Outcomes following interval delayed first rib resection for acute axillosubclavian deep venous thrombosis.

BACKGROUND: Current management of axillosubclavian deep venous thrombosis (DVT) often uses thrombolysis for the DVT, prompt first rib removal, and occasional venoplasty or stenting. Our institution has increasingly used anticoagulation alone followed by interval first rib resection. We sought to analyze the effectiveness of this simplified technique. METHODS: Between September 2012 and April 2021, 27 patients were identified within the institution's electronic medical record as having undergone first rib resection for upper extremity DVT. Seven of these patients had undergone preoperative thrombolysis before referral and were excluded. Among the remaining 20 patients, preoperative clinic charts were evaluated for age, venous segment involvement, contralateral limb involvement, presence of documented hypercoagulable state, duration of preoperative and postoperative anticoagulation, and postoperative outcomes. RESULTS: Of the 20 patients (mean age, 26.2 years; 13 males) presenting with acute axillosubclavian DVT, all patients had right (n = 8) or left (n = 12) arm swelling. Five patients had extremity pain and four had extremity discoloration. Ten had axillosubclavian vein involvement, 9 had subclavian vein involvement, and 1 had axillary vein involvement. Two patients were on oral contraceptives and no patients had any other diagnosed hypercoagulable conditions. The mean duration of preoperative and postoperative anticoagulation was 3.2 ± 2.6 months and 2.1 ± 2.1 months, respectively. Nineteen patients underwent supraclavicular first rib resection and 1 patient underwent transaxillary resection. Twelve patients (60%) demonstrated complete DVT resolution by venous duplex examination during the postoperative period and 8 patients (40%) demonstrated partial recanalization/chronic DVT. Complications included one hemothorax and one thoracic duct injury. All 20 patients remain asymptomatic without arm swelling, with a mean follow-up of 55.1 ± 34.7 months. CONCLUSIONS: Among patients presenting with acute axillosubclavian DVT, anticoagulation alone followed by interval first rib resection proved to be successful in providing symptomatic relief in the short to medium term. By eliminating the need for preoperative thrombolysis and postoperative venograms, this potentially cost-saving algorithm simplifies our management for acute venous thoracic outlet syndrome while maintaining good clinical outcomes. Because this study only analyzed our management algorithm's effectiveness in the short to medium term, the long-term effectiveness of this treatment will need to be demonstrated.

Effect of subclavian vein diameter combined with perioperative fluid therapy on preventing post-induction hypotension in patients with ASA status I or II.

BACKGROUND: Perioperative hypotension is frequently observed following the initiation of general anesthesia administration, often associated with adverse outcomes. This study assessed the effect of subclavian vein (SCV) diameter combined with perioperative fluid therapy on preventing post-induction hypotension (PIH) in patients with lower ASA status. METHODS: This two-part study included patients aged 18 to 65 years, classified as ASA physical status I or II, and scheduled for elective surgery. The first part (Part I) included 146 adult patients, where maximum SCV diameter (dSCVmax), minimum SCV diameter (dSCVmin), SCV collapsibility index (SCVCI) and SCV variability (SCVvariability) assessed using ultrasound. PIH was determined by reduction in mean arterial pressure (MAP) exceeding 30% from baseline measurement or any instance of MAP < falling below 65 mmHg for ≥ a duration of at least 1 min during the period from induction to 10 min after intubation. Receiver Operating Characteristic (ROC) curve analysis was employed to determine the predictive values of subclavian vein diameter and other relevant parameters. The second part comprised 124 adult patients, where patients with SCV diameter above the optimal cutoff value, as determined in Part I study, received 6 ml/kg of colloid solution within 20 min before induction. The study evaluated the impact of subclavian vein diameter combined with perioperative fluid therapy by comparing the observed incidence of PIH after induction of anesthesia. RESULTS: The areas under the curves (with 95% confidence intervals) for SCVCI and SCVvariability were both 0.819 (0.744-0.893). The optimal cutoff values were determined to be 45.4% and 14.7% (with sensitivity of 76.1% and specificity of 86.7%), respectively. Logistic regression analysis, after adjusting for confounding factors, demonstrated that both SCVCI and SCVvariability were significant predictors of PIH. A threshold of 45.4% for SCVCI was chosen as the grouping criterion. The incidence of PIH in patients receiving fluid therapy was significantly lower in the SCVCI ≥ 45.4% group compared to the SCVCI < 45.4% group. CONCLUSIONS: Both SCVCI and SCVvariability are noninvasive parameters capable of predicting PIH, and their combination with perioperative fluid therapy can reduce the incidence of PIH.

[Descending Necrotizing Mediastinitis with Subclavian Vein Injury due to Cervical Re-debridement: Report of a Case].

A 58-year-old man was admitted to our hospital with fever and neck swelling after dental treatment. He was diagnosed with a cervical abscess and underwent cervical abscess drainage, but 1 week later he developed descending necrotizing mediastinitis and was referred to our department. He underwent mediastinal and pleural drainage, but neck abscess was recured, Re-debridment of the neck abscess resulted in bleeding from right subclavian vein. The bleeding was successfully stopped with TacoSeal after L-shaped sternotomyand dissection of sternocleidomostoid muscle.

Is ultrasound guidance necessary to avoid complications in the implantation of venous access ports?

BACKGROUND: The aim of this study was to present demographic information of patients undergoing totally implantable venous access port (TIVAP) implantation and to investigate the rates of early and late complications, assessing the benefits of performing the procedure underUS guidance. METHODS: From May 2018 to December 2023, the outcomes of a total of 537 TIVAP implantation procedures were analyzed retrospectively. Data of the surgeons' experiences for both puncture methods (anatomical landmarks and ultrasound guidance) are presented in the study. RESULTS: The average age of the patients was 53.1±11.9 years, and 261 (48.6%) were female. The right subclavian vein was the preferred insertion site. Fourteen patients developed early complications and 11 developed late complications. Arterial puncture was the most common early complication, while catheter-related infection was the most common late complication. The age, sex, and body mass index of the patients were not independent risk factors for developing complications. Early complications increased as the number of puncture attempts did (p=0.034) and developed significantly less when ultrasound guidance was used during insertion (p=0.011). CONCLUSION: The risk of developing complications was not affected by patient's age or sex. In addition, body mass index was not shown to be an independent risk factor for patients developing complications. It may be concluded from the study that early complications in particular can be reduced with ultrasound-guided implantation.

A Neonatal Rodent Model of Retroorbital Vein Injection.

Intravenous (iv) injection is the most used route of drug administration in neonates in the clinical setting. Therefore, retroorbital vein injection is an important method for compound administration in research, where successful proof-of-concept studies can progress into much-needed neonatal clinical trials. Most intravenous studies in neonatal rodents use the superficial temporal/facial vein. However, retroorbital injection becomes unreliable in neonatal rodents older than 2 days after the skin darkens and the vein is no longer visible. In the present protocol, we describe the retroorbital injection of the venous sinus in both the neonatal mouse and rat at ages when the superficial temporal vein is no longer visible, but the eyes have not opened yet. Eye-opening facilitates retro-orbital injection by enabling the researcher to clearly see that they are not perforating the eye when inserting the needle. We demonstrate that this technique can be performed in a reliable and reproducible manner without adverse effects. Additionally, we show that it can be used in many studies, such as administering compounds to study neonatal brain injury.

Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis.

BACKGROUND: Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein. OBJECTIVE: This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm. METHODS: In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review. RESULTS: The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence). CONCLUSION: Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

Percutaneous infraclavicular subclavian vein catheters in paediatric cancer patients in comparison with critically ill children: a one-year experience from a Tunisian hospital.

BACKGROUND: Paediatric cancer and critically ill patients frequently require central venous catheters for prolonged intravenous therapy. The aim of this study is to compare the difficulty of catheter insertion and the morbidity related to this procedure in these two populations and to investigate risk factors for complications. METHODS: This prospective observational study was conducted at the Hedi Chaker University Hospital in Sfax, Tunisia, from July 2021 to July 2022. We included all patients aged three months to 14 years who required an infraclavicular subclavian vein catheterization. Patients were divided into two groups: Group 1 included children with malignancies; and Group 2 included critically ill paediatric patients. Then, we compared the demographic data, the difficulty of the catheterization procedure, and catheter-related complications. We also investigated risk factors for complications using a logistic regression model. The significance level was P<0.05. RESULTS: We included 65 infants and children requiring central venous access, 28 of whom suffered from malignancies. The demographic parameters were comparable. However, the time for the procedure and the number of attempts were higher in the malignancy group with P<0.001. Central venous catheter complications were present 46.4% of the time in Group 1 compared to 21.6% in Group 2 (P=0.032). Malignancies were associated with an increased risk of complications (aOR = 2.95; 95%CI: 0.63-13.8). CONCLUSIONS: This study showed increased difficulty and higher morbidity related to infraclavicular subclavian vein catheterization among infants and children suffering from cancer.

Drainage Pattern of Craniofacial Veins With Emphasis on its Influence on Facial Reconstruction Procedures.

As the facial transplantation procedures are becoming more popular and frequent in recent years, for repairing facial trauma, variations in the veins of head and neck needs to be reported time and again. This study was undertaken to examine the course and drainage pattern of the facial vein and external jugular vein on this context and emphasize its surgical implications. The authors studied the head and neck region of 50 embalmed cadavers of both sexes to document normal and variant anatomy of facial, retromandibular, and external jugular veins. In 30% of the head and neck regions, different draining pattern of the above-mentioned veins were observed. One of the rare variation discovered was the splitting of the retromandibular vein to embrace the external carotid artery within the parotid gland. The data about variations in the termination of facial vein, retromandibular vein, and external jugular vein, as observed in the present study might be useful in avoiding accidental injury to these vessels during any surgical intervention in the face as well as neck. Level of Evidence: IV.

Novel Percutaneous Mechanical Thrombectomy Device for Treating Upper Extremity Deep Vein Thrombosis in Patient With Paget-Schroetter Syndrome.

Paget-Schroetter Syndrome (PSS) is a form of upper extremity deep vein thrombosis (DVT) caused by the external compression of the subclavian vein at the thoracic outlet. Here we describe a complex PSS case in a 43-year-old female who experienced multiple recurrent DVTs and a right-sided hemothorax following two continuous aspiration thrombectomy procedures and a first rib resection. Rapid and complete symptom resolution was achieved with the InThrill Thrombectomy System (Inari Medical), a novel, thrombolytic-free, percutaneous mechanical thrombectomy device that removed all recurrent acute and subacute thrombus in a single session without significant blood loss.

Ultrasound-guided subclavian vein catheterisation with a needle guide (ELUSIVE): protocol for a randomised controlled study.

INTRODUCTION: Central venous catheters are indispensable in modern healthcare. Unfortunately, they are accompanied by minor as well as major complications, leading to increased morbidity, mortality and costs. Immediate insertion-related complications (mechanical complications) have decreased due to the implementation of real-time ultrasound guidance, but they still occur and additional efforts to enhance patient safety are warranted. This study aims to investigate whether the use of a needle guide mounted on the ultrasound probe in subclavian catheterisations may decrease the number of catheterisations with >1 skin puncture (primary outcome). METHODS AND ANALYSIS: This is an investigator-initiated, non-commercial, randomised, controlled, parallel-group study conducted at Skåne University Hospital, Lund, Sweden. Adults (≥18 years) with a clinical indication for a subclavian central venous catheter and the ability to give written informed consent will be eligible for inclusion. Exclusion criteria include subclavian catheterisation deemed unsuitable based on the preprocedural ultrasound examination. Patients will be randomised to catheterisation by certified operators using a microconvex probe (long-axis, in-plane technique) with (n=150) or without (n=150) a needle guide. The ultrasound imaging from the procedures will be recorded and assessed by two reviewers individually. The assessors will be blinded for group affiliation. Secondary outcomes include the total number of skin punctures, mechanical complications, time to successful venous puncture, number of failed catheterisations and operator satisfaction with the needle guide at the end of the study period.Recruitment started on 8 November 2022 and will continue until the sample size is achieved. ETHICS AND DISSEMINATION: This study was approved by the Swedish Ethical Review Authority (#2022-04073-01) and the Swedish Medical Products Agency (#5.1-2022-52130; CIV-21-12-038367). The findings will be submitted to an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05513378, clinicaltrials.gov.

Can subclavian/infraclavicular axillary vein collapsibility index predict spinal anesthesia-induced hypotension in cesarean-section operations?

OBJECTIVE: Spinal anesthesia-induced hypotension (SAIH) is relatively common in pregnant women and has serious maternal and fetal side effects. In patients who are hypovolemic during spinal anesthesia, there may be a significant decrease in blood pressure caused by the decrease in preload. Subclavian vein sonography is a useful method for evaluating preoperative intravascular volume status. This study aimed to evaluate the efficacy of the pre-operative subclavian vein or infraclavicular axillary vein (SCV-AV) collapsibility index for predicting SAIH in cesarean-section (C-section). PATIENTS AND METHODS: In this prospective observational study, 82 women undergoing elective C-sections were recruited. Sonographic evaluation of SCV-AV was assessed before spinal anesthesia. After spinal anesthesia, changes in blood pressure were noted. The main outcome was the association between the SCV-AV measurements (diameter and collapsibility index) and SAIH. RESULTS: Hypotension developed in 53 (64%) patients after spinal anesthesia. The collapsibility index of the SCV-AV during spontaneous breathing and deep inspirium was not a significant predictor of a decrease in mean blood pressure (MBP) after spinal anesthesia (p<0.979, p<0.380). CONCLUSIONS: It was found that the SCV-AV collapsibility index is not a predictor of SAIH in pregnant women undergoing elective C-sections.

Thoracic outlet syndrome in females: A systematic review.

Thoracic outlet syndrome (TOS) is a rare anatomic condition caused by compression of neurovascular structures as they traverse the thoracic outlet. Depending on the primary structure affected by this spatial narrowing, patients present with one of three types of TOS-venous TOS, arterial TOS, or neurogenic TOS. Compression of the subclavian vein, subclavian artery, or brachial plexus leads to a constellation of symptoms, including venous thrombosis, with associated discomfort and swelling; upper extremity ischemia; and chronic pain due to brachial plexopathy. Standard textbooks have reported a predominance of females patients in the TOS population, with females comprising 70%. However, there have been few comparative studies of sex differences in presentation, treatment, and outcomes for the various types of TOS.

Subclavian Vein Blood Sampling in Conscious Rats.

There are several established methods for obtaining repeated blood samples from rats, with the most commonly employed methods being lateral tail vein sampling without anesthesia and jugular vein sampling with anesthesia. However, most of these methods require assistance and anesthetic equipment and sometimes pose difficulties in terms of blood collection or the poor quality of blood samples. In addition, these methods of blood collection consume significant time and human resources when repeated blood sampling is required for a large number of rats. This study presents a technique for repetitive blood sampling in non-anesthetized rats by a single proficient individual. Highly satisfactory blood samples can be obtained by puncturing the subclavian vein. The method demonstrated an impressive overall success rate of 95%, with a median time of merely 2 min from rat restraint to the completion of blood collection. Furthermore, performing consecutive blood collections within the designated range does not inflict any harm on the rats. This method is worth promoting for blood collection, especially in large-scale pharmacokinetic studies.

Comparison of success rate of abducted and neutral arm position for right infraclavicular subclavian vein cannulation under real-time ultrasound guidance in patients undergoing elective neurosurgery under general anesthesia.

Background: Classically subclavian vein catheterization is done in neutral arm position; recently, it has been done in different arm positions to compare success rate and catheter misplacement. There is a paucity of literature for comparing abducted and neutral arm position for right infraclavicular subclavian vein cannulation. Aim: Comparison of success rate of abducted and neutral arm position for right infraclavicular subclavian vein cannulation under real-time ultrasound guidance in patients undergoing elective neurosurgery under general anesthesia. Design: Randomized comparative study. Materials and Methods: After approval from Institutional Review Board and Ethical Committee, 100 patients of 18-70 years of age, of either sex, posted for elective neurosurgery under general anesthesia, requiring right subclavian vein cannulation were included in our study. They were randomly divided into two groups: abducted arm position (group 1-AG) and neutral arm position (group 2-NG) using sealed envelope technique. Results: First attempt success rate was higher in AG group compared to NG group (P value- 0.741). Times taken (seconds) for cannulation in NG and AG group, catheter misplacement and hematoma (P value- 0.37, P value- 0.37, P value- 1, respectively) were lesser in AG Group. Conclusion: For USG-guided infraclavicular subclavian vein cannulation, abducted arm position, and neutral arm position in terms of first attempt success rate, number of attempts and associated complications has comparable results; however, further studies with larger group of patients are required to assess the overall advantage of abducted arm position over neutral arm position.