Internal Thoracic Research Articles

Letter to editor on a rare central venous catheter malposition.

Dear Editor, We read A Rare Central Venous Catheter Malposition: A Case Report by Moeinipour et al. (1) with interest. Insertion of central venous catheters (CVCs) is without a doubt an essential component of both peri-operative and critical care monitoring and management (2). It is also considered as a fundamental skill to achieve Certificate of Completion of Training for any anaesthetic trainees in the United Kingdom (3). Insertion of CVCs is associated with complications in more than 15% of patients, mainly mechanically, from infection and from thromboembolic events (4). Hence, the importance of correct positioning of CVCs could not be undermined as malposition could lead to lethal consequences. There is currently no quoted incidence of malposition of central venous catheters into the left internal mammary (thoracic) vein from the literature. We also would like to report a rare case of a 69-year-old female who had a left internal jugular vein quad-lumen CVC inserted for venous access and iontropic support during her admission to the critical care unit. Left internal jugular vein was chosen to free up the right internal jugular vein for renal dialysis line. Apart from mild resistance when feeding the guide wire, the insertion was uneventful: full aseptic technique under ultrasound, first pass, seldinger technique using J-guide wire and blood was easily aspirated from all 4 lumen. Malposition was identified on the post-procedure chest x-ray with the catheter lying on the left side, parallel to the tracheal shadow, under the level of the carina (see Figure 1). This line was used without complications after initial hesitancy about its location. Subsequently, a renal dialysis line was inserted without any difficulties under ultrasound to the right internal jugular vein in the correct position (again checked by chest x-ray). The malposition was identified by non-contrast Computed Tomography (CT). Figure 1. A Chest X-ray showing the malposition of a left internal jugular central venous catheter down the left internal mammary (thoracic) vein Both of these cases lead us to believe that the incidence of this type of malposition may be more common than we think. It emphasises the importance to appreciate the anatomy of the left internal jugular vein and its course to the superior vena cava. In addition, during the insertion of CVCs to the left internal jugular vein, we should pay extra attention to ensure that we lead with the guide wire and catheter with the bevel aiming towards the right hand side to ensure it aim towards the right subclavian vein and therefore avoid turning into the left internal mammary (thoracic) vein. Resistance to guide wire insertion should raise a high index of suspicion for potential malpositioning. Finally, apart from the left internal mammary (thoracic) vein, another rare malposition of CVCs into a duplicated left-sided superior vena cava is also possible. A duplicated left-sided superior vena cava is seen in 0.3-0.5% of the normal population and in 4.4% of those with congenital heart disease (5). This anatomical variation could only be diagnosed by contrast CT.

Clinical application of the adjacent horn shaped perforator fasciocutaneous flap in the trunk area

To study the anatomy basis for the clinical application of the adjacent horn shaped perforator fasciocutaneous flap for the reconstruction of small and medium-sized defects in the trunk area. (1) Ten adult antiseptic cadavers (20 sides) were perfused with red latex. The skin blood supply, line of the blood vessels, branches in accordance with the distribution and crossing were observed. (2) Fifteen cases with defects in the trunk were treated with the adjacent horn shaped perforator fasciocutaneous flaps. The defects size ranged from 5 cm x 5 cm to 13 cm x 13 cm with the size of the flaps ranging from 10 cm x 6 cm to 35 cm x 15 cm. The trunk skin is supplied by mainly 17 groups arteries such as thyrocervical trunk, internal thoracic artery, posterior intercostal arteries, superior epigastric artery, arteria epigastrica inferior, lumbar arteries, and so on. The perforators (diameter > 0.5 mm) numbers are about 20, 40, 24, 6, on the chest, abdomen and perineum, upper back, waist, respectively. All the flaps survived completely with primary healing both on donor and recipient sites. The flaps color, texture, function and appearance were satisfactory during the follow-up period of 1-24 months. The adjacent horn shaped perforator fasciocutaneous flap should be designed flexibly. The defects in the donor sites could be closed directly without skin graft. It is an effective, easy and ideal method for the reconstruction of large defects in the trunk.

Pericardial fat and postoperative atrial fibrillation after coronary artery bypass surgery

[3], as we have a 12-year survival of 75% for left internal mammary artery (LIMA) and saphenous vein grafts and 85% for LIMA with the radial as the second graft, compared with theirs of 31 and 49%, respectively. Obesity differences between the USA and Europe may be an issue [4]. It should not be forgotten that speculation on hormone status and outcomes remains an association and not a mechanism. In addition, we are wondering why no patients after 2001 are included in their study. As pointed out in our work, males and females should be analysed separately to identify the gender differences in outcome, and we wonder if Lin et al. [2] would consider doing the same with their cohort. We have written to Buxton on this issue, but received no response. Buxton, who conducted a randomized trial regarding the radial artery and its effect on survival, failed to identify the radial artery as a beneficial factor affecting long-term survival [5, 6], and needs to be remembered by both of our groups when interpreting retrospective extensively statistically manipulated data.

Cephalic Vein Transposition versus Vein Grafts for Venous Outflow in Free-flap Breast Reconstruction.

Introduction:When recipient veins for free-flap breast reconstruction are unavailable or inadequate, vein grafts or cephalic vein transposition (CVT) an option to provide alternate venous outflow. There are no comparative data to elucidate the indications and outcomes for each. We hypothesize that the CVT is as reliable as vein grafts when indicated.Methods:All consecutive cases where a CVT or venous vein grafts were used for free-flap breast reconstruction between 2000 and 2012 were reviewed. Patient demographics, operative notes, indications, and flap survival were compared between the 2 groups.Results:Ten patients underwent a CVT and 38 patients received a vein graft for insufficient venous outflow. There were no differences in average age, body mass index, or comorbid conditions between the groups. Similarly, there was no difference in previous radiotherapy, timing of reconstruction, or side of reconstruction. A CVT was used for salvage following venous thrombosis in 7 patients (70.0%) and for primary venous outflow in the remaining patients due to inability to use the internal mammary vein. Vein grafts were performed primarily in 31 patients, 22 for augmenting venous drainage (supercharge), 9 for the dominant venous outflow, and 7 for salvage of a thrombosis. One patient in each group suffered a complete loss of the free flap (cephalic: 10.0% vs vein graft: 14.3%, P = 0.36).Conclusions:The CVT is a reliable alternate venous outflow that can be used as a primary recipient vein or as a salvage option following venous thrombosis. Surgeons should consider a CVT when primary recipient veins are compromised or unavailable.

The Use of Retrograde Limb of Internal Mammary Vein in Autologous Breast Reconstruction With DIEAP Flap

It has been postulated that the abdominal skin may have either predominantly deep or superficial venous drainage. This may account for complications arising from autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEAP) flap. In this study, we evaluate the use of the retrograde limb of the internal mammary vein (IMV) as a second recipient vein in reconstructions with the DIEAP flap. In Part A, 10 IMVs were harvested from 5 fresh cadavers and the flow of methylene blue through the retrograde limb and the presence of valves were evaluated under a stereoscopic microscope.In Part B, the clinical outcomes of 38 patients who underwent single or bilateral autologous breast reconstruction using the DIEAP flap technique between January 2007 and March 2011 were reviewed. A total of 48 flaps were evaluated: 31 with single vein anastomosis and 17 with 2-vein anastomosis. In Part A, no valves were identified in the IMVs. In all 10 cadaver IMVs, there was free flow of methylene blue in both antegrade (superior) and retrograde (inferior) directions.In Part B, a retrospective analysis of the 2 patient outcomes was performed. Outcomes assessed included total flap loss, partial flap necrosis, fat necrosis, wound infection, wound dehiscence, and hematoma. Results were compared using a 2-tailed Fisher exact test with a critical P value of 0.05. No statistically significant differences between groups were identified. The retrograde limb of the IMV seems to be a safe alternate recipient vein in DIEAP and muscle sparing free TRAM autologous breast reconstruction. This study does not identify a significant reduction in overall fat necrosis or overall complications when using the 2 venous repair techniques versus the simple venous repair technique.

PM169 Disease free patency of radial artery, internal mammary artery and saphenous vein grafts at a minimum of 10 years post coronary surgery

PM169 Disease free patency of radial artery, internal mammary artery and saphenous vein grafts at a minimum of 10 years post coronary surgery

A Rare Central Venous Catheter Malposition: A Case Report

Introduction:Central venous catheter placement is a routine procedure for the management of critically ill patients; however, it is important to ensure its proper placement. A central venous catheter malposition may cause various complications, some of which can be fatal.Case Presentation:We report an unexpected malposition of a catheter in the left internal jugular vein, where it entered into the left internal mammary vein.Conclusions:We think one of the influential factors for leading a guidewire and catheter into a nominated vein may be the left sided bevel of the needle at the time of internal jugular vein needle and catheter insertion. We were required to continue going towards the subclavian vein and accidentally turned into the left internal mammary vein.

Comparative Histology of Coronary Artery, Internal Thoracic Artery, Radial Artery, Saphenous Vein & its Importance in CABG (Coronary Arterial Bypass Graft)

Comparative histology of Coronary artery, Internal Thoracic Artery (ITA), Radial artery and Sephanous vein was studied in Dept of Anatomy, JSS Medical College, Mysore, Karnataka. Routine histological processing and sectioning was done. Sections were studied using H & E staining and Verhoeff Van Gieson's special staining procedure for elastic fibres was done. It was noted that histologically, internal thoracic artery and coronary arteries appear similar having tunica media predominantly of elastic fibres and prominent internal elastic and external elastic lamina. Tunica adventia of both coronary and ITA are found to be containing more of elastic fibres.

Massive Haemothorax and Tension Pneumothorax Due to Fractured Second Rib

Massive haemothorax and tension pneumothorax due to injury of internal thoracic vein and second rib fracture after blunt trauma is very rare. Possible mechanisms of injury to the thoracic vein include fracture of an bony structure, such as a rib, clavicle and sternum or shearing forces acting on the vessel during period of extreme acceleration or decelerations. We presented an urgent thoracotomy and ligation of the internal thoracic vein ruptured by blunt trauma immediately.

An unexpected position of the dialyses catheter during routine x-ray examination: a case of the double superior vena cava

Abstract This paper presents a case of a 55 year old male patient, who after hospitalization at the Intensive Care Unit, due to acute renal failure, at first had a central venous catheter inserted through his right subclavian vein, and then a dialysis catheter inserted through his left subclavian vein. A routine X-ray examination confirmed that the central venous catheter was visualised in the expected position of the right atrium, which was reached via superior vena cava. The dialysis catheter was not visualised in the expected position of the right atrium, but in the surprising location of the left ventricle, with its line continuously passing by the left sternal edge instead of crossing the middle line in order to enter the superior vena cava, thus raising a concern over its misplacement and possible side-effects (abstract image photo). Due to the absence of pneumo- or haemato-thorax, as the most common signs of the venous rupture, the possible explanation was an anatomical variation. Dialysis catheter displacement in the left internal thoracic vein was proposed as another possibility. Literature research explained it as a case of double superior vena cava, which was confirmed by analysis of the computerised tomography pulmonary angiogram.

A two-stage operation for thoracic esophageal cancer: esophagectomy and subsequent reconstruction by a free jejunal flap

When the stomach is unavailable for esophageal reconstruction due to previous gastrectomy or synchronous gastric cancer, a pedicled jejunum or colon, with or without vascular supercharge, has been the alternative. However, these reconstructions are not free from severe complications, such as necrosis. We have introduced a new surgical technique for delayed esophageal reconstruction using a free jejunal flap. We used this technique in 11 patients. Four weeks after subtotal esophagectomy, reconstruction using free jejunal flaps was performed. A free jejunum was placed at the pre-sternum, and the internal thoracic artery and vein were usually used as the recipient vessels. There were no cases of flap necrosis and no hospital deaths. Anastomotic leakage occurred in two cases. Both leakages were cured by conservative treatment. Delayed esophageal reconstruction using a free jejunal flap can be considered to be a safe procedure when the stomach is unavailable as an esophageal substitute.

Postoperative patency of the retrograde internal mammary vein anastomosis in free flap transfer

A caudal limb of the internal mammary vein (IMV) can be used as an additional venous drainage route in free flap transfer. However, there remains the possibility that unrecognised occlusion of the retrograde IMV occurs in the early postoperative period due to non-physiologic flow, thus affecting venous drainage. There are no reports regarding the postoperative patency rates of the anastomosed retrograde IMV. This study aimed to clarify the efficacy of the retrograde IMV as an additional venous drainage route in the case of two-vein anastomosis in free flap transfer. We performed a hospital-based prospective case series study to clarify the patency rates of retrograde IMV anastomoses as an additional venous drainage route in cases of two-vein anastomosis in free flap transfer. Both antegrade and retrograde IMV anastomoses were performed in patients who underwent free flap transfer using the IMV as a recipient vein. The postoperative flow vector and peak blood velocity of the retrograde IMV anastomosis were examined using two-dimensional phase contrast magnetic resonance imaging (2D PC-MRI) and colour Doppler imaging. A total of five retrograde IMV anastomoses in five patients were performed in the study period. The postoperative patency rate of the retrograde IMV was 60%. In the patent group, the postoperative peak venous blood velocity of the retrograde IMV was significantly slower than that of the antegrade IMV (4.6 ± 0.5 vs 7.2 ± 0.8 cm s(-1), P < 0.05). We described the postoperative patency rate of retrograde IMV anastomosis in cases of two-vein anastomosis in free flap transfer. Further study is needed to evaluate the reliability of the retrograde IMV as an additional venous drainage route.

Demystifying the Use of Internal Mammary Vessels as Recipient Vessels in Free Flap Breast Reconstruction

The internal mammary vessels are commonly used as primary recipient vessels for free flap breast reconstruction. However, there is debate about the reliability of the left internal mammary vein. The authors explored the anatomy of the internal mammary vessels as revealed during free flap breast reconstruction to determine whether microvascular complications differed between the left and right sides. All free flap breast reconstructions performed using internal mammary recipient vessels at the authors' institution between January of 2000 and December of 2010 were reviewed. The authors compared left and right breast reconstructions for internal mammary vessel diameters and microvascular complications, pedicle thrombosis, and total flap losses. Overall, 1773 free flap breast reconstructions were performed in 1336 patients using the internal mammary vessels: 899 unilateral and 437 bilateral. The left side was used in 904 cases and the right side in 869 cases. Although the mean sizes of the left and right internal mammary arteries (2.44 and 2.47 mm, respectively) did not differ significantly, the left vein was significantly smaller than the right vein (2.47 mm versus 2.93 mm; p = 0.038). The overall rate of venous thrombosis was significantly higher on the left than on the right (3.0 percent versus 2.3 percent; p = 0.028). The rates of flap loss in left and right breast reconstructions did not differ significantly (1.9 percent versus 2.2 percent). Although the left internal mammary vein is smaller than the right and is at higher risk for venous complications, it remains an acceptable recipient vessel for free flap breast reconstruction. Therapeutic, III.

Venous coupler size in autologous breast reconstruction—does it matter?

Autologous microvascular breast reconstruction is an increasingly common procedure. While arterial anastomoses are traditionally being hand-sewn, venous anastomoses are often completed with a coupler device. The largest coupler size possible should be used, as determined by the smaller of either the donor or recipient vein. While its efficacy has been shown using 3.0-mm size and greater couplers, little is known about the consequences of using coupler sizes less than or equal to 2.5 mm. A retrospective chart review of patients undergoing autologous breast reconstruction was conducted at NYU Medical Center between November 2007 and November 2011. Flaps were divided into cohorts based on coupler size used: 2.0 mm, 2.5 mm, and 3.0 mm. Outcomes included incidence of arterial or venous insufficiency, hematoma, fat necrosis, partial flap loss, full flap loss, and need for future fat grafting. One-hundred ninety-seven patients underwent 392 flaps during the study period. Patients were similar in age, type of flap, smoking status, and radiation history. Coupler size less than or equal to 2.0 mm was found to be a significant risk factor for venous insufficiency (P = 0.038), as well as for development of fat necrosis (P = 0.041) and future need for fat grafting (P = 0.050). In multivariate analysis, body mass index was found to be an independent risk factor for skin flap necrosis (P = 0.010) and full flap loss (P = 0.035). Complications were significantly increased in patients where couplers of 2.0 mm or less were used, therefore to be avoided whenever possible. When needed, more aggressive vessel exposure through rib harvest, the use of thoracodorsal vessels or hand-sewing the anastomosis should be considered in cases of internal mammary vein caliber of 2.0 mm or less. Therapeutic. Level III.

OPCABG using right internal mammary artery and sequential saphenous vein graft in reverse sequence) in a PT with right pneumonectomy with compensatory hyperexpansion of the left lung

Case report 77 years old male with worsening angina and shortness of breath and diagnosed with 3 vessel disease and history of right pneumonectomy was referred for coronary artery bypass grafting.Other co morbidities included hypercholesterolemia, exsmoking, recurrent pneumonia, colorectal resection and chemotherapy for cancer and also had gastric ulcers and could not tolerate aspirin (hence not an ideal candidate for PCI). CT chest was performed which showed heart to be deviated to the right side with tracheal deviation due to compensatory hyperexpansion of left lung. Initial plan was to perform on pump CABG in view of single lung. However after midline sternotomy it was clear that the left lung dominated the chestand the heart lay posteriorly in the right hemi-thorax with slight rotation to theright. This made on-pump surgery difficult as there was no access to the right atrium and majority of the aorta lay behind the Pulmonary artery. Femoral venous cannulation would havebeen risky due to the right atrial shift at the level of the diaphragm. Decision was made to perform the procedure without cardiopulmonary bypass. The Right internal mammary artery was harvested in semi-skeletonised fashion and was anastomosed to the mid LAD. There was enough aorta accessible to place a single vein sequentially on the OM2 and PDA performing the top end to the aorta first and then OM2 anastomoses in side to side fashion followed by PDA anastomosesas end to side anastomosis. There were no periods of instability. The postoperative course was uneventful apart from patient going into atrial fibrillation which was treated with amiodarone. Patient was discharged home on 6 postoperative day.

27 years experience with the gastroepilopic artery graft in CABG

To improve the long-term outcome after CABG, several strategies have been used using arterial conduits.In 27 years experience with the right gastroepiploic artery (GEA) graft, 1552 patients having CABG with the GEA graft, (1142 men, mean 64 years, 99% multivessel disease, and mean EF 0.51), internal thoracic artery, saphenous vein, and radial artery grafts were concomitantly used in 1505 (97%), 853 (55%), and 130 (9%) patients, respectively. The mean number of distal anastomoses was 3.2, and 2.4 coronary arteries were bypassed with arterial grafts. The sites for GEA grafting were 70 anterior descending, 318 circumflex, and 1239 right coronary arteries. The operative mortality was 1.26%. In 1118 follow-up patients (72.0%), 5, 10, and 15 years survival rates were 91.7%, 81.4%, and 71.3%, and the cardiac death-free survival rates were 95.8%, 91.7%, and 88.6%, respectively. The cumulative patency rate of the GEA graft was 98.5% at 1 month, 93.7% at 1 year, 86.2% at 5 years, and70.2% at 10 years, respectively. In 372 skeletonized GEA grafts with 452 distal anastomoses, thepatency rate at immediate, 1, and 5 years after surgery was 98.6%, 94.9%, and 88.4%, respectively. In conclusion the GEA graft is a safe and effective arterial conduit for CABG.

EComment. Aneurysm of the internal mammary artery may imitate a mediastinal mass

We read with great interest the presentation by Lindblom et al. [1] regarding an aneurysm of the left internal mammary artery (IMA), which is a rare and potentially devastating pathology. The case presented has diagnostic challenges and a spontaneous rupture resulting in life-threatening bleeding. The authors suggested the importance of the careful interpretation of radiological findings and the significance of multidisciplinary collaboration between radiologist and clinician. We fully agree with their implications regarding this unusual scenario and would also like to add a short comment on this topic. Mediastinal masses may present a challenge in diagnosis. A mediastinal mass is sometimes detected during routine screens by chest radiography. Mediastinal masses generally originate from the thymus, thyroid, parathyroid, and lymph glands. Vascular pathologies are among the most important causes for mediastinal masses and should always be excluded [2-4]. Vascular lesions include aneurysms of the thoracic aorta, the brachiocephalic artery, the IMA, the intercostal artery, the innominate vein, the superior vena cava, the azygos vein, and the internal mammary vein [2]. True IMA aneurysms are uncommon clinical entities. They are associated with atherosclerotic disease, hereditary connective tissue disorder, fibromuscular dysplasia, type 1 neurofibrinomatosis, vasculitis, and idiopathic causes. Whildhirt and associates[2] reported a case with an atherosclerotic aneurysm of the right IMA, which is a rare cause of a mediastinal mass. Iatrogenic pseudoaneurysms after sternotomy arise from a variety of vessels including the coronary artery, saphenous vein graft(SVG), the intercostal arteries and the IMA. Pseudoaneurysm of the IMA after sternotomy is extremely rare. It may result from central venous catheterization, pacemaker lead implantation, local infection, and trauma to the branches of IMA by steel wires, or may be spontaneous. Iatrogenic IMA pseudoaneurysm may present as an asymptomatic mediastinal mass. However, a high index of suspicion is important in the diagnosis of pseudoaneurysms of the IMA, especially in a haemodynamically unstable patient after sternotomy [3]. Almassi [4] presented a case of an aneurysm of the internal mammary vein presenting as an enlarging anterior mediastinal mass. Diagnosis of internal mammary vein aneurysm can be established by contrast computed tomography scan of the chest with image acquisition in the venous phase. This vascular pathology should be considered in the differential diagnosis of mediastinal masses[4]. Aneurysm of saphenous vein graft(SVG) may also present as a mediastinal mass and is a rare but potentially fatal complication of coronary artery bypass grafting(CABG). Many factors may actually play a role in the development of SVG aneurysm. This aneurysm may be located anywhere along the graft[5]. A computed tomographic scan with intravenous contrast, magnetic resonance imaging and echocardiography is helpful in identifying the consistency, vascularity, and patency of the SVG aneurysm [5]. Coronary angiography also demonstrates the vascular nature of this lesion and can detect other lesions in the native coronary artery. In a patient who has undergone CABG, the appearance of a mediastinal mass on a chest radiography should raise the suspicion of an SVG aneurysm [5]. We think that patients presenting with a mediastinal mass should always be evaluated first for the existence of these vascular abnormalities. Conflict of interest: none declared

Is it safe to divide and ligate the left innominate vein in complex cardiothoracic surgeries?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is safe to divide the left innominate vein (LIV) in aortic arch surgery to improve access. Altogether, 228 relevant papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Following LIV division, the venous drainage takes place via multiple collateral systems such as the azygous/hemiazygous, the internal mammary veins, the lateral thoracic and superficial thoracoabdominal veins, vertebral venous plexus as well as the transverse sinus. The possible complications are mainly left upper limb swelling and neurological symptoms. In one case series of 14 patients, the LIV was divided and ligated to facilitate the exposure for aortic arch surgery. More than 2-year follow-up did not reveal upper limb oedema or neurological symptoms. In two cohorts of 52 patients, the LIV was ligated prior to the superior vena cava (SVC) resection for malignancy. During the mid-term follow-up, no neurological or upper limb symptoms were reported. Although in two studies with 72 and 70 patients undergoing SVC resection it was not specified how many of them had LIV ligation, no relevant complications were reported. In a report, LIV occlusion was observed in 4 patients undergoing left internal jagular vein catheterization for haemodialysis. The reported symptom was left arm swelling with no neurological problems. In a cohort of 18 patients undergoing SVC resection for malignancy and major vein reconstruction, 7 patients underwent ligation of the LIV with no neurological symptoms. It was also concluded that reconstruction of the LIV is not consistent with favourable patency. In a case series of 10 patients with central venous obstruction, collateral pathways to conduct efficient venous drainage were mapped. We conclude that division of the LIV is safe in selected patients and operations. Patients will initially have symptoms of central vein obstruction, but these will decrease with conservative management as collaterals form.

Comparison of endoscopic versus conventional internal mammary harvesting regarding unligated side branches

In an effort to minimise access in cardiac surgery, endoscopic vessel harvesting has become more popular. The endoscopic approach, however, allows for only the harvest of the mid to distal internal mammary artery (IMA), leaving the more proximal branches of the conduit available for collateral flow away from the coronary bed. To compare the number and anatomic variation of remaining side branches in thoracoscopic vs. conventional IMA harvesting. 199 fresh cadavers were randomly divided into two groups. Group A (n = 100) underwent endoscopic IMA harvesting. In Group B (n = 99), IMAs were harvested using an open conventional approach. In both groups during surgery, side branches of the IMA were isolated and identified. The two groups were comparable with regard to mean age and age distribution, male sex (56% vs. 63%, respectively), cause of death and coronary risk factors including smoking, diabetes, dyslipidaemia and hypertension. 24 of 199 cadavers(12%) had a lateral costal branch. The left IMA arose from the third part of the subclavian artery in 6%, and from the thyrocervical trunk in 7% of the cadavers. There were significantly more unligated side branches in Group B compared to Group A (14 branches vs. 3 branches, p < 0.01). The first intercostal artery and lateral costal artery were found unligated in 3% and 5% of cadavers in Group B, whereas no side branch remained unligated in Group A. There was no subclavian artery or IMA injury in either group. Internal mammary vein was damaged in 2% of cadavers in Group B. Thoracoscopic left IMA harvesting is more accurate in finding and ligating the side branches of IMA.

Internal Mammary Artery and Vein as Recipient Vessels in Head and Neck Reconstruction&lt;alt-title&gt;Internal Mammary Vessels in Head and Neck Surgery&lt;/alt-title&gt;

Free-tissue transfer for head and neck reconstruction has evolved since the mid-1950s. A variety of different recipient arteries and veins have been described for use in head and neck reconstruction. In our experience, the internal mammary artery (IMA) and internal mammary vein (IMV) have become increasingly important for achieving successful microvascular reconstruction. To illustrate the efficacy of the IMA and IMV recipient vessels in head and neck reconstruction, highlighting the different techniques used to harvest these vessels and outline decision making when approaching a neck where commonly used vessels are unavailable. Retrospective medical record review. Outpatient clinic setting. All free-tissue transfers performed between 2005 and 2011. All patients in whom the IMA or IMV recipient vessels were used were included. Twelve cases were performed with IMA and IMV harvest. Donor site, flap used, recipient artery and vein, success of transfer, flap survival, and presence of donor site complications. The IMA and IMV were harvested in 12 patients, with 11 successful free-tissue transfers. In 1 patient, the vessels were unusable, and a regional tissue transfer was performed. The IMA and IMV are excellent recipient vessels for use in head and neck reconstruction and should be considered for use in challenging reconstructive cases.