Internal Thoracic Research Articles

The Use of Bilateral Internal Mammary Arteries for Coronary Revascularization in Patients with COPD: Is It a Good Idea?

The use of bilateral internal mammary arteries (BIMA) is limited worldwide, especially in patients with chronic obstructive pulmonary disease (COPD). Thus, we assessed the safety of the use of BIMA in COPD patients. From cohorts of 8846 patients operated on at our center for primary isolated multi-vessel coronary bypass operations between 2002 and 2012, we studied two propensity-matched groups of patients with COPD who received either single internal mammary artery and saphenous vein grafts (SIMA group: 137 patients) or exclusively BIMA (BIMA group: 137 patients). Preoperative data were similar regarding age (63.59 ± 10.62 versus 65.55 ± 9.61 years; P = .10), body mass index (BMI) (28.6 ± 4.71 versus 28.42 ± 3.86 kg/m2; P = .72), diabetes mellitus (32% versus 27%; P = .08), EuroSCORE (4.34 ± 2.23 versus 4.8 ± 2.52; P = .09) and ejection fraction (58.7 ± 13.08% versus 60.29 ± 14.13%; P = .32). No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.07 ± 0.77 versus 3.06 ± 0.85; P = .90), total operation time (192.17 ± 43.06 versus 200.63 ± 39.24 min; P = .08), postoperative stroke (0.7% versus 0%; P = .29), myocardial infarction (2.92% versus 3.6%; P = .81), reintubation (2.9% versus 4.4%; P = .66), reexploration (0.7% versus 2.2%; P = .32), deep sternal wound infection (2.9% versus 3.6%; P = .81) and 30-day mortality (2.2% versus 2.9%; P = .77). However, postoperative blood loss (726.1 ± 468.35 versus 907 ± 890.58 mL; P = .03) was higher in the BIMA group. COPD patients can benefit from coronary artery revascularization with BIMA; however, postoperative blood loss can be higher using this technique.

Complications Related to Pectus Carinatum Correction: Lessons Learned from 15 Years' Experience. Management and Literature Review.

Various methods of corrective thoracoplasty for pectus carinatum deformity have been described, but to date no studies describe a review of complications and how to manage them. Complications are dependent not only on the technique used and the patient's age, but also on the experience of the treating surgeon. The authors present their 15 years' experience with surgical correction of pectus carinatum and the complications that have occurred. A literature review regarding complications with pectus carinatum surgery is performed. A retrospective review of 95 patients (mean age, 19 years) was performed. One hundred four surgical procedures for repair of pectus carinatum were performed from July of 2000 to July of 2015 using a modified Ravitch technique, bioabsorbable material, postoperative bracing, and in some cases a diced rib cartilage graft technique. Intraoperative and postoperative complications were evaluated. The mean patient follow-up was 13.6 months (range, 4 months to 9.75 years). Intraoperative complications were pleura lesion and laceration of the internal mammary vein. Postoperative complications were recurrent mild protrusion, persistent protrusion of one or two costal cartilages, minor wound healing delay, skin ulcer, hypertrophic scar, transient intercostal dysesthesia, marginal pneumothorax, seroma, meningitis, and epidural hematoma. In our reported series of pectus carinatum repair, increasing experience and progressively less extensive techniques have resulted in fewer complications, low morbidity, and early return to activity. Complications were observed in the early period of application, predominantly because of a lack of experience, and usually subsided with increasing numbers of patients and frequency of surgery. Therapeutic, IV.

Abstract 30: In vitro Fabrication of Human Cardiac Tissues With Porcine Perfusable Blood Vessels

The definitive treatment of severe heart failure is heart transplantation; however the number of heart transplantation procedures performed in Japan per year ranges from 30-40 due to donor shortage. Therefore, recently other treatments such as ventricular assist device or regenerative therapy by human cardiac tissue engineering have been developed and are considered as appropriate alternatives. We have developed an original technology, which was named cell-sheet based tissue engineering to fabricate functional three-dimensional tissue by layering cell sheets. The utilization of this technique allowed us to successfully engineer thick rat cardiac tissue with perfusable blood vessels in vitro. Here, we demonstrate a technique to engineer human cardiac tissue with perfusable blood vessels using cardiac cell sheets derived from human induced pluripotent stem cells, and porcine small intestine as a vascular bed for perfusion culture. The small intestine was harvested from with a branch of the superior mesenteric artery and vein and underwent mucosal resection after harvested tissue was cut open. To engineer cardiac tissue with perfusable blood vessels, cardiac cell sheets co-cultured with endothelial cells, were triple-layered and then was overlaid on the vascular bed in the bioreactor system. One day after perfusion culture, overlaid cardiac tissues pulsated spontaneously and were synchronized. The cardiac tissue construct was viable tissue without any observable necrosis. Furthermore we examined the possibility of transplantation of the in vitro engineered human cardiac tissue with the connectable host artery and vein. Engineered cardiac tissue was removed from the bioreactor system after 4-day perfusion, and transplanted to another pig heart. The branch of the superior mesenteric artery and vein of the graft were then reconnected to the host internal thoracic artery and vein. When the cardiac tissue reperfused, it began to beat spontaneously after a few minutes. We believe that this method is useful to fabricate functional cardiac tissue and may become an appropriate treatment for severe heart failure.

Predictors of internal mammary vessel diameter: A computed tomographic angiography-assisted anatomic analysis

The internal mammary vessels are the most common recipient vessels in free flap breast reconstruction. The literature on internal mammary vascular anatomy is limited by small sample sizes, cadaveric studies, or intraoperative changes. The purpose of this study is to analyze internal mammary anatomy using computed tomographic angiography. A retrospective review of 110 consecutive computed tomographic angiography studies of female patients was performed. Measurements of vessel caliber, distance of internal mammary vessels to sternum, location of internal mammary vein bifurcation, intercostal space height, and chest width were analyzed. Patient demographics and comorbidities were reviewed. The right internal mammary artery and vein were larger than the left in all intercostal spaces (p=0.02 and p<0.001, respectively). A significant correlation was found between both skeletal chest width and body mass index with internal mammary vessel caliber at the third intercostal space (p≤0.02). The internal mammary vein bifurcated at the third intercostal space bilaterally, 4.3 and 1.2mm caudal to the third rib on the right and left sides, respectively. The third intercostal space was <1.5cm in 25% of patients. Understanding the anatomy, bifurcation, and caliber of internal mammary vessels can aid preoperative planning of autologous, free flap breast reconstruction. On average, the internal mammary vein bifurcates at the third intercostal space; patients with larger chest widths and body mass index had larger caliber internal mammary vessels, and 25% of patients had third intercostal space <1.5cm and, thus, may not be suitable candidates for rib-sparing techniques.

Misplacement of central venous catheter into the left internal mammary vein

SummaryCentral venous catheter insertion is a commonly performed procedure in anaesthesia and critical care in order to assist fluid management and to allow administration of intravenous medications. Central venous catheter misplacement can occur, even in expert hands, despite the widespread use of ultrasound guidance. In this case report, we describe central venous catheter misplacement into the left internal mammary vein and subsequent patient management.

The vertical posteromedial thigh (vPMT) flap for autologous breast reconstruction: A novel flap design.

The vertical posteromedial thigh (vPMT) perforator flap is a new reliable flap with versatility. The purpose of this article was to report our experience with the use of free vPMT flap for reconstruction of the breast. From May 2015 to December 2015, seven patients received immediate unilateral breast reconstruction with seven free vPMT flaps. The flaps were raised based on the first medial perforator of the profunda femoris artery (PFA). The internal mammary artery and vein were dissected as recipient vessels. The flap sizes varied from 25 × 9 cm to 30 × 10 cm. The average weight of the flap and mastectomy specimen was 431 g (range: 390 to 470 g) and 410 g (range: 360 to 450 g) respectively. The average pedicle length was 10.4 cm (range, 8.5 to 12.5 cm) and the average arterial diameter was 2.1 mm (range, 1.8 to 2.6 mm). All of the flaps survived completely after surgery. The donor sites were all primarily closed with minimal morbidities. Follow-up observations were conducted from 3 to 9 months. All of patients were satisfactory with the reconstruction. The vertical vPMT is suitable for breast reconstruction in women with small to moderate breast size; the vertical pattern of the PMT avoids some of the problems related to other flaps with transverse patterns and represents an alternative design that can be successfully used for breast reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery 37:371-376, 2017.

Use of the retrograde limb of the internal mammary vein to avoid venous congestion in DIEP flap breast reconstruction: Further evidences of a reliable and time-sparing procedure.

Venous congestion is a common cause of DIEP flap failure. When identified intraoperatively, an additional venous anastomosis can improve the venous outflow and prevent flap failure. The aim of this study was to assess if the retrograde limb of the internal mammary vein (IMV) could be considered a good recipient vessel to be used when persistent flap congestion is present, and a second venous anastomosis is required. A retrospective study was conducted in 74 patients who had undergone DIEP flap breast reconstruction. Patients were classified into two groups: SVA (single venous anastomosis) and DVA (dual venous anastomosis). In the SVA group (n = 38), the IMV antegrade limb was used for venous drainage. A single DIEV (Deep Inferior Epigastric Vein) was anastomosed to the superior arm of the IMV. In the DVA group (n = 36), both the antegrade (superior) and retrograde (inferior) stumps of the IMV were used, connecting the larger DIEV to the antegrade IMV and the other DIEV or the SIEV (Superficial Inferior Epigastric Vein) to the IMV retrograde limb. No venous congestion or flap loss was observed when two venous anastomoses were performed using both the IMV antegrade and retrograde limbs (P = 0.3271). In the DVA group, no major complication occurred (P = 0.0453). Operative explorations were significantly reduced in the DVA group (P = 0.0242). These findings suggest that when an additional venous outflow is required, the use of the IMV retrograde limb may help to avoid flap venous congestion. © 2016 Wiley Periodicals, Inc. Microsurgery 36:447-452, 2016.

The "Rolled-Up Sleeve" Technique for Microvascular Venous Anastomosis in Head and Neck Reconstruction: Animal Study and Clinical Series.

Venous anastomosis is challenging especially when encountering the thin recipient vein wall in the head and neck region. The authors developed the "rolled-up sleeve" technique to solve this scenario. An animal study was performed to access the safety and reliability of the "rolled-up sleeve" technique. This technique was performed in 53 consecutive patients during head and neck reconstruction. In the animal study, all anastomoses were patent. Histological analysis revealed neo-endothelialization over the anastomotic site. This technique was applied to 59 recipient veins: branch of internal jugular vein (27), external jugular vein (17), superficial temporal vein (9), retromandibular vein (4), facial vein (2), and internal mammary vein (2). No venous thrombosis occurred in these clinical series. The "rolled-up sleeve" technique is a useful procedure that can be performed safely to deal with thin vascular walls for venous anastomoses in head and neck reconstructions.

Emergency Transplantation of Free Flap between Separated Thoraco-Omphalopagus Conjoined Twins.

Emergency Transplantation of Free Flap between Separated Thoraco-Omphalopagus Conjoined Twins.

Total Arterial Revascularization

Total arterial revascularization (TAR) has been shown to improve both short- and long-term mortality in coronary artery bypass grafting patients when compared with a single internal thoracic artery (ITA) and vein grafts (Buxton, 2014; Zacharias, 2009). This benefit has been demonstrated in both younger and older (>70 years) patients (Habib, 2012). TAR typically uses bilateral ITA grafts, the left as a pedicled graft and the right either pedicled, free or as a Y graft. Skeletonization of the ITA grafts increases available length, decreases devascularization of the chest wall and may decrease sternal wound infection rates. Radial artery grafts are a very versatile conduit also commonly used in TAR. They are long enough to reach any target as an aortocoronary graft; alternatively, they lend themselves well to Y grafts, T grafts and sequential grafts.

An aberrantly positioned central venous catheter: A presage of an underlying anatomical anomaly

Sir, The left subclavian vein was cannulated uneventfully using bony landmark technique in a 52-year-old male for hyperalimentation and administration of inotropes and intravascular fluids in Intensive Care Unit (ICU). He was a postoperative case of cancer of the sigmoid colon and had undergone a hemicolectomy. He was admitted in view of massive intraoperative blood loss leading to hemodynamic instability and long duration of surgery. His stay was further complicated by development of septic shock. Postinsertion chest radiograph revealed the position of the catheter in the left para mediastinal location [Figure 1]. This raised suspicion of a left-sided superior vena cava (SVC). Cross-sectional imaging with computed tomography (CT), magnetic resonance, or a saline contrast echocardiography was the options available to confirm the diagnosis. A bedside CT (contrast-enhanced) of the thorax is not available in our ICU and decision to shift the patient to radiology was deferred in view of hemodynamic instability of the patient and requirement of high dose of inotropes. Bedside transthoracic echocardiography was performed which showed a structurally normal heart with a dilated coronary sinus. The tip of the central venous catheter, however, could not be observed with confidence. Agitated saline was infused via the central venous catheter and this was followed by opacification of the coronary sinus and the right atrium. Persistent left-sided SVC (PLSVC) draining to right atrium via coronary sinus was confirmed. Malpositioning into tributaries of left brachiocephalic vein (left internal thoracic vein, left superior intercostal vein) and left pericardiophrenic vein was unlikely as the pressure tracing was consistent with central venous placement (a, c, x, v, y waves could be identified). Placement in left subclavian artery and descending thoracic aorta was ruled out as pressures ranged from 5-8cm of H20 and results of blood gas analysis were consistent with venous placement. Figure 1 Chest X-ray suggestive of persistent left-sided superior vena cava; widening of the aortic shadow, a paramedian bulge along the left heart border. An electrocardiography lead and a surgical drain can also be visualized The incidence of PLSVC is 0.3–0.5% in healthy individuals and 1.3–4.5% in patients with coexisting cardiac defects.[1,2] About 82% of PLSVC coexist with a right SVC and so this anomaly is often missed when central venous catheters are inserted on the right side. Venous drainage of PLSVC is into right atrium in majority of cases but could be in the left atrium also [Table 1]. Table 1 Venous drainage of persistent left-sided superior vena cava Left-sided jugular venous distention and an abnormal and exaggerated jugular venous waveform on left-sided catheterizations due to direct transmission of left atrial pressures raise suspicion of this anomaly. Anesthetist and intensivist need to be aware of this anomaly as it may cause the following complications:[3,4,5] Difficulty in insertion of left-sided pulmonary artery catheters or pacing wire Systemic embolization of air or thrombus in patients with PLSVC draining into the left atria Right-to-left shunting and unexplained cyanosis and clubbing in the patient (PLSVC draining into left atria) Arrythmias, cardiac arrest, and coronary sinus thrombosis Causes distention of the right heart during cardiac surgeries if not ligated or separately cannulated. It is a contraindication to retrograde cardioplegia. Left para mediastinal location of central venous catheter led to diagnostic dilemma in our patient, but a methodological assessment of all the differential diagnosis using simple bedside tests enabled us to make a diagnosis of PLSVC draining into right atria. It is the most common congenital venous anomaly in the chest and it is thus important for the clinicians to be aware of this. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

P18. Thoracoscopic complete thymectomy for thymoma

Background Thymectomy was the standard method for the treatment of thymoma. Video-assisted thoracoscopic (VATS) thymectomy was developed more than 20 years ago and has become a widely accepted surgical approach. We consistently performed 3-port VATS simple thymectomy for thymoma. Our indications for VATS simple thymectomy are thymoma without myasthenia gravis (MG) less than 10 cm in the maximum diameter and positioned below jugular notch of the sternum. Extended surgical procedures are thymectomy with combined resection of internal thoracic artery and vein, lung, pericardium, phrenic nerve and diaphragm.

78. Coronary bypass using bilateral internal mammary arteries in an achondroplast

Coronary bypass grafting for ischemic heart disease in achondroplastic dwarfs is very rare. Shortage of veins and sometimes, inadequate vein quality can cause difficulties during surgery. Only two achondroplastic cases were reported in literature that underwent coronary bypass surgery, in which the left internal mammary artery and vein grafts were used. To the best of our knowledge using bilateral internal mammary arteries in such patients was not reported. We report here a 55 years old male achondroplastic dwarf who had triple vessels coronary disease that underwent successful coronary bypass surgery using bilateral mammary arteries. Anatomic and surgical challenges in achondroplasia are highlighted

Double versus single internal thoracic artery in coronary artery bypass grafting: role in sterna wound healing

Objective To investigate the effect of double versus single internal thoracic artery on sterna wound healing in coronary artery bypass grafting (CABG). Methods Patients undergoing CABG were randomly divided into experimental group (double internal thoracic artery group) and control group (single internal thoracic artery group) according to the number of internal thoracic artery used in operations. Experimental group: skeletonized double internal mammary arteries were harvested in all 50 cases (37 males and 13 females). Control group: skeletonized left internal mammary artery was harvested in all 50 cases (34 males and 16 females). Sterna wound healing and post-operational complications were observed. Results The incidence of poor sterna wound healing and volume of drainage after operation in the experimental group were more than those in the control group [volume of drainage on the first day: (350.67±56.86)ml vs (240.72±48.35)ml; total volume of drainage: (595.65±102.35)ml vs (398.85±75.84)ml; poor sterna wound healing rate: 20% vs 0; P<0.05 or P<0.01]. The sterna wound healing rate of high-risk patients between two groups had significant difference (8 cases vs 0 case, P<0.05). Conclusions Compared to the single internal mammary artery grafting, the double internal mammary artery grafting increased the risk of sternal wound healing. Key words: Coronary artery bypass/MT; Mammary arteries/SU; Sternum/IN/SU; Fracture healing

The Case Files

FigureFigureA 56-year-old black man presented to the ED complaining of face and neck swelling. An initial history was difficult to obtain because the patient did not speak English fluently and had slurred speech. Symptoms started approximately a week earlier when the patient was at his nursing home. He denied dysphagia or odynophagia, he had no rashes, pruritus, dyspnea, or peripheral edema, his face was flushed, and he had visibly-engorged neck veins. He noticed that his tongue was mildly swollen, so he took Benadryl for a week with no relief. The patient said he believed that the symptoms might have been because a nurse gave him an incorrect medication at the nursing home. He had been a pack-a-day smoker for 30 years, and had a history of schizoaffective disorder, bipolar disorder with psychotic features, and GERD. A CBC with differential, PT, PTT, BMP, and UA were all within normal limits. A chest x-ray confirmed a large mediastinal mass, and a soft tissue neck CT scan with contrast found a large mass in the upper mediastinum with extensive adenopathy in the base of the right side of his neck on the right, a right lobe thyroid mass, and occlusion of the superior vena cava and left subclavian vein. The report suggested that the findings were consistent with aggressive lymphoma or lung cancer. The patient was admitted to the hospital with a scheduled emergent biopsy of the neck mass/lymph nodes. He was diagnosed with superior vena cava (SVC) syndrome and small cell lung carcinoma (SCLC) by tissue biopsy and pathology. The SVC drains venous blood from the head, neck, upper extremities, and thorax. Obstruction of the SVC is usually because of neoplasms that invade the tissue wall or put pressure on the SVC. (J Clin Oncol 1984;2[8]:961.) SCLC accounts for 25 percent of SVC syndrome because of malignancy. (HemOnc Today Feb. 10, 2012; http://bit.ly/1H3Uggt.) Clinical features of SVC syndrome include facial edema, difficulty swallowing, engorged neck veins, cough, and dyspnea. (Int J Radiat Oncol Biol Phys 1987;13[4]:531.) Obstruction of the SVC can divert blood flow to the azygous veins, internal mammary veins, superior and inferior epigastric veins, or femoral and vertebral veins, but the venous pressure remains elevated. Complications of this condition include cerebral edema, coma, and death. (Joint Bone Spine 2002;69[4]:416.)FigureThe patient presented with only neck swelling and difficulty speaking. The speech impediment was most likely from the combination of SVC syndrome and right-sided thyroid mass occluding the right recurrent laryngeal nerve. The prognosis of SVC syndrome is poor because of the underlying neoplasm. The patient was promptly started on a dose of approximately 2900 cGy in 13 fractions to the mediastinum and neck nodes and scheduled to receive chemotherapy. After three weeks, he was medically stabilized, and had tolerated chemotherapy and radiation. The SVC syndrome did not compromise his breathing. The patient was advised that he could be discharged with a PORT-A-CATH for future chemotherapy, but the prognosis of his condition remained poor. Lung cancer is the leading cause of cancer-related death in the United States. (CA Cancer J Clin 2008;58[2]:71.) Its incidence is decreasing, but 13 percent of all new cancers are still from lung cancer. (“Lung Cancer Statistics,” American Cancer Society, March 4, 2015; http://bit.ly/1JSd82D.) Even with current screening techniques, approximately half of patients have a metastatic presentation and a 45 percent five-year survival rate. Approximately 90 percent of lung cancer patients are active smokers or had recently stopped. Signs and symptoms of this cancer include shortness of breath, cough, bone pain, weight loss, fatigue, and neurologic dysfunction. (Medscape, March 26, 2014; http://bit.ly/1dPWx29.) None of these were present in the patient. Most SCLCs are metastasized by the time of diagnosis, and are not curative by surgery. A combination of chemotherapy and radiation therapy is required. SCLCs are centrally located masses found in the lung parenchyma. (J Clin Oncol 2006;24[28]:4526.) These pale gray tumors are fusiform-shaped and quite fragile. They can also express neuroendocrine markers and secrete polypeptide hormones that can cause paraneoplastic syndromes (PNS), such as syndrome of inappropriate antidiuretic hormone (SIADH). (Chest 2003;123[1 Suppl]:97S.) The time frame of disease development was unclear, but this patient's presentation was unique because he had nonthreatening symptoms. Lung cancer and SVC syndrome symptoms are usually aggressive, and can compromise the quality of life for patients. Our patient is now being treated to try to prevent the expected disease outcomes.

The Retrograde Limb of Internal Mammary Vessels as Reliable Recipient Vessels in DIEP Flap Breast Reconstruction

For many microsurgeons, antegrade internal mammary vessels (AIMVs) represent the recipients of choice in autogenous breast reconstruction. For the past few years, the retrograde internal mammary vessels (RIMVs) have been demonstrated to be a further reliable option when needed, according to many papers focusing more on the vein than on the artery. Besides the clinical evidence, the hemodynamic features of the retrograde system have been very seldom analyzed.In this article, we report our clinical experience with deep inferior epigastric perforator (DIEP) flaps anastomosed to RIMVs, along with a perioperative radiological follow-up to study RIMVs' hemodynamics and to further support the reliability of the retrograde system with particular focus on the retrograde internal mammary artery.Prospective, preoperative, and postoperative (3 days, 21 days, and 3 months, respectively) color Doppler sonographies of the internal mammary artery (IMA) and DIEPs have been performed to collect the velocity of flow (v) and resistive index (RI) data. Twenty-two patients agreed to undergo this protocol, of which 10 unipedicle flaps were anastomosed to AIMVs ("control" group), 10 bipedicle DIEPs to both AIMVs and RIMVs ("study" group), and 2 DIEPs anastomosed to retrograde internal mammary artery and antegrade internal mammary vein (not statistically analyzed for their paucity). Student t test was performed to compare the "control" and "study" groups.All the flaps survived, and no re-exploration was needed. Internal mammary artery and perforators v showed similar but speculate trend, whereas IMA and perforators RI looked stable during that time. Significant differences have been found in the "study" group for IMA v at 3-day period, for perforator v at 21- and 90-day periods, and for perforator RI at 90-day period, without any clinical implication for flap viability.Retrograde internal mammary vessels can be considered reliable vessels for both arterial flap input and venous flap outflows, either as additional or the sole recipients. However, further and larger studies would be useful to better understand the hemodynamics of the retrograde system.

Accidental placement of central venous catheter tip into internal mammary vein.

Sir, Central venous catheter (CVC) plays an important role in the management of critically ill patients in terms of central venous pressure (CVP) monitoring, administration of vasopressors, inotropes, blood products, and parenteral nutrition. The ultrasound guided central venous cannulation has become a routine practice in recent years due to its lower complication rates and lesser errors during insertion. The ultrasound-guided catheter insertion does not prevent or help in the detection of misplaced catheter tips. We present a case of a 25-year-old male, known case of fungal sinusitis and mycotic aneurysm of right internal carotid artery admitted to our tertiary care Intensive Care Unit following surgery (craniotomy) at an outside hospital. He was shifted for evaluation and management of shortness of breath and sepsis. It was decided to remove his old left subclavian central line in view of sepsis and replace it with a new left internal jugular vein (IJV) cannulation with the help of ultrasound guidance. Left internal jugular site was selected as all other sites were cannulated previously. The CVC on chest X-ray looked as if the catheter was entering the left atrium [Figure 1]. Flush tests on two-dimensional echo with agitated saline through the left jugular catheter showed that the catheter was draining into right atrium [Figure 2]. When patient was taken for computed tomography cerebral angiography, the neck vessel angiography was also done which on venous reconstruction showed that there were no anomalies in the venous system, but the catheter tip was seen entering the left internal mammary vein (IMV) [Figure 3]. Later the central line was removed and replaced at a different location (since it was not showing CVP trace, and there was no backflow of blood through the port). Figure 1 Central venous catheter in the left internal jugular vein appears to be entering left atrium Figure 2 Agitated saline flush through the central port of the catheter showing bubbles in the right atrium Figure 3 Angiogram of neck showing left central venous catheter entering into left internal mammary vein The incidence of CVC malposition during IJV cannulation is around 2%.[1] There have been very few reported cases of accidental left IMV cannulation in the past.[2] CVC, which are misdirected into tributaries of central veins, are more common during central venous cannulation of the left side.[3] Reason may be due to the left brachiocephalic vein, which is anatomically longer and left smaller tributaries anastomose with the brachiocephalic vein opposite to the orifice of the left jugular vein.[4] Internal mammary vein receives the anterior intercostal veins and some abdominal branches, later drain into the brachiocephalic vein behind the sternal end of the clavicle and the first costal cartilage. Portal hypertension and portal to systemic collateral circulation dilates the IMV causing a higher risk of malpositioning of the catheter, which in our patient did not have any of these complaints. Complication related to IMV placement includes laceration of IMV with massive hemothorax and altered patency of the vein.[2,5] Ultrasound might reduce the complications associated with insertion, but chest X-ray would be needed to confirm the tip of catheter positioning.

Thymic artery: uncommon origin from proximal aortic arch or distal ascending aorta.

Internal thoracic and inferior thyroid arteries mainly supply the thymus. However, very few studies have been reported on the arterial variations of the thymus. The first author, a cardiac surgeon, happened upon a thymic artery arising from either proximal aortic arch or distal ascending aorta in a few cases during routine cardiac surgery in infants and neonates. Hence a study on the prevalence of the variant thymic artery during open heart surgery was contemplated, as knowledge of its presence could avoid its injury during surgical and diagnostic procedures of the region. The prevalence of the variant thymic artery was observed during 100 consecutive cardiac surgeries in infants and neonates. In addition to two branches from internal thoracic and inferior thyroid arteries, a thymic artery originating from the distal ascending aorta or proximal arch was found in 15 (15%) out of 100 patients who underwent open heart surgery for the correction of congenital heart defects. The artery took origin from the anterior surface of aorta, a little to the left. These were small arteries, single in origin, which started at right angles from the aorta and pierced the pericardium at its reflection, from visceral to parietal, to reach the posterior surface of the thymus where they divided into two branches, one for each lobe. Since this variant artery was present in 15% cases, being aware of its presence can help prevent troublesome bleeding during surgical thymectomy, and more importantly, during surgical and diagnostic interventions in the mediastinum.

Structural features of arterial grafts important for surgical myocardial revascularization: Part I - Histology of the internal thoracic artery

[Projekat Ministarstva nauke Republike Srbije, br. 175005, 175061, III41002, III45005 i 41022]

Prospective angiographic data in asymptomatic patients with all three internal mammary, radial artery and saphenous vein grafts more than 10 years postoperative

Introduction: The standard surgical treatment of resectable early-stage non-small cell lung cancer (NSCLC) involves a lobectomy or greater resection through a conventional thoracotomy or thoracoscopic approach. However, changes to radiological screening programs, patient selection strategies and a greater understanding of histological prognostic factors have heightened the interest in sublobar resection in recent years. Patients who undergo segmentectomies or wedge resections may benefit from less morbidity and greater lung volume preservation. The aim of the present systematic review and meta-analysis was to compare lobectomy versus segmentectomy and wedge resection procedures in the ‘intentionally selected’ and ‘compromised’ patient cohorts. Methods: A systematic review was performed using 6 online databases from their dates of inception to December 2013. The primary outcomes for themeta-analysis was overall survival. Data were extracted from article texts, tables, and figures. Two investigators independently reviewed each retrieved article and discrepancies were resolved by discussion and consensus.Meta-analysiswas performed by combining the reported overall survival outcomes of individual studies. Hazard ratio (HR) and standard error were extracted or calculated from each study. Results: Twenty-five studies identified relevant data on overall survival for segmentectomy versus lobectomy, including 8 studies that demonstrated superior overall survival after lobectomy (p = 0.05) in the ‘compromised’ cohort and 5 studies that demonstrated no significant difference after either procedure (p = 0.62) in the ‘intentional’ cohort. Similarly, 8 studies found superior survival after lobectomy compared to sublobar resections in the ‘compromised’ group but no significant difference when the ‘intentional’ cohort was compared (p = 0.48). In regards to disease-free survival, there was a strong trend favouring lobectomy compared to segmentectomy (p = 0.06) in the ‘compromised’ group but no significant difference in the ‘intentional’ cohort (p = 0.46). Discussion: The present meta-analysis is the first to compare sublobar resections versus lobectomy procedures with a focus on the patient selection process. Our findings suggest that patients who undergo sublobar resections have worse overall survival outcomes in ‘compromised’ patients who were not eligible for a lobectomy procedure. However, for those ‘intentionally’ selected patients who underwent a sublobar resection but could have tolerated a lobectomy procedure, their overall and disease-free survival were similar to the lobectomy group. The selection process of these ‘intentional’ patients have been examined in detail, and two randomised-controlled trials currently underway were discussed.