A surgical method to be reminded for the treatment of symptomatic ipsilateral central venous occlusions in patients with hemodialysis access: Axillo-axillary venous bypass case report and review of the literature.

BACKGROUND: In this case report, we present two chronic hemodialysis patients with upper extremity swelling due to central venous occlusions together with their clinical presentation, surgical management and brief review of the literature. METHODS: The first patient who was a 63-year-old female patient with a history of multiple bilateral arteriovenous fistulas (AVFs) was referred to our clinic. Physical examination demonstrated a functioning right brachio-cephalic AVF, with severe edema of the right arm, dilated venous collaterals, facial edema, and unilateral breast enlargement. In her history, multiple ipsilateral subclavian venous catheterizations were present for sustaining temporary hemodialysis access. The second patient was a 47-year-old male with a history of failed renal transplant, CABG surgery, multiple AV fistula procedures from both extremities, leg amputation caused by peripheral arterial disease, and decreased myocardial functions. He was receiving 3/7 hemodialysis and admitted to our clinic with right arm edema, accompanied by pain, stiffness, and skin hyperpigmentation symptoms ipsilateral to a functioning brachio-basilic AVF. He was not able to flex his arms, elbow, or wrist due to severe edema. RESULTS: Venography revealed right subclavian vein stenosis with patent contralateral central veins in the first patient. She underwent percutaneous transluminal angioplasty (PTA) twice with subsequent re-occlusions. After failed attempts of PTA, the patient was scheduled for axillo-axillary venous bypass in order to preserve the AV access function. In second patient, venography revealed right subclavian vein occlusion caused secondary to the subclavian venous catheters. Previous attempts for percutaneously crossing the chronic subclavian lesion failed multiple times by different centers. Hence, the patient was scheduled for axillo-axillary venous bypass surgery. CONCLUSION: In case of chronic venous occlusions, endovascular procedures may be ineffective. Since preserving the vascular access function is crucial in this particular patient population, venous bypass procedures should be kept in mind as an alternative for central venous reconstruction, before deciding on ligation and relocation of the AVF.

The risk of fatal bleeding complications in jugular catheterization in patients with coagulopathy: A retrospective analysis of death cases in closed claims and the Medical Accident Investigating System in Japan.

BACKGROUND: To prevent recurrence of medical accidents, the Medical Accident Investigating System was implemented in October 2015 by the Japan Medical Safety Research Organization (Medsafe Japan) to target deaths from medical care that were unforeseen by the administrator. Medsafe Japan analyzed the 10 cases of central venous catheterization-related deaths reported in the system and published recommendations in March 2017. However, the particular emphasis for the prevention of central venous catheterization-related deaths is unclear. METHODS: This study aimed to identify the recommendation points that should be emphasized to prevent recurrence of central venous catheterization-related deaths. We assessed central venous catheterization in 8530 closed-claim cases between January 2002 and December 2016 covered by the medical insurer Sompo-Japan. Moreover, we compared central venous catheterization-related death in closed-claim cases with death in reported cases. RESULTS: The background, error type, anatomic insertion site, and fatal complication data were evaluated for 37 closed-claim cases, of which 12 (32.4%) were death cases. Of the 12 closed-claim cases and 10 reported cases, 9 (75.0%) closed-claim cases and 9 (90.0%) reported cases were related to vascular access. Among these, 5 closed-claim cases (41.7%) and 7 reported cases (77.8%) were related to internal jugular vein catheterization (p = 0.28). Coagulopathy was observed in 3 (60.0%) of 5 closed-claim cases and 6 (85.7%) of 7 reported cases. CONCLUSIONS: The risk of internal jugular catheterization in patients with coagulopathy must be carefully considered.

Intravenous lobular capillary haemangioma presenting as neck discomfort associated with neck anteflexion.

Lobular capillary haemangioma, also known as pyogenic granuloma, is a benign vascular tumour that usually originates in the skin and mucosal membrane. It sometimes derives from the lumen of a vein and the clinical presentations are various and non-specific. A 72-year-old woman complained of a sensation of pressure in her left neck for 1 month when cooking. Her left cephalic vein was enlarged with no signs of oedema, and cervical ultrasound revealed a space-occupying lesion in the left subclavian vein. Contrast-enhanced CT and MRI revealed an intravascular tumour. This tumour was removed with operation, and histopathological examination revealed intravascular capillary haemangioma. Intravascular lobular capillary haemangioma is a rare condition that occurs in the veins of the neck and upper extremities. Intravascular tumours could cause a unique symptom, such as neck discomfort associated with neck anteflexion.

The outcomes of carbon dioxide digital subtraction angiography for percutaneous transluminal balloon angioplasty of access circuits and venous routes in hemodialysis patients.

The outcomes of carbon dioxide digital subtraction angiography (CO2-DSA) for performing percutaneous transluminal balloon angioplasty (balloon PTA) in hemodialysis patients has not been fully clarified. The purpose was to compare the outcomes of balloon PTA of hemodialysis shunts in terms of vessel patency between patients treated using CO2-DSA and conventional digital subtraction angiography using iodine contrast medium (C-DSA).We retrospectively evaluated 76 patients (38 males and 38 females, mean age: 65.0 ±â€Š14.0 years). They were under hemodialysis and treated with balloon PTA using CO2-DSA or C-DSA at our institution between 2009 and 2016. Mean duration of the follow-up period was 25.59 ±â€Š21.45 months. We compared the patency rates obtained after CO2-DSA-based balloon PTA with those after C-DSA-based balloon PTA. Secondary patency, which was defined as the duration of patency after all further endovascular interventions until surgical repair, was considered as the endpoint in this study.Overall, 19 and 57 patients underwent CO2-DSA- and C-DSA-based balloon PTA, respectively. CO2-DSA- and C-DSA-based balloon PTA produced clinical success rates of 100% and 96.5%, respectively. Blood vessel injury occurred in one patient who underwent C-DSA-based balloon PTA. No major complications occurred in CO2 group. At 24 months, the post-PTA secondary patency rates of CO2-DSA- and C-DSA-based balloon PTA were 94.1% and 93.9%, respectively (P = .9594).CO2-DSA is safe for hemodialysis patients. Compared with C-DSA, CO2-DSA-based balloon PTA produces have a similar secondary patency rate.

Costoclavicular ligament as a novel cause of venous thoracic outlet syndrome: from anatomic study to clinical application.

PURPOSE: Venous thoracic outlet syndrome (VTOS) is a compressive disorder of subclavian vein (SCV); we aimed to investigate the role of costoclavicular ligament (CCL) in the pathogenesis of VTOS. METHODS: A cadaver study was carried out to investigate the presence and morphology of CCL in thoracic outlet regions, as well as its relationship with the SCV. Six formalin-fixed adult cadavers were included, generating 12 dissections of costoclavicular regions (two sides per cadaver). Once CCL was identified, observation and measurement were made of its morphology and dimensions, and its relationship with SCV was studied. To take a step further, a clinical VTOS case was reported to prove the anatomical findings. RESULTS: Two out of twelve costoclavicular regions (2/12, 16.7%) were found to possess CCLs. Both ligaments were located in the left side of two male cadavers and were closely attached to the lateral aspect of sternoclavicular joint capsules. The lateral fibers of the ligament proceed in a superolateral-to-inferomedial manner, while the medial fibers proceed more vertically. Both ligaments were tightly adherent to the SCV, causing significant compression on the vein. In the clinical case, multiple bunches of CCLs were found to compress the SCV tightly intraoperatively. After removing the ligaments, the patient's symptom kept relief during a follow-up period of 2 years. CONCLUSION: Our study demonstrated that CCL could be a novel cause of VTOS by severe compression of SCV. Patients diagnosed with this etiology could get less invasive surgical treatment by simply removing the ligament.

Urschel's Sign in Paget-Schroetter Syndrome: Multimodality Evaluation by Extravascular and Intravascular Imaging.

Paget-Schroetter Syndrome is potentially life-threatening. In this case, multidisciplinary imaging with extravascular and intravascular evaluation guided the proper diagnosis and treatment planning.

[Síndrome de Paget-Schrötter: presentación de cuatro casos]. / Paget-Schrötter syndrome: description of four cases.

Deep vein thrombosis (DVT) of the upper limb is a rare entity, estimated to account for 10% of all cases of DVT. Classically, they are classified into primary (idiopathic, due to subclavian vein compression or exercise related) and secondary (cancer, thrombophilia, trauma, shoulder surgery, associated to venous catheters or due to hormonal causes). The Paget- Schrötter syndrome is a primary thrombosis of the subclavian vein in the subclavian-axillary junction, related either to repetitive movements or to exercise; leading to microtrauma in the endothelium with consequent activation of the coagulation cascade. Clinically, it presents abruptly with pain, edema and feeling of heaviness in the affected limb. The treatment varies from thrombolytics and anticoagulation to surgical intervention, depending on the time of evolution. We present four cases of exercise-related subclavian vein thrombosis.

Síndrome de Paget-Schrötter: presentación de cuatro casos / Paget-Schrötter syndrome: presentation of four cases

La trombosis venosa profunda (TVP) del miembro superior es una entidad poco frecuente, se estima que representa el 10% de todos los casos de TVP. Clásicamente se clasifican en primarias (idiopáticas, por compresión de la vena subclavia o relacionadas con el ejercicio) y secundarias (cáncer, trombofilia, traumatismo, cirugía del hombro, asociadas a catéteres venosos o de causa hormonal). El síndrome de Paget- Schrötter es una trombosis primaria de la vena subclavia en la unión subclavio-axilar, ya sea por movimientos repetitivos o relacionada al ejercicio; llevando a microtrauma en el endotelio con la consiguiente activación de la cascada de coagulación. Clínicamente se presenta de forma brusca con dolor, edema y sensación de pesadez en el miembro afectado. El tratamiento varía desde trombolíticos y anticoagulación a la intervención quirúrgica, dependiendo del tiempo de evolución. Presentamos cuatro casos de trombosis de vena subclavia relacionada con el ejercicio.

Deep vein thrombosis (DVT) of the upper limb is a rare entity, estimated to account for 10% of all cases of DVT. Classically, they are classified into primary (idiopathic, due to subclavian vein compression or exercise related) and secondary (cancer, thrombophilia, trauma, shoulder surgery, associated to venous catheters or due to hormonal causes). The Paget- Schrötter syndrome is a primary thrombosis of the subclavian vein in the subclavian-axillary junction, related either to repetitive movements or to exercise; leading to microtrauma in the endothelium with consequent activation of the coagulation cascade. Clinically, it presents abruptly with pain, edema and feeling of heaviness in the affected limb. The treatment varies from thrombolytics and anticoagulation to surgical intervention, depending on the time of evolution. We present four cases of exercise-related subclavian vein thrombosis.

Hemangioendotelioma cérvico-mediastínico gigante de la vena subclavia / Giant Cervical and Mediastinal Hemangioendothelioma Arising from Subclavian Vein

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Superior vena cava syndrome due to central port catheter thrombosis: a real life-threatening condition.

Superior vena cava syndrome (SVCS) represents undoubtedly a rare life-threatening condition. Herein, we present a rare case of a 69-year-old woman, with a history of hepatic flexure tumor and an indwelling central venous port, presenting with acute signs and symptoms of SVCS due to thrombosis of the catheter. The patient was treated with intravenous anticoagulation and fibrinolytic therapy and showed regression of symptoms. It is reported that central venous catheters are routinely used in clinical practice mainly in oncological cases for chemotherapy, parenteral nutrition or dialysis. However, complications related to implantation technique, care, or maintenance of these catheters may arise. High index of suspicion for SVCS should always arise when a patient presents with common symptoms and long-term central catheters, in order to avoid unfavorable outcomes. Local thrombolysis appears to be a safe and effective therapy for port catheter-associated thrombosis.

Novel variations in spatial relations between the facial nerve and superficial temporal and maxillary veins.

Variations in the relationship of the retromandibular vein to the facial nerve have been widely reported due to their relevance for surgical approaches in parotid, osteotomy and mandibular condyle surgery. In the context of the retromandibular retroparotid approach, remaining deep to the retromandibular vein is advised to decrease the likelihood of encountering the facial nerve during mandibular condyle surgery. In the present report, an unusual variant of the superficial temporal vein lying superficial to the facial nerve is described. This represents a variation of the venous branching pattern within the parotid gland, whereby the superficial temporal vein joins the maxillary vein inferior to its usual communication. These findings are discussed in the context of commonly used surgical approaches to the mandible for condylar trauma or osteotomy surgery.

Venous outlet syndrome caused by capillary hemangioma of the subclavian vein.

We report a case of intravenous lobular capillary hemangioma in the subclavian vein, causing venous thoracic outlet syndrome. A 32-year-old woman was referred to our unit with facial and left arm oedema. Ultrasound evaluation, computed tomography and magnetic resonance imaging showed a hypervascular mass in the middle portion of the subclavian vein, with arrest of venous flow. Through an infraclavicular approach, we excised the venous axis with the endovascular palpable tumour that extended from the axillary-subclavian junction to the jugular-subclavian junction, without reconstruction. The postoperative period was uneventful. The patient recovered well without recurrence at one year from surgery.

[Venous thromboembolic complications in patients with cardiovascular implantable electronic devices]. / Venoznye tromboémbolicheskie oslozhneniia u patsientov s serdechno-sosudistymi implantiruemymi élektronnymi ustroistvami.

The problem of venous thromboembolic complications (VTECs) in patients with cardiovascular implantable electronic devices (CIEDs) is extremely important today because of an annually increasing number of surgical interventions for life-threatening arrhythmias and chronic heart failure. There are hitherto no clearly defined reliable risk factors for VTECs due to heterogeneity of the available literature data. Some sources point to elevated thrombus formation in patients with a large number of electrodes, in repeat operative interventions, in the presence of a temporary pacemaker, in implantation on the left side, silicon cover of an electrode, others refute these facts. Still undetermined remains the choice of antithrombotic therapy for prevention and treatment of VTECs in this cohort of patients. Implantation of a VTEC may be accompanied by thrombosis of deep veins of the upper extremities up to the development of total occlusion of veins. In rare cases, thrombosis extends proximally, there appears superior vena cava syndrome which may require surgical treatment. Diagnosis of these diseases is complicated by their symptom-free course in the majority of cases. The most dangerous VTEC is pulmonary thromboembolism very commonly not accompanied by clinical symptomatology or taking its course under the mask of other more frequent diseases. Despite the fact that pulmonary thromboembolism with a source in the system of the superior vena cava is rarely massive, it may lead to the development of chronic postembolic pulmonary hypertension and to decreased quality of life. The article contains a review of the present-day literature and a clinical case report concerning the development of VTECs in a patient with a CIED in the form of thrombosis of the right internal jugular, subclavian and brachiocephalic veins, pulmonary embolism of small branches of the right pulmonary artery, suppuration of the pacemaker's bed and sepsis. Therapy with antibiotics, low-molecular-weight heparins, antiplatelet drugs and anti-inflammatory agents with regular sanitation of the pacemaker's bed turned out effective.

Spontaneous Subclavian Vein Thrombosis in a Healthy Adolescent Cheerleader: A Case of Paget-Schroetter Syndrome.

We present the case of a healthy 13-year-old female adolescent who developed acute progressive swelling and pain in her right upper extremity that was secondary to an acute deep venous thrombosis of her right subclavian vein. Dynamic imaging revealed subclavian vein compression at the junction of the first rib and proximal third of the clavicle consistent with Paget-Schroetter syndrome, also known as effort-related thrombosis. The compressive etiology of her thrombus was most likely related to her cheerleading activity, in which she served as the pyramid base. The patient received multimodal therapy including anticoagulation, mechanical and site-directed thrombolysis, and a first rib resection. This case illustrates that frontline providers should have a high index of suspicion for an upper extremity thrombosis in pediatric patients who present with unilateral arm swelling.

Diagnosis and treatment of effort-induced thrombosis of the axillary subclavian vein due to venous thoracic outlet syndrome.

Venous thoracic outlet syndrome (VTOS) is uncommon but most frequently occurs in young, active, healthy patients. This condition typically presents as subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome. The pathophysiology underlying VTOS is chronic repetitive compression injury of the SCV in the costoclavicular space, resulting in progressive venous scarring, focal stenosis, and eventual thrombosis. Clinical evaluation includes a history and physical examination followed by catheter-based venography, for definitive confirmation of the diagnosis and initial treatment with pharmacomechanical thrombolysis. After restoration of SCV patency, patients are maintained with anticoagulation and surgical therapy is usually planned within 4 to 6 weeks. Surgical management of VTOS can be accomplished via different protocols involving either the transaxillary, infraclavicular or paraclavicular approaches to thoracic outlet decompression. The paraclavicular approach is emphasized in this review, because it affords the surgeon the ability to safely perform complete thoracic outlet decompression (complete anterior and middle scalenectomy, removal of the entire first rib, and resection of the subclavius muscle and costoclavicular ligament), along with definitive management of the damaged SCV (external venolysis, intraoperative venography, and direct vein reconstruction, if needed, using patch angioplasty or bypass grafting), in one operative setting. After surgical therapy, interval anticoagulation and a comprehensive physical therapy and rehabilitation program are important in achieving a return to full function. Current protocols on the basis of the paraclavicular surgical approach have thereby routinely provided patients with lasting symptomatic relief, freedom from indefinite anticoagulation, and the ability to return to unrestricted upper extremity activity.

Bilateral Subclavian Vein Occlusion in a SAPHO Syndrome Patient Who Needed an Implantable Cardioverter Defibrillator.

A 79-year-old Asian man was hospitalized because of progressive exertional dyspnea with decreasing left ventricular ejection fraction and frequent non-sustained ventricular tachycardia. Pre-procedure venography for implantable cardioverter defibrillator (ICD) implantation showed occlusion of the bilateral subclavian veins. In consideration of subcutaneous humps in the sterno-clavicular area and palmoplantar pustulosis, we diagnosed him as having synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome and speculated that it induced peri-osteal chronic inflammation in the sterno-clavicular area, resulting in occlusion of the adjacent bilateral subclavian veins. An automatic external defibrillator (AED) was installed in the patient's house and total subcutaneous ICD was considered. Venous thrombosis in SAPHO syndrome is not frequent but has been reported. To the best of our knowledge, this is the first case of bilateral subclavian vein occlusion in a SAPHO syndrome patient who needs ICD implantation.

Spontaneous Upper Extremity Venous Thrombosis in a Collegiate Soccer Player: A Case Report.

Spontaneous effort-induced thrombosis is a rare but reported phenomena that was originally described over 100 years ago. The pathogenesis of this thrombosis arises from an abnormality of the thoracic outlet usually combined with a history of physical activity that includes repetitive arm motions, usually of the dominant hand. We present the case of an adolescent patient who presented to a pediatric emergency department with progressive pain, discoloration, and swelling of the shoulder of his nondominant hand. The pain became acutely worse with graying appearance of his arm. The patient was diagnosed with spontaneous thrombosis of the upper extremity extending from the left subclavian vein extending to the axillary vein. Treatment of this patient included aggressive anticoagulation, thrombolysis, and costectomy.