Axillary Vessels Research Articles

Research advances on risk factors for arm lymphedema following breast cancer surgery

Arm lymphedema is a common and persistent complication of breast cancer surgery. Surgery or radiotherapy damages axillary lymphatic vessels and obstructs lymphatic reflux, leading to the accumulation of lymph fluid in the superficial soft tissues of the upper limbs and the subsequent formation of edema. Clinical treatment of breast cancer-related lymphedema remains a worldwide problem. Currently, there is still no cure. Key words: Breast neoplasms; Lymphedema; Risk factors

Le lambeau fessier inférieur libre en reconstruction mammaire : analyse des résultats de 69 lambeaux

The inferior gluteal musculocutaneous flap described by Shaw then Le-Quang offers the possibility of harvesting a large amount of tissue with a well-concealed scar in the inferior fold. Since 1996, we used this flap for breast reconstruction without implant. The purpose of this study was to assess short and for long-term results in our patients. Between 1996and 2005, 64patients underwent 69musculocutaneous flaps by two seniors surgeons, for secondary unilateral reconstruction (57cases, 51total mastectomy, three partial mastectomy, three constitutional breast asymmetry), five bilateral reconstruction or one thoracic skin ulceration after radiotherapy. The average flap weight and size was respectively 360g and 18 × 7cm. For short results, the assessment was based on flap success and surgical morbidity. For long-term results, the assessment was based on breast result (shape, volume, symmetry, skin and scar) and donor-site morbidity (scar, contour deformity, muscle function and sensation). Patients and surgeons global satisfaction were compared. Minimal follow-up was three years for 60patients. Two patients died with metastasis. Sixty-three flaps succeeded. We had five flap necrosis, one after general complication (pulmonary embolism), four after venous thrombosis during the first period of our experience. Forty patients underwent a second procedure on the flap or on the other breast (25cases). For the patients, the global result was excellent in 20cases, good in 32cases, fair in nine cases. For surgeons the global result was excellent in 13cases, good in 32cases, fair in 13cases and poor in three cases. Concerning the donor-site, only one patient had an asymmetry of the buttock. Mostly, the scar of the donor site was good. Five cases needed a new surgery for poor scar. Five patients had functional complaints (for bicycle and squatting). Twenty-three patients noticed the hypoesthesia in the territory of the posterior femoral cutaneous nerve. For breast reconstruction, the gluteal region is an acceptable donor site with low morbidity and stable results. This technique needed a relative long learning curve, especially for the venous pedicle. We recommend to use a large vein dissected from the arm and axillary vessels. We also reduce the harvesting volume of the muscle to preserve the function. The reconstructive breast had a good shape, sufficient volume and acceptable symmetry.

The axillary arch – morphological and histological study with clinical importance

The latissimus dorsi is a muscle of the back which forms the posterior fold of the axilla and its tendon twists to insert into the floor of the intertubercular sulcus of the humerus. Occasionally, the muscle has a muscular slip which crosses the axilla to insert into the pectoralis major. This muscular slip is often termed as "axillary arch." In the present study, we report bilateral axillary arch detected in a 45-year-old male cadaver. The average vertical length of the axillary arch measured 7 cm. The average maximum width of the uppermost, middle and lower part of the arch measured 2, 3.5 and 3.2 cm, respectively. The presence of the axillary arch is an uncommon finding in humans, considering the fact that it is solely found in the animals who prefer to hang on the trees. A histological study of the axillary arch was also performed and it showed skeletal muscle fibres which was uniformly arranged. The presence of the axillary arch may assist in the adduction of the shoulder. It may also compress the axillary vessels and nerves thereby causing resultant symptoms. Prior anatomical knowledge of the presence of axillary arch may be helpful for surgeons performing radical dissection of the axillary lymph nodes and ligation of axillary vessels, clinicians diagnosing abduction syndromes and interventional radiologists interpreting axillary mass in day to day clinical practice.

Alterations of Anatomic Relationships on Chest Computed Tomography as a Function of Arm Position

To determine the effects of arm position on the appearance of structures in the upper chest as seen on computed tomography (CT), such as clavicular angle, course of axillary vessels, pectoralis major muscle, and bicipital groove. The study consisted of 52 chest CT examinations (32 from men and 20 from women; mean [SD] age, 64 [20] years) performed with 1 or both arms at or above the shoulder (n = 44 arms) or by the side of the body (n = 60 arms). Three chest radiologists assessed randomized CT examinations for specific anatomical structures including orientation of the bicipital groove of the humerus, appearance of the pectoralis major muscle, and the course of the axillary vessels. Orientation of the clavicle and the scapula were assessed by measuring their angles with the mid-sagittal plane. Data were analyzed using the Student t test. There was a significant difference in the mean angle of the clavicles with the mid-sagittal plane in arms at or above the shoulder level (41.3 +/- 11.7 degrees) compared with arms-by-side position (54.8 +/- 14.7 degrees; P < 0.0001), but no significant difference was found in scapular angles (P = 0.4). All 3 radiologists found anteriorly directed bicipital groove, flat pectoralis major, and straight course of the axillary vessels from the chest to the axilla when arms were by the side. With arms at or above the level of the shoulder, however, the bicipital groove was directed posteromedially, the pectoralis major was buckled, and the axillary vessels had an angulated course. The bicipital groove, the pectoralis muscles, the axillary vessels, or the angle of the clavicle with the mid-sagittal plane on transverse CT images can help predict the position of the arms in patients undergoing chest CT.

Ultrasound-guided approach for axillary brachial plexus, femoral nerve, and sciatic nerve blocks in dogs

ObjectiveTo describe an ultrasound-guided technique and the anatomical basis for three clinically useful nerve blocks in dogs. Study designProspective experimental trial. AnimalsFour hound-cross dogs aged 2 ± 0 years (mean ± SD) weighing 30 ± 5 kg and four Beagles aged 2 ± 0 years and weighing 8.5 ± 0.5 kg. MethodsAxillary brachial plexus, femoral, and sciatic combined ultrasound/electrolocation-guided nerve blocks were performed sequentially and bilaterally using a lidocaine solution mixed with methylene blue. Sciatic nerve blocks were not performed in the hounds. After the blocks, the dogs were euthanatized and each relevant site dissected. ResultsAxillary brachial plexus block Landmark blood vessels and the roots of the brachial plexus were identified by ultrasound in all eight dogs. Anatomical examination confirmed the relationship between the four ventral nerve roots (C6, C7, C8, and T1) and the axillary vessels. Three roots (C7, C8, and T1) were adequately stained bilaterally in all dogs. Femoral nerve blockLandmark blood vessels (femoral artery and femoral vein), the femoral and saphenous nerves and the medial portion of the rectus femoris muscle were identified by ultrasound in all dogs. Anatomical examination confirmed the relationship between the femoral vessels, femoral nerve, and the rectus femoris muscle. The femoral nerves were adequately stained bilaterally in all dogs. Sciatic nerve blockUltrasound landmarks (semimembranosus muscle, the fascia of the biceps femoris muscle and the sciatic nerve) could be identified in all of the dogs. In the four Beagles, anatomical examination confirmed the relationship between the biceps femoris muscle, the semimembranosus muscle, and the sciatic nerve. In the Beagles, all but one of the sciatic nerves were stained adequately. Conclusions and clinical relevanceUltrasound-guided needle insertion is an accurate method for depositing local anesthetic for axillary brachial plexus, femoral, and sciatic nerve blocks.

Nerve loop around the axillary vessels by the roots of the median nerve a rare variation in a south Indian male cadaver: a case report.

IntroductionMedian nerve is normally formed by the union of medial and lateral root arising from the medial and the lateral cords of the brachial plexus respectively. However, variations in the formation and its relation with the axillary vessels are not uncommon. Therefore, knowledge of the variations in the nerve formation and course is useful for the clinicians during surgery and for differential diagnosis of uncommon clinical conditions.Case presentationDuring the routine dissection in the department of anatomy, Kasturba Medical Collage, Manipal, India, we found unique anatomical variations in the formation and the course of the roots of the median nerve forming the neural loops around the axillary artery and vein.ConclusionHere we report the detailed description of these variations along with its clinical, embryological relevance and review of literature.

Limb-Sparing Resection of the Scapula and Reconstruction with a Constrained Total Scapula Prosthesis: A Case of Multicentric Epithelioid Hemangioendothelioma Involving the Scapula and Surrounding Soft Tissues

The scapula is a relatively uncommon site for primary bone sarcomas. Tumors arising from the scapula are often initially contained by the rotator cuff muscles that protect pertinent adjacent muscles as well as the brachial plexus and axillary blood vessels. Limb-sparing resection of a scapula sarcoma is technically complex and requires meticulous dissection and mobilization of the brachial plexus and axillary blood vessels. Several muscles must be capable of being preserved in order to reconstruct the scapula and shoulder girdle with a special customized total scapula replacement. The goal of reconstruction is to restore a stable shoulder girdle to preserve elbow and hand function. In the procedure demonstrated in this video, limb-sparing scapula resection and reconstruction was performed for a patient with a multicentric epithelioid hemangioendothelioma. The steps of the procedure are detailed along with accommodations made for the multicentric nature of the tumor. To allow for optimal postoperative function and maximum soft tissue coverage, a small constrained scapular prosthesis was utilized. The glenohumeral ligaments were reconstructed with a Gore-Tex aortic graft. Multiple muscle rotation flaps were performed to cover and protect the prosthesis as well as restore shoulder girdle stability. Limb-sparing surgery for scapula sarcomas and anatomic reconstruction with a constrained total scapula prosthesis is a reliable and safe technique for resecting selected sarcomas and reconstructing the shoulder girdle. A stable shoulder girdle can be restored for optimal hand and elbow function. A total scapula prosthetic reconstruction is the authors' procedure of choice when the deltoid, trapezius, rhomboid, latissimus, and serratus anterior muscles are capable of being preserved. The functional outcome is superior to a forequarter amputation and a flail (nonreconstructed) shoulder in which the extremity is left hanging by soft tissues (nonanatomic method).

The Pectoralis Minor Pedicled Muscle Flap in Axillary Reconstruction

We report on the case of a patient undergoing resection of a large axillary and chest wall tumor, resulting in exposure of the brachial plexus and axillary vessels. Our experience of the use of the pectoralis minor pedicled flap for the reconstruction of such a defect is described, providing for excellent postoperative mobility of the axilla and minimal donor-site morbidity.

Deltoido-pectoralis approach to axillary vessels for full-flow cardiopulmonary bypass

Axillary artery has been proposed as a safe and effective alternative for arterial cannulation in surgical procedures involving ascending aorta and/or aortic arch, and is nowadays the site of choice in many centres. Advantages of axillary artery cannulation include antegrade flow and the possibility of selective mono-hemispherical brain perfusion during circulatory arrest. Experiences with the axillary vein cannulation, however, are scarce. Here we report our preliminary experience with axillo-axillary cardiopulmonary bypass, through both axillary artery and vein cannulation (using echo-guided Seldinger technique) at deltoido-pectoralis groove. We have used such an approach in 5 cases of redo surgery on ascending aorta and we have not had any inconvenience during cardiopulmonary bypass. Full flow was maintained in all patients (in 2 with vacuum assisted drainage) including 2 cases with deep hypothermic circulatory arrest. In conclusion such an approach seems to be feasible and effective and can be safely performed providing that accurate TE echo monitoring is provided.

Cross-site anastomosis for a free flap with a long pedicle in the rat

We describe a simple and reliable technique for tunneling of the vascular pedicle of the free flap with a long pedicle, that may otherwise cause twisting and/or kinking of the pedicle. There are two modifications of the technique. In the cross-groin anastomosis modification, using a haemostat in a blunt manner, a suprapubic subcutaneous tunnel is created between two groin regions. The vascular pedicle of the flap is pulled and passed through this tunnel to the contralateral region. While the anastomoses are done on one site, the flap is inserted to the contralateral groin. In the second modification ('groin anastomosis-cross dorsum flap insert procedure'), the flap is transferred to the dorsum of the rat at approximately the same level of the groin. Using a haemostat, a large subcutaneous tunnel safe enough for the pedicle is created between the groin region and the rat dorsum lateral to the hip region. The anastomoses are done in the groin region, and the flap is inserted on the dorsum. This technique was used in 16 animals, with a free cutaneous maximus muscle musculocutaneous flap transfer based on the axillary vessels being done in eight animals; and a posterior thigh perforator-based flap based on the popliteal vascular pedicle in the remaining eight. Both groups had a pedicle length of approximately 4 cm, with a 100% survival rate. In conclusion, the technique is simple, reliable, and can be easily carried out without necessitating special procedures. It provides a straight course for the vascular pedicle with tension-free anastomosis by appropraitely adjusting the distance of the vascular anastomosis and flap insertion site.

Sonoanatomie der Axilla

The axilla represents a region of special interest for small-part sonography. It is easy to demonstrate musculocutaneous, osseous, neurovascular and lymphatic structures. Especially in the presence of breast malignomas with lymphatic drainage to the axillary region sonography of the axillary lymphatic tracts and nodes is essential. The examination is performed with a linear 7.5 MHz transducer with the patient in supine position and the arm hyperabducted. The transducer is directed in transversal and sagittal planes and along the axillary vessels. It is of importance to know exactly the complex topographic anatomy of the axilla. The very dominant pectoral muscles serve as guiding structures. In their vicinity one can find some important groups of lymph nodes. The last station of axillary lymph nodes is the apical group situated along the axillary neurovascular bundle. With their typical echo, the head of the humerus and the coracoid-process facilitate the orientation. Ultrasound is now generally available and should always be used as a secondary method of examination, it breast malignomas are present or suspected in mammogramms, since it supplies important clinical information.

Effect of Recipient Arterial Blood Inflow on Free Flap Survival Area

The influence of using different recipient arteries on free flap survival area has not been well studied. The purpose of the authors' present study was to compare the survival areas of free flaps transferred to different recipient arteries with different blood inflow and to investigate the vascular structural changes in the flaps. The authors developed a free three-territory flap model on the back of a rat. This three-territory flap was elevated based on the thoracodorsal vessels, which were dissected to the axillary vessels. In group 1, the control group (n = 16), the flap was transferred to the abdominal skin defect as a pedicled flap after 60 minutes of clamp ischemia. Groups 2 (n = 24) and 3 (n = 24) were free flap models that were transferred to different recipient vessels. The axillary vessels were anastomosed to the common carotid artery and the external jugular vein in group 2, and to the femoral vessels in group 3. On day 5, evaluation of the survival area of the flap, whole-body angiography, and measurement of arterial inflow to the flap were performed. The greatest mean flap survival was seen in group 2 (94.3 percent). The differences between groups 1 and 2 and groups 2 and 3 were statistically significant. Angiographic studies demonstrated that the second choke zone in group 2 dilated extensively, but in groups 1 and 3, the second choke zone dilated only slightly or remained unopened. The results suggest that augmenting the arterial inflow of a free flap could open the second choke zone and improve flap survival area.

Outcome of Simultaneous and Staged Microvascular Free Tissue Transfer Connected to Arteriovenous Loops in Areas Lacking Recipient Vessels

Arteriovenous loops are an indispensable tool in free flap surgery when appropriate recipient vessels are missing. In this study, the authors analyzed whether the outcome differs when flaps were transferred simultaneously or subsequently after construction of arteriovenous loops. Twenty-seven patients requiring free tissue transfer received arteriovenous loops by pedicled or free vein grafts because of inadequate local recipient vessels. In head and neck reconstruction, pedicled brachiocephalic or free saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled major saphenous vein grafts were used in the pelvic area whereas, in lower leg and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n = 10) or 4 to 17 days later (n = 17). Thrombosis required revision in staged transfer (n = 3 patients) or in simultaneous flap transfer (n = 2). No free flap was lost. Fisher's exact test did not indicate a significant difference between a simultaneous or staged flap transfer. Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer.

Reconstruction mammaire par lambeau libre DIEP : à propos de 30 cas

The purpose of this study was to analyse the surgical procedure and the complications in case of breast reconstruction by deep inferior epigastric perforator flap (DIEP). This retrospective study concerns 30 cases performed between 2001 and 2005. The reconstruction was delayed (73%), immediate (3%) or realised after failed attempt to reconstruct the breast with implant or flap (27%). We studied perforator selection, operative time, total flap loss, partial flap loss, and postoperative complications. Flap was raised with one pedicle in 22 cases and with two pedicles in eight cases. The recipient vessels were the axillary vessels (70%), circumflex scapular vessels (27%), and the thoracodorsal vessels (1%). Mean operating time was 6h 17min for the one-pedicle flaps and 8h 43min for the double-pedicle flaps. We noted two total flap necrosis, four partial flap necrosis, one deep venous thrombosis and one pulmonary embolism. Postoperative abdominal hernia or bulge never occurred. Although the use of DIEP flap reduces morbidity of the harvest, long operative time and thrombosis complications cause significant morbidity. Therefore we only use the DIEP flap when other procedures cannot be performed.

Diagnosis and management of vascular injuries in the shoulder girdle of the overhead athlete

Vascular injuries represent a rare cause of shoulder pain and functional limitation among overhead athletes. Complaints of heaviness, fatigue, paresthesias, and effort-related pain should prompt the sports medicine clinician to consider vascular pathology as a possible cause of such symptoms. Position-dependent compression of the subclavian and axillary vessels within the thoracic outlet may result in functional limitation and a decline in overhead athletic performance, particularly when symptoms occur in the dominant upper limb. Treatment options include physical therapy and (in the case of thrombus) thrombolysis, but surgical decompression of the neurovascular bundle is generally advocated. This article reviews the diagnosis and management of effort thrombosis (also known as Paget-Schroetter syndrome), arterial thoracic outlet syndrome, and entrapment of the posterior circumflex humeral artery within the quadrilateral space. Familiarity with these conditions may help to minimize the risk of delayed diagnosis and associated morbidity.

Diagnosis and Management of Vascular Injuries in the Shoulder Girdle of the Overhead Athlete

Vascular injuries represent a rare cause of shoulder pain and functional limitation among overhead athletes. Complaints of heaviness, fatigue, paresthesias, and effort-related pain should prompt the sports medicine clinician to consider vascular pathology as a possible cause of such symptoms. Position-dependent compression of the subclavian and axillary vessels within the thoracic outlet may result in functional limitation and a decline in overhead athletic performance, particularly when symptoms occur in the dominant upper limb. Treatment options include physical therapy and (in the case of thrombus) thrombolysis, but surgical decompression of the neurovascular bundle is generally advocated. This article reviews the diagnosis and management of effort thrombosis (also known as Paget-Schroetter syndrome), arterial thoracic outlet syndrome, and entrapment of the posterior circumflex humeral artery within the quadrilateral space. Familiarity with these conditions may help to minimize the risk of delayed diagnosis and associated morbidity.

Injuries to the clavicle and acromioclavicular joint

The clavicle is a doubly-curved long bone which acts as the only osseous strut connecting the trunk to the shoulder and arm (Figure 1). Medially the clavicle articulates with the manubrium of the sternum at the sternoclavicular joint, while laterally it articulates with the acromion of the scapula at the acromioclavicular joint. Trapezius and deltoid muscles attach to the flat outer third, as do the acromioclavicular and coracoclavicular ligaments. The tubular medial third is a boundary of the cervicoaxillary canal, and as such affords protection to the neurovascular bundle supplying the upper limb, including the brachial plexus, subclavian and axillary vessels. The junction between these two different crosssectional configurations occurs in the middle third, which constitutes an area vulnerable to injury.

Is the Berg Axillary Lymph Node Categorization Useful in the 3D Environment?

The Berg muscle-based categorization of axillary lymph node location (commonly referred to as levels I, II, and III) was used extensively by pathologists and surgeons to describe the extent of axillary node dissection in breast cancer patients. However, its reproducibility with different arm positions and utility in 3-dimensional radiation treatment planning hasn't been tested. Computed tomography scans were observed in 16 patients in 2 positions: historical position (HP), ipsilateral arm abducted 90 degrees to the body axis; standard position (SP), arms above head. The volume, contents, and location of Berg lymph node levels (LNL) and the location of lymph nodes, surgical clips, pectoral muscles, and vascular structures relative to reference points were compared. From HP to SP there was no difference in LNL volumes. However, if measured from an anatomic landmark, the third thoracic vertebra (T3), LNL position varied: level I, an average of 23.1 mm anteriorly, P < 0.01; level II, 7.5 mm medially, P = 0.04; level III, 18.8 mm medially, P = 0.05. Using T3 as a reference: pectoralis major and minor muscles displaced medially (23.9 mm, P < 0.01 and 7.5 mm, P = 0.09) and anteriorly (18.2 mm, P < 0.01 and 11.2 mm, P < 0.01); axillary (18.0 mm, P < 0.01), subscapular (25.4 mm, P < 0.01), and lateral thoracic (8.4 mm, P < 0.01) vessels displaced anteriorly; axillary vessels displaced also medially (15.1 mm, P = 0.03). Disagreements in LN coverage with changes in arm position were observed in 60% (LNs) and 66% (clips) for level II. Surgeons, radiologists, and radiation oncologists should be aware that LNL coverage based on muscle boundaries varies significantly with arm position changes, making objective comparisons of information collected in different arm positions unreliable.

Experimental safety and efficacy evaluation of an extracorporeal pumpless artificial lung in providing respiratory support through the axillary vessels

We sought to investigate the safety and feasibility of implanting the pumpless interventional lung assist device (Novalung; Novalung GmbH, Hechingen, Germany) to the axillary vessels either by means of direct cannulation or end-to-side graft interposition and the capability of either type of vascular access to provide respiratory support during apneic ventilation in adult pigs. Ten pigs were ventilated for 4 hours (respiratory rate, 20-25 breaths/min; tidal volume, 10-12 mL/kg; fraction of inspired oxygen, 1.0; positive end-expiratory pressure, 5 cm H2O). Thereafter, the interventional lung assist device was surgically connected to the right axillary artery and vein by using direct cannulation (n = 5) or end-to-side ringed polytetrafluoroethylene graft interposition (n = 5), and ventilatory settings were reduced to achieve near apneic ventilation (respiratory rate, 4 breaths/min; tidal volume, 1-2 mL/kg; fraction of inspired oxygen, 1.0; positive end-expiratory pressure, 20 cm H2O). Hemodynamic and intrathoracic volumes and lung cytokine levels were measured. Blood flow through the interventional lung assist device was 1.7 +/- 0.4 L/min or 30% +/- 14% of the cardiac output, and the mean pressure gradient across the interventional lung assist device was 10 +/- 2 mm Hg. The interventional lung assist device allowed an O2 transfer of 225.7 +/- 70 mL/min and a CO2 removal of 261.7 +/- 28.5 mL/min. Although the amount of blood flow perfusing the interventional lung assist device was significantly higher (P < .01) with direct cannulation (2.1 +/- 0.3 L/min) compared with that seen in graft interposition (1.3 +/- 0.3 L/min), the latter allowed similar respiratory support with reduced hemodynamic instability. The axillary vessels are a safe and attractive cannulation site for pumpless partial respiratory support. Compared with direct cannulation, graft interposition was equally able to support the interventional lung assist device-driven gas exchange requirements during apneic ventilation with better hemodynamic stability.

Use of Magnetic Resonance Imaging to Define the Anatomical Location Closest to All Three Cords of the Infraclavicular Brachial Plexus

Infraclavicular techniques are often used to perform brachial plexus blocks. In our volunteer study we used magnetic resonance imaging to identify the brachial plexus and axillary vessels in a sagittal plane corresponding to the lateral sagittal infraclavicular block. In 20 volunteers, all cords were positioned within 2 cm from the artery approximately within 2/3 of a circle. We derived an injection site that was closest to all cords, cranio-posterior and adjacent to the axillary artery. We conclude that this knowledge may be useful for the performance of infraclavicular blocks aided by ultrasound. However, our proposals should be tested by clinical studies.