Anatomical features of a crossing vein connecting left and right internal mammary veins: A preliminary study with computerized tomography or magnetic resonance imaging.

BACKGROUND: In breast reconstruction with free flaps, retrograde venous anastomosis into the internal mammary vein (IMV) is often unavoidable. Utility of a crossing vein between the right and left IMV, one of the anatomical foundations which make retrograde flow possible, has been reported but only with a few detailed features. This study evaluated the presence, actual location, and diameter of the crossing veins using preoperative imaging such as contrast-enhanced computed tomography (CECT), or contrast-enhanced magnetic resonance imaging (CEMRI). Moreover, this is a preliminary non-invasive study to clarify these processes on a larger scale. METHODS: We included 29 cases of unilateral breast reconstruction performed between July 2018 and September 2023 at our institution using unipedicled or bipedicled free deep inferior epigastric artery perforator (DIEP) flaps with retrograde venous anastomosis to only one IMV at the level of anastomosis. No congestion or necrosis was observed. In the final 24 cases with sufficient imaging coverage of preoperative contrast-enhanced images (15 CECT and 9 CEMRI), the crossing veins of IMVs were detected and the number, localization, and diameter were measured. RESULTS: In 20 cases of 24 images, the crossing veins between IMVs were completely identified (83%). In 18 of the cases, only one crossing vein was established immediately ventral to the xiphoid process, averaging 19.3 ± 7.18 mm caudal to the fibrous junction between the sternal body and xiphoid process. The average diameter of the veins was 1.57 ± 0.42 mm. In two other cases, the second crossing vein originated on the dorsal surface of the sternum, but it was a very thin vein of about 0.4 mm. Three images indicated incomplete identification of the crossing vein at the xiphoid process, and in one case, no crossing vein was observed between bilateral IMVs. CONCLUSION: The contrast-enhanced imaging study revealed an anatomic feature that the crossing veins (about 1.5 mm in diameter) connecting the right and left IMVs are located just ventral to the xiphoid process. Furthermore, the crossing veins can be identified on contrast-enhanced images, and refinement of this method is expected to lead to future non-invasive anatomical investigations in an even larger number of cases.

Overlapping lockup lymphaticovenous anastomosis: A useful addition to supermicrosurgery.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is a minimally invasive surgical procedure used to treat lymphedema. This surgical procedure connects the superficial lymphatic vessels to nearby veins to establish lymphatic-venous pathways. One of the most common challenges encountered by lymphatic surgeons when performing LVA is a mismatch in the sizes of the veins and lymphatic vessels, with the effectiveness limited by technical constraints. We conducted a pilot study to evaluate the feasibility of an overlapping lockup anastomosis (OLA) LVA technique to address these problems. METHODS: In this study, we present a novel OLA technique for LVA that addresses the challenges with conventional techniques. The OLA technique was used in 10 lymphedema patients between September 2022 and March 2023 to compare OLA and end-to-end anastomosis. The time required for anastomosis, method of anastomosis, patency rates, and lymphedema volume were evaluated in this study. RESULTS: Of 123 LVAs, 44 were performed using the OLA technique in 10 patients, with indocyanine green lymphangiography revealing unobstructed drainage. A single case of slight fluid leakage occurred, which was resolved by reinforcing the sutures. The average anastomosis time for OLA and the end-to-end technique was 5.55 minutes and 12.1 minutes, respectively. The wounds of the patients healed without infection, and the subjective limb circumference decreased. CONCLUSIONS: The OLA technique could serve as a valuable addition to the current LVA technique, especially for cases with a mismatch in the sizes of the lymphatic vessels and veins. This technique has the potential to promote the broader application of LVA in the treatment and prevention of lymphedema.

Outcomes of one-stage and two-stage aneurysm repair in arteriovenous fistulae.

OBJECTIVE: Maintenance of long-term arteriovenous access is important in long-term care for patients with end-stage renal disease. Arteriovenous access is associated in the long term with the development of fistula aneurysms (FAs). This study aims to evaluate the outcomes of staged FA treatment in dialysis access arteriovenous fistulae (AVF). METHODS: A retrospective review of all patients over a 12-year period with primary autogenous AVF was undertaken at a single center. Patients undergoing elective open aneurysm repair were identified and were categorized into three groups: single FA repair (single, control group) and staged and unstaged repair of two FAs (staged and unstaged). A staged repair was a procedure in which the initial intent was to treat both aneurysms in the AVF and in which the most symptomatic aneurysm was treated first. When the incision from the first surgery had healed, the second symptomatic aneurysm in the AVF was treated. An unstaged repair was a procedure in which the initial intent was to repair both symptomatic aneurysms simultaneously. All patients had a fistulogram before the FA repair. Thirty-day outcomes, cannulation failure, line placement, reintervention, and functional dialysis (continuous hemodialysis for 3 consecutive months) were examined. RESULTS: Five hundred twenty-seven patients presented with FA that met requirements for open intervention; 44% underwent single FA repair, whereas the remaining 34% and 22% underwent staged and unstaged repair of two FAs, respectively. The majority of patients were diabetic and Hispanic. Ninety-one percent of the patients required percutaneous interventions of the outflow tract (37%) and the central veins (54%). Thirty-day major adverse cardiovascular events were equivalent across all modalities. Thirty-day morbidity and early thrombosis (<18 days) were significantly higher in the unstaged group (4.3%) compared with the two other groups (1.3% and 2.1%, single and staged, respectively), which led to an increased need for a short-term tunneled catheter (8.9%) compared with the two other groups (3.4% and 4.4%, single and staged, respectively), Unstaged repair resulted in an increased incidence of secondary procedures (5.0%) compared with the two other groups (2.6% and 3.1%, single and staged, respectively). Functional dialysis at 5 years was equivalent in the single and staged groups but was significantly decreased in the unstaged group. CONCLUSIONS: Open interventions are successful therapeutic modalities for FAs, but unstaged rather than staged repair of two concurrent FAs results in a higher early thrombosis, an increased secondary intervention rate, and a need for a short-term tunneled central line. Staged and single FA repairs have equivalent results. In the setting of two symptomatic FAs, staged repair is recommended.

Acute venous problems: Integrating medical, surgical, and interventional treatments.

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.

Surgical and endovascular treatment of pelvic venous disorder: Results of a multicentre retrospective cohort study.

OBJECTIVE: In the present study, we investigated the clinical outcomes after gonadal vein resection (GVR) and gonadal vein embolization (GVE) with coils in patients with pelvic venous disorder (PeVD). We also assessed the rates of procedural complications and disease recurrence. METHODS: Our multicenter retrospective cohort study included 361 female patients with PeVD-related chronic pelvic pain (CPP) and gonadal vein reflux who underwent GVR (n = 184) or GVE with coils (n = 177) from 1999 to 2020. The clinical outcomes (ie, presence and severity of CPP, procedural complications, disease recurrence) were assessed at 1 month and 1, 3, and 5 years after intervention. The pain intensity before and after treatment was assessed using a visual analog scale. All the patients underwent duplex ultrasound after GVR and GVE, and those with persistent CPP and suspected perforation of the gonadal vein by the coils were also evaluated by multiplanar pelvic venography. RESULTS: GVR and GVE was associated with the reduction or elimination of CPP at 1 month after treatment in 100% and 74% of patients and postprocedural complications in 14% and 37% of patients, respectively (Р < 0.01 for both). The most common complication after either GVR or GVE was pelvic vein thrombosis (11% and 22% patients, respectively; P < .01 between groups). GVE was associated with postembolization syndrome in 20%, coil protrusion in 6%, and coil migration in 1% of patients. The long-term recurrence rate after GVR and GVE was 6% and 16%, respectively (P < .01). CONCLUSIONS: Both GVR and GVE were found to be effective in treating patients with PeVD. However, GVR was associated with better efficacy in the relief of CPP and lower rates of procedural complications and disease recurrence.

Early clinical experience and comparison between percutaneous and surgical arteriovenous fistula.

BACKGROUND: Percutaneous arteriovenous fistula (pAVF) has been recently developed as an alternative to surgical AVF (sAVF). We report our experience with pAVF in comparison with a contemporaneous sAVF group. METHODS: Charts of all 51 patients with pAVF performed at our institution were analyzed retrospectively, in addition to 51 randomly selected contemporaneous patients with sAVF (2018-2022) with available follow-up. Outcomes of interest were (i) procedural success rate, (ii) number of maturation procedures required, (iii) fistula maturation rates, and (iv) rates of tunneled dialysis catheter (TDC) removal. For patients on hemodialysis (HD), sAVF and pAVF were considered mature when the AVF was used for HD. For patients not on HD, pAVF were considered mature if flow rates of ≥500 mL/min were documented in superficial venous outflow; for sAVF, documentation of maturity based on clinical criteria was required. RESULTS: Compared patients with sAVF, patients with pAVF were more likely to be male (78% vs 57%; P = .033) and less likely to have congestive heart failure (10% vs 43%; P < .001) and coronary artery disease (18% vs 43%; P = .009). Procedural success was achieved in 50 patients with pAVF (98%). Fistula angioplasties (60% vs 29%; P = .002) and ligation (24% vs 2%; P = .001) or embolization (22% vs 2%; P = .002) of competing outflow veins were more frequently performed on patients with pAVF. The surgical cohort had more planned transpositions (39% vs 6%; P < .001). When all maturation interventions were combined, pAVF required more maturation procedures, but this was not statistically significant (76% vs 53%; P = .692). When planned second-stage transpositions were excluded, pAVF had a statistically significant higher rate of maturation procedures (74% vs 24%; P < .001). Overall, 36 pAVF (72%) and 29 sAVF (57%) developed mature fistulas. This difference, however, was not statistically significant (P = .112). At the time of AVF creation, 26 patients with pAVF and 40 patients with sAVF were on HD, all through use of a TDC. Catheter removal was recorded in 15 patients with pAVF (58%) and 18 patients with sAVF (45%) (P = .314). The mean time until TDC removal in pAVF group was 146 ± 74 days, compared with 175 ± 99 in the sAVF group (P = .341). CONCLUSIONS: Compared with sAVF, rates of maturation after pAVF seem to be similar, but this result may be related to the higher intensity of maturation procedures and patient selection. An analysis of appropriately matched patients will assist in elucidating the possible role of pAVF vis-a-vis sAVF.

The Distensibility of the Human Vena Cava and Its Importance to In Vitro Studies of Venous Compression Syndromes: A Search for a Suitable Polymer for 3-Dimensional Printing.

BACKGROUND: Venous compression syndromes are clinical conditions in which the large veins are compressed by other anatomical structures. Laboratory simulations may help us better understand the hemodynamics in venous compressions by creating situations similar to those seen in vivo. The aim of this study is to produce a model of the caval bifurcation using a polymer with distensibility similar to the human vena cava. METHODS: Fragments of the inferior vena cava were collected from 13 deceased kidney donors (aged 15-37 years) and were tested for deformation (strain) when subjected to distension at 50 N/cm2. Strips of 5 different polymers-thermic polyurethane and Agilus30 with Vero Magenta (AV) (in 3 different hardnesses) and silicone-were subjected to the same biomechanical tests and compared with the vena cava. A model of the caval bifurcation was produced with 3-D printing. RESULTS: The deformation (strain) of the vena cava wall was 0.16 ± 0.9 when submitted to stress close to 50 N/cm2. Silicone showed a strain higher than the standard deviation of venous fragments. The strain of AV resin 95 Shore was lower than the standard deviation of the venous fragments. AV Resins 70 and 85 Shore showed strains within the standard deviation of the venous specimen, with 70 Shore being closest to the mean venous strain. Therefore, this material was selected for modeling the caval bifurcation. The computed tomography scan image generated a computer model of the caval bifurcation and was printed in 3 dimensions. In addition, the segments of 2 adjacent vertebrae were also printed to reference the compression site. CONCLUSIONS: The 3-D printing of large veins can produce models with anatomy and biomechanics similar to those of human veins and opens a field of investigation into the hemodynamics of venous compression syndromes. Polymers with Shore A70 appear to have biomechanical properties similar to those of the vena cava wall. The model obtained in this study can be used in several in vitro studies of May-Thurner Syndrome.

Outcome after surgical treatment of venous malformations of the hand in childhood.

OBJECTIVE: Surgical treatment of venous malformations (VMs) of the hand is challenging. The hand's small functional units, dense innervation, and terminal vasculature can be easily compromised during invasive interventions like surgery or sclerotherapy, leading to an increased risk of functional impairment, cosmetic consequences, and negative psychological effects. METHODS: We have conducted a retrospective review of all surgically treated patients diagnosed with VMs of the hand between 2000 and 2019 and evaluated their symptoms, diagnostic investigations, complications, and recurrences. RESULTS: Twenty-nine patients (females, n = 15) with a median age of 9.9 years (range, 0.6-18 years) were included. Eleven patients presented with VMs involving at least one of the fingers. In 16 patients, the palm and/or dorsum of the hand was affected. Two children presented with multifocal lesions. All patients presented with swelling. Preoperative imaging was done in 26 patients and consisted of magnetic resonance imaging in nine patients, ultrasound in eight patients, and both modalities in nine patients. Three patients underwent surgical resection of the lesions without any imaging. Indications for surgery were pain and restriction of function (n = 16), and when lesions were preoperatively evaluated as completely resectable (n = 11). In 17 patients, a complete surgical resection of the VMs was performed, whereas in 12 children, an incomplete resection of VM was deemed due to nerve sheath infiltration. At a median follow-up of 135 months (interquartile range, 136.5 months; range, 36-253 months), recurrence occurred in 11 patients (37.9%) after a median time of 22 months (range, 2-36 months). Eight patients (27.6%) were reoperated because of pain, whereas three patients were treated conservatively. The rate of recurrences did not significantly differ between patients presenting with (n = 7 of 12) or without (n = 4 of 17) local nerve infiltration (P = .119). All surgically treated patients who were diagnosed without preoperative imaging developed a relapse. CONCLUSIONS: VMs in the region of the hand are difficult to treat, and surgery is associated with a high recurrence rate. Accurate diagnostic imaging and meticulous surgery may contribute to improve the outcome of the patients.

The First Latin American Consensus on Superficial and Perforating Venous Mapping.

With the aim of obtaining a map which is useful as a diagnostic tool and therapeutical orientation, complementing the written report of duplex ultrasound venous study, Latin-American Scientific Societies of Phlebology, Vascular Surgery and Vascular Imaging were invited to participate, through their regional representatives, to the First Consensus of Superficial and Perforating Venous Mapping. A consensus process using a modified Delphi method was carried out. An International Working Group was formed, which developed a Prototype of the Venous Mapping that worked as a starting point for consensus, and was presented in a first virtual meeting of 54 experts (societies' representatives) when the methodology was explained. For the consensus process, two rounds of self-administrated questionnaires with feedback were used. In the first questionnaire a 100% consensus was obtained in the 15 statements (an agreement range of 85.2% to 100%) In the analysis of qualitative data, three categories according to the actions to implement were identified - actions which involved no action, minor changes and major changes. This analysis was used to build the second questionnaire, which reached a consensus in its six statements (agreement range of 87.1% to 98.1%). A final consensus on every field proposed was established with the approval of all the experts consulted and it was presented at a third online meeting. The document of the superficial and perforating venous mapping reached by consensus is presented hereafter.

Intravenous Lobular Capillary Hemangioma of the Neck: A Report of 2 Cases.

Background: Intravenous lobular capillary hemangioma (IVLCH) of the neck is a kind of rare benign tumor of vein. Purpose: In this paper, we report two female patients who were hospitalized because of neck masses. Results: The tumors in the neck veins of our patients were white oval masses with pedicle, clearly defined and of different sizes. Their immunohistochemical staining results showed CD31 (+), CD34 (+), SMA (+), ERG (+). The pathological diagnosis was intravenous lobular capillary hemangioma. Conclusions: Due to the location, morphology and immunohistochemistry, This lesion needs to be distinguished from other intravascular lesions such as thrombus, hemangiosarcoma and papillary endothelial hyperplasia.

Quantitative phase analysis and hyperspectral imaging for the automatic identification of veins and blood perfusion maps.

INTRODUCTION: Medical workers commonly physically identify subcutaneous veins to locate a suitable vesselto implant a catheter for drug administration or blood sample. The general rule of thumb is to locate a big, clean vein that will allow the medication to readily pass within the intended blood vessel. Peripheral problematic venous access happens when a patient's veins are difficult to palpate because of factors like dark skin tone, edema or excess tissue. The ability to see how the vasculature changes to support the therapeutic methods without damaging the surrounding tissue is another challenge. MATERIALS AND METHODS: Hyperspectral imaging (HI) is a developing technique with several potential uses in medicine. Using its spectroscopic data, veins and arterioles could be noninvasively detected and discriminated. It is frequently important to use quantitative phase analysis for vein localization. To assess hyperspectral image data for the detection of both veins and peripheral arteries, we suggest using an advanced image processing and classification algorithm based on the phase information related to the index of refraction change and associated scattering. We show that this need may be satisfied using quantitative phase imaging of forearm skin tissue at different depths. RESULTS: To demonstrate the variations in the diffuse reflectance characteristics between skin surface and veins, phase resolved pictures were successfully produced for twelve volunteers using our imaging methodology. We found that the skin surface details are completely apparent at the unique wavelength of 441 nm. The 500-nm wavelength was the most efficient for grouping peripheral arteries and illuminating the blood perfusion maps. Using our HI experimental setup and our phase imaging procedure on the 600 nm and 650 nm visible spectral pictures, we were able to properly describe the vein map. This spectral area may be utilized as a vein locator marker which could approximately reach till 3 mm depth under skin surface. CONCLUSIONS: Initial findings suggested that our imaging technique would be able to assist medical examiners in safely assessing the veins and arteriole's locations automatically without exposing the skin to infrared radiation. Meanwhile, our pilot research in this work to determine the best spectral wavelengths for localizing veins and mapping blood perfusion using our phase analysis imaging strategy with the HI camera. By substituting the HI camera with a custom conventional RGB camera that only functions at specific wavelengths during the discovering of blood perfusion locations or prior to intravenous catheterization, a distinctive and efficient system for precise identification may be developed to serve in the field of the vascular therapeutic methods.

Pelvic pain and venous congestion revisited: examining relationship between chronic pelvic pain and uterine venous size and blood flow.

OBJECTIVE: To investigate the relationship between increased uterine venous plexus diameter and chronic pelvic pain in women attending a gynecology clinic. METHODS: This was a retrospective study of patients attending a tertiary university hospital in London, UK. Women presenting to the gynecology clinic undergoing transvaginal ultrasound examination were recruited into the study. The largest trunk of the uterine venous plexus was measured on each side. Blood flow within the uterine veins was categorized into continuous or interrupted flow and evaluated using color and spectral Doppler ultrasound during normal respiration and on Valsalva maneuver to demonstrate the presence of venous reflux. The largest uterine vein diameter and its blood flow were used for the analysis. The main variables of interest were chronic pelvic pain, uterine vein diameter and type of blood flow. RESULTS: We included 1500 women in the study, of whom 584 (38.9% (95% CI, 36.5-41.5%)) reported chronic pelvic pain. Dysmenorrhea was the most common type of pelvic pain. Age (P < 0.001), menopausal status (P = 0.02), varicose veins (P = 0.01), adenomyosis (P < 0.001) and endometriosis (P < 0.001) were found to be independently associated with the occurrence of pain on multiple logistic regression analysis. There was no difference in uterine vein diameter between women with and those without pain (P = 0.10). Neither uterine vein diameter (P = 0.47) nor type of blood flow (P = 0.07) was significantly associated with the occurrence of pelvic pain on multiple logistic regression. CONCLUSIONS: Our findings show that uterine vein diameter is not associated with pelvic pain. However, we found other important clinical and demographic factors that are associated with chronic pelvic pain. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Discordant imaging: adrenal vein sampling in almost half of patients with primary aldosteronism and a unilateral adrenal adenoma.

BACKGROUND: Primary hyperaldosteronism (PHA) is an underdiagnosed cause of secondary hypertension, with an increased risk of cardiovascular and renal complications compared with those with essential hypertension alone. Distinguishing between unilateral and bilateral aldosterone secretion is important as management differs. Adrenal vein sampling (AVS) is the gold standard for determining lateralisation. Current international guidelines suggest AVS may be omitted in those aged <35 years with PHA and a unilateral adrenal adenoma on imaging. AIM: To characterise all patients referred for AVS at Waitemata District Health Board (WDHB), review the success rate of AVS and compare concordance of AVS with imaging. METHODS: All patients who underwent AVS in WDHB from January 2015 to September 2020 were retrospectively assessed. Clinical records, laboratory data and radiological findings were reviewed. RESULTS: Ninety-six patients underwent AVS, with four excluded as private records were unable to be obtained. Of the 92 patients included, age ranged from 22 to 79 years. AVS was successful on first attempt in 89 (96.7%) patients. AVS and imaging findings were concordant in 62.2% of patients. One (14.3%) of seven aged <35 years had discordant results, and 16 (47%) of 34 patients with a unilateral adenoma on imaging had discordant results to AVS. CONCLUSIONS: AVS at WDHB is successful on first attempt in most patients. AVS is essential in the management of PHA for those deemed to be surgical candidates, regardless of age.

Intraoperative vascular mapping improves patient eligibility for arteriovenous fistula creation.

BACKGROUND: We assessed the utility of intraoperative vein mapping performed by the operating surgeon for evaluating vessel suitability for arteriovenous fistula (AVF) creation. METHODS: In a retrospective review of 222 AVFs, vein diameter measurements were compared between intraoperative and preoperative mapping in the same anatomical location. AVF creation was based on intraoperative vein diameter ≥2 mm, using a distal to proximal and superficial veins first approach. Potential selection of access type based on preoperative findings alone was analyzed. RESULTS: The mean diameter of the veins used for AVF creation measured 3.6 ± 0.8 mm on intraoperative duplex versus 2.5 ± 0.9 mm when the same veins were measured on preoperative duplex. Based on preoperative mapping alone, 23% of patients would have received a more proximal AVF and 5% would have needed a graft. AVFs created more distally based on intraoperative findings had similar maturation rates compared to the rest of the cohort, 79% versus 84% (p = 0.2). CONCLUSIONS: Intraoperative vein mapping can be used to evaluate vessel suitability for AVF and compared to pre-operative vein mapping may increase the eligibility of distal veins for fistula creation while reducing the need for AV grafts.