Exercise-Induced Mondor's Disease of the Chest Wall in a Nigerian Man: A Case Report.

BACKGROUND: Mondor's disease (MD) is a rare cause of chest pain, characterized by thrombophlebitis of the subcutaneous veins of the anterolateral thoracoabdominal wall. It is a benign, self-limiting condition that is often underdiagnosed due to lack of knowledge of the condition. Although the exact aetiology is unclear, several predisposing factors, including excessive physical activity have been postulated. To the best of our knowledge, there is no previous published report of MD of the chest wall in an adult Nigerian man. OBJECTIVE: To describe the association between muscular strain and the development of MD. CASE PRESENTATION: A 40-year-old Nigerian man presented with a one-month history of dull, aching right-sided chest pain. He gave a history of engaging in intense thoracoabdominal exercises for 6 weeks prior to onset of symptoms. Physical examination revealed a tender, subcutaneous cord-like swelling extending from below the right anterior axillary fold to the right hypochondrium and accentuated by overhead abduction of the right arm. Ultrasonography revealed a hypoechoic, noncompressible right thoracoepigastric vein with no flow on Doppler interrogation, in keeping with superficial venous thrombosis. He was treated with nonsteroidal anti-inflammatory agents and paracetamol. The pain and lesion resolved completely within two weeks after presentation and there was no recurrence over the subsequent four months of follow-up. CONCLUSION: MD is an uncommon cause of chest pain that is often underdiagnosed and underreported due to lack of awareness. It can suddenly appear in persons performing extreme thoracoabdominal exercises. Treatment is essentially symptomatic. Prompt diagnosis of this self-limiting condition is essential in distinguishing it from malignant diseases.

CONTEXTE: La maladie de Mondor (MD) est une cause rare de douleur thoracique, caractérisée par une thrombophlébite des veines sous-cutanées de la paroi thoraco-abdominale antérolatérale. Il s'agit d'une maladie bénigne et spontanément résolutive qui est souvent sous-diagnostiquée en raison d'un manque de connaissance de la maladie. Bien que l'étiologie exacte ne soit pas claire, plusieurs facteurs prédisposants, y compris une activité physique excessive, ont été postulés. Au meilleur de notre connaissance, il n'y a aucun rapport publié précédemment de MD de la paroi thoracique chez un homme Nigérian adulte. OBJECTIF: Décrire l'association entre la tension musculaire et le développement de la MD. PRÉSENTATION DE CAS: Un homme Nigérian de 40 ans s'est présenté avec une histoire d'un mois de douleur thoracique sourde et douloureuse du côté droit. Il a indiqué qu'il s'était engagé dans des exercices thoraco-abdominaux intenses pendant 6 semaines avant l'apparition des symptômes. L'examen physique a révélé une tuméfaction sous-cutanée semblable à un cordon s'étendant du dessous du pli axillaire antérieur droit à l'hypochondre droit et accentuée par une abduction au-dessus du bras droit. L'échographie a révélé une veine thoraco-épigastrique droite hypoéchogène, non compressible et sans débit à l'examen Doppler, en rapport avec une thrombose veineuse superficielle. Il a été traité avec des anti-inflammatoires non stéroïdiens et du paracétamol. La douleur et la lésion ont complètement disparu dans les deux semaines suivant la présentation et il n'y a eu aucune récidive au cours des quatre mois suivants de suivi. CONCLUSION: La MD est une cause rare de douleur thoracique qui est souvent sous-diagnostiquée et sous-déclarée en raison d'un manque de sensibilisation. Il peut apparaître soudainement chez les personnes effectuant des exercices thoraco-abdominaux extrêmes. Le traitement est essentiellement symptomatique. Un diagnostic rapide de cette maladie spontanément résolutive est essentiel pour la distinguer des maladies malignes. Mots clés: maladie de Mondor, exercice, douleur thoracique, thrombophlébite.

"Please mind the gap": successful use of ultrasound-assisted spinal anesthesia for urgent cesarean section in a patient with implanted spinal cord stimulation system for giant chest wall arteriovenous malformation - a case report.

BACKGROUND: The use of Spinal Cord Stimulation (SCS) system to treat medically refractory neuropathic pain is increasing. Severe neuropathic pain can be found in giant chest wall arteriovenous malformations (AVMs), exceedingly rare and debilitating abnormalities, rarely reported during pregnancy. CASE PRESENTATION: We present a report of a pregnant patient with implanted Spinal Cord Stimulation (SCS) system because of painful thoracic AVM scheduled for an urgent cesarean section in which we used lumbar ultrasound (US) to rule out the possibility to damage SCS electrodes and to find a safe site to perform spinal anesthesia. CONCLUSIONS: The use of lumbar US to find a safe site for a lumbar puncture in presence of SCS system in a patient affected by painful thoracic AVM makes this case a particularly unique operative challenge and offers a new possible use of ultrasound to detect a safe space in patients with SCS implant.

Visualization of angiogenesis and vasculogenesis in a late tissue radiation injury of the chest wall treated with adjuvant hyperbaric oxygen therapy using fluorescence angiography.

Adjuvant radiation therapy for breast cancer treatment often involves high doses of radiation, making patients more susceptible to late radiation tissue injury (LRTI), severe complications of which involve necrosis and ulceration. Treatment of such wounds is challenging. One modality that can be utilized is hyperbaric oxygen (HBO2) therapy. However, an optimal dose and the objective evidence of its benefit in use as an adjunctive treatment modality is limited. Presented here is a case of a non-surgical candidate in which serial indocyanine green fluorescence angiography (ICGFA) was utilized to determine if it could detect changes in tissue perfusion over the course of treatment. Serial ICGFA allowed for visualization of the current phase of wound healing, angiogenesis and vasculogenesis. Future large studies should be employed to better determine the utility of serial ICGFA to improve HBO2 utilization in patients who are undergoing HBO2 as part of their course of treatment for LRTI.

Anatomical study of the perforator flap based on the acromial branch of the thoraco-acromial artery (abTAA flap): a cadaveric study.

PURPOSE: The aim of this anatomical study was to describe a local perforator flap, for covering shoulder defects, by determining the features of the acromial branch of the thoraco-acromial artery (abTAA), and the supplied cutaneous area. METHODS: Thirteen fresh cadaveric thoraxes were dissected bilaterally. A precise and reproducible protocol was performed. For each abTAA flap cadaveric dissection, the following parameters were measured after arterial injection: distances between the origin of the perforator artery on the abTAA and the sternum, the acromion, the clavicle, diameter of the perforator artery of the abTAA, length of the perforator pedicle course through major pectoralis muscle, and rotation arc. We also calculated the surface of the injected skin paddle. These measurements were related to morphometric parameters evaluated through the distance between sternum and acromion. RESULTS: The mean distances measured from the origin of the perforator artery on the abTAA were 14.25 cm to the sternum, 3.45 cm to the acromion, 5.65 cm to the clavicle. The mean diameter of the abTAA was 1.20 mm ± 0.2. The arc of rotation was 180°, and the length of the perforator pedicle could be extended to 7.46 cm ± 1.15. We observed an colored elliptical cutaneous paddle with a longer radius 18 cm and a small radius 15 cm. CONCLUSIONS: Our results suggest that this type of flap could be useful in clinical practice for reconstruction and covering of the acromial area with a thin cutaneous flap with low sequelae on the donor site.

Giant Chest Wall Arteriovenous Malformation: A Case Report and Literature Review.

BACKGROUND: We present an interesting case of a 55-year-old male with a large left chest mass after significant cutaneous bleeding. Computed tomography angiogram of the chest revealed arteriovenous malformation with blood supply from sub-branches of the left subclavian artery, left internal mammary artery, and left external carotid artery. Measuring 5.0 × 14.0 × 10.8 cm, the mass extended superior to the clavicle and inferior to the third rib with medial and lateral borders at the level of the clavicular head and coracoid, respectively. METHODS: Arteriovenous malformations (AVMs) are characterized by abnormal connections between arteries and veins which bypass the capillary system. Often small and asymptomatic, large AVMs can be painful, prone to bleeding and, if large enough, interfere with activities of daily living. While described involving various parts of the body, most notably in the central nervous system, there is a paucity of literature involving chest wall AVMs. RESULTS: Using a staged, multidisciplinary approach, treatment began with an endovascular exclusion of the arterial blood supply, which involved a combination of coil embolization and stent exclusion of feeder vessels. Two days postembolization, the patient underwent an en bloc resection of affected portion of his chest wall. Reconstruction was completed with a combination rotational flap and split-thickness skin graft. Following the procedures, the patient had an uncomplicated recovery. Three years following procedure, he has no signs of recurrence of his AV malformation. CONCLUSION: Surgical planning and indications for giant arteriovenous malformations remains a unique and difficult problem. The complex anatomy and extreme rarity of a chest wall AVM requires a multidisciplinary staged approach but can be treated with a multistage, multidisciplinary surgical approach with satisfactory and long-lasting results.

Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review.

Selecting potential recipient vessel options for free flap anastomosis is an important consideration in microsurgical breast and chest wall reconstruction. In these settings, the most common comprise the internal mammary and thoracodorsal vessels, although alternative anastomotic sites have also been described. On occasion, consideration of these alternatives becomes a necessity. The use of five separate recipient vessels is highlighted in a unique case of recurrent locally advanced breast cancer requiring multiple complex reconstructions using free tissue transfer. A 56-year-old lady presented for delayed breast reconstruction one year after radical mastectomy for locally advanced lobular breast cancer. Despite wide resections, local chest-wall recurrence five times necessitated five microsurgical reconstructions, using separate recipient pedicles: internal mammary vessels, thoracodorsal vessels, serratus branch of thoracodorsal vessels, intercostal vessels and thoracoacromial vessels. All flaps survived completely, without donor or recipient complications. There has not been a subsequent recurrence at 6 months since last reconstruction. The purpose of this report is to present the first reported case of microsurgical chest wall reconstruction using five separate free flaps requiring anastomosis to multiple recipient vessels for anterior chest wall coverage, to present a literature-based and clinical review of the regional vascular anatomy of the anterior chest wall, and to present an operative approach algorithm. In such complex cases, this understanding can facilitate a streamlined approach to management. © 2014 Wiley Periodicals, Inc. Microsurgery 37:66-70, 2017.

Rotational flaps in oncologic breast surgery. Anatomical and technical considerations. / Colgajos por rotación en la cirugía oncológica de la mama. Fundamentos anatómicos y técnicos para su planificación quirúrgica.

Local flaps are a group of surgical procedures that can solve the thoracic closure of large defects after breast cancer surgery with low morbidity. Its use in skin necrosis complications after conservative surgery or skin sparing mastectomies facilitates the initiation of adjuvant treatments and reduces delays in this patient group. This article describes the anatomical basis for the planning of thoracic and abdominal local flaps. Also, the application of these local flaps for closing large defects in the chest and selective flaps for skin coverage by necrosis in breast conserving surgery.

Experience with chest wall arteriovenous grafts in hemodialysis patients.

BACKGROUND: Maintaining long-term hemodialysis access in end-stage renal disease patients presents a serious challenge to surgeons. Over time, patients' remaining access sites diminish while complications and comorbidities simultaneously multiply; often resulting in the use of permanent tunneled catheters, which have a well-known high rate of complications and short-term usefulness. In this study, we report the results of a dialysis graft based on the axillary artery and ipsilateral axillary vein and tunneled in the subcutaneous tissues of the chest. METHODS: We identified patients who had a chest wall arteriovenous graft (CWAVG) placed at our institution between May 2007 and December 2012. After institutional review board approval, the patients were retrospectively and then prospectively identified and followed for 2 years to document the performance, required maintenance, and complications of the graft. RESULTS: Sixty-seven grafts in 67 patients were reviewed, representing 0.56% of our 1,192 total dialysis access creations during the study period. The average patient was 55-year-old with an average history of 3.97 explicitly documented prior accesses. Sixty interventions were performed postoperatively including 32 for thrombosis and 28 for venous stenosis. Six documented graft infections occurred (9%). Three minor wound complications occurred, but the graft was preserved. Notably, no patient developed symptoms of steal syndrome. The primary and secondary patency rates at 1 and 2 years were 69.5% and 36.9% and 81.6% and 57.6%, respectively. Twenty-three of the 67 patients died in the 2-year follow-up period (34%). CONCLUSIONS: CWAVGs are useful and appropriate for patients with difficult upper extremity access. The patency rates for this "exotic" procedure are at least equivalent to other upper extremity grafts. The infection rate is lower than that for femoral grafts or tunneled catheters, and there is no risk of steal syndrome. CWAVGs can even be considered for primary use in patients who have disadvantaged upper extremity vasculature or who are at increased risk of steal syndrome.

Vitamin K2 for the reversal of warfarin-related coagulopathy.

The American Heart Association/American College of Cardiology Foundation recommends vitamin K1 for warfarin-related coagulopathy. In Japan, vitamin K2 is used more commonly for such purpose. The difference between vitamins K1 and K2 in reversing warfarin-related coagulopathy has not been discussed. Herein, we report a case that was reversed with vitamin K2; alterations in vitamins K1 and K2 levels and coagulation markers are also presented.

Factors influencing the diameter of human anterior and posterior intercostal arteries.

At present, there have not been any detailed studies examining the size relationships of the intercostal arteries. This study was carried out to investigate the relationship between the vessel lumenal diameter of ipsilateral, paired anterior and posterior IC arteries, as well as with the length of the IC space supplied by each artery. Samples were collected from the second-sixth anterior and posterior IC arteries near their site of origin, and the lengths of the corresponding IC spaces were measured in 42 cadavers. Lumenal diameters of both the anterior and posterior IC arteries at consecutive IC space closely followed second degree polynomial regression models (R(2) = 0.9655, and R(2) = 0.9741, respectively), and reached maximum size at the fifth IC space, which was found to be the longest of the IC spaces. No direct relationship was observed between diameters of the paired anterior and posterior IC arteries, although there was a trend for the larger anterior IC arteries to be paired with the larger posterior IC arteries. The calculated rate of blood flow at each IC artery was approximately two-fold greater in males than in females. These results suggest that the length of the IC space, and hence the extent of the thoracic wall supplied, is a major factor in determining the diameter of both anterior and posterior IC arteries. Since COPD is such a prevalent disease, this study also examined its influence on the IC arteries, and found that the posterior IC arteries are significantly larger among afflicted subjects.

[Combined treatment of complicated forms of angiodysplasias in conditions of a multimodality hospital].

Presented herein is a case report dealing with successive combined treatment for arteriovenous malformation of the left part of the chest, macrofistular form complicated by necroses of the left thoracic portion with arrosive haemorrhage from the area of necrosis. The authors describe diagnosis of this disease, technical peculiarities of performing transcatheter endovascular occlusion and topical treatment of wounds, underlining difficulties of verifying the pathology concerned at the prehospital stage and prevention of complications. Particular emphasis in management of these patients is placed upon therapeutic decision-making. Radical excision of tissue practically completely consisting of dilated thin-walled vessels may result in massive perfuse haemorrhage and is often impossible. Selective exclusion of feeding arteries by endovascular methods frequently leads to formation of necroses, does not differ in radical nature because of the presence of multiple arteriovenous fistulas and requires regular follow up of the patient due to a possibility of relapse. The final therapeutic decision should be made in the context of a particular patient, since there are no versatile approaches to management of the pathology concerned.

Posterior intercostal artery tortuosity and collateral branch points: a cadaveric study.

Publications report observing tortuosity in the posterior intercostal arteries of elderly patients. Studies also describe the size and course of the collateral intercostal arteries. This information is clinically significant when performing thoracentesis and video-assisted thorascopic surgery. To the best of our knowledge, no studies have examined arterial tortuosity or described collateral artery origins relative to bony landmarks. The purpose of this study was to define a safe surgical zone for thoracic access using palpable external bony landmarks. A total of 348 intercostal spaces (3rd-8th) of 29 male and female embalmed cadavers were dissected from the vertebral body to the mid-axillary line to observe the posterior intercostal artery and its collateral branch. The origins of the collateral intercostal arteries relative to the midline of thoracic spinous processes were measured. Mild to moderate tortuosity (arterial curves covering 25- -50% of the intercostal space) was observed in at least one posterior intercostal artery in the majority of cadavers. The origins of the collateral intercostal arteries were variable relative to the midline. Additional collateral intercostal arteries distal to the primary collateral branch were observed, most commonly in the 5th intercostal space, which is used in video-assisted thorascopic surgery and thoracentesis. Tortuosity is common in the 3rd to the 8th posterior intercostal arteries, especially in individuals over the age of 60 years. Given the findings of this study, we recommend that any procedure involving placement of a surgical instrument into these intercostal spaces does so at least 120 mm lateral to the midline of the spinous processes. We also recommend pre-procedure ultrasound (intercostal scan) of the posterior and collateral intercostal arteries when performing non-emergent thoracentesis and video-assisted thorascopic surgery, particularly in patients over 60 years of age.

The Importance of Fifth Anterior Intercostal Vessels following Nipple-Sparing Mastectomy.

BACKGROUND: The authors describe the vascular anatomy of the fifth anterior intercostal artery perforator and its role for perfusion of the nipple-areola complex following nipple-sparing mastectomy. METHODS: Twenty fresh cadavers were injected with 20 cc of colored latex through the internal mammary artery. The catheter was placed at the level of the second intercostal space after removal of the rib. The fifth intercostal space was dissected under magnification to observe the origin and trajectory of the fifth anterior intercostal artery perforator. Six selective computed tomographic angiograms of the fifth intercostal artery perforator were performed. A clinical case of nipple-sparing mastectomy in a woman with mammary hypertrophy is provided to demonstrate the utility of preserving the fifth anterior intercostal artery perforator. RESULTS: The fifth anterior intercostal artery perforator was consistently observed in all the cases and confirmed by angiography. The perforator gives rise to several branches that traverse in all directions. The ascending branches of the fifth anterior intercostal artery perforator are directed toward the nipple-areola complex and course within the subcutaneous layer between the skin and the parenchyma. The fourth and fifth anterior intercostal artery perforators are independent of one another. CONCLUSION: The main ascending branch of the fifth anterior intercostal artery perforator reaches the nipple-areola complex by the subcutaneous tissue independently of the Würinger fascia.

Management challenges of a large upper extremity vascular malformation in a patient with capillary malformation-arteriovenous malformation syndrome.

We describe a 17-year-old boy with capillary malformation-arteriovenous malformation syndrome and a massive vascular malformation of the right chest wall, shoulder, and upper arm. Persistent growth of the malformation caused cutaneous ulcerations and recurrent massive bleeding episodes. We proceeded with a modified shoulder disarticulation preceded by ligation of the subclavian artery and innominate vein by median sternotomy. After a staged debulking resection of the residual chest wall arteriovenous malformation with rotational transverse rectus abdominis myocutaneous flap coverage, the patient was discharged home safely. This report demonstrates that a multidisciplinary approach is critical for management of life-threatening complications in capillary malformation-arteriovenous malformation patients.

Mondor's syndrome: a clinical finding on subfascial breast augmentation.

Mondor's syndrome is a clinical finding that can present in young to middle-age women 7-14 days after subfascial breast augmentation. Three cases of women who presented Mondor's syndrome after subfascial breast augmentation are reported. The cases were characterized by a tender and painful cord that originates on the middle clavicle line from the inframammary border to the umbilicus scar on the thoracoabdominal wall.

A 22-Year-Old Man With Back Pain, Dilated Veins Over Chest, and Mass in Right Atrium.

CASE PRESENTATION: A 22-year-old nonsmoker male, without any previous comorbidity, presented with 4 months' history of right upper back pain. Pain was constant dull aching type, nonpleuritic, aggravated by lying on the right lateral side and partially relieved on taking analgesics. He then developed progressive dyspnea over 2 months and noticed dilated veins over his neck and front of chest. There was associated unintentional weight loss of 6 kg. There was no history of cough, expectoration, wheeze, or hemoptysis, nor any episodes of night sweats or fever.