Innominate Vein Research Articles

Radical mediastinal lipectomy for tamponade-like cardiac physiology

BackgroundRe-opening the chest is an unwanted and potentially morbid complication after open heart surgery, most commonly required for refractory bleeding or tamponade. In this report, we present a unique case of a postoperative coronary artery bypass patient, demonstrating clinical features of cardiac tamponade of the right atrium and ventricle with inconclusive findings on imaging.Case presentationA 62 year-old male presented to hospital with exertional angina and a coronary angiogram found severe three-vessel coronary artery disease with preserved left ventricular function. He underwent an uncomplicated triple coronary artery bypass surgery. Over the following hours in the cardiac intensive care unit, the patient had a climbing serum lactate level and increasing vasopressor requirements. On investigations, there was evidence of compression of the right heart. The patient was taken back to the operating room where very little clot or bleeding was identified, rather there was significant amounts of mediastinal fat surrounding the heart which was subsequently resected with wide margins. The patient had complete resolution of their symptoms and an uncomplicated postoperative course thereafter.ConclusionsTo our knowledge, this case is the first reported occurrence of cardiac constriction from excessive mediastinal fat after open heart surgery. Identifying patients at high-risk for excessive pericardial fat, as well as considering alternative modalities of imaging appear to be the main stay in diagnosis at this point. Current treatment is a mediastinal lipectomy with wide margins, avoiding injury to surrounding structures such as the phrenic nerve and innominate vein. Future study might consider the value of prophylactic mediastinal lipectomy at time of surgery, and methods to improve detection with current and future imaging modalities.

Abstract 15979: En Bloc Heart-Lung Transplantation and Vascular Reconstruction With Native Tissue in a Patient With Situs Inversus Totalis

Case: A 62-year-old male with primary ciliary dyskinesia, bronchiectasis, dextrocardia, ccTGA, VSD, ASD, and severe ventricular dysfunction was listed for HLTx. Suitable organs became available from a 21-year-old male donor after brain death. The right sided aorta, persistent left superior vena cava (LSVC), RIJ, and LCFV were cannulated for CPB. The bloc was procured in the typical fashion along with the donor’s pericardium and intact innominate vein. During the recipient cardiectomy, the LSVC was transected proximally, and right atrial (RA) tissue preserved in continuity with the left inferior vena cava (LIVC). To achieve situs solitus positioning of the mediastinum, a pericardial sling was created by plicating the right pericardium to the diaphragmatic pericardium, and the left pericardium was augmented with excess donor pericardial tissue to create a neo-pericardium in the left chest. The recipient’s RA tissue was used to extend the LIVC by forming a cavoatrial conduit and anastomosed to the donor RA, which required a slightly counterclockwise rotation of the cardiac axis and facilitated positioning the left phrenic nerve posterior to the apex. The tracheal and aortic anastomoses were performed in the typical fashion. The donor innominate vein was of sufficient caliber and length to complete the anastomosis to the recipient LSVC and the donor RIJ was ligated. Discussion: HLTx remains the only definitive therapy for patients with combined end-stage cardiopulmonary disease. The leading indication for HLTx is congenital heart disease. Accordingly, centers performing HLTx must be experienced in complex vascular reconstructions and concomitant procedures to address a broad spectrum of anatomical variants. With thoughtful pre-operative planning, close communication with the procurement team, and surgical experience, these procedures may be performed without the use of synthetic materials that predispose to infectious and thromboembolic complications.

Review article: Feasibility of brachiocephalic vein central venous access for the resuscitation of shocked adult trauma patients: A literature review.

Venous access is a key component of managing haemorrhagic shock. Obtaining intravenous access in trauma patients is challenging due to circulatory collapse in shock. This literature review examines the feasibility of direct puncture and cannulation of the brachiocephalic veins (BCVs) for intravenous access in shocked adult trauma patients. Three literature searches were conducted. OVID Medline was searched for articles on the use of the BCVs for venous access in adults and on the BCVs in shock. A third systematic search of OVID Medline, OVID Embase and Cochrane Library was conducted on the use of the BCVs for access in shocked trauma patients. After full-text review, 18 studies were selected for inclusion for the search on the use of the BCVs for access in adults. No studies met the inclusion criteria for the search on the BCVs in shock and BCV access in shocked trauma patients. The BCVs are currently used for central venous access, haemodialysis and totally implantable venous access devices (TIVADs) in adults. There is a preference for the right BCV (RBCV) over the left as the RBCV is more superficial, straighter, larger, has less anatomical variation and avoids the risk of thoracic duct puncture. The BCVs appear to be stabilised in shock by surrounding bony structures. The BCVs may provide a site for initial, rapid access in trauma resuscitation. Further research is required to determine if the BCVs collapse in shock and if venous access using the BCVs is feasible in a trauma resuscitation setting.

Downhill varices in the hypopharynx due to huge thyroid tumor: a case report.

Downhill varices are usually caused by superior vena cava (SVC) obstruction due to bronchogenic carcinoma or mediastinal tumors. These structures show retrograde blood flow and are located in the proximal esophagus. Varices in the hypopharynx resulting from mediastinal thyroid tumor are extremely rare. A 70-year-old man visited a local hospital with a 35-year history of enlarging thyroid tumor in the right neck. Fine needle aspiration cytology of the tumor revealed benign goiter. Contrast-enhanced computed tomography showed a huge tumor (13×10×5 cm) in the right to left lobe of the thyroid extending into the mediastinum. Further, a well-enhanced mass mimicking hypopharyngeal cancer was identified in the hypopharynx. Endoscopic examination demonstrated varices in the postcricoid region, so we avoided biopsy. The preoperative diagnosis was huge adenomatous goiter and hypopharyngeal varices caused by obstruction of the internal jugular and brachiocephalic vein by the goiter. Total thyroidectomy was performed and hypopharyngeal varices had disappeared by the next day. The histopathological diagnosis of the thyroid tumor was poorly differentiated carcinoma. Mediastinal thyroid tumor rarely causes downhill varices due to SVC obstruction. However, in this case, signs of SVC obstruction were absent and varices were found not in the upper esophagus, but in the hypopharynx. Obstructed venous flow from the thyroid plexus might circulate via superior laryngeal vein and cause varices in the postcricoid region. When a patient with large mediastinal tumor shows a tumor-like lesion in the hypopharynx, considering the possibility of downhill varices is important before conducting immediate biopsies.

Comparison of supraclavicular brachiocephalic and femoral vein approaches for tunneled dialysis catheter placement in patients with thrombosed internal jugular veins.

There is still debate on the best access route in case of bilateral internal jugular vein thrombosis. We aimed to compare the safety, effectiveness, and outcomes of tunneled dialysis catheter placement via supraclavicular brachiocephalic and femoral vein approaches in patients with bilateral internal jugular vein thrombosis. Between January 2018 and December 2021, data of the patients in whom tunneled dialysis catheters were placed via the supraclavicular brachiocephalic vein (n = 42) and femoral vein (n = 57) approaches were extracted. Patient demographics, technical and clinical success rates, complications, and outcomes were noted. The Likert scale was used to assess patient satisfaction. Forty two (42.4%) patients were men, and the mean age was 61.9 (range, 12-93) years. The technical and clinical success rate was 100% for both groups. No major complication was encountered. The mean follow-up period was 497.5 (range, 32-1698) catheter days. Thirty-day patency was similar for the brachiocephalic vein and femoral vein group (40 [95.2%] vs. 55 [96.5%], p = 0.754). Also, primary and cumulative patency rates were comparable (p = 0.158; p = 0.660). The infection rate was 2.6 and 4.1 per 1000 catheter days for the brachiocephalic vein and femoral vein group. The infection-free survival was significantly higher in the brachiocephalic vein group (71.9% vs. 35.3% at 12 months, p < 0.001). Patient satisfaction was higher in the brachiocephalic vein group (median satisfaction, 5 vs. 4, p < 0.001). Both supraclavicular brachiocephalic vein and femoral vein approaches have high technical and clinical success with comparable patency rates. However, low infection rate and high patient satisfaction make the supraclavicular brachiocephalic vein approach a reasonable alternative before proceeding to the femoral vein access.

Picc Line Associated Brachiocephalic Vein Rupture with Consequent Mediastinal Placement Causing Pneumomediastinum and Large Total Parenteral Nutrition Bilateral Effusion.

PICC lines, although seen as safer, have potential for catastrophic adverse effects.The use of intracavitary electrocardiogram may be a safe adjunct and even an alternative to the use of a chest X-ray.Aspirating blood from all lumens with particular emphasis on the distal most lumen is very important.

Outcomes in patients managed with endovascular stent for malignant superior vena cava syndrome

BackgroundMalignant Superior Vena Cava Syndrome (SVCS) corresponds to the clinical manifestations due to the restriction of venous return to the right atrium secondary to obstruction of the superior vena cava and/or its main tributaries for a tumor. Endovascular management has proven to be safe, effective and cause a fast symptomatic relief in patients with SVCS. There is limited evidence in factors associated with outcomes in malignant setting for this procedure. Materials and methodsAn analytical retrospective study was conducted and included patients that underwent endovascular management for malignant SVCS at the National Cancer Institute of Colombia between May 2016 and May 2021. Clinical and technical variables were analyzed to found associations with outcomes in these patients. Results54 patients were analyzed. Successful procedure rate was 94.4 %. At 10 months, the OS of the entire cohort of patients was 25 %. Patients with breast or lung cancer (P = 0.031), unsuccessful procedure (P = 0.011), and also with short time of symptoms to the date of the endovascular procedure (P = 0.027) had worse OS. Multivariate analysis showed that lung cancer [HR = 2.55, 95%IC:(1.21–5.36)] and left internal jugular vein or left Innominate vein distal stent attachment [HR = 3.27, 95%IC:(1.31–8.15)] were independent factors for worst OS. ConclusionsBased in the high success rate of the endovascular management and the better outcome in patients with early and successful procedure, this procedure should be considered as part of the multimodal treatment in patients with SVCS independent of the clinical scenario and the oncological diagnosis.

The predictive value of a computed tomography-based radiomics model for the surgical separability of thymic epithelial tumors from the superior vena cava and the left innominate vein.

The aim of this study was to develop a radiomics machine learning model based on computed tomography (CT) that can predict whether thymic epithelial tumors (TETs) can be separated from veins during surgery and to compare the accuracy of the radiomics model to that of radiologists. Patients who underwent thymectomy at our hospital from 2009 to 2017 were included in the screening process. After the selection of patients according to the inclusion and exclusion criteria, the cohort was randomly divided into training and testing groups, and CT images of these patients were collected. Subsequently, two-dimensional (2D) and three-dimensional (3D) regions of interest were labelled using ITK-SNAP 3.8.0 software, and Radiomics features were extracted using Python software (Python Software Foundation) and selected through the least absolute shrinkage and selection operator (LASSO) regression model. To construct the classifier, a support vector machine (SVM) was employed, and a nomogram was created using logistic regression to predict vascular inseparable TETs based on the radiomics score (radscore) and image features. To assess the accuracy of these models, area under receiver operating characteristic (ROC) curves of these models were calculated, and differences among the models were identified using the Delong test. In this retrospective study, 204 patients with TETs were included, among whom 21 were diagnosed with surgical vascularly inseparable TETs. The area under ROC curve (AUC) of the 2D model, 3D model, 2D + 3D model, and radiologist diagnoses were 0.94, 0.92, 0.95, and 0.87 in the training cohort and 0.95, 0.92, 0.98, and 0.78 in testing cohort, respectively. The Delong test revealed a significant improvement in the performance of the radiomics models compared to radiologists' diagnoses. The logistic regression selected 3 image features, namely maximum diameter of the tumor, degree of abutment of vessel circumference >50%, and absence of the mediastinal fat layer or space between the tumor and surrounding structures. These features, along with the radscore, were included to develop a nomogram. The AUCs of this nomogram were 0.99 in both the training set and testing set, and the Delong test did not find a significant difference between ROC plots of the nomogram and radiomics models. The proposed radiomics model could accurately predict surgical vascularly inseparable TETs preoperatively and was shown to have a higher predictive value than the radiologists.

Open reconstruction of severe superior vena cava syndrome with right internal jugular-Superior vena cava bypass using femoral vein.

Current treatment of chronic benign superior vena cava syndrome (SVCS) is endovascular with angioplasty/stenting1Rizvi A.Z. Kalra M. Bjarnason H. Bower T.C. Schleck C. Gloviczki P. Benign superior vena cava syndrome: Stenting is now the first line of treatment.J Vasc Surg. 2008; 47: 372-380Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar,2Wilson L.D. Detterbeck F.C. Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes.N Engl J Med. 2007; 356: 1862-1869Crossref PubMed Scopus (355) Google Scholar. Open surgical bypass is typically considered for patients who fail endovascular therapy3Picquet J. Blin V. Dussaussoy C. Jousset Y. Papon X. Enon B. Surgical reconstruction of the superior vena cava system: Indications and results.Surgery. 2009; 145: 93-99Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar,4Kalra M. Sen I. Gloviczki P. Endovenous and Operative Treatment of Superior Vena Cava Syndrome.Surg Clin North Am. 2018; 98: 321-335Abstract Full Text Full Text PDF Scopus (20) Google Scholar. This report illustrates the surgical treatment of symptomatic SVCS. The patient consented to the publication. A 31-year-old male patient presented with recurrent edema and dilated veins of the upper extremities, head, neck, and chest, with concomitant severe headache. His history was significant for previous left lower extremity osteomyelitis six years before, being treated with antibiotics through a left upper extremity peripherally inserted central catheter (PICC). Symptoms of SVCS developed three years later. He was treated with bilateral subclavian and innominate vein stenting extending into the superior vena cava (SVC). Despite oral anticoagulation since the first intervention, the patient had multiple in-stent reocclusions and seven reinterventions with only temporary symptom improvement. Physical examination evidenced facial edema, plethoric facies, and dilated veins in the chest and abdomen. Computed tomography venogram (CTV) demonstrated occlusion of all stents. The right internal jugular vein (RIJV) was patent at the upper-neck level, close to the carotid bifurcation and the SVC was also patent caudally to the azygos vein. A left upper extremity and central venogram were performed and attempts were made to cross the occluded stents, without success. The patient then agreed to proceed with an open reconstruction. A RIJV to SVC bypass was performed using the patient´s right femoral vein, which had 8 mm in diameter, via a median sternotomy and a right neck incision (01:39). The suitable diameter of the vein-graft relies upon the main vessels’ diameter and patient´s anatomy, although a minimum dimeter of 6 mm is generally accepted. After the SVC anastomosis, a Valsalva maneuver was performed, and the clamp was opened with the patient in Trendelenburg position to minimize the risk of air embolism. At the two-year follow-up, a patent bypass was demonstrated with symptoms resolution. Annual follow-up with duplex ultrasound will be pursued. Open surgical treatment of SVC syndrome is associated with long-term symptoms relief and is an excellent option for patients who fail endovascular treatment. The femoral vein-graft was an excellent conduit with a good size-match to the RIJV, durable results and symptoms resolution. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3OTBmNTRkMDM4ODYxZjBkNTkxYTBlMWZlNDc5OGU3NyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NTk5NzY2fQ.cmFN_OFbjDH4lOiwl1zKkjrgnyVQ2yXQnj_hVfumqU1CX0DvODIdqDnFjP8WKhsd08e_hL8cEQf62356emnlqTr0YQ3Taf7QzqEzXDSXdshLabCLWCJSBJImuFBTwhSNEbChKp9VtQEQaGgQFyoxmim8ywtDZOp91FbZKEyqSzPRGpQZ1TaQTnYdofXOPWy6HWHwpA7L72nUSdtDa6DKZAo-7fV2qqKuAhpR-b2_-TYFZ5QDsM4894KbXMoSfpiuH1MyYN3E2RcS1dja_5IiR_wUucRBjC65wTnhE2xRmiUL_0CZXxMNdfGKpq8bBaTg1GNl69QgdXWvXJkmViQ8Mw Download .mp4 (86.14 MB) Help with .mp4 files

A case report of prenatal diagnostics and surgical correction of pulmonary agenesis associated with total anomalous pulmonary venous connection and vascular ring

Abstract Pulmonary agenesis is a rare malformation associated with congenital heart disease and may lead to a life-threatening condition and death without pre-planned surgical and medical support. We report an unusual case of unilateral pulmonary agenesis in combination with total anomalous pulmonary venous connection, complete vascular ring, retroaortic, retroesophageal innominate vein, secondary atrial septal defect, which was prenatally identified by fetal ultrasound and magnetic resonance imaging, later confirmed by postnatal computed tomography.

228. THORACOACROMIAL ARTERY PERFORATOR FLAP REPAIR OF ACQUIRED INTRATHORACIC NONMALIGNANT TRACHEOESOPHAGEAL FISTULAS THROUGH A MIDSTERNAL INCISION APPROACH

Abstract Background Acquired intrathoracic nonmalignant tracheoesophageal fistulas (TEFs) are rare and challenging surgical problems. They can constitute a life-threatening condition due to severe pulmonary complications and poor nutrition. The current treatment strategy for TEFs is controversial, and postoperative mortality and complication morbidity have been ignored in recent studies. Here, we introduce our innovative experience repairing acquired tracheoesophageal fistulas with a thoracoacromial artery perforator flap, in which no mortality or complications were observed within 180 days after the operation. Methods Surgical repair with a thoracoacromial artery perforator flap through a midsternal incision approach was performed in 3 patients. During the procedure, a midsternal incision was made. After the thymus and anterior mediastinal fat were resected, and the left innominate vein was transected, the trachea and esophagus were mobilized. The trachea was incised and pulled to the cranial and caudal sides. Then, the thoracoacromial artery perforator flap was harvested and transferred into the superior mediastinum for esophageal reconstruction. Subsequently, the trachea was anastomosed end to end after debridement, and the left innominate vein was either anastomosed or not. Results Two patients developed esophageal anastomotic leakage postoperatively and healed well after nonsurgical treatment. No mortality or other complications were observed at 180 days after the operation. Conclusion Repair of acquired tracheoesophageal fistulas using a thoracoacromial artery perforator flap through a midsternal incision approach is an effective, safe surgical treatment.

Minimally Invasive Surgical Repair of Left- Sided Partial Anomalous Pulmonary Venous Connection: A Case Report

Left side atrial anomalous pulmonary venous connection (PAPVC) is a rare entity. We report one case surgical treated off-pump with minimally invasive approach. We present a case of left side PAPVC with a non-significant atrial septal defect (ASD) in an asymptomatic 40-year old patient. Angiographic computed tomography (CT) scan has confirmed the diagnosis of vertical vein between left superior pulmonary vein and left brachiocephalic vein, responsible of a significant shunt and right heart dilation. Surgical repair consisted of implantation of the vertical vein into the left appendage through a left mini-thoracotomy and video-assistance. Outcome was event free and patient was discharged on day 4. Conclusion: Off-pump minimally invasive surgical repair of left side PAPVC is safe, effective and easily reproducible. Possible associated ASD may be treated with hybrid approach and percutaneous closure if indicated.

The International Association for the Study of Lung Cancer Thymic Epithelial Tumor Staging Project: Proposal for the T Component for the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors

IntroductionA TNM-based stage classification system of thymic epithelial tumors was adopted for the eighth edition of the stage classification of malignant tumors. The Thymic Domain of the Staging and Prognostics Factor Committee of the International Association for the Study of Lung Cancer developed a new database with the purpose to make proposals for the ninth edition stage classification system. This article outlines the proposed definitions for the T categories for the ninth edition TNM stage classification of thymic malignancies. MethodsA worldwide collective database of 11,347 patients with thymic epithelial tumors was assembled. Analysis was performed on 9147 patients with available survival data. Overall survival, freedom-from-recurrence, and cumulative incidence of recurrence were used as outcome measures. Analysis was performed separately for thymomas, thymic carcinomas, and neuroendocrine thymic tumors. ResultsProposals for the T categories include the following: T1 category is divided into T1a (≤5 cm) and T1b (>5 cm), irrespective of mediastinal pleura invasion; T2 includes direct invasion of the pericardium, lung, or phrenic nerve; T3 denotes direct invasion of the brachiocephalic vein, superior vena cava, chest wall, or extrapericardial pulmonary arteries and veins; and T4 category remains the same as in the eighth edition classification, involving direct invasion of the aorta and arch vessels, intrapericardial pulmonary arteries and veins, myocardium, trachea, or esophagus. ConclusionsThe proposed T categories for the ninth edition of the TNM classification provide good discrimination in outcome for the T component of the TNM-based stage system of thymic epithelial tumors.

Diagnostic Value of Contrast-Enhanced Ultrasonography for Catheter-Related Right Brachiocephalic Vein and Superior Vena Cava Lesions in Patients Undergoing Hemodialysis-A Pilot Study.

To evaluate the diagnostic efficacy of contrast-enhanced ultrasonography (CEUS) for detecting catheter-related right brachiocephalic vein (RBV) and superior vena cava (SVC) obstructions in patients undergoing hemodialysis (HD). From June 1, 2021 to December 31, 2022, we enrolled 80 patients undergoing HD who had used or were using a central venous catheter as vascular access. We evaluated the diagnostic efficacy of conventional ultrasonography and CEUS for identifying RBV and SVC obstructions and compared them with that of digital subtraction angiography (DSA). In the stratified analysis, the SVC was divided into the upper and lower segments. In total, we analyzed 240 central venous segments, including the RBV. Among the RBV and SVC visualized by DSA, conventional ultrasonography and CEUS could visualize 67.92 and 100% of the vein segments, respectively; however, the lengths and diameters of the RBV and SVC were smaller than those recorded with DSA (P < .001). The diagnostic efficacy of CEUS for detecting catheter-related central venous obstruction was better than that of conventional ultrasonography, with a higher sensitivity (83.95 vs 41.98%), specificity (89.94 vs 53.46%), accuracy (87.92 vs 49.58%), and F1 score (82.42 vs 49.64%). CEUS showed good agreement (κ = 0.732) with DSA. In the stratified analyses, CEUS also showed higher sensitivity (83.93, 83.33, and 84.62%, respectively) and better agreement with DSA (κ = 0.635, 0.655, and 0.673, respectively) than conventional ultrasonography for detecting the RBV and the upper and lower segments of the SVC. CEUS had high sensitivity and specificity in diagnosing catheter-related RBV and SVC obstructions.

Superior Vena Cava Syndrome: An Umbrella Review.

Superior vena cava syndrome (SVCS) is a medical emergency that encompasses an array of signs and symptoms due to obstruction of blood flow through the superior vena cava (SVC). It poses a significant healthcare burden due to its associated morbidity and mortality. Its impact on the healthcare system continues to grow due to the increasing incidence of the condition. This incidence trend has been attributed to the growing use of catheters, pacemakers, and defibrillators, although it is a rare complication of these devices. The most common cause of SVCS remains malignancies accounting for up to 60% of the cases. Understanding the pathophysiology of SVCS requires understanding the anatomy, the SVC drains blood from the right and left brachiocephalic veins, which drain the head and the upper extremities accounting for about one-third of the venous blood to the heart. The most common presenting symptoms of SVCS are swelling of the face and hand, chest pain, respiratory symptoms (dyspnea, stridor, cough, hoarseness, and dysphagia), and neurologic manifestations (headaches, confusion, or visual/auditory disturbances). Symptoms generally worsen in a supine position. Diagnosis typically requires imaging, and SVCS can be graded based on classification schemas depending on the severity of symptoms and the location, understanding, and degree of obstruction. Over the past decades, the management modalities of SVCS have evolved to meet the increasing burden of the condition. Here, we present an umbrella review providing an overall assessment of the available information on SVCS, including the various management options, their indications, and a comparison of the advantages and disadvantages of these modalities.

Clinical characteristics of hemodialysis patients with left brachiocephalic vein obstruction due to extrinsic compression or prior catheterization.

Left brachiocephalic vein (LBCV) stenosis is a common complication in hemodialysis patients and is a heterogenous disorder associated with either prior catheterization or extrinsic compression. This study aimed to characterize patients with LBCV stenosis or occlusion with and without a history of central venous catheterization. We performed a retrospective study in 84 hemodialysis patients with LBCV stenosis or occlusion with (n = 22) or without (n = 62) prior catheterization. We compared the clinical features, anatomical factors, restenosis after balloon venoplasty, and patency rates of patients in these two groups. In the cohort of 84 patients with LBCV stenosis or occlusion, 73.8% (62 patients) of them had no history of catheterization. Patients without prior catheterization had more stenotic lesions (p < 0.05) but less occlusive lesions (p < 0.05) than patients with prior catheterization. The space between the sternum and the aorta was narrower in patients without prior catheterization than that in patients with prior catheterization (p < 0.05). Percutaneous venography was performed in 81 patients, and the occurrence of recoil after venoplasty in patients without prior catheterization was significantly higher than that in patients with prior catheterization (p < 0.05). The rate of stent implantation was significantly higher in patients without prior catheterization than patients with prior catheterization (p < 0.05), whereas there was no significant difference in primary patency between the two groups. LBCV stenosis and occlusion are mainly due to extrinsic compression rather than prior central venous catheterization. Stent implantation is frequently required after venoplasty to treat LBCV obstructive lesions in patients without prior catheterization.

Direct superior vena cava puncture for inferior vena cava filter retrieval.

Most inferior vena cava (IVC) filters are designed for retrieval from a superior approach. Retrieval becomes technically challenging when the central veins in the chest are occluded. In a patient with thrombosis of the bilateral brachiocephalic veins, the authors describe direct puncture of the superior vena cava (SVC) under fluoroscopy, followed by the successful retrieval of a fractured IVC filter using forceps. A snare inserted into the SVC via the common femoral vein was used as a radiopaque target for direct SVC puncture from the lower neck. Cone beam computed tomography and pullback tractography were used to confirm a safe access trajectory. Thus, direct SVC access may be used for filter retrieval in similar clinical scenarios.

Anesthesia Management of a Patient with Papillary Thyroid Carcinoma Recurrence and Metastasis to the Right Atrium and Superior Vena Cava: A Case Report

Postoperative recurrence and metastasis of papillary thyroid carcinoma (PTC) to the superior vena cava (SVC) and right atrium (RA) are rare. The application of Extracorporeal Jugular-femoral Vein Bypass and anesthesia management for SVC reconstruction in this rare situation holds instructive significance. In this case, we describe the successful anesthesia management of a patient with multiple tumor thrombi due to postoperative recurrence of PTC. The diagnosis was based on computed tomography of the chest and blood vessels, revealing three-dimensional SVC, postoperative recurrence of PTC, and multiple tumor thrombi in the internal jugular vein (IJV), subclavian vein, brachiocephalic vein, SVC, and RA. An experienced multidisciplinary team was established, and a detailed plan was made for respiration and circulation support, with cardiopulmonary bypass on standby.

Preoperative computed tomography in the planning of median resternotomy in children

The capabilities of computed tomography (CT) in the diagnosis of mediastinal adhesions and measuring the density of adhesions when planning midline resternotomy in children were assessed, and the effect of preoperative CT on the incidence of surgical complications was studied. According to several authors, the frequency of resternotomies in cardiac surgery is up to 20% of the total number of surgeries per year and is accompanied by significant difficulties in the isolation of the heart and vessels. In pediatric cardiac surgery, complex congenital heart disease (CHD) mostly requires a staged approach. The staging of complex CHD correction and the need for repeated surgeries in most cardiac defects make the problem of safe repeated surgical access urgent. Postoperative adhesions are one of the most acute problems in modern cardiac surgery. The formation of adhesions is an inevitable reaction of the body after primary cardiac surgery. Massive adhesions that develop after surgery most commonly lead to adhesion of the heart and major great vessels to the posterior surface of the sternum. These changes are especially pronounced in children due to the high reactivity of the body and the lack of technical possibility and expediency of pericardial suturing after surgery. Rough adhesions during resternotomy complicate the cardiac surgeons task and increase the risk of complications. The main dangers are damage to various structures in the thorax such as the right and left heart, aorta, coronary arteries, pulmonary artery, and brachiocephalic vein. The diagnosis of postoperative adhesions in the mediastinum before resternotomy is difficult. CT has the widest diagnostic capabilities for assessing mediastinal adhesions. When performing CT as a part of preoperative resternotomy planning, it is important to examine the mediastinal topography, assess the degree of adjacency of the pericardium and mediastinal structures, determine the presence and density of adhesions, and assess patency and diameter of great vessels to select cannulas and cannulation methods necessary for emergency start of cardiopulmonary bypass (CPB) in cardiac trauma. These criteria are important when planning midline resternotomy to reduce the risks of traumatization of cardiac structures and great vessels and allow correction of surgical tactics and timely preventive surgical measures. Depending on the density, extent, and localization of adhesions, the cardiolysis technique and cannulation of great vessels required for initiation of emergency CPB may be changed. The use of preoperative CT when planning midline resternotomy in children allows to predict the risks of damage of cardiac structures and great vessels and visualize adhesive bands and measure their density, which helps the surgeon to adjust surgical tactics regarding the method and volume of cardiolysis and assess patency and diameter of great arteries and veins, thus determining the cannulation method and cannula diameter in advance if urgent CPB is needed. Therefore, standardization of CT description protocols for midline resternotomy planning with assessment of key criteria is an urgent task and requires further development.

Normal variations of the superior vena cava and azygos venous system depiction by CT scan in the adult Thai population.

Identification of normal variations to the thoracic central venous system anatomy is essential in radiological intervention and cardiothoracic surgery to prevent complications. To estimate the prevalence and pattern of normal variations of superior vena cava (SVC) and azygos venous system as well as factors associated with normal variations of SVC. Venous-phase chest CT of 1336 patients were retrospectively reviewed. Age, sex, and underlying disease were recorded. SVC diameter and cross-sectional area were measured to evaluate for associations with normal variations. The prevalence of normal anatomical variations of SVC and azygos venous system were 0.3% and 1.5%, respectively. Duplicated SVC was the most common variations. The most common variation for the azygos venous system was the connection between the hemiazygos and accessory hemiazygos veins draining into the left brachiocephalic vein (12/1336 cases, 0.9%). The median (interquartile range [IQR]) cross-sectional area compared between normal SVC (297.2 mm2) and duplicated SVC (223.5 mm2) showed a statistically significant difference (P = 0.033). This study determined the prevalence of rare normal variations of the azygos venous system, a connection between the hemiazygos and accessory hemiazygos veins draining into the left brachiocephalic vein. The prevalence of normal variations of the SVC and azygos venous system in the adult Thai population was similar with that of previous publications. Cross-sectional area was the only factor with a significant association with SVC variations.