Infraclavicular Region Research Articles

Confirmation of local anesthetic distribution by radio-opaque contrast spread after ultrasound guided infraclavicular catheters placed along the posterior cord in children: a prospective analysis.

The needle tip placed at the level of posterior cord under ultrasound guidance is described as the most effective way to obtain single shot successful block in adults, for forearm and hand surgeries. The aim of this research was to study the spread of dye (depicting the local anesthetic) through catheters placed along the posterior cord. This was performed with continuous infraclavicular blocks placed under ultrasound guidance in children. Twenty-four ASA 1 and 2 children, aged 7months to 8years old, scheduled for upper limb orthopedic surgeries were included in this prospective descriptive study. They received continuous infraclavicular block under ultrasound guidance. Skin markings were obtained from catheters that were placed below the posterior cord inserted 2-3cm beyond the tip of the Tuohy needle. A radio-opaque dye was injected into the catheters and 5min later, the dye spread was evaluated fluoroscopically. Postoperatively, all patients received a continuous infusion of 0.125% bupivacaine for pain relief. All 24 cases showed the presence of the dye along the neurovascular bundle in the infraclavicular region suggesting successful blocks. The mean±standard deviation of the skin marking for the catheter was 5.61±1.77cm. Postoperatively, all patients had adequate pain relief with the catheters. One patient had break through pain on day 1 and four catheters were accidentally dislodged on day 2. We conclude that continuous infraclavicular catheters can be accurately and effectively placed along the posterior cord exclusively under ultrasound guidance in infants and small children.

Analysis of adverse events in the management of chronic migraine by peripheral nerve stimulation.

In this study, we analyze device- and procedure-related adverse events (AEs) from a recent prospective, multicenter, double-blinded controlled study that utilized peripheral nerve stimulation (PNS) of occipital nerves for management of chronic migraine. PNS device characteristics (lead length and spacing), surgical techniques including lead orientation (parallel or perpendicular to the nerve), and implantable pulse generator (IPG) placement (upper buttock, abdomen, infraclavicular, or lower axilla) in 157 patients were analyzed to identify any relationship with the AE incidence rate. Number of prior PNS implants performed (NPPIP) by the implanter and its relationship with different AE categories (hardware-related, biological, and stimulation-related events) and frequently observed device/procedure-related AEs (lead migration/fracture/breakage, persistent pain at the lead/IPG location, unintended/undesirable changes in stimulation, infection) were also evaluated. Three-way ANOVA tests were utilized to evaluate the dependence of AE occurrence on the variables described above. IPG pocket locations closer to the lead (e.g. infraclavicular region) were associated with a lower AE incidence rate (p < 0.05). Higher NPPIP was related to lower stimulation- and hardware-related AEs (p < 0.05), frequently observed AEs like lead migration, pain, and infection (p < 0.05), and procedure-related additional surgeries (p < 0.05). Implantation of the IPG closer to the lead location was associated with reduced AEs. PNS is a relatively new procedure, and the skill and precision in performing these procedures improves with experience. Our results demonstrate that as the implanter gains more experience with these procedures, a significant reduction in device- and procedure-related AEs may be expected.

Infraclavicular free flap for head and neck reconstruction: Surgical description and early outcomes in 7 consecutive patients

The primary purposes of this study were to introduce a novel fasciocutaneous free flap from the infraclavicular region based on the anterior perforator (AP) branch of the transverse cervical artery (TCA) and the retrograde external jugular vein (EJV), describe a reliable approach to flap design and elevation, and assess early clinical results. This was a prospective observational study of 7 consecutive cases of head and neck reconstruction using the infraclavicular free flap (ICFF) based on the AP of the TCA. Seven patients underwent ICFF reconstruction within a 6-month period. There was 100% flap survival in all cases at 14 days. Mean dimensions of the flap were 13.3 × 6.3 cm. The EJV drained the flap in all cases but the transverse cervical vein (TCV) was used in 1 case. The retrograde EJV was used in 5 cases to increase the venous pedicle length. No vein grafts were required. ICFF demonstrated similar outcomes compared to conventional fasciocutaneous free flaps. This flap has the potential for common application given its consistent anatomy and donor site advantages.

Unusual Infra-Clavicular Venous Circle – A Case Report

Currently, numerous invasive procedures are preferred in cephalic vein (CV) and axillary vein (AV) than other veins in the neck. Anatomical variations of these veins in the axilla and delto-pectoral region may result in failure and postoperative complications of the procedures. A thorough knowledge of possible variations of AV and CV may immensely contribute to the success of any such procedures where the veins are involved. We report the variations of the CV, tributaries of AV and median cubital vein. We observed a venous circle formed by the tributaries of AV in the infra-clavicular region, deep to the pectoral muscles. Cephalic vein joined proximal end of venous circle just before ending into AV. Further, duplication of the median cubital vein was observed.

Isolated Extrapulmonary Thoracic Hydatid Cyst with Subcutaneous Extension - A Rare Entity

Hydatid disease is a parasitic infestation, the pulmonary variant, caused by Echinococcus multilocularis is less common and the extra pulmonary thoracic variant even rare .We report a case of 52 year old female who underwent complete surgical excision of isolated right sided thoracic extrapulmonary hydatid cyst with subcutaneous extension. The postoperative period was uneventful. She was discharged on the 6 th post op day and is in regular follow up and doing well. I. Case Report A 52 year multigravida, normotensive, nondiabetic, female presented with complains of cough, shortness of breath, associated with right sided chest heaviness and pain for 4 years. A non-tender gradually progressive lump of size 5x3cm was present over the the right infraclavicular region lateral to midclavicular line upto anterior axillary line. There was no history of haemoptysis or tuberculosis. The blood investigation showed eosinophilia, with ELISA-Hydatid serology positive. X-ray chest showed a large single rounded opacity over the right upper and middle lung field(figure 1). CT Scan showed a large lobulated mass of size 11.6 x 7.7 cm arising in the right upper chest with extension into the anterolateral chestwall overlying 2 nd

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Introduction: The patient is a 78 y.o. female who presented to the hospital with complains of weakness, shortness of breath and cough. The cough was dry initially and then became productive along with malaise. She had minimal shortness of breath to begin with which increased to severe shortness of breath on presentation.She denied any chest pain, hemoptysis, fever, abdominal pain, nausea,diarrhea, vomiting. She denies any diplopia, diarrhea, constipation, headache. She had no recent sick contact. she has a pet cat which was healthy.Her immunisation was uptodate. Her past medical history was significant with atrial fibrillation,COPD,DVT off anticoagulation for one month,history of Ca breast s/p mastectomy and chemotherapy and she had been off chemotherapy for 2 years. She was recently diagnosed with a lesion of the brain with an inconclusive biopsy and was started on dexamethasone in a recent hospitalization due to partial seizures and vasogenic edema on MRI of the brain. On examination the patient was awake alert oriented in severe respiratory distress. she has a pulse of 120/min irregular, blood pressure of 126/65, respiratory rate of 25/minute and saturation of 91% on nonrebreather mask. she was febrile .The physical examination was negative except for crackles in the right infraclavicular region and rhonchi bilaterally.The patient was intubated and treated with esmolol and cardizem which controlled her heart rate. The lab studies revealed pancytopenia with white count of 0.9 K/uL with absolute neutrophil count of 0.6k/ul and platelet count of 14 K/uL. The other laboratory values including hepatic, renal function were within normal range. The chest xray revealed right upper lobe dense consolidation. The CT chest without contrast revealed dense consolidative infiltrate in the right upper lobe with air bronchograms along with infiltrates in the left upper lobe.The patient was started on treatment for health care associated pneumonia with piperacillin tazobactam, levofloxacin and vancomycin. The test results for L. pneumophila urinary antigen were sent and were negative.In view of neutropenia the patient underwent a bronchoscopy which was essentially normal except for purulent lavage from the the right upper lobe. Hematology was consulted for the panctyopenia who suggested a possibility of metastasis to the marrow vs a new hematological malignancy in light of a recent discovery of brain lesion. The patients white count and the platelet continued to decrease. The patient was given filgrastim with a brisk rise of the white count. In view of response of the white count to filgrastim metastasis to the bonemarrow was lowered in differential. The patient received mechanical ventilation which resulted in progressive improvement of blood gas exchange and the patient was extubated on day 3.The patient remained afebrile and hemodynamically stable with no need for pressors. In view of persistent thrombocytopenia a plan for bone marrow aspiration and biopsy was made. The bronchoalveolar lavage was positive for LEGIONELLA PNEUMOPHILA DFA stain and negative for bacterial, viral or fungus. The patients antibiotics were descalated to only levofloxacin. The platelet count and the white returned to normal on day 12 of treatment and remained normal therafter through the course of admission. Her hospital stay was complicated with new deep venous thrombosis for which she had an inferior venecava filter placed. The patient was subsequently transferred from the intensive care unit with a diagnosis of pancytopenia secondary to severe legionella pneumonia. In conclusion - we present a case of severe legionella pneumonia which presented with severe pancytopenia. she was initially treated as pneumonia secondary to pancytopenia with a differential of new hematological malignancy vs metastatic breast cancer to the bone marrow. we suggest legionella pneumonia to be kept as a differential in patients with pneumonia and pancytopenia.

Subglandular Placement of an Implantable Cardioverter-Defibrillator for an Improved Cosmetic Outcome

Implantable cardioverter-defibrillator (ICD) technology has progressed through the years decreasing the size of the device, and its effectiveness in preventing sudden cardiac death has made it a mainstay of treatment for many patients. As the use of ICDs in younger patients has increased, issues with placement of an ICD in the usual prepectoral, infraclavicular region have arisen. Subglandular placement through an inframammary incision provides a unique approach and an aesthetically pleasing outcome for ICD placement. We present a review of the current literature and 3 cases of young female patients who had placement of an ICD using this approach.

LEARNING FROM IMAGES Oops!! Can we Prevent this Fundamental Mistake?

Tunneled central venous catheters (TCVC) are a frequently used vascular access option to initiate hemodialysis across the globe. These TCVC are placed by resident physicians, mid-level providers and physicians from several different subspecialties. TCVC vary in their designs, including the catheter tip and their lengths, though all of them have a polyester cuff that helps secure the catheter in the subcutaneous tunnel. The tips of the TCVC used for dialysis differ widely and may be stepped, split or symmetric in design. Ideal placement of a TCVC in the internal jugular vein involves: 1) Initial venous puncture positioned as low in the neck as possible, thus providing a smooth wide curve to the catheter segment in the subcutaneous tunnel 2) The polyester cuff positioned 1-2 cm from the exit site in the subcutaneous tunnel 3) The exit site located in the infraclavicular region, avoiding the breast tissue and 4) The catheter tip positioned in the mid right atrium A standard teaching and learning process in the medical field involves peer-review and evaluation of fundamental mistakes that physicians encounter in clinical practice. The current images are examples demonstrating improperly placed TCVC providing a resource to the growing international interventional nephrology community to learn and preferably avoid duplicating them. The catheter cuff in Fig. (1) was not only placed deep in the subcutaneous tunnel, but the catheter hub was pushed in all the way up to the exit site. A deeply placed catheter cuff makes removal of these catheters difficult when the TCVC is no longer needed. The catheter in Fig. (2) was removed when it was no longer needed, revealing the trimmed off venous tip of the split-tip design. The tips are manufactured with a smooth surface to avoid endothelial trauma. Trimming of the catheter tip can lead to ragged edges that can cause endothelial trauma and potentially lead to stenosis and thrombosis. Moreover, the venous tip in a TCVC with split-tip is designed to minimize

A Case of Recurrent Tumoral Calcinosis in a Young Female

ABSTRACT Tumoral calcinosis, a rare benign clinical condition resembling a neoplasm is characterized by calcium and phosphate deposits, usually located around large joints. It can be primary or secondary to renal failure and hyperparathyroidism. This report describes a rare case of tumoral calcinosis in a 13 years old girl presenting as a huge lump around left shoulder and elbow joint with discharging sinus over left infraclavicular region. How to cite this article Kumar A, Singh P, Dobhal H. A Case of Recurrent Tumoral Calcinosis in a Young Female. World J Endoc Surg 2013;5(1):18-20.

Reticular perineurioma, a rare variant of perineurioma

Reticular perineurioma is a rare, morphologically distinctive variant of perineurioma, characterised by perineural cells with elongated cell processes interconnected in a lace-like pattern, associated with abundant myxoid matrix. The majority have been reported in soft tissue, in the upper limb of adults, with occasional cases reported in the inguinal region, gingiva, lower lip and within nerves of the head and neck. We present a case of a reticular perineu-rioma in the infraclavicular region of a 56-year-old male which was clinically suspected to be a sebaceous cyst. An excision biopsy showed a well-circumscribed tumour in the dermis and subcutis with a prominent reticular pattern of growth. Transition to more compact, fascicular spindle cell areas were seen in the periphery of the lesion. The diagnosis was clinched on both morphological and immunohistochemical features, with the tumour cells staining for epithelial membrane antigen but not for S100 protein or CD34. Electron microscopy was attempted to confirm that the tumour cells were perineurial cells. The reticular pattern, although distinctive, raises the differential diagnosis of other myxoid nerve sheath tumours, myoepithelioma and extraskeletal myxoid chon-drosarcoma. This report of reticular perineurioma of the chest wall also documents its rare occurrence in the truncal region.

Abstract P5-02-01: Discrepancy between CT and FDG-PET/CT in the staging of patients with inflammatory breast cancer: Implications for radiation therapy treatment planning

Abstract Background: To compare suspected areas of cancer involvement based on the findings of CT and FDG-PET/CT in patients with inflammatory breast cancer (IBC) and to determine if discrepancies would modify radiation therapy treatment fields. Methods: This is a retrospective study of 29 consecutive female patients with IBC (median age 49 years, range 28–78) who had both CT and PET/CT scans prior to the initiation of systemic therapy. CT and PET/CT scans were obtained within a median of 3 days (range 0–64). CT and PET/CT scans were independently reviewed by a board-certified radiologist (PD) and a board-certified nuclear medicine physician (HJ), respectively. Findings were recorded by anatomic site and graded as negative, equivocal or positive for malignancy. Radiation fields were then determined by a breast radiation oncologist (JB) after separately reviewing the CT and PET/CT images. Discrepancies between the two modalities were recorded. The study was approved by the hospital institutional review board. Results: Seven of 29 patients (24%) had discrepant findings that likely would have resulted in a modification of radiation treatment fields and/or radiation dose. In four patients, internal mammary nodal involvement was suspected on PET/CT but not on CT. In two of these four patients, PET/CT also detected additional disease (supraclavicular in one patient and chest wall in the other) that likely would have required a change in radiation field and/or dose. Another patient had subpectoral adenopathy on PET/CT that was not considered abnormal on CT. One patient had equivocal findings in the infraclavicular region on CT which was negative on PET/CT. In one patient, body habitus limited the CT evaluation; more extensive infiltrative soft tissue and nodal disease was seen on PET/CT. In four patients, there were discrepant findings for distant disease that likely would have resulted in a change in management or additional imaging studies. In two of these cases, PET/CT showed a clearly positive finding that was negative or equivocal on CT. In an additional two cases, equivocal PET/CT findings would have resulted in additional testing that would not have been recommended by CT alone. In another 4 cases, metastatic disease was suspected based on CT, but additional sites (all in bone and not seen on CT) were suspected on PET/CT. Conclusions: Inflammatory breast cancer patients have a high probability of presenting with extensive local/regional disease and distant metastases. In our IBC population, PET/CT imaging would have likely resulted in a change of radiation field or dose in 7 of 29 (24%) patients. Additionally, in four instances PET/CT suspected additional metastatic disease (14%). These discrepancies most commonly involved inclusion of an internal mammary nodal radiation field and identification of distant metastases. Pathologic verification of abnormal findings is necessary to verify these results. PET/CT imaging should be considered a standard component of radiographic staging for patients with IBC. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-02-01.

Factors influencing students' decisions to participate in a short “dissection experience” within a systemic anatomy course

Changes in medical education have affected both curriculum design and delivery. Many medical schools now use integrated curricula and a systemic approach, with reduced hours of anatomy teaching. While learning anatomy via dissection is invaluable in educational, professional, and personal development, it is time intensive and supports a regional approach to learning anatomy; the use of prosections has replaced dissection as the main teaching method in many medical schools. In our graduate-entry medical degree, we use an integrated curriculum, with prosections to teach anatomy systemically. However, to not exclude dissection completely, and to expose students to its additional and unique benefits, we implemented a short "Dissection Experience" at the beginning of Year 2. Students attended three two-hour anatomy sessions and participated in dissection of the clinically relevant areas of the cubital fossa, femoral triangle, and infraclavicular region. This activity was voluntary and we retrospectively surveyed all students to ascertain factors influencing their decision of whether to participate in this activity, and to obtain feedback from those students who did participate. The main reasons students did not participate were previous dissection experience and time constraints. The reasons most strongly affecting students' decisions to participate related to experience (lack of previous or new) and new skill. Students' responses as to the most beneficial component of the dissection experience were based around practical skills, anatomical education, the learning process, and the body donors. We report here on the benefits and practicalities of including a short dissection experience in a systemic, prosection-based anatomy course.

Diurnal Blood Pressure Variations Are Associated with Changes in Distal–Proximal Skin Temperature Gradient

It is generally assumed that skin vascular resistance contributes only to a small extent to total peripheral resistance and hence to blood pressure (BP). However, little is known about the impact of skin blood flow (SBF) changes on the diurnal variations of BP under ambulatory conditions. The main aim of the study was to determine whether diurnal patterns of distal SBF are related to mean arterial BP (MAP). Twenty-four-hour ambulatory measurements of BP, heart rate (HR) and distal (mean of hands and feet) as well as proximal (mean of sternum and infraclavicular region) skin temperatures were carried out in 51 patients (men/women = 18/33) during a 2-d eye hospital investigation. The standardized ambulatory protocol allowed measurements with minimal interference from uncontrolled parameters and, hence, some conclusive interpretations. The distal minus proximal skin temperature gradient (DPG) provided a measure for distal SBF. Individual cross-correlation analyses revealed that the diurnal pattern of MAP was nearly a mirror image of DPG and hence of distal SBF. Scheduled lunch and dinner induced an increase in DPG and a decline in MAP, while HR increased. Low daytime DPG (i.e. low distal SBF) levels significantly predicted sleep-induced BP dipping (r = −.436, p = .0014). Preliminary path analysis suggested that outdoor air temperature and atmospheric pressure may act on MAP via changed distal SBF. Changes in distal SBF may contribute to diurnal variation in MAP, including sleep-induced BP dipping and changes related to food intake. This finding might have an impact on individual cardiovascular risk prediction with respect to diurnal, seasonal and weather variations; however, the underlying mechanisms remain to be discovered.

Sternalis Muscle: An Uncommon Finding During Aesthetic Breast Surgery

The sternalis muscle is an uncommon anatomic variant of the chest wall musculature. It was first reported in Anatomes Elenchus Accuratissimus in 1604.1,2 Few reports of this muscle have appeared in the literature, and there is debate about its anatomic origin, insertions, function, and innervations. Reported as an inconstant finding in Netter’s Atlas ,3 the sternalis muscle is described as an analogous muscle that develops along with the rectus abdominis muscle but resorbs when chest development occurs during intrauterine life. Over the years, anatomists have coined a number of terms to refer to the sternalis muscle, such as the accessorius ad rectum and the parasternal, pectoris rectus , or praesternalis muscle .4 The sternalis is an accessory muscle that can originate from the upper sternum and the infraclavicular region, which inserts upon the anterior pectoral fascia, the lower ribs, the costal cartilages, the sheath of the rectus abdominis muscle, and the aponeurosis of the abdominal external oblique muscle. An adipose tissue layer can be interposed between the pectoralis major and sternalis muscles. Some anatomists consider the sternalis a rudiment of the panniculus carnosus in humans.5 Existence of the sternalis muscle varies between the sexes and among ethnic groups; it is reported in …

Postoperative Monitoring in Free Muscle Transfers for Reconstruction in Brachial Plexus Injuries

Free gracilis transfers are done for reanimation of the upper limb in traumatic total brachial plexus palsy. Because of buried nature of the free muscle and monitoring skin flap in the axillary or infraclavicular region, it is always a tricky situation for continuous and repeated monitoring to assess vascular status. Critical ischemia times vary between the muscle and monitoring skin flap because of which signs of ischemic changes in the monitoring skin flap are always delayed with respect to the muscle. We describe a novel method that uses the principle of evoked potentials from the muscle to assess the vascular status of the free muscle and detects vascular compromise early before the skin changes are apparent.

Idiopathic Lymphocele: A Possible Diagnosis for Infraclavicular Masses

Lymphoceles are usually related to trauma or surgery, and its spontaneous development is rare. The aim of this paper is to report an uncommon case of idiopathic lymphocele located on the right infraclavicular region, in a female patient with no previous local trauma or surgery and unremarkable medical history. The diagnose was suggested by the tomographic aspect of the lesion and confirmed by ultrasound-guided fluid aspiration and cytological analysis. The authors also provide a brief review of the most important thing diagnostic features and treatment options for this condition. For the practicing clinician, the most important is to achieve an accurate diagnose and to choose the proper therapeutic method according to each clinical scenario.

Aneurysm of the left atrium in a child with patent ductus arteriosus and mitral valve prolapse

CLINICAL DATA Infant 9 months, 6.5 kg, female with history of dyspnea during feeding and poor weight gain. Born at term weighing 3.2 kg. In the first month, was diagnosed with congenital heart disease with increased pulmonary hemodynamic, being the child sent from her hometown for surgical treatment. Physical examination showed malnutrition with weight below the percentile 3 for age, tachydyspneic, acyanotic and pale. Hyperdynamic precordium with apical impulse deviated to the left and chest bulging to the left. Continuous murmur 3 + / 6 +, with multiple clicks in the left infraclavicular region. Liver 3 cm from the right costal margin. Large and palpable peripheral pulses in all four limbs.

Mycobacterium fortuitum infection caused by the organism in subcutaneous abscess mediated by central venous catheter

A 49-year-old woman with a Mycobacterium fortuitum bloodstream infection, who has been managed with central venous (CV) catheterization for two years, was reported. She had undergone rectectomy for rectal cancer and gastectomy for stomach cancer at the ages of 36 and 42, respectively. Also, she had undergone adhesiotomy for four times for postoperative ileus at the ages between 44 and 47. She was admitted to our hospital because of fever (38.4 degrees C) with chill and fatigue, and a subcutaneous abscess at the right infraclavicular region located at the insertion site of the CV catheter (Hickman catheter). After the catheter was removed, the subcutaneous abscess was incised and a Penrose drain tube was inserted. M. fortuitum was detected after three days of blood culture and on the blood agar medium inoculated with purulent discharge from the drainage tube. After receiving these treatments, she was discharged from the hospital one month later. The isolates from these blood and purulent discharge specimens were identical on pulsed-field gel electrophoresis. Based on these findings, we concluded that the M. fortuitum bloodstream infection in this case might be caused by the organism in the subcutaneous abscess mediated by the CV catheter.

Occipital nerve stimulation in a patient with an intractable chronic headache -A case report-

Occipital nerve stimulation (ONS) is a form of peripheral nerve stimulation used to treat refractory headaches. The trial of ONS was carried with the midline incision C1-2 level, inserted electrical lead subcutaneously to oblique and cephalad direction followed by trajectory of blunt dissection. We used 8 pole electrical lead to cover lesser occipital nerve, greater occipital nerve, third occipital nerve and great auricular nerve. We anchored the lead at the midline insertion site after confirming the stimulation of the patient. And then we looped and tightened the lead loosely, connected the lead and the extension under right supraspinatus muscle region. After 1 week trial period, we performed the permanent implantation of occipital nerve stimulator. We inserted internal pulse generator under a pocket located at right infraclavicular region. The VAS score dropped from 8/10 to 1-2/10. No serious complications were detected during 1 month follow-up.

Seizure complicating placement of a nerve stimulator-guided infraclavicular block: could the use of ultrasound decrease the risk?

The case of a patient who suffered a seizure following a nerve stimulator-guided coracoid infraclavicular brachial plexus block, is reported. Following the seizure, an ultrasound machine was used to image the patient's infraclavicular region, which showed an anatomical variation in the position of the axillary vein relative to the axillary artery. The use of ultrasound in regional anesthesia provides additional safety information beyond nerve stimulation, which may help decrease the likelihood of such complications.