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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., (© 2022. The Author(s).)

Variants of the axillary artery and brachial plexus were found bilaterally in the axilla of an 86-year-old Asian female. On the left, the cadaver donor had a high bifurcation of the second part of the axillary artery, creating a superficial brachial artery. Meanwhile, the right axilla presented with root, trunk, and cord variations in the formation of the brachial plexus, the most interesting feature being a single, unified cord. Presented in this case report are the structural relationships of the variants with considerations regarding anatomy, embryology, prevalence, and clinical importance.

Background: Medium-long catheters are being used more and more widely in clinical practice, but we still do not know the impact of different placements, but this is an important clinical issue that cannot be ignored., Objective: At present, the tip positioning of the mid-length catheter mainly includes the anterior part of the axilla and the midclavicular line. Different positioning may have different effects. Therefore, we did this research to confirm which positioning is more safety., Methods: We systematically searched the Chinese and English databases: PubMed, Embase, CENTRAL, CINAHL, Web of Science, China Knowledge Network, China Biomedical Literature Database, VIP, Wan Fang. Literature screening, data extraction, and quality evaluation were carried out by 2 researchers, and finally, use Stata to carry out meta-analysis., Results: This study is ongoing and the results will be submitted to a peer-reviewed journal for publication., Ethics and Dissemination: Ethical approval is not applicable, since this is an overview based on published articles., Protocol Registration Number: INPLASY2020110042.

Although the variability of the upper limb arteries is a clinically important problem, the prevalence is varying across the existing studies and classification is rather complicated, not well established and sometimes even unclear for simple and direct understanding and usage. Multiple case reports appearing in the last years apply incorrect, inappropriate, and sometimes misleading terminology. We performed an anatomical cadaveric study of the variability of the arteries of the upper limb, namely, the axilla, arm, and forearm, in 423 upper limbs embalmed with classical formaldehyde method (Central European population). We proposed to apply the Equality system based on the common trunks for denomination of the axillary artery branches principal variations: Truncus subscapulocircumflexus (22.9%), truncus profundocircumflexus (13.75%), and truncus bicircumflexus (13.95%). Further, we proposed the terminology system developed by Rodríguez-Niedenführ et al. for the free upper limb principal arterial trunk variations based on the origin, location (in the arm only, or in the arm and forearm), and course (related to the forearm flexor muscles) of the involved artery: Arteria brachialis superficialis (9.5%), arteria brachioradialis superficialis (6.4%), arteria brachioulnaris superficialis (1.9%), arteria brachiomediana superficialis (0.5%), and arteria comitans nervi mediani manus (3.3%). Extensive development of the catheterization methods via the arteria radialis et ulnaris as well as surgical procedures using flaps based on perforating branches of these arteries (including arteria brachioradialis superficialis et brachioulnaris superficialis) necessitate thorough data on prevalence of the variant vessels for safe performance of these procedures to prevent any unexpected situations or to react adequately in such.

Background: Brachio-basilic/brachial transposition arteriovenous fistula has emerged as one of the autologous arteriovenous fistula options. However, there have not been many reports on the outcomes of basilic or brachial elevation of arteriovenous fistula compared with those of conventional transposition. We evaluated the efficacy of modified brachio-basilic and brachio-brachial arteriovenous fistula creation with short-segment elevation preserving the axillary area., Methods: From March 2016 to August 2018, medical records of the patients who underwent short-segment elevation of brachio-basilic or brachio-brachial arteriovenous fistula in the upper arm (sBAE or sBRE) were reviewed retrospectively., Results: Of the 51 patients, 37 underwent sBAE and 14 underwent sBRE. Maturation failure occurred in two patients (3.92%), who underwent sBAE. Stenosis was the most common complication, which developed in 13 patients (25.5%), and there was no significant difference between the sBAE and the sBRE. In the 51 patients, cumulative primary patency rates at 6 and 12 months were 88.3% and 69.1%, respectively. Assisted primary patency rates at 6 and 12 months were 97.8% and 90.7%, respectively. Secondary patency rates at 6 and 12 months were both 100%. There were no significant differences between the sBAE and the sBRE in 1-year primary patency (79.1% vs. 46.7%; P = 0.20), assisted primary patency (91.6% vs. 88.1%; P = 0.36), and secondary patency rates (100% vs. 100%)., Conclusions: Brachio-basilic/brachial arteriovenous fistula with short-segment elevation preserving the axilla showed excellent 1-year patency rate, easier cannulation, and other future advantages, and therefore, is a logical modification of conventional transposition of arteriovenous fistula., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Our study aimed to compare regional node coverage and doses to the organ at risk (OAR) using conventional technique (CT) vs "AMAROS" (AT) vs intensity-modulated radiation therapy (IMRT) techniques in patients receiving regional nodal irradiation (RNI) for breast cancer (BC)., Methods: We included 30 consecutive patients with BC who received RNI including axillary nodes. Two independent and blinded dosimetric RNI plans were generated for all patients. For target volume coverage, we analyzed the V95%, the D95%, the mean and the minimal dose within the nodal station. For hotspots within nodal target volume, we used the V105%, the V108% and the maximal doses. For OAR, lung V20, mean lung and heart doses, the maximal dose to the brachial plexus and the axillary-lateral thoracic vessel junction region were compared between the three techniques., Results: Target volume coverage and hotspots: Mean V95% in stations I, II, III and IV were 35.8% and 75% respectively with CV, 22.59 and 59.9% respectively with AT technique and 45.58 and 99.6% respectively with IMRT with statistically significant differences ( p < 0.001). Mean V105% (cc) in axillary and supraclavicular stations were 21.3 and 6.4 respectively with CV, 1.2 and 0.02 respectively with AT technique and 0.5 and 0.4 respectively with IMRT with statistically significant differences ( p < 0.001)..OARs: The mean ipsilateral lung V20 was 16.9%, 16.4 and 13.3% with CT, AT and IMRT respectively. The mean heart dose (Gy) was 0.3, 0.2 and 0.2 with CT, AT and IMRT respectively. The maximal dose to the plexus brachial (Gy) was 50.3, 46.3 and 47.3 with CT, AT and IMRT respectively. The maximal dose to the axillary-lateral thoracic vessel junction (Gy) was 52.3, 47.3 and 47.6 with CT, AT and IMRT respectively. The differences were statistically significant for all OAR ( p < 0.001)., Conclusion: AT is a valuable technique for RNI including axilla in patients with limited sentinel lymph node biopsy involvement without additional axillary lymph node dissection since it decreases hotspots in the target volume and lowers the radiation exposure of the OAR. For more advanced tumors or patients who did not respond to primary systemic therapy, CT or IMRT should be considered because of their better coverage of the potentially residual nodal disease. IMRT combines several advantages of offering high conformal plans, limited hotspots and protection of main OAR. The clinical impact of these dosimetric differences need to be addressed., Advances in Knowledge: This study is to our knowledge the first to compare conventional three-dimensional and IMRT techniques for regional nodal irradiation for each nodal station in breast cancer in a context of increasing utilization of axillary irradiation .

Background: Technical advances have improved the safety of cardiac implantable electronic device (CIED) insertion, but periprocedural complications persist. Despite ultrasound (US) guidance for vascular access being feasible and exhibiting shorter fluoroscopy times, it is not widely adopted for insertion of CIEDs. Thus, we studied the use of US for CIED insertion to (1) quantify the success rate of venous cannulation, (2) identify predictors of failed cannulation, and (3) quantify the rate of complications using US guidance., Methods: We studied 166 consecutive patients who underwent US-guided CIED implantation. Anatomic parameters of the axillary vein were measured. The primary outcome was success (group 1) or failure (group 2) to obtain vascular access utilizing US guidance. Secondary outcomes included pneumothorax and hematoma., Results: Successful US-guided cannulation occurred in 154 of 166 patients (93%). No patient had a pneumothorax. Hematoma occurred in 1 of 166 patients (0.01%). Group 2 exhibited higher male proportion at 11 of 12 (92%) compared with 94 of 154 (61%) in group 1 (P = .03), increased vein depth at 3.84 versus 2.85 cm (P = .003), more right-sided implants (P = .03), higher weight at 104.6 versus 85.3 kg (P = .017), higher body mass index at 35.6 versus 29.2 kg/m 2 (P = .049), and higher body surface area at 2.24 versus 1.99 m 2 (P = .013). Other parameters were statistically nonsignificant. In multivariate analysis, vein depth remained significantly associated with failure., Conclusion: Using US guidance for CIED implantation is successful in the vast majority (93%) of patients. Rare cases of unsuccessful cannulation were associated with right-sided implants and increased venous depth., (© 2019 Wiley Periodicals, Inc.)

Background: Combined ultrasound (US)-guided pectoral nerves (PECS) block and axillary vein (AV) puncture for cardiac implantable electronic devices can be effective to achieve optimal perioperative pain management and prevent access-related complications., Methods: A total of 36 patients who underwent combined US-guided PECS block and AV puncture were included. All routinely recorded parameters, including clinical and demographic characteristics, periprocedural medical administrations, the time taken for both PECS block and AV puncture, procedure time, postprocedural pain score, and procedure-related complications, were collected and analyzed., Results: In total, 54 leads were placed in 36 patients. The combined US-guided PECS block and AV puncture was performed successfully in 35 (97.2%) patients without the need for fluoroscopy or venography. AV access for each lead was achieved in a single attempt in 80.6% of cases. The time for both PECS block and AV puncture was 223.6 ± 52.1 s, including the time to apply incision site anesthesia. Additional sedatives and/or local anesthetics were required in two patients during procedure. Visual analog scale average of the patients in the 1st, 6th, and 24th h was 3.7 ± 1.14. 1.61 ± 1.29, and 0.08 ± 0.28, respectively. After the procedure, four patients (three of them woman) needed analgesics. There were no venous access-related complications., Conclusions: This new combined technique maintains both surgical and postoperative analgesia and prevents vascular access-related complications without significant increase on procedure time., (© 2019 Wiley Periodicals, Inc.)

Purpose: While anatomical variations of the subscapular vessels are frequently encountered during axillary dissection, little is found in the literature. The aim of this cadaveric study was to define arterial and venous anatomical variations and frequencies of the subscapular vascular pedicle and its terminal/afferent vessels in women., Methods: We performed 80 dissections of the axillary region on forty female formalin-embalmed cadavers. Each anatomical arrangement was photographed and recorded on a scheme before analysis., Results: We propose a new classification of the subscapular pedicle variations. We observed three types of subscapular arterial variation. The type Ia was the most frequent arrangement (71% of our dissections), the type Ib was observed in 11% and the type II in 18% of cases. We observed four types of subscapular venous variation. The type Ia was observed in 63% of cases, the type Ib in 14%, the type II in 14% and the type III in 10% of cases., Conclusions: This knowledge of the anatomical variation arrangement and frequencies of the subscapular vascular pedicle will assist the surgeon when dissecting the axillary region for malignant or reconstructive procedures.

Background: Junctional tourniquets have been incorporated into tactical combat casualty care for junctional vascular trauma. They apply external compression to stop blood flow in the groin and axilla., Objectives: The primary outcome was effectiveness in achieving arterial occlusion. Secondary outcomes included time to application and pain scores., Data Sources: Medline and EMBASE databases were searched., Study Appraisal and Synthesis Methods: A random-effects meta-analysis was conducted to estimate the average effectiveness and time to effective application for each device., Results: Eight studies reported the effectiveness of junctional tourniquets in healthy volunteers. The average effectiveness was 52% (95% confidence interval [CI], 15-87%) for the abdominal application of the abdominal aortic and junctional tourniquet (AAJT), 83% (95% CI, 73-89%; 26%) for the junctional Emergency Treatment Tool, 87% (95% CI, 79-92%; 15%) for the SAM junctional tourniquet (SJT), and 95% (95% CI, 90-98%) for the Combat Ready Clamp. The groin application of the AAJT was studied in two articles with 100% in both studies. The average time to application was 101 seconds for the SAM junctional tourniquet (95% CI, 50-152 seconds) and the Combat Ready Clamp (95% CI, 63-139 seconds), while it was 130 seconds (95% CI, 85-176 seconds) for the Junctional Emergency Treatment Tool. The abdominal application of AAJT had an average time to application of 92 and 171 seconds in two studies., Limitations: All studies were conducted in healthy volunteers., Conclusion and Implications: Junctional tourniquets may meet a medical need in combat, and in the civilian environment, to control hemorrhage from these difficult injuries. All four Food and Drug Administration-approved devices demonstrate the ability to achieve vascular occlusion in healthy volunteers; however, effectiveness in patient transport has not been evaluated, and outcomes of their use in the field need to be captured and reported., Level of Evidence: Systematic review, level III.

To investigate the topographic anatomy of the median, musculocutaneous, radial and ulnar nerves with respect to the axillary artery and to seek whether these configurations are associated with baseline descriptive data including age, gender, and body-mass index. This cross-sectional trial was carried out on 199 patients (85 women, 114 men; average age: 46.78 ± 15.45 years) in the department of anaesthesiology and reanimation of a tertiary care center. Topographic anatomy of the median, musculocutaneous, radial and ulnar nerves was assessed with ultrasonography. Localization of these nerves with respect to the axillary artery was marked on the map demonstrating 16 zones around the axillary artery. Frequencies of localizations of every nerve in these zones were recorded, and the correlation of these locations with descriptive data including age, gender and BMI was investigated. There was no difference between women and men for the distribution of the median (p = 0.74), ulnar (p = 0.35) and radial (p = 0.64) nerves. However, the musculocutaneous nerve was more commonly located in Zone A13 in men compared to women (p = 0.02). The localization of the median (p = 0.85), ulnar (p = 0.27) and radial (p = 0.88) nerves did not differ remarkably between patients with BMI < 25 kg/m 2 and patients with BMI ≥ 25 kg/m 2 . Notably, the musculocutaneous nerve was more often determined in Zone A10 in cases with BMI ≥ 25 kg/m 2 (p = 0.001). Our results imply that the alignment of the musculocutaneous nerve may vary in men and overweight people. This fact must be considered by the anaesthetist before planning the axillary block of brachial plexus. All these informations may enlighten the planning stages of the brachial plexus blockade.

Objective: To determine the proximity of neurovascular structures to multiplanar distal interlocking screws and proximal interlocking devices for an antegrade inserted humeral nail., Methods: Humeral nails (Depuy Synthes Humeral Nail-EX, Paoli, PA) were inserted into 10 matched cadavers with 3 distal interlocking trajectories: anterior to posterior (A-P), anterolateral to posteromedial, and anteromedial to posterolateral (AM-PL). The distance of the screw path and screw head to the radial, lateral antebrachial cutaneous nerve (LACN), and median nerves and the brachial artery was measured. Proximally, the distance of spiral blades and/or interlocking screws to the axillary nerve was measured., Results: The median distance of the screw path/screw head inserted (A-P) to the LACN was 0 mm/0 mm in the left arm and 3.5 mm/1.6 mm in the right arm. The median distance of the screw path/screw head inserted AM-PL to the median nerve was 7.08 mm/0 mm in the left arm and 0 mm/0.12 mm in the right arm. The median distance of the screw path/screw head inserted AM-PL to the brachial artery was 4.05 mm/3.83 mm in the left arm and 2.19 mm/2.84 mm in the right arm. The humeral head was radiographically divided into 3 zones. The average distances of the axillary nerve to interlocking devices placed into zone 2 and zone 3 of the humeral head are 14.65 mm and 1.07 mm, respectively., Conclusions: When using the DePuy Synthes Humeral Nail-EX, AM-PL screws may risk the median nerve and brachial artery; thus, this trajectory is not recommended. The LACN may be at risk with A-P and to a lesser degree, anterolateral to posteromedial screws. Proximally, interlocking devices in zone 3 of the humeral head may risk the axillary nerve.

Background: Axillary lymph node (LN) status of patients with breast cancer is important in the surgical management. Sonographic evaluation of axillary LNs in newly diagnosed breast cancer is required to predict prognosis., Objective: The purpose of this study was to describe the morphologic features by sonographic evaluation of the cortices and sinuses as well as patterns of blood flow of axillary LNs and correlate same with the clinical staging in women with newly diagnosed breast cancer in a tertiary referral centre., Patients and Methods: This was a prospective and descriptive study of 106 newly diagnosed female breast cancer patients recruited from the surgical outpatient clinic of the University College Hospital, Ibadan, during a period of 9 months in 2015. All 106 patients had clinical evaluation, sociodemographic documentation and ultrasound scans of the breast and axillae performed., Results: The mean age of patients was 48.1 (±11.1) years with age range 20-82 years. Most patients have a negative family history of breast cancer as seen in 97 (91.4%) of them. Abnormal cortex-hilum area ratio was more frequent in the right (66.7%) than the left (41.2%) axillary LNs. Longitudinal-transverse ratio was abnormal in 93.5% and 86.3% of LNs in the right and left axillae, respectively. Slit-like hilum, eccentric cortical thickening, replaced node and rat-bite appearance, respectively, were found in 40.7%, 10.4%, 48.4% and 44.4% of LNs in the right axilla. The peripheral flow type was demonstrated in 46.8% and 48.1% of LNs in the right and left axillae, respectively., Conclusion: Ultrasonography is a good diagnostic tool that can be employed with reasonable accuracy in the initial assessment of axillary involvement in breast cancer. Although the assessment of tumour size and clinical staging leaves little doubt as to the stage of breast cancer disease, sonographic evaluation of the breast and the axilla painted a more ominous picture., Competing Interests: There are no conflicts of interest

Background: The only definitive treatment of chronic axillar hidradenitis suppurativa (HS) that prevents relapses is 'in toto' excision of the infected glandular tissue. This way a deficiency emerges, which needs to be restored. Reconstruction with split skin graft (SSG) is a most common way of recovery, but thoracodorsal artery perforator (TDAP) fasciocutneous flap delivers better functional and aesthetic results., Method: Between May 2014 and July 2016, 14 patients underwent reconstructive surgery after excision of axillary HS, 2 of them had bilateral lesion. In 15 cases TDAP was used, in 1 case we used thoracodorsal artery capillar perforator flap (TAPcp)., Results: In all but 2 cases 1 dominant perforator was found. 1 flap had 2 dominant perforators and 1 flap was supplied by capillary perforators. Size of the flaps spread between 6 × 8 and 10 × 15 cm. 15 reconstructions were successful, 1 flap necrotised because of the lack of compliance of the patient., Conclusion: As a result of the glandular tissue excision carried out because of a chronic HS, a deficiency emerges. TDAP flap is an ideal solution for surgical reconstruction of axillar deficiencies, and a great alternative to SSG.

Background: Axillary plexus block is a common method for regional anesthesia, especially in hand and wrist surgery. Local anesthetics (e.g., mepivacaine) are injected around the peripheral nerves in the axilla. A vasodilatory effect due to sympathicolysis has been described, but not quantified., Materials and Methods: In a prospective controlled study between October 2012 and July 2013, we analyzed 20 patients with saddle joint arthritis undergoing trapeziectomy under axillary plexus block. Patients received a mixture of mepivacaine 1% and ropivacaine 0.75% in a 3:1 ratio. The measurements were carried out on the plexus side and the contralateral hand, which acted as the control. Laser-Doppler spectrophotometry (oxygen to see [O2C] device) was used to measure various perfusion factors before and after the plexus block, after surgery and in 2-h intervals until 6 h postoperatively., Results: Compared with the contralateral side, the plexus block produced an enhancement of tissue oxygen saturation of 117.35 ± 34.99% (cf. control SO 2 : 92.92 ± 22.30%, P < 0.010) of the baseline value. Furthermore, blood filling of microvessels (rHb: 131.36 ± 48.64% versus 109.12 ± 33.25%, P < 0.0062), peripheral blood flow (219.85 ± 165.59% versus 129.55 ± 77.12%, P < 0.018), and velocity (163.86 ± 58.18% versus 117.16 ± 45.05%, P < 0.006) showed an increase of values., Conclusions: Axillary plexus block produces an improvement of peripheral tissue oxygen saturation of the upper extremity over the first 4 h after the inception of anesthesia., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: This study sought to evaluate the effect of elastic compression, functional compressive bandaging, and kinesiotherapy on blood flow of the upper limb with lymphedema secondary to the treatment of breast cancer., Methods: This was a randomized blind crossover clinical trial with a washout period of 7 days between treatments. We evaluated 20 women with a mean age of 66.85 years (standard deviation = 11.76), undergoing three types of therapeutic procedures randomly applied by lot: kinesiotherapy, functional compressive bandaging + kinesiotherapy (FCB), and elastic compression + kinesiotherapy (EC). Blood flow, including mean and maximum velocity, was assessed by Doppler ultrasound before and after the therapeutic procedure (immediately after, 15 minutes, and 30 minutes). We used two-way analysis of variance for repeated measures followed by Bonferroni's test, considering a significance level of 5%., Results: The EC and FCB groups showed a significant increase in the mean velocity of blood flow in the axillary and brachial arteries and veins compared to the group that received only kinesiotherapy (p < 0.05), but no difference between them (p > 0.05). Moreover, the EC and FCB groups showed greater increase in maximum velocity of blood flow in the brachial artery (p < 0.05) compared to the group that received only kinesiotherapy, but no difference between them (p > 0.05)., Conclusion: Elastic compression and functional compressive bandaging combined with kinesiotherapy increased blood flow of upper limb lymphedema.

Aim: Surgical treatment is still the cornerstone in the treatment of breast cancer, a very common neoplasia, particularly affecting the female elderly population. Axillary dissection is crucial in the treatment of some tumours, but variations in axillary vessels anatomy are poorly described in standard anatomy and surgical textbook. We aimed to describe anatomical variations in axillary vessels found in our institutional experience., Patients and Methods: A prospective 3-year study was conducted in our institution from January 2012 to December 2014. Sixty-one consecutive axillary lymph node dissections (ALNDs) were performed in 61 patients who underwent surgery for stage II and III invasive breast cancer. Anatomical details of axillary vascular anatomy and its variations have been evaluated, described and stored in a prospective database., Results: Sixty-one ALNDs have been performed in the study period. The anatomy of lateral thoracic vein, angular vein and axillary vein was studied and compared with standard anatomical description. Eighteen percentage of venous variations were found out of the 61 dissection performed., Conclusions: Vascular anatomy of axilla is complex and variable. A better knowledge of all possible variations might be helpful in preventing injuries during ALND.

A 44-year-old woman was diagnosed cT4bcN3cM1(LYM), Stage IV triple-negative breast cancer.Enhanced computed tomography revealed ipsilateral axillary lymph node metastasis, 10 cm in diameter.The supraclavicular and cervical lymph nodes also had metastases.She received paclitaxel(90mg/m2, on days 1, 8, and 15 every 4 weeks)in combination with bevacizumab(10mg/kg, on days 1 and 15 every 28 days).Her height was 165 cm, and her body weight was 100 kg.After 1 course of chemotherapy, a metastatic axillary lymph node with necrotic changes was removed spontaneously.A few days later, she experienced severe bleeding from her axillary artery, and she went into hypovolemic shock.Despite undergoing surgical hemostasis, the bleeding recurred twice, so we performed coil embolization of her subclavian artery.Thirty -five days after the first occurrence of bleeding, the patient died of sepsis and ARDS due to left arm necrosis.Bevacizumab is effective for the treatment of large tumors, but when the tumor is close to an artery, clinicians should be wary of fatal bleeding after necrosis.

Background: Epithelioid sarcoma is a rare, high-grade malignant tumor of the soft tissue. The incidence of local recurrence, regional lymph node involvement, and distant metastases is high. Epithelioid sarcoma is most often seen in adolescents and young adults. In the early stage before the development of full clinical features, epithelioid sarcoma is often misdiagnosed as a benign disease such as granuloma., Case Presentation: We report a case of a 74-year-old Japanese woman whose epithelioid sarcoma was initially misdiagnosed as fungal infection. Rebiopsy revealed the proliferation of atypical polygonal or oval epithelioid cells in the dermis and lymphocyte infiltration through the dermis. Immunohistochemically, the tumor cells were positive for vimentin, cell adhesion molecule 5.2, epithelial membrane antigen, and E26-related gene. The nuclear expression of integrase interactor 1 was lost in the tumor cells., Conclusions: We encountered a rare case of epithelioid sarcoma and had difficulty in making the correct diagnosis. We suggest that in patients whose lesions are resistant to conventional treatments, repeat biopsy and immunohistochemical studies should be considered to rule out rare epithelioid sarcoma.

Purpose: To update the gross and sonographic anatomy and propose landmarks to perform ultrasound-guided (US-guided) axillary brachial plexus block (BPB) in rabbits., Methods: Forty New Zeeland's rabbit (NZR) cadavers were dissected and the nerves were trimmed, identified, measured, and photographed. Additionally, in twenty NZRs, sonographic images of brachial plexus (BP) were performed through a simple-resolution ultrasound device. The US-guided block was achieved through a minimum volume of lidocaine necessary to surround the BP roots. The effectiveness of the brachial plexus block was assessed on sensitivity and motor functions., Results: The BP resulted from connections between the ventral branches of the last four cervical spinal nerves and the first thoracic spinal nerve. In the axillary sonoanatomy, the BP appeared as an agglomerate of small, round hypoechoic structures surrounded by a thin hyperechoic ring. The amount of time and the minimum volume required to perform was 4.3 ± 2.3 min and 0.8 ± 0.3ml, respectively., Conclusions: The gross and sonographic anatomy of the BP showed uncommon morphological variations. Moreover, from sonographic landmarks, we showed complete reproducibility of the axillary US-guided brachial plexus block with simple resolution equipment and small volume of anesthetics required.

Background: Thoracodorsal artery perforator flap (TAP) is a feasible option to reconstruct defects in upper limb where only skin and subcutaneous tissue is required., Methods: This case series was carried out at department of Plastic and Reconstructive Surgery Combined Military Hospital Rawalpindi. A total of 5 patients with upper limb defects were reconstructed with thoracodorsal artery musculocutaneous perforator flaps. Among them, 3 were pedicled and two free TAP flaps. All flaps except one pedicled flap were raised on a single perforator pedicle. Recipient sites were one axilla, two shoulder regions and two hands. The soft tissue defects in the patients had resulted from burns, trauma, wide local excision of synovial sarcoma and surgery for hidradenitis suppurativa. Preoperative hand held Doppler ultrasound was used to locate and mark the perforator., Results: All flaps survived without significant complications. All flaps were hyperemic in the immediate postoperative period. We designed and raised all the five flaps on eccentrically placed perforators. All the raised perforators originated from the descending branch of the thoracodorsal artery. The donor sites were closed primarily with linear scars in all cases except one, in which partial closure was accomplished with split thickness skin grafting (STSG)., Conclusion: The thoracodorsal artery perforator flap has great potential for reconstructing large, relatively shallow, defects of upper limb because of its suitable skin quality, texture and appropriate thickness, as well as hidden donor site, a reliable pedicle and sparing of muscle unit.

Background: Axillary web syndrome is a rare disease similar to Mondor's disease and is usually seen after axillary surgery. Herein, we describe five new cases, all of which occurred in a setting of melanoma., Patients and Methods: Five patients presented axillary web syndrome following sentinel node surgery, adenectomy or axillary curettage in a setting of melanoma. Therapy involving analgesics and physiotherapy to snap the cord-like structure helped accelerate resolution., Discussion: Some debate continues to surround the physiopathology of axillary web syndrome in the literature, particularly regarding its relationship with Mondor's disease, which is considered to result from superficial venous thrombosis. The lymphatic and myofascial explanation for the syndrome appears to us to be more coherent and justifies the non-aggressive therapeutic approach we adopt for our patients, who receive assurances about the benign nature of their condition and the absence of sequelae., Conclusion: Axillary surgery in patients presenting melanoma appears to be a risk factor for axillary web syndrome. No relationship has as yet been demonstrated between this syndrome and the presence of axillary metastases., (Copyright © 2015. Published by Elsevier Masson SAS.)

Posttraumatic aneurysms of the axillary artery are extremely scarce. In pediatrics, no similar case has been described. Injuries of axillary artery are often associated with ischemic complications, whereas the bleeding risks are not well documented. We report the case of a 5-year-old boy who was admitted with a scapular pulsatile lump 2 weeks after a domestic accident. During his stay, he suddenly presented a hemorrhagic shock. The patient was immediately admitted to the operating room to undergo surgical hemostasis and was then transferred to intensive care unit to stabilize his vital functions. This case shows the possibility of spontaneous and life-threatening acute bleeding of posttraumatic aneurysms of the axillary artery., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: We examined the effectiveness of right axillary arterial perfusion through an interposed Dacron graft in the prevention of cerebral embolism or complications related to ascending aortic cannulation in open proximal anastomosis technique of descending thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA) repair under deep hypothermic circulatory arrest through left thoracotomy., Methods: Between May 2000 and August 2012, 44 patients underwent TAA or TAAA repair using open proximal technique under DHCA. These patients were divided into two groups for evaluation of the effectiveness of right axillary arterial perfusion. Group A included patients who underwent TAA or TAAA repair with ascending aortic cannulation (n=15). Group B was composed of patients who had TAA or TAAA repair with right axillary arterial perfusion through the interposed Dacron graft (n=29)., Results: Mortality in this series was 4.5% (2 of 44 patients; 1 in each group); wherein, the causes were sepsis due to graft infection and aortic dissection (Stanford type A). The incidence rates of cerebral embolism were 27 % (4 of 15 patients in group A) and 3.4% (1 of 29 patients in group B) (p=0.0392, Fisher's exact test). The rates of complications in relation to the aortic cannulation site (dissection or bleeding) were 13% (2 of 15 patients in group A) and 0% (0 of 25 patients in group B)., Conclusions: Right axillary perfusion facilitates easy evacuation of air and allows prompt recommencement of upper body circulation. Consequently, it minimizes the risk of cerebral embolism or complications in relation to aortic cannulation through left thoracotomy.

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.)

Objectives: To describe the distribution of the terminal branches of the brachial plexus at the axillary level and define distribution patterns after ultrasound evaluation., Material and Method: Fifty volunteers underwent ultrasound bilateral axillary brachial plexus scanning exploration. Nerve distribution around the humeral artery was described and the distance between each nerve and the center of the artery was measured. The distance and relationship between the ulnar nerve and the humeral vein were also recorded., Results: The median nerve was located in the anterolateral quadrant (-29±40°) and at a mean distance of 2.1±0.9mm from the artery (85%). The ulnar nerve was found at 53±26° and at 4.2±2.1mm from the artery in the anteromedial quadrant (90%), anterolateral to the vein in 46% of cases, and deep to it in 54%. The radial nerve was at 122±38° and at 3.3±1.7mm from the artery in the posteromedial quadrant (86%). The musculocutaneous nerve was found at -103±22° and 9.3±5.6mm from the artery in the posterolateral quadrant (90%) and in the anterolateral quadrant (-55±16°) at 4.8±2.7mm (10%). There were no differences regarding laterality, gender or overweight patients., Conclusions: Our results allow defining four different anatomical patterns, two based in the position of the musculocutaneous nerve and two based on the disposition of the ulnar nerve with respect to the humeral vein. These patterns were not related to laterality, gender or body weight., (Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.)

Chronic axillary hidradenitis invariably ultimately requires surgical intervention to ameliorate this often painful, unrelenting, recurrent disease that can be disabling. The treatment of choice requires radical excision of at least all hair-bearing skin and its associated apocrine sweat glands. The ensuing large defect often is amenable to closure using a local flap instead of a skin graft to better expedite healing, to allow more rapid rehabilitation, and to minimize the risk of later scar contracture. The island thoracodorsal artery perforator V-Y advancement flap is another alternative that allows unrestricted insetting with primary donor-site closure, as presented here with 2 clinical examples.

Anatomic variations in branching pattern of axillary artery (AxA) are common and typically involve subscapular artery (SsA) and posterior circumflex humeral artery (PCHA). Several skin and muscle flaps are based on the branches of AxA. Furthermore, these branches are frequently used as recipient vessels in functioning free muscle transfers for upper extremity reconstruction and in breast reconstruction. Accurate knowledge of the normal anatomy and variations in branching pattern of AxA is of significant clinical importance for the reconstructive microsurgeon. The purpose of this article is to report the variable branching pattern of AxA based on multidetector-row computed tomography angiography study of 62 upper extremities. The thoracoacromial artery consistently originated from the first or second part of AxA. The classic origin and branching patterns of SsA and PCHA were observed in 21 cases (33.9%). Anatomic variations of SsA and PCHA were observed in 41 upper extremities (66.1%). In addition to the classic pattern, five distinct variations were noted., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Peripheral aneurysms typically present as asymptomatic incidental findings or may present with symptoms when there is local compression of other structures, such as nerves or veins, with ischemia, or rarely with rupture. Larger and symptomatic aneurysms should be repaired. Ultrasonography, computed tomography angiography, and magnetic resonance angiography can be used to define inflow and outflow and better characterize the aneurysm, particularly size and thrombus. Repair of peripheral aneurysms typically involves resection with interposition grafting, although certain anatomic sites may be amenable to endovascular approaches. Femoral pseudoaneurysms can be managed with observation, surgical repair, ultrasound-guided compression, or ultrasound-guided thrombin injection., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Hypothermia is becoming a common treatment for newborns with hypoxic ischaemic encephalopathy. Cerebral metabolic effects have been studied extensively. However, acute effects on peripheral microcirculation are unknown. The effects of therapeutic hypothermia on peripheral microcirculation assessed by side-stream dark field (SDF) imaging technique are presented., Methods: Peripheral microcirculation was assessed in seven newborns undergoing selective head-cooling treatment with SDF imaging video recordings during core temperature 34°C, and then after re-warming at 37°C, and also in seven control patients with rectal temperature 37°C. Microvascular flow index (MFI) and per cent of vessels with sluggish flow were determined by using appropriate software., Results: Sluggish microcirculation was observed during hypothermia compared with controls. MFI and per cent of vessels with sluggish flow returned to normal after re-warming., Conclusions: The results of this small group of newborns going through therapeutic hypothermia suggests that microcirculation is effected with this treatment. Whether this finding has other clinical impacts requires further research.

Background: Axillary block is the most commonly performed brachial plexus block and may be guided by nerve stimulation or ultrasound. Magnetic resonance imaging (MRI) has proven to be beneficial in presenting anatomy of interest for regional anaesthesia and in demonstrating spread of local anaesthetic. The aim of this pilot study was to demonstrate the anatomy as shown by MRI of the brachial plexus in the axillary region., Methods: Nine volunteers and nine patients were examined in a 3.0 Tesla MR. The patients had two different brachial plexus blocks. Subsequently, they were scanned by MRI and finally tested clinically for block efficacy before operation. Axial images, with and without local anaesthetics injected, were viewed in a sequence loop to identify the anatomy., Results: With the high-resolution MRI, we obtained images of good quality, and cords and all terminal nerves could be identified. When local anaesthetics are injected, neurovascular structures are displaced, and the vein is compressed. Viewing the images in a sequence loop facilitates identification of the different nerves and has high instructive value (links S1-3 to these loops are enclosed)., Conclusion: Clinical high-field 3.0 Tesla MRI scanner gives good visualization of brachial plexus in the axilla. The superior ability to detect local anaesthetics after it has been injected and the multiplanar imaging capability make MRI a useful tool in studies of the brachial plexus., (© 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: Classical anatomical descriptions fail to describe variants often observed in the axilla as they are based on studies that looked at individual structures in isolation or textbooks of cadaveric dissections. The presence of variant anatomy heightens the risk of iatrogenic injury. The aim of this study was to document the nature and frequency of these anatomical variations based on in vivo peroperative surgical observations., Methods: Detailed anatomical relationships were documented prospectively during consecutive axillary dissections. Relationships between the thoracodorsal pedicle, course of the lateral thoracic vein, presence of latissimus dorsi muscle slips, variations in axillary and angular vein anatomy, and origins and branching of the intercostobrachial nerve were recorded., Results: Among a total of 73 axillary dissections, 43 (59 per cent) revealed at least one anatomical variant. Most notable variants included aberrant courses of the thoracodorsal nerve in ten patients (14 per cent)--three variants; lateral thoracic vein in 12 patients (16 per cent)--four variants; bifid axillary veins in ten patients (14 per cent); latissimus dorsi muscle slips in four patients (5 per cent); and variants in intercostobrachial nerve origins and branching in 26 patients (36 per cent). The angular vein, a subscapular vein tributary, was found to be a constant axillary structure., Conclusion: Variations in axillary anatomical structures are common. Poor understanding of these variants can affect the adequacy of oncological clearance, lead to vascular injury, compromise planned microvascular procedures and result in chronic pain or numbness from nerve injury. Surgeons should be aware of the common anatomical variants to facilitate efficient and safe axillary surgery., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

The axillary arch (AA) has been thoroughly studied and described as a supernumerary muscle, present unilaterally or bilaterally. This study aims to provide an in vivo demonstration of the influence of an AA on vascular, biometrical, and hemodynamic parameters. Two-hundred thirty-nine subjects with a mean age of 21.3 ± 2.7 years participated in this study. After visual screening by two independent experts, 20 subjects (8.4%) presented with an AA unilaterally (n = 12) or bilaterally (n = 8). An echo-Doppler examination of the vena and arteria axillaris was performed to measure blood flow, velocity of circulating elements, and blood vessel diameter in different positions of the arm (abduction: 45°, 90°, 90° combined with exorotation 'ER', 120°). The arteria axillaris parameters, measured in the test (n = 9; six women, three men) and control group (n = 11; six women, five men), were equivalent for all tested positions. The axillary vein parameters, compared to variations within the groups, revealed no significant differences. However, when comparing variation between groups, significant differences were found for (i) diameter in 90° abduction + ER and 120° abduction; (ii) velocity in 90° and 120° abduction. Blood flow demonstrated no significant difference between groups in any of the positions. The results of this study indicate that there is no functional vascular implication of the AA in the test samples. This study also questions the interpretation of some hypotheses regarding the AA and entrapment syndromes., (Copyright © 2011 Wiley Periodicals, Inc.)

Extramammary Paget's disease (EMPD) is a rare intraepithelial neoplasm occurring less frequently in men and even more rarely in the axilla. A 59-year-old man with severe Parkinson's disease presented with axillary EMPD. The neurological comorbidity made treatment of the EMPD problematical and prompted us to propose locoregional intra-arterial chemotherapy in single short sessions. Two innovative chemotherapeutic macrocomplexes were used: doxorubicin incorporated in large liposomes and the taxane paclitaxel incorporated in albumin nanoparticles. A therapeutic response was seen right from the first treatment and was macroscopically close to complete after four cycles. Five months after the end of treatment the patient had minimal visible disease and had enjoyed a distinct improvement in quality of life, with no noteworthy complications related to the intra-arterial chemotherapy with percutaneous transfemoral catheterization.

We present a case of axillary hematoma complicating an ultrasound-guided infraclavicular block in a patient with undiagnosed mycotic aneurysms of the peripheral arteries. Mycotic aneurysm is a rare medical condition with well-identified risk factors. When performing regional anesthesia in patients with these risk factors, clinicians should have a high degree of suspicion about the possible existence of vascular anomalies. A preprocedure Doppler study of the block area and real-time guidance of the needle using ultrasound may be useful.

Background: Axillary vein compression is an important differential diagnosis in swelling of the upper extremities besides deep venous thrombosis., Case Report: We present a rare case of axillary vein compression in a 17-year-old female with intermittent swelling and pain of the left arm due to an aberrant muscle bundle of the left latissimus dorsi. After resection of this bundle, which corresponded to Langer's axillary arch, the swelling and pain on the left arm resolved completely., Conclusion: In symptomatic patients with axillary vein compression due to Langer's axillary arch, a resection of the muscle bundle is an effective way of treatment., (Copyright 2010 Elsevier Inc. All rights reserved.)

Introduction: Selective antegrade cerebral perfusion is a well-described neuroprotective technique used in proximal aortic surgery. This study investigated whether selective antegrade cerebral perfusion is associated with improved outcomes in both emergency and elective settings compared with deep hypothermic circulatory arrest alone., Methods: Retrospective review was performed for all cases of proximal aortic surgery between January 2004 and May 2007. Of these 271 patients, 105 had emergency and 166 had elective operation. Selection bias was controlled using propensity scoring methods. Multivariable logistic regression analysis was used to model adverse outcomes as a function of selective antegrade cerebral perfusion, emergency status, and their interaction, adjusted for the propensity score. Adjusted odds ratios were formulated with 95% confidence intervals., Results: Operative mortality occurred in 12.1% (33/271) of patients: 8.8% (18/205) in patients with selective antegrade cerebral perfusion versus 22.7% (15/66) in those with deep hypothermic circulatory arrest alone (P = .003). Temporary neurologic dysfunction occurred in 5.9% (15/255) of patients: 4.5% (9/198) in selective antegrade cerebral perfusion versus 10.5% (6/57) in deep hypothermic circulatory arrest alone (P = .09). Stroke occurred in 4.3% (11/255) of patients with no difference between groups. In the elective setting, selective antegrade cerebral perfusion was associated with a significant decrease in operative mortality compared with deep hypothermic circulatory arrest alone. Overall, selective antegrade cerebral perfusion was associated with shorter intensive care unit and ventilator times and fewer renal and pulmonary complications. Significant multivariable predictors of operative mortality were emergency status, previous coronary surgery, and cardiopulmonary bypass time., Conclusions: Use of selective antegrade cerebral perfusion confers a survival advantage during proximal aortic surgery that is most apparent in the elective setting. Improved resource utilization and fewer pulmonary and renal complications were observed in patients with selective antegrade cerebral perfusion.

De novo generation of axially vascularized tissue with clinically relevant dimensions in a large animal model and implementation of clinically established imaging modalities for in vivo evaluation of vascularization. To be used for reconstruction of tissue defects, engineered grafts need to be axially vascularized to enable transplantation without graft loss due to hypoxia. Limitations to dimensions in small animal models had not yet been overcome, which is necessary to yield clinical relevance. Anatomical studies of groin and axillary regions in eight merino sheep were followed by microsurgical creation of an arteriovenous loop (AV-loop), embedded in an isolation chamber filled with fibrin matrix. Constructs were implanted in the groin of six sheep for up to 6 weeks. Course of vascularization in de novo forming tissue was assessed by sequential computed tomography angiography (CTA) and magnetic resonance angiography (MRA) in vivo, as well as by postexplantational micro-computed tomography and histology. A vascular axis was constantly found epifascially at the medial aspect of all sheep's thighs, which was used for AV-loop creation. Patency of AV-loop could be visualized by CTA and MRA scans during 1-6 weeks. Complex 3D-vessel-reconstruction revealed increasing axial vascularization of the fibrin matrix and growing connective tissue within the isolation chamber, which was confirmed by micro-computed tomography and histology postexplantation. De novo formation of axially vascularized tissue was demonstrated for the first time ever in a large animal model, paving the way for the first application of tissue engineering vascularized grafts with clinically relevant dimensions.

The preservation of neurovascular elements passing through the axillary fibrofatty tissue (the intercostobrachial nerve and the lateral thoracic vein) could be techniqually demanding if an en bloc axillary dissection is performed in the conventional way. In this paper we describe a surgical technique for more successful preservation of these elements, by which fragmentation of the axillary fibrofatty tissue is planned and performed "in advance". The techniques of axillary sampling biopsies, where lymphatic vessels are always divided, have shown that cutting of the lymph routes does not increase the risk of local regional recurrence. After adopting and applying this technique in a series of 22 consecutive dissections, the nerve was spared in 22 patients (100%) (compared to an earlier series where the nerve was spared in 53 of 65 patients (81.5%)), while the vein was spared in 21 patients (95%) (earlier 22 of 65 patients (34%)).

Brachial plexus block using axillary approach is a simple and safe method of regional anesthesia often used for elbow, forearm and hand surgery. Different techniques can be used to achieve brachial plexus block. On using perivascular approach to brachial plexus, we neither searched for paresthesia nor used nerve stimulator to identify the correct needle position within the neurovascular sheet. Axillary artery was palpated and a mixture of local anesthetic agents was injected into the neurovascular sheet above and below axillary artery at the site of strongest artery pulsation. The local anesthetic solution comprised equal volumes of lidocaine 2% and bupivacaine 0.5% without adrenaline, in a total volume of 30-40 mL, depending on body mass. This technique is used in more than 150 patients per year at our department. In the present study, 158 patients undergoing upper extremity surgery under brachial plexus block were retrospectively assessed. Successful anesthesia was achieved in 135 (85.0%) patients using brachial plexus block alone, 19 (12.5%) patients required additional medication, two patients required supplementation with intravenous regional anesthesia, and another two patients required general anesthesia. The incidence of successful blocks, latency time of onset, local and systemic complications or allergic skin reactions were investigated. There were no significant complications attributed to the anesthetic technique.

Purpose: This study reports our midterm results with arteriovenous axillary loop grafts (AVALG) and evaluates their role in construction of vascular access for patients on chronic hemodialysis., Methods: The clinical data of 27 patients who underwent construction of an AVALG for hemodialysis access at our institution between July 2002 and December 2006 were analyzed retrospectively. Outcome measures included graft patency, the complication rate, and the frequency and morbidity of secondary procedures after AVALG creation. The Kaplan-Meier method was used to calculate the primary and secondary patency curves., Results: AVALG was constructed as the first access procedure in eight patients: five patients with no suitable vein to construct an adequate angioaccess on the upper limbs, and three patients with elbow and forearm arteritis. The 19 other patients had all had two to five failed prior vascular accesses leading to exhaustion of venous access sites on the upper extremities (18 cases), or a steal syndrome (one case). No postoperative death occurred, but four patients died of causes unrelated to the intervention between the second and the tenth postoperative months. The mean follow-up was 15 months (range, 2-48 months). The primary patency rate at 12 months and the secondary patency rate at 18 months were 51% and 80%, respectively. Infection (three cases), thrombosis (seven cases), and stenosis of the outflow vein (two cases) were the main complications, occurring in 10 of the 27 patients (41%). Twelve secondary procedures were performed in these 10 patients with little additional morbidity. Five of the 27 patients developed irreversible AVALG occlusion leading to access loss: two patients with concomitant graft infection and three patients with a history of subclavian vein catheterization., Conclusion: AVALG may represent a supplementary option for chronic hemodialysis patients with vascular steal or inadequate upper extremity venous access sites.