Tetralogy of Fallot with an Anomalous Course of the Brachiocephalic Vein.

CLINICAL DATA: Infant, 11-month-old, male, diagnosis of Tetralogy of Fallot with retrotracheoesophageal course of the brachiocephalic vein. Usual findings of Tetralogy of Fallot on physical examination. Technical description: Chest radiography showed slightly reduced pulmonary vascular markings and no cardiomegaly. Normal preoperative electrocardiogram with postoperative right bundle branch block. Usual findings of Tetralogy of Fallot on echocardiogram. Postoperative computed tomography angiography confirmed left brachiocephalic vein with anomalous retrotracheoesophageal course, configuring a U-shaped garland vein, in addition to postoperative findings of total correction of Tetralogy of Fallot. OPERATION: Complete surgical repair was performed with pulmonary valve commissurotomy and placement of bovine pericardial patch to solve right ventricular outflow tract obstruction, pulmonary trunk enlargement, and ventricular septal defect closure. COMMENTS: Systemic venous drainage may show variations in patients with Tetralogy of Fallot. These abnormalities are usually of little clinical relevance, as they are asymptomatic. We presented a rare case of retrotracheoesophageal course of an anomalous left brachiocephalic vein with intraoperative diagnosis, confirmed by imaging during postoperative follow-up, without compromising clinical management or surgical approach.

Accidental guide wire migration and late percutaneous externalization after central venous catheterization.

A 70-year-old man was admitted to the emergency department with recent spontaneous externalization of a metallic device from his right inner thigh. He had been experiencing mild local pain for 2 weeks and had a recent hospitalization due to cardiogenic hemodynamic instability, requiring a central venous catheter placement in his right internal jugular vein 3 months earlier. Doppler ultrasound confirmed the intravascular foreign body hypothesis as a guidewire was identified inside the right femoral vein, associated with femoropopliteal venous thrombosis. The guidewire was successfully removed percutaneously through simple manual traction guided by radioscopy. The patient was discharged the following day on oral anticoagulation with rivaroxaban. On outpatient follow-up 4 weeks post discharge, he had no complaints in the right lower limb except for slight swelling. Central venous catheterization is a common invasive procedure that, although unquestionably safe and well stablished in medical practice, can lead to serious complications when performed without proper technique.

Surgical Resection of an Intravascular Lipoma of the Superior Vena Cava.

Intravascular lipomas (IVL) located in the superior vena cava (SVS) are rare benign primary venous tumors with less than 15 cases reported in the literature. We report a case of a 64-year-old woman with IVL of the SVC extending to the right brachiocephalic vein. She was treated successfully using a hybrid procedure which involved endovascular control of the right subclavian vein and surgical approach via median sternotomy followed by mass resection and use of pericardial patch for vein defect closure.

Brachiocephalic Vein and Superior Vena Cava Reconstruction with a Superficial Femoral Vein Graft.

Superior vena cava syndrome (SVCS) is an entity that has become more frequent due to the increasing use of indwelling central venous catheters. Surgical management is considered in patients with extensive venous thrombosis and when endovascular therapy is not feasible. The use of superficial femoral vein is an excellent technique for reconstruction of the brachiocephalic vein and superior vena cava (SVC) in cases with benign and malignant etiologies. We describe two cases of SVCS that were managed surgically at our institution with replacement of the SVC and brachiocephalic veins with a superficial femoral vein graft technique.

Multicenter Experience with the Surfacer Inside-Out Access Catheter System in Patients with Thoracic Venous Obstruction: Results from the SAVE Registry.

PURPOSE: To report the device performance and safety for the Surfacer Inside-Out access catheter system in patients with thoracic central venous obstruction (TCVO) requiring central venous access (CVA). MATERIALS AND METHODS: Five sites prospectively enrolled 30 patients requiring a tunneled dialysis catheter between February 2017 and September 2018 in the SAVE (Surfacer System to Facilitate Access in Venous Obstructions) registry. Patient demographics, medical history, and type of TCVO were documented at enrollment. Device performance and adverse events were collected during the procedure and upon hospital discharge. Twenty-nine of the 30 patients enrolled required CVA for hemodialysis. Retrospective classification of TCVOs according to SIR reporting standards showed 9 patients (30%) had Type 4 obstructions, 8 (26.7%) had Type 3, 5 (16.7%) had Type 2, and 8 (26.7%) had Type 1 obstruction. RESULTS: Central venous catheters (CVCs) were successfully placed in 29 of 30 patients (96.7%). The procedure was discontinued in 1 patient due to vascular anatomical tortuosity. All 29 patients with successful CVC placement achieved adequate catheter patency and tip positioning. There were no device-related adverse events, catheter malposition, or intra- or postprocedural complications. Mean time from device insertion to removal for the 29 patients who successfully completed the procedure was 24 ± 14.9 (range, 6-70) minutes. Mean fluoroscopy time was 6.8 ± 4.5 (range, 2.2-25.5) minutes. CONCLUSIONS: The Surfacer Inside-Out procedure provided an alternative option to restore right-sided CVA in patients with TCVO.

Partial Anomalous Pulmonary Venous Connection: A Great Imitator?

In isolated partial anomalous pulmonary venous connections (PAPVCs), an abnormal vein connects venous blood from the pulmonary circulation to the systemic circulation, resulting in an extracardiac shunt. A single aberrant pulmonary vein (PV) is usually hemodynamically insignificant, and affected patients are generally asymptomatic. We describe a young Caribbean-Black woman with an isolated, singular PAPVC from the left inferior PV to the left innominate (brachiocephalic) vein that was hemodynamically significant, obfuscated by recurrent pleural effusions from catamenial pleural endometriosis.

Comparison between ultrasonography and X-ray as evaluation methods of central venous catheter positioning and their complications in pediatrics.

PURPOSE: This study evaluates the capacity of ultrasonography as a diagnostic method to confirm the proper positioning of central venous catheter (CVC) when compared to the current gold standard, chest radiography (CR). METHODS: A prospective study was performed including children from 0 to 14 incomplete years, who underwent CVC placement between March and May 2018 at a teaching hospital in Brazil. A four-chamber view of the heart was performed with ultrasound during a rapid injection of saline solution to identify hyperechoic images and confirm the central position of the catheter. After that, a CR was performed. The diagnostic quality of ultrasound was evaluated based on accuracy, sensitivity, specificity, positive and negative predictive values. RESULTS: A total of 21 patients were analyzed. The mean age was 3.95 ± 4.01 years. The preferred puncture site was the right internal jugular vein (71.4%). Ultrasound accuracy to detect CVC positioning was 81%. Sensitivity, specificity and positive and negative predictive values were 33%, 100%, 100% and 79%, respectively. CONCLUSION: Ultrasound is a reliable method for detection of CVC positioning. Even so, with the four-chamber cardiac view, this method is unable to identify catheters inside heart chambers, therefore, needing to confirm the positioning with CR.

A prominent brachiocephalic vein masquerading as an aortic dissection flap on transthoracic echocardiogram: A case for multimodality imaging.

A 30-year-old female patient with past medical history of supraventricular tachycardia presented with shortness of breath and underwent a transthoracic echocardiogram (TTE). The TTE noted a concerning partially mobile linear echo density, with positive Doppler color flow across it along the aortic arch, which was concerning for a dissection flap. The patient accordingly underwent a cardiac MRI which revealed that the anomaly seen on echocardiogram was in the setting of a prominent left brachiocephalic (innominate) vein and without evidence of aortic dissection. While this is a relatively common phenomenon, there is no literature on prominent brachiocephalic vein masquerading as an aortic dissection flap on TTE.

Fibrosis mediastínica post-irradiación: un factor a tener en cuenta en cirugía cardiaca / Post-radiation mediastinal fibrosis: a factor to take into account in cardiac surgery

Resumen La radioterapia mediastínica es uno de los tratamientos fundamentales de las enfermedades malignas torácicas, pero también representa una causa potencial de complicaciones, tanto a corto como a largo plazo. Se presenta una serie de casos de rotura de vena innominada durante esternotomía media en pacientes con fibrosis mediastínica. Los tres casos descritos corresponden a pacientes intervenidos de cirugía cardiaca con antecedentes de radioterapia mediastínica, entre 15-30 años antes de la cirugía, por tres diferentes enfermedades malignas (linfoma de Hodgkin, timoma y cáncer de mama). En los tres casos se reporta rotura de la vena innominada, con desinserción de su origen en la vena cava superior debido a fibrosis mediastínica intensa.

Abstract Although mediastinal radiotherapy is one of the basic treatments of malignant thoracic diseases, it is also a potential cause of short and long-term complications. A series of cases of rupture of the innominate vein during sternotomy are presented in patients with mediastinal fibrosis. The three cases described correspond to patients intervened by cardiac surgery, with a history of mediastinal radiotherapy between 15 to 30 years before the surgery, due to three different malignant diseases (Hodgkin lymphoma, thymoma, and breast cancer). In the three cases, a rupture of the innominate vein is reported; with de-insertion of its origin in the superior vena cava sue to intense mediastinal fibrosis.

Trauma vascular de extremidad superior: presentación de un caso y revisión de la literatura / Upper extremity vascular trauma: a case report and literature review

INTRODUCTION: Vascular trauma is a low frequency event and is related to a high burden of morbidity and mortality. Vascular trauma of the upper limb is of different etiology. More frequent, secondary to closed trauma. It is usually associated with other lesions, soft tissue and nerves. OBJECTIVES: To present a case of complex vascular trauma of the upper limb and its multidisciplinary management. METHOD: Description of the clinical case and literature review. The information was obtained from the patient's clinical record, review and analysis of the published literature was performed using search engines. CASE REPORT: Young man, fall with upper limb in extension, results in elbow dislocation associated with acute ischemia. AngioTAC confirms stop in brachial. Emergency surgery: brachio-radial saphenous bridge. It evolves with absence of pulses. It is reexplored finding incomplete fasciotomy, brachial artery bridge to cephalic vein with inverted saphenous. Elbow dislocated, unstable. Arterial bridge, external fixation and fasciotomy is completed. Coming out with radial pulse. He undergoes multiple surgeries and surgical toilets, achieving skin closure at 45 days. Then traumatology removes external tutors. Electromyography confirms incomplete lesion of median, radial and ulnar. Currently in the process of rehabilitation. DISCUSSION AND CONCLUSION: Vascular trauma of the upper limb is of low incidence. However, they are associated with a high burden of morbidity and mortality, generally occurring in young men. The diagnostic pillar is through the medical history and physical examination. its surgical management.

Cardiorespiratory evaluation of brachycephalic syndrome in dogs / Avaliação cardiorespiratória da síndrome braquiocefálica em cães

Brachycephalic syndrome (BS) in dogs is characterized by the combination of primary and secondary upper respiratory tract abnormalities and may result in significant upper airway obstruction. It can trigger inspiratory dyspnea, culminating in secondary respiratory distress, soft tissue edema, upper airway obstruction, turbulent airflow, inspiratory noise, and even death. These changes lead to increased resistance of the air passages, which can cause elevation of pulmonary pressure and clinical manifestations attributable to pulmonary hypertension. The consequence is right-sided cardiac remodeling (Cor pulmonale) with possible progression to right congestive heart failure. To investigate the effects of BS on the cardiovascular system, 28 animals were recruited for a prospective study and assigned to either the Brachycephalic Group (BG), composed of 22 French bulldogs with BS or the Control Group (CG), which was composed of 6 healthy Beagle dogs. All animals underwent a detailed physical examination, as well as laboratory analyses, electrocardiography, echocardiography, chest radiography and indirect measurement of systemic arterial blood pressure. The most relevant finding was a lower PaO2 (90.6±12.9mmHg) in BG as compared to CG (104.9±5.2), (p≤0.05), possibly attributable to hypoventilation due to anatomical alterations.(AU)

A síndrome braquicefálica (BS) é caracterizada pela combinação de anormalidades primárias e secundárias do trato respiratório superior em cães, podendo resultar em obstrução significativa das vias aéreas superiores. Pode desencadear dispneia inspiratória, culminando em dificuldade respiratória secundária, edema de tecidos moles, obstrução das vias aéreas superiores, fluxo de ar turbulento, ruído inspiratório e até morte. Essas alterações levam ao aumento da resistência da passagem do ar, o que pode causar elevação da pressão pulmonar e manifestações clínicas atribuídas à hipertensão pulmonar. A consequência é o remodelamento cardíaco do lado direito (Cor pulmonale) com possível progressão para insuficiência cardíaca congestiva direita. A fim de averiguar os efeitos da BS sobre o sistema cardiovascular, 28 animais foram recrutados para um estudo prospectivo e distribuídos em Grupo Braquicefálico (GB), composto por 22 Bulldogs franceses com síndrome braquicefálica ou Grupo Controle (GC), composto por 6 cães Beagles saudáveis. Todos os animais foram submetidos a exame físico detalhado, bem como análises laboratoriais, eletrocardiografia, ecocardiografia, radiografias torácicas e mensuração indireta de pressão arterial sistêmica. Os achados mais relevantes foram relacionados ao GB (90,6±12,9mmHg) com menor PaO2 em relação ao GC (104,9±5,2), (p≤0,05), possivelmente atribuível à hipoventilação, em decorrência das alterações anatômicas.(AU)

Cardiorespiratory evaluation of brachycephalic syndrome in dogs / Avaliação cardiorespiratória da síndrome braquiocefálica em cães

Brachycephalic syndrome (BS) in dogs is characterized by the combination of primary and secondary upper respiratory tract abnormalities and may result in significant upper airway obstruction. It can trigger inspiratory dyspnea, culminating in secondary respiratory distress, soft tissue edema, upper airway obstruction, turbulent airflow, inspiratory noise, and even death. These changes lead to increased resistance of the air passages, which can cause elevation of pulmonary pressure and clinical manifestations attributable to pulmonary hypertension. The consequence is right-sided cardiac remodeling (Cor pulmonale) with possible progression to right congestive heart failure. To investigate the effects of BS on the cardiovascular system, 28 animals were recruited for a prospective study and assigned to either the Brachycephalic Group (BG), composed of 22 French bulldogs with BS or the Control Group (CG), which was composed of 6 healthy Beagle dogs. All animals underwent a detailed physical examination, as well as laboratory analyses, electrocardiography, echocardiography, chest radiography and indirect measurement of systemic arterial blood pressure. The most relevant finding was a lower PaO2 (90.6±12.9mmHg) in BG as compared to CG (104.9±5.2), (p≤0.05), possibly attributable to hypoventilation due to anatomical alterations.(AU)

A síndrome braquicefálica (BS) é caracterizada pela combinação de anormalidades primárias e secundárias do trato respiratório superior em cães, podendo resultar em obstrução significativa das vias aéreas superiores. Pode desencadear dispneia inspiratória, culminando em dificuldade respiratória secundária, edema de tecidos moles, obstrução das vias aéreas superiores, fluxo de ar turbulento, ruído inspiratório e até morte. Essas alterações levam ao aumento da resistência da passagem do ar, o que pode causar elevação da pressão pulmonar e manifestações clínicas atribuídas à hipertensão pulmonar. A consequência é o remodelamento cardíaco do lado direito (Cor pulmonale) com possível progressão para insuficiência cardíaca congestiva direita. A fim de averiguar os efeitos da BS sobre o sistema cardiovascular, 28 animais foram recrutados para um estudo prospectivo e distribuídos em Grupo Braquicefálico (GB), composto por 22 Bulldogs franceses com síndrome braquicefálica ou Grupo Controle (GC), composto por 6 cães Beagles saudáveis. Todos os animais foram submetidos a exame físico detalhado, bem como análises laboratoriais, eletrocardiografia, ecocardiografia, radiografias torácicas e mensuração indireta de pressão arterial sistêmica. Os achados mais relevantes foram relacionados ao GB (90,6±12,9mmHg) com menor PaO2 em relação ao GC (104,9±5,2), (p≤0,05), possivelmente atribuível à hipoventilação, em decorrência das alterações anatômicas.(AU)

Variante de las venas hemiácigos: ¿vena ácigos izquierda? reporte de un caso / Variant of the hemiazygos veins: left azygos vein? a case report

INTRODUCCIÓN: El sistema venoso ácigos-hemiácigos es imprescindible en el drenaje del tórax. Estos vasos se originan en la etapa embrionaria a partir de las venas supracardinales, con una serie de afluentes que parten de la pared torácica y mediastino principalmente, encontrando variedades, como nuestro hallazgo, mismos que deben ser considerados en la práctica médica. PRESENTACIÓN DEL CASO: Se presenta un caso encontrado en una disección de pieza cadavérica, de sexo masculino, en el cual se halló un tronco venoso paralelo al lado izquierdo de la columna, que resultaría de la unión de las venas hemiácigos; originándose por la confluencia de la vena subcostal y lumbar ascendente, drenando en la vena braquiocefálica del mismo lado, muy parecido a la vena ácigos, sin conexión entre ambas. DISCUSIÓN: Son muchas las variedades reportadas en diversos estudios, encontrando una clasificación de dichas anomalías en tres tipos, correspondiendo nuestro caso a la variedad tipo I, con una incidencia del 1%; dichas alteraciones pueden originarse en etapa embrionaria por la falta de diferenciación de las venas supracardinales. De esta manera, resaltamos la importancia de estas variantes en el ámbito clínico, quirúrgico e imagenológico. CONCLUSIÓN: El presente hallazgo resulta ser un caso muy particular, a diferencia de otros estudios revisados, por lo que sería pertinente ampliar el trabajo para obtener la incidencia del mismo

INTRODUCTION: The azygos-hemiazygos venous system is necessary in the drainage of the thorax. These vessels originate in the embryological phase from the supracardinal veins, with a series of tributaries that begin in the thoracic Wall and mediastinum mainly, finding varieties, such as our finding, which must be considered in medical practice. CASE PRESENTATION: In a male corpse dissection we found a venous trunk parallel to the left side of the vertebral column which would result in the joining of the hemiazygos veins; beginning in the confluence of the subcostal vein and ascending lumbar, draining in the brachiocephalic vein on the same side, similar to the azygos vein, without any connection between them. DISCUSSION: There are many varieties reported in diverse studies, which can be categorized in three types. Ours corresponds to type I, with an incidence of 1%. Such varieties can originate in embryological phase due to the lack of differentiation of supracardinal veins. We can highlight the importance of such varieties in the clinical and surgical fields. CONCLUSION: Our finding is a very particular case, unlike other revised studies, which is why it would be pertinent to further research this topic

Biometric measurements involving the terminal portion of the thoracic duct on left cervical level IV: an anatomic study.

To determine the point of entrance of the thoracic duct in the venous system, as well as to evaluate some biometric measurements concerning its terminal portion, we conducted an anatomic study on 25 non-preserved cadavers. The termination of the thoracic duct occurred on the confluence between the left internal jugular vein and the left subclavian vein in 60 % of the individuals. The average results for the biometric measurements were: distance between the end of left internal jugular vein and omohyoid muscle 31.2 ± 2.7 mm; distance between the end of thoracic duct and the left internal jugular vein 0.0 ± 0.0 mm; distance between the end of thoracic duct and the left subclavian vein 3.6 ± 1.0 mm; distance between the end of thoracic duct and the left brachiocephalic vein 10.7 ± 3.1 mm. Moreover, it was identified that the left internal jugular vein length in level IV, measured between its entrance in the left subclavian vein and the omohyoid muscle, was able to predict the termination of the thoracic duct on the junction between the left internal jugular vein and the left subclavian vein (OR = 2.99) with high accuracy (79.3 %). In addition, the left internal jugular vein length at level IV was able to predict the localization of thoracic duct termination. Thus, this finding has practical value in minimizing the risk for a potential chyle leak during or after a left-sided neck dissection.

Case Report Unicentric Castleman disease located in the anterior mediastinum misdiagnosed as invasive thymoma: a case report.

Castleman disease is a rare lymphoproliferative disorder of unknown etiology. The localized form, which usually presents as a slow-growing mass, is most commonly located in the mediastinum. Invasion of the vena anonyma by a mass has rarely been reported. We herein describe a case of initially misdiagnosed invasive thymoma in a 72-year-old woman, but postoperatively proven to have anterior mediastinal Castleman disease with invasion of the vena anonyma.

Lymph node distribution in the central compartment of the neck: an anatomic study.

BACKGROUND: Dissection of the central compartment of the neck (CCN) is performed for proven or suspected lymph node metastases of thyroid carcinoma. During this procedure, the recurrent laryngeal nerves and the parathyroid glands are at risk. The purpose of this study was to determine the anatomic distribution of the lymph nodes in the CCN. METHODS: The anatomic distribution of the lymph nodes in the CCN was studied by dissection of 30 fresh cadavers. The soft tissue between the cricoid cartilage and the innominate vein, carotid arteries, and prevertebral fascia was removed and divided according to CCN sublevels. Nodules were identified by palpation in the specimen and sent for pathological examination. RESULTS: Three to 44 (18.5 ± 10.29) nodules were identified macroscopically. Two to 42 nodules were confirmed as lymph nodes after microscopic examination. The lymph node distribution was as follows: precricoid: 0 to 2 (0.9 ± 0.72); pretracheal: 1 of 35 (12.4 ± 8.19); lateral to the right recurrent laryngeal nerve (RLN): 0 to 11 (3.4 ± 2.34); and lateral to the left: 0 to 4 (1.7 ± 1.30). Twenty-six parathyroid glands were removed by 14 dissections. The innominate vein was found at 15 mm above the superior border of the clavicles to 35 mm below on the left side of the neck and 5 to 45 mm on the right side. CONCLUSION: The number of confirmed lymph nodes in the central neck varied from 2 to 42. Sixty-seven percent of the lymph nodes were in the pretracheal sublevel. There was no division between level VI and VII lymph nodes. Additionally, the innominate vein was found to be from 15 mm above the superior border of the clavicles to 35 mm below on the left side of the neck and 5 to 45 mm on the right side. Parathyroid glands were identified to be far away from the thyroid gland.

Intravenous lipoma and pulmonary sarcoidosis treated with prednisone.

Corticosteroid-induced lipomatosis is not a rare condition, but lipoma in the central veins has scarcely been described. According to the databases consulted, this is the first report of a lipoma within the central veins coexistent with long-term use of corticosteroid. It involved a 47-year-old male under treatment for pulmonary sarcoidosis with prednisone. Computerized tomography of the thorax was performed and incidentally the images showed a mass within the central veins with the characteristics of lipoma. He was asymptomatic and refused surgical procedures. The intraluminal lipoma originated in the right brachiocephalic and subclavian veins. Control tomography showed a slow development of this lipoma, without obstructive effects or malignant features. Oral prednisone was changed for methotrexate. The patient is asymptomatic and under longstanding out-patient surveillance. Corticosteroid treatments for sarcoidosis can play a role in the development of intravascular lipoma, but this association is not well defined. Case reports could contribute to clarifying whether this relationship is causal or merely casual.