly position‐dependent, measurements were performed supine at 30–45°. Results: Thirty‐three patients were included with 36 encounters. The sample size was adequately powered for receiver‐operator characteristic (ROC) analysis. SCV CI correlated with IVC CI during relaxed breathing (R =.65, n = 36, p <.001) and forced inhalation (R =.47, n = 36, p =.0036). SCV CI < 22% and >33% corresponded to IVC CI < 20% and >50% suggesting hypervolemia (sensitivity/specificity: 72%) and hypovolemia (sensitivity/specificity: 78%), respectively. Moderate to severe tricuspid regurgitation (TR) compared to less than moderate TR was associated with lower SCV CI (medians: 12.4% vs. 25.3%, p =.022) and IVC CI (medians: 9.6% vs. 35.6%, p =.0012). SCV CI and IVC CI were not significantly different among chronic kidney disease stages. Conclusion: In non‐ventilated ADHF, SCV CI at 30–45° correlates with paired IVC CI, and may provide an alternative to IVC CI for assessment of relative intravascular volume, which may facilitate clinical management. Moderate to severe TR decreases SCV CI and IVC CI and may result in overestimation of relative intravascular volume. [ABSTRACT FROM AUTHOR]

The subclavian muscle (MS) is closely related to the neurovascular structures (VNS) in the middle third of the clavicular region, and is critical when performing invasive procedures in this region. Few studies have determined the distance from the MS to the subclavian vein (VS), subclavian artery (AS) and brachial plexus (PB). The purpose of this study was to evaluate the morphological expression of MS and its relationship with VNS in a sample of fresh cadaveric specimens. The study involved the anatomical dissection in the clavicular region of 30 specimens of fresh unclaimed human cadavers from the National Institute of Forensic Medicine and Sciences, Colombia. The qualitative and quantitative characterization of the MS was carried out and the relationship of the MS with the VNS in the clavicular region was determined. The MS presented a length of 102.4 ± 10.3 mm, with an anteroposterior thickness of 8.8 ± 1.9 mm and a superoinferior thickness of 7.0 ± 1.9 mm. The DM was characterized as follows: type I in 12 (40 %) specimens, type II in 18 specimens, type IIa: 10 specimens. We did not find types III and IV. The SV, AS and PB were related to the MS in the medial and middle third of its length at a distance from the upper edge of the MS of 9.4 ± 2.2 mm, 11.3 ± 2.1 mm and 12.0 ± 1, 5 mm respectively. The MS were related to the VNS of the clavicular region in an area between 36.2 ± 3.6 % and 89.4 ± 4.8 % of its total length. The qualitative and morphometric findings of this study enrich the subclavicular anatomical concepts and are useful for the surgical management of clavicle fractures. [ABSTRACT FROM AUTHOR]

Background: Internal jugular vein catheterization (IJVC) and subclavian vein catheterization (SCVC) have been the most preferred central venous catheterizations (CVC) clinically. Individual preference and institutional routine dominate the traditional CVC choice; however, it is lack of high-level evidence. We sought to provide better clinical strategy for CVC site choice based on anatomical landmark technique between IJVC and SCVC. Methods: We systematically reviewed eligible studies from PubMed, OVID, Cochrane and ClinicalTrials.Gov till February 2020. The primary outcomes were catheterization time and overall success rate, and the secondary outcomes were the first-attempt success rate and the instant mechanical complications. Ethical problems are not applicable. Results: A total of 3378 patients from 7 studies were included in the analyses. Neither difference was found on the catheterization time (SMD 95% CI: −0.095–0.124, p = 0.792), nor any difference on the overall success rate (RR = 1.017, 95% CI: 0.927–1.117, p = 0.721, I2 = 89.6%) between the 2 procedures. However, subgroup analyses showed overall success rate of IJVC was significantly lower than that of SCVC (RR = 0.906, 95% CI: 0.850–0.965, p = 0.002) in adults. The first-attempt success rate of IJVC group was higher in the adults (RR = 1.472, 95% CI: 1.004–2.156, p = 0.047). No significance was detected in arterial injury (RR = 1.137, 95% CI: 0.541–2.387, p = 0.735) and pneumothorax (RR = 0.600, 95% CI: 0.32–1.126, p = 0.112) between the two procedures. Hematoma was significantly more in IJVC group than that in SCVC group (RR = 2.824, 95% CI: 1.181–6.751, p = 0.02). Conclusions: Compared with IJVC, SCVC shows a higher overall success rate while a lower first-attempt success rate in adults, and has involved with less hematoma. PROSPERO Registration: CRD42020165444. [ABSTRACT FROM AUTHOR]

Central venous and arterial access through minimally invasive techniques has been described in adult pigs. This article demonstrates success in juvenile animals. Using ultrasound guidance and the modified Seldinger technique, 5 Fr/15 cm single-lumen central venous catheters and 20 Ga 4.5 cm femoral arterial catheters were placed in six Yorkshire cross-bred swine. All six cases had no loss of venous catheter patency or infection during the 96-hour follow-up period. Arterial catheters remained patent, and no significant bleeding was noted after removal. [ABSTRACT FROM AUTHOR]

Background Pulmonary vein isolation (PVI) has entrenched itself as one of the main approaches for the treatment of paroxysmal symptomatic atrial fibrillation (AF). Pulmonary vein isolation prevents focal triggers from pulmonary veins from initiating AF paroxysms. As standard—PVI is performed through the inferior vena cava (IVC) approach, through the femoral vein. However, there are conditions when this approach is not appropriate or is not available. Case summary We report a case of a 53-year-old male who was referred to Pauls Stradins Clinical University Hospital for PVI due to worsening AF. Due to the rare anatomical variant of the venous system, the standard approach to PVI could not be applied. Interrupted cava inferior did not allow for femoral vein and IVC access. We had to figure out a different path—a combination of internal jugular and subclavian veins was used. Transseptal puncture was performed under transoesophageal echocardiography (TOE) control with a puncture needle stiletto. Pulmonary veins were isolated successfully, no complications were observed, and the patient was discharged in sinus rhythm. Discussion In some patients, PVI cannot be done through the standard IVC approach. In such cases, a different venous access must be chosen. Our patient had a rare variant of interrupted IVC and we had to use superior vena cava approach for the procedure. The difficulty of this approach is that procedure instruments are not designed for non-standard venous access; however, a combined use of TOE, general anaesthesia, and contact force-guided ablation has succeeded in isolating patients' pulmonary veins. [ABSTRACT FROM AUTHOR]

The article discusses the case of a female patient with chronic non-bacterial osteomyelitis (CNO) and synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome, with contrast-computed tomography revealing left subclavian vein obstruction.

This article discusses the technique of ultrasound-guided subclavian vein cannulation using the "Open Door Technique." The subclavian vein is challenging to cannulate due to its anatomical location, but this technique has been successful in 20 patients with a 100% success rate. The results are comparable to other studies, and there were no major complications. The article emphasizes the importance of avoiding pneumothorax and arterial punctures by keeping the pleural movement in sonographic view and dynamically visualizing the artery during needle insertion. [Extracted from the article]

Paget-Schroetter Syndrome is a rare condition characterized by the thrombosis of the axillary and/or subclavian vein due to repetitive activity of the upper extremity. This effect results in exertion-induced deep venous thrombosis (DVT) of the upper extremity. In the literature, it has been reported more frequently among the adult population. We aimed to introduce a 15-year-old female patient who suffered an acute DVT of the left upper extremity, and her successful treatment using the Cleaner thrombectomy device. [ABSTRACT FROM AUTHOR]

Those who fail physical therapy or have vascular compression can be successfully treated with relatively risk-free nerve blocks or PM tenotomies, thereby avoiding more invasive thoracic outlet operations and their potential complications.[1][2]-[3] Over 90% of patients with isolated PMS have resolution of symptoms with tenotomy, whereas about 35% of patients with PMS and TOS require both tenotomy and thoracic outlet surgery.[2] Patients A and B underwent PM tenotomy with symptom improvement. The forgotten pectoralis minor syndrome: 100 operations for pectoralis minor syndrome alone or accompanied by neurogenic thoracic outlet syndrome. About 82% of PMS cases are secondary to trauma and 70% of patients evaluated for neurogenic thoracic outlet syndrome (TOS) also have PMS.[1],[2] PMS is often thought to be a subset of TOS, but they must be distinguished as treatment for TOS does not relieve symptoms due to compression of the axillary neurovascular bundle. [Extracted from the article]

Temporary pacing lead is placed through the internal jugular, subclavian or femoral vein under fluoroscopic, echocardiographic, or electrocardiographic guidance. However, in most of the developing world, this procedure is done without fluoroscopic guidance. Blind procedures are known to be associated with more complications as compared to guided procedures. Here, we report a case of the right internal jugular vein perforation while placing the temporary pacing lead in an 80-year-old male patient who had permanent pacemaker implantation done 10 years back and had developed right subclavian and brachiocephalic vein stenosis. Clinicians need to be aware of this rare complication and preferably do these procedures under fluoroscopic guidance and avoid an overzealous approach if the pacing lead does not pass through easily. Patients who had undergone any procedure through their central venous system, especially with retained catheters and pacing leads in situ in the past should undergo a venogram before planning any reintervention from the ipsilateral side to avoid such complications. [ABSTRACT FROM AUTHOR]

Background: Polyarticular septic arthritis (PASA) accounts for approximately 15% of all septic arthritides and is rare in immunocompetent adults. Even with appropriate therapy PASA's mortality rate is nearly 50%.Case Report: We report a rare presentation of PASA caused by idiopathic septic thrombophlebitis of the brachiocephalic vein in an immunocompetent adult female patient who presented with symptoms of right clavicular, left wrist, and right hip pain associated with fevers. Methicillin-sensitive Staphylococcus aureus was isolated in blood cultures and joint aspiration of one of the affected hips. Transesophageal echocardiogram was negative for valvular vegetations and computed tomography chest with contrast revealed thrombi in the brachiocephalic and subclavian veins extending to the superior vena cava. It also showed bilateral pulmonary nodules consistent with septic pulmonary emboli. No clear precipitant for the underlying septic thrombophlebitis was identified. Management was conservative, with systemic anticoagulation and IV antibiotics. The patient's symptoms improved, and she was discharged to subacute rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early diagnosis and treatment of PASA in the emergency department is imperative to reducing overall morbidity and mortality associated with this condition. To the best of our knowledge, this is the only case report of idiopathic septic thrombophlebitis of the subclavian vein causing PASA in an immunocompetent adult. [ABSTRACT FROM AUTHOR]

Background. Chylopericardium is the accumulation of lymphatic fluid in the pericardial cavity. It can be idiopathic or secondary to trauma, cardiothoracic surgery, neoplasm, radiation, tuberculosis, lymphatic duct dysfunction, thrombosis, or other causes. We present a case of chylopericardium due to subclavian vein thrombosis in a patient with protein S deficiency. Clinical Case. A 48-year-old man with a history of protein S deficiency presented to the emergency department with shortness of breath and a productive cough. CT of the chest showed pulmonary emboli, moderate pericardial effusion, and a large thrombus of the superior vena cava, brachiocephalic vein, and subclavian veins. He developed echocardiographic evidence of cardiac tamponade so he underwent pericardiocentesis with drainage of milky-appearing fluid. Analysis of the fluid showed elevated triglycerides consistent with chylopericardium. The pericardial effusion reaccumulated, likely secondary to lymphatic duct obstruction due to his subclavian vein thrombus. Catheter-assisted thrombolysis was performed with resolution of the patient's effusion and symptoms. Conclusion. Chylopericardium is a rare but important complication of subclavian vein thrombosis. Management is typically with surgical intervention, although our case represents successful treatment with catheter-assisted thrombolysis. [ABSTRACT FROM AUTHOR]

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Background: Mediastinal and abdominal lymphatic malformations may not be diagnosed until adulthood. Radiologic and pathologic diagnosis is often challenging due to the rarity of the lesion. Surgical excision of these lesions may be curative but lymphatic leak is a known complication. Lymphatic duct embolization may then be required to treat the leak. Case presentation: We describe a patient with post-surgical chylothorax where thoracic duct lymphangiography and embolization was performed by catheterizing the thoracic duct at the venous angle where it drains into the subclavian vein. Conclusion: Lymphatic duct embolization can be challenging in patients with lymphatic malformations. In these patients, if there is adequate visualization on ultrasound or fluoroscopy, terminal aspect of the thoracic duct can be accessed through the subclavian vein to perform the procedure. [ABSTRACT FROM AUTHOR]

Purpose This article provides evidence that detection of venous air microbubbles (VAMB) in chest computed tomography angiography (CTA) can be an indicator for "normalization of deviance" phenomenon in CT. Method and Materials Institutional review board-approved retrospective study, with waiver for informed consent. Contrast-enhanced chest CT performed during 6 months were reviewed for presence of VAMB in venous segments visible in chest CT (subclavian, brachiocephalic vein, superior vena cava) and cardiac chambers. VAMB volumes were quantified through a semiautomatic method (MIAlite plugin for OsiriX), using a region of interest (ROI) covering the bubble. With basal results, protocols for correct injection technique were reinforced, and VAMB were estimated again at 1 and 3 months. Six months later, questionnaires were sent to the CT technologists to inquire about their perception of VAMB. Descriptive measures with central distribution and dispersion were performed; statistical significance was considered at p < 0.05. Results A total of 602 chest CTA were analyzed, 332 were women (55.14%), with a median age of 58 (interquartile range [IQR] 44–72) years. Among those, 16.11% (100 cases) presented VAMB. Most were emergency department patients (51.6%), male (50.3%), with a median age of 54 (IQR 26) years. There was no difference on detection of VAMB regarding sex (p = 0.19), age (p = 0.46), or referral diagnosis (p = 0.35). Mean air bubbles volume was 0.2 mL (range 0.01–3.4 mL). After intervention, the number of exams with VAMB dropped to 3.29 % (3/91) (p < 0.001). On the 6-month query, 50% of the technicians still considered that VMAB is inevitable, and 60% thought that the occurrence is not associated to risk, and therefore, not actionable. Conclusion VAMB are a frequent finding in chest CTA, and being independent from patient-related variables, it is likely due to technical issues such as intravenous access manipulation during the exam. Reduction after reinforcement of proper performance, and certification of a low concern from CT technicians for any risk associated, provides evidence that there is normalization of deviance in this everyday procedure. [ABSTRACT FROM AUTHOR]

Objective: Puig types 2 through 4 venous malformations (VMs) are challenging to treat with sclerotherapy given their robust systemic outflow. Endovenous balloon occlusion offers a means of temporarily occluding systemic venous outflow to allow for more complete sclerotherapy. This study reviews our experience of implementing this technique in patients with Puig advanced (types 2 through 4) VMs. Methods: An IRB approved review of treated venous malformations from 2013–2016 revealed 10 patients fitting inclusion criteria. Patient demographics, pre-procedural imaging, intra-procedural technical parameters, and post-procedural follow-up outcomes were recorded. All patients underwent temporary balloon occlusion of a systemic or major draining vein during sclerotherapy. Embolic agents included n-butyl cyanoacrylate glue, sodium tetradecyl sulfate foam, and coils. Standard 5 French angioplasty balloons ranged from 4 to 8 mm diameter and 2 to 8 cm length depending on vessel requiring occlusion. All patients underwent minimum 3-year follow-up questionnaire administration re-assessing resolution of lesion symptomology and post-procedural quality of life (QoL) measures. Results: Of the 10 VMs treated, 2 were Type 2, 6 were Type 3, and 2 were Type 4. More than one sclerotherapy session was required in 7/10 patients (mean: 2, range: 1–4). Most common sites of VM systemic drainage included subclavian, popliteal, internal/external jugular, and basilic veins. All patients had no indication for further sclerotherapy following adjunctive balloon occlusion. No non-target embolization or immediate post-procedural complications occurred. Follow-up questionnaires (mean interval: 3 years 6 months, range: 3 years–3 years 11 months) confirmed the persistence of embolization effects, improved QoL, and no additional sclerotherapy sessions for all patients in the cohort. Conclusions: Endovenous balloon occlusion as an adjunct to sclerotherapy can be considered when treating patients with types 2–4 venous malformations. This technique lowers the risk of non-target systemic venous embolization, allowing for operator-driven deeper intralesional sclerosant penetration and subsequently maintained treatment efficacy. [ABSTRACT FROM AUTHOR]

Background: In living donor liver transplantation (LDLT), reported donors' mortality and morbidity were highly correlated with surgeon skills. Therefore, liver transplantation has become a distinct maneuver. In addition, minor liver surgeries complications include shoulder pain, pruritus, urinary retention, as well as major morbidity such as central venous catheter-induced thrombosis of brachial and/or subclavian vein, neuropraxia, foot drop also prolonged post-dural puncture headache. Objective: to compare effectiveness of transcutaneous electrical nerve stimulation (TENS) versus low level laser therapy (LLLT) on pain and functional performance of liver donors' suffering from shoulder pain. Patients and Methods: Thirty donors of both genders with ages ranging from 20 to 40 years old were selected from the Physical Therapy Outpatient Clinic of National Liver Institute, Menoufia University. They were randomly allocated into two equal groups: Group A included 15 donor patients who received 30 minutes TENS, 3 times per week, plus conventional physical therapy exercise program for 12 sessions along 4 weeks and group B that included 15 donor who received fifteen minutes LLLT 3 times per week plus conventional physical therapy exercise program for 12 sessions along 4 weeks. Results: A significant improvement of VAS values post-treatment in both groups, also a significant SST benefits, plus improvement in shoulder flexion and abduction post-treatment compared to pre-values (p > 0.001) unless group A values that were superior to those of group B. Conclusion: It could be concluded that both TENS as well LASER were effective in shoulder functional performance in donor' painful shoulders, but TENS was more effective. [ABSTRACT FROM AUTHOR]

A 10-year-old male patient was admitted to the paediatric intensive care unit due to septic shock and oliguric acute renal failure. A haemodialysis catheter (11.5 Fr) was inserted into left subclavian vein for haemodialysis and cytokine-adsorption therapy. Haemodialysis and cytokine adsorption filter was applied to the patient for a total of two days, and then haemodialysis catheter was not used. The catheter was removed from the patient who was decided to transfer to the service on the fifth day of his admission. Tachycardia and hypotension developed and general condition deteriorated immediately after removal of the catheter. With rapid interventions, shock findings were corrected and the patient was reintubated and followed up in mechanical ventilation. On chest X-ray and thorax ultrasonography, the left hemithorax was completely filled, and a total of 1,500 mL of blood was drained by inserting a thorax tube. The patient was transferred to the paediatric pulmonology clinic after nine days of intensive care stay. Haemothorax development after subclavian catheter removal is a rare but a life-threatening condition. For these reasons, we believe that cases with removed subclavian or internal jugular vein catheters should be followed up for a suitable period of time. [ABSTRACT FROM AUTHOR]

OBJECTIVE To describe an ultrasound-guided technique for central venous catheter placement via the external jugular vein (EJV) in pigs. ANIMALS 96 healthy Landrace-Poland China barrows (approx 16 weeks old with a mean weight of 70 kg). PROCEDURES Pigs were anesthetized. With ultrasound guidance, a needle was inserted into the EJV without a large incision or cutdown procedure. A guidewire was inserted through the needle into the vein. A modified Seldinger technique was used to advance a catheter into the vessel until the tip was in the cranial vena cava near the right atrium. A trocar was used to create a tunnel through the subcutaneous tissues from the catheter insertion site to between the dorsal borders of the scapulae. The free end of the catheter was passed through that tunnel. An extension was attached to the catheter and secured to the skin. Pigs were euthanized and underwent necropsy at completion of the study for which they were catheterized. RESULTS Central venous catheters were successfully placed in all 96 pigs and facilitated collection of serial blood samples with minimal stress. Catheters remained in place for a mean of 6 days (range, 4 to 10 days). Necropsy revealed abscesses along the subcutaneous catheter tract in 9 pigs. Twenty pigs had histologic evidence of phlebitis and fibroplasia in the cranial vena cava. CONCLUSIONS AND CLINICAL RELEVANCE The described technique, in combination with extensive socialization, allowed serial collection of blood samples with minimal stress and restraint and is an alternative to surgical cutdown procedures for catheter placement. [ABSTRACT FROM AUTHOR]

Background Ultrasound (US) guidance is frequently used in critically ill patients for central venous catheter (CVC) insertion. The effect of US on infectious risk remains controversial, and randomized controlled trials (RCTs) have assessed mainly noninfectious complications. This study assessed infectious risk associated with catheters inserted with US guidance vs use of anatomical landmarks. Methods We used individual data from 3 large RCTs for which a prospective, high-quality data collection was performed. Adult patients were recruited in various intensive care units (ICUs) in France as soon as they required short-term CVC insertion. We applied marginal Cox models with inverse probability weighting to estimate the effect of US-guided insertion on catheter-related bloodstream infections (CRBSIs, primary outcome) and major catheter-related infections (MCRIs, secondary outcome).We also evaluated insertion site colonization at catheter removal. Results Our post hoc analysis included 4636 patients and 5502 catheters inserted in 2088 jugular, 1733 femoral, and 1681 subclavian veins, in 19 ICUs. US guidance was used for 2147 catheter insertions. Among jugular and femoral CVCs and after weighting, we found an association between US and CRBSI (hazard ratio [HR], 2.21 [95% confidence interval {CI}, 1.17–4.16]; P  = .014) and between US and MCRI (HR, 1.55 [95% CI, 1.01–2.38]; P  = .045). Catheter insertion site colonization at removal was more common in the US-guided group (P  = .0045) among jugular and femoral CVCs in situ for ≤7 days (n = 606). Conclusions In prospectively collected data in which catheters were not randomized to insertion by US or anatomical landmarks, US guidance was associated with increased risk of infection. [ABSTRACT FROM AUTHOR]

Aim: Even though TIVADs have been implanted for a long time, immediate complications are still occurring. The aim of this work was to review different techniques of placing TIVAD implants to evaluate the aetiology of immediate complications. Methods: A systematic literature review was performed using the PubMed, Cochrane and Google Scholar databases in accordance with the PRISMA guidelines. The patient numbers, number of implanted devices, specialists involved, implant techniques, implant sites and immediate complication onsets were studied. Results: Of the 1256 manuscripts reviewed, 36 were eligible for inclusion in the study, for a total of 17,388 patients with equivalent TIVAD implantation. A total of 2745 patients (15.8%) were treated with a surgical technique and 14,643 patients (84.2%) were treated with a percutaneous technique. Of the 2745 devices (15.8%) implanted by a surgical technique, 1721 devices (62.7%) were placed in the cephalic vein (CFV). Of the 14,643 implants (84.2%) placed with a percutaneous technique, 5784 devices (39.5%) were placed in the internal jugular vein (IJV), and 5321 devices (36.3%) were placed in the subclavian vein (SCV). The number of immediate complications in patients undergoing surgical techniques was 32 (1.2%) HMMs. In patients treated with a percutaneous technique, the number of total complications were 333 (2.8%): 71 PNX (0.5%), 2 HMT (0.01%), 175 accidental artery punctures AAP (1.2%) and 85 HMM (0.6%). No mortality was reported with either technique. Conclusion: The percutaneous approach is currently the most commonly used technique to implant a TIVAD, but despite specialist's best efforts, immediate complications are still occurring. Surgical cut-down, 40 years after the first implant, is still the only technique that can avoid all of the immediate complications that can be fatal. [ABSTRACT FROM AUTHOR]

Purpose: Traditional treatment of axillary-subclavian venous thrombosis is resource intensive due to the need for advanced nursing care and increased utilization of intensive care units for thrombolysis procedures. We recently encountered this in the management of 2 patients with effort-induced upper extremity venous thrombosis following COVID-19 infection and offer a treatment paradigm for consideration. Case Reports: A 30-year-old presented with 2 weeks of left upper extremity symptoms following COVID-19 infection. Duplex ultrasound demonstrated axillary-subclavian venous thrombosis and venogram confirmed total occlusion of the axillary and subclavian veins with profuse collaterals around the occlusion. Suction thrombectomy was performed successfully and veins remained patent at 6 month follow up. The patient declined first rib resection and stopped lifting weights. A 16-year-old presented with 4 days of right arm symptoms 1 month after testing positive for COVID-19. Duplex ultrasound revealed acute axillary and subclavian vein thrombosis and she underwent successful thrombectomy followed by balloon angioplasty with improvement in symptoms. Conclusion: The pandemic has strained health care resources such that the treatment of non-life-threatening conditions must be triaged to conserve resources. While axillary-subclavian venous occlusion is usually not life-threatening, timely treatment leads to decreased morbidity and better outcomes. Percutaneous aspiration and thrombectomy without adjunctive thrombolysis may be of benefit in reducing healthcare resource utilization while still achieving good outcomes during the COVID pandemic and beyond. [ABSTRACT FROM AUTHOR]