Lateral Thoracic Vein Research Articles

Gross anatomy of vascular supply and drainage of mammary fat pads in mice models.

This work extensively studied the vasculature of mice mammary fat pads (BALB/c and C57BL/6) with special reference to haematogenous drainage routes. Mammary fat pads were five pairs (first cervical, second and third thoracic, fourth abdominal and fifth inguinal), bilaterally symmetrical, extending laterally and continuously with the subcutaneous fascia. The superficial cervical artery and vein primarily accomplished the blood vasculature of the first mammary fat pad, while the lateral thoracic and external thoracic arteries and veins supplied the second and third mammary fat pads. The superficial cervical vein (found parallel to the superficial cervical artery) drained into the external jugular vein. The lateral thoracic artery and external thoracic artery branched almost at the same level as the axillary artery (branch of subclavian artery), the latter being more medial in position. However, in some specimens, the branching of both arteries appeared to be at the same level, and their origins were indistinguishable. The lateral thoracic vein that was parallel to the lateral thoracic artery drained to the axillary vein close to the drainage of the external thoracic vein. The lateral thoracic, superficial caudal epigastric, iliolumbar and external thoracic arteries and veins vascularized the fourth mammary fat pad and displayed anastomosis among themselves. The iliolumbar vein (found parallel to the iliolumbar artery) drained into the inferior vena cava. The superficial caudal epigastric vein (found parallel to the superficial caudal epigastric artery (SCaEA)) drained into the femoral vein. Unlike humans, the internal thoracic artery and vein did not participate in the vasculature of mammary fat pads. The SCaEA and vein supplied blood and drained the fifth mammary fat pad. The anatomical continuity of the fourth and fifth mammary fat pads provided common drainage for both mammary fat pads. The BALB/c and C57BL/6 mice strains studied did not differ in topography and size of mammary fat pads. The vascular supply and drainage of the mammary fat pads also did not differ in the strains studied. Only minor variations could be noted in the small veins draining into the lateral thoracic vein. Lateral tributaries seen in the terminal end of the lateral thoracic vein were absent in the C57BL/6 mice.

Lateral Thoracic Vessel as a Recipient Vessel in Immediate Breast Reconstruction after Nipple/Skin-Sparing Mastectomy: Experience with 270 Flaps.

The selection of recipient vessels for free-flap breast reconstruction is important for the success of the surgery and the aesthetics of the breast mound. The thoracodorsal artery and vein (TDA/V) allow reconstruction without noticeable scars from the anterior view, but TDA/V exposure is an invasive and time-consuming process on sentinel node biopsy. This study aimed to determine the effectiveness of the lateral thoracic artery and vein (LTA/V) as recipient vessels by comparing them with the TDA/V. This study included 270 flaps that underwent immediate free-flap breast reconstruction after nipple/skin-sparing mastectomy by lateral incision. The patients were categorized into two groups (LTA and TDA) based on the recipient vessel selected. The LTA and TDA groups comprised 78 and 192 flaps, respectively. Among the 131 short and small pedicle flaps, such as gluteal artery perforator flap and profunda artery perforator flap, 65 (50%) used the LTA as the recipient vessel. The external diameters of the LTA/LTV (median, 1.2 mm/1.5 mm) were significantly lower than those of the TDA/TDV (median, 1.65 mm/2.0 mm). The LTV was present in 94%, and the second vein was present in 49% of cases with anastomosis. No significant differences in flap-related complications were observed between the two groups. The LTA/V can be used as recipient vessels for immediate free-flap reconstruction. Because of their superficial location and small caliber, they are easily accessible and suitable for short and small pedicle flaps. Therapeutic, III.

Giant Ascending Aortic Aneurysm Causing Central Venous Occlusion.

HomeRadiologyVol. 305, No. 1 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyGiant Ascending Aortic Aneurysm Causing Central Venous OcclusionPedro V. Staziaki , Sandeep S. HedgirePedro V. Staziaki , Sandeep S. HedgireAuthor AffiliationsFrom the Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114.Address correspondence to P.V.S. (email: [email protected]).Pedro V. Staziaki Sandeep S. HedgirePublished Online:Jul 19 2022https://doi.org/10.1148/radiol.220414MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In An 82-year-old woman with hypertension presented with epistaxis and hemoptysis. Physical examination revealed distended veins in the chest and abdominal wall, which prompted chest radiography followed by a CT angiography (CTA) of the chest, abdomen, and pelvis. CTA showed a giant ascending thoracic aortic aneurysm (TAA) measuring 10.5 × 10 cm at its largest dimension, with normal-sized sinuses of Valsalva (Fig 1). The aneurysm was notably compressing the superior vena cava, bilateral brachiocephalic vein, and right internal thoracic (internal mammary) vein, resulting in multiple superficial collateral veins in the thoracic and abdominal wall. The patient was referred to cardiothoracic surgery for repair but declined surgical intervention, and a decision was made to continue medical therapy with antihypertensives.Figure 1: (A) CT angiogram in the axial plane in an 82-year-old woman shows a large saccular ascending thoracic aortic aneurysm with wall calcifications and a partially thrombosed lumen (*). The right internal thoracic vein, superior vena cava, and azygos arch are not visualized due to extrinsic compression, whereas the left internal thoracic vein can still be seen (arrow). Notice a right lateral thoracic vein (white arrowhead) and large bilateral superficial venous tributaries (black arrowheads) coursing in the subcutaneous tissue. (B) CT angiogram in the coronal plane depicts the large size of the thoracic aortic aneurysm and the eccentric thrombus (*).Figure 1:Download as PowerPointOpen in Image Viewer Giant ascending TAAs are defined as aneurysms greater than 10 cm in size (1,2). Here, we show an example of a giant ascending TAA resulting in central venous occlusion and development of multiple collateral vessels throughout the chest and abdominal walls. Venous collateral pathways include deep or superficial venous pathways (3–5). In this case, the predominant collateral pathway was by means of superficial veins (Fig 2).Figure 2: Cinematic rendering of the same CT angiogram in Figure 1 of the chest, abdomen, and pelvis reveals the extent of superficial collateral veins throughout the torso. Because the bilateral brachiocephalic veins, superior vena cava, and right internal thoracic vein were extrinsically compressed by the ascending thoracic aortic aneurysm, the collateral venous pathway on the right is superficial, with enlargement of multiple superficial venous tributaries in the upper chest, right lateral thoracic and thoracoepigastric veins (arrowheads), and right superficial epigastric vein (white arrow). Because the left internal thoracic vein (black arrow) is still present, the superficial pathway on the left is from the left internal thoracic vein to the multiple superficial tributaries to the left superficial epigastric vein (white arrow). The azygos system was not available as a collateral option because the azygos arch was also compressed by the large thoracic aortic aneurysm.Figure 2:Download as PowerPointOpen in Image Viewer Disclosures of conflicts of interest: P.V.S. Member of the Radiology: Artificial Intelligence Trainee Editorial Board. S.S.H. Member of the RadioGraphics Social Media and Digital Innovation Team.AcknowledgmentCinematic rendering access was provided in cooperation with Siemens Healthineers.

Evaluation of Role of Arterialization of Venous Flaps in Abdomen in Rats.

Introduction Reconstruction forms the primary tenet in plastic surgery. Venous flaps are a known option but the survival is limited. Arterialization of venous flap can enhance its survival. While various techniques of arterialization of venous flaps are described, there are very few studies comparing them. Material and methods The current study was conducted among 34 rats weighing 160 to 200 grams. The rats were divided into four groups. Group I—islanded epigastric flap was raised with superficial caudal epigastric vessels as pedicle. Group II—arterialized flow through venous flap was raised with superficial caudal epigastric vein (SCEV) as afferent and lateral thoracic vein as drainage vein. Side-to-side anastomosis was done between femoral artery and vein, lateral to the origin of superficial caudal epigastric artery. Group III—after raising the flap, as in group II, femoral vein was ligated proximal to superficial caudal epigastric vessels. Group IV—an arterialized flow through venous flap was raised with superficial caudal epigastric vein as afferent and lateral thoracic vein as drainage vein. End-to-side anastomosis was done between femoral artery and superficial caudal epigastric vein. Animals that died before completion of the study were excluded. The color changes of flaps were noted. Flap survival was expressed as a percentage of the total flap surface area. The patency of anastomosis was seen on postoperative day 5. Results There was no total flap failure. On statical analysis, the flap survival area on day 5 between Group I and Group IV was not significant ( p value 0.431). The survival area in Group I (78.85 ± 10.54%) was comparable to Group IV (65.71 ± 20.70%). Group II and III had poor results as compared with Group I. In four rats, thrombosis of arteriovenous anastomosis was noted with flap survival area of 30 to 33%. Conclusion It was noted that epigastric venous flaps with end-to-side anastomosis between femoral artery and superficial caudal epigastric vein (group IV) have survival area comparable to islanded flaps.

Pharmacokinetic study of oral amitriptyline in horses.

The purpose of this study was to evaluate the pharmacokinetics of oral amitriptyline in horses. Oral amitriptyline (1mg/kg) was administered to six horses. Blood samples were collected from jugular and lateral thoracic vein at predetermined times from 0 to 24hr after administration. Plasma concentrations were determined by high-performance liquid chromatography and analyzed using noncompartmental methods. Pharmacodynamic parameters including heart rate, respiration rate, and intestinal motility were evaluated, and electrocardiographic examinations were performed in all subjects. The mean maximum plasma concentration (Cmax ) of amitriptyline was 30.7ng/ml, time to maximum plasma concentration (Tmax ) 1-2hr, elimination half-life (t1/2 ) 17.2hr, area under plasma concentration-time curve (AUC) 487.4ngml-1 hr-1 , apparent clearance (Cl/F) 2.6Lhr-1 kg-1 , and apparent volume of distribution (Vd/F) 60.1L/kg. Jugular vein sampling overestimated the amount of amitriptyline absorbed and should not be used to study uptake following oral administration. Heart rate and intestinal motility showed significant variation (p<.05). Electrocardiography did not provide conclusive results. Further studies are required to discern if multiple dose treatment would take the drug to steady state as expected, consequently increasing plasma concentrations.

Correction: The axillary vein and its tributaries are not in the mirror image of the axillary artery and its branches

[This corrects the article DOI: 10.1371/journal.pone.0210464.].

Circulating tumor cells detection in tumor draining vein of breast cancer patients

Circulating tumor cells (CTCs) in tumor draining vein blood (DB) are potential sources for liquid biopsy. However, the identification of CTCs in DB of breast cancer has not been attempted. In this study, we investigated the feasibility of CTC detection in DB of breast cancer patients using a newly developed filtration-based microfluidic CTC detection device. Samples of peripheral vein blood (PB) and DB drawn from the lateral thoracic vein of the resected breast tissue were collected during the perioperative period. We investigated 41 breast cancer patients who underwent breast surgery with axillary lymph node dissection. DB was successfully collected in 36 patients (87.8%), with a mean amount of 0.85 ml. CTCs were detected in 58.3% of PB samples and 80.6% of DB samples. DB had significant higher number of CTCs compared with PB (p < 0.001). CTCs were detected in 75.0% of DB samples and 50.0% of PB samples from patients achieving pathological complete response after neoadjuvant chemotherapy. These results suggest that abundant CTCs are released into the DB of breast cancer patients, indicating that CTCs in DB would be alternative sources for liquid biopsy and potential indicators for monitoring of treatment response and prognosis in breast cancer patients.

The axillary vein and its tributaries are not in the mirror image of the axillary artery and its branches.

IntroductionThe axillary and cephalic veins are used for various clinical purposes but their anatomy is not fully understood. Increased knowledge and information about them as well as superficial veins in the upper arm would be useful.ObjectiveThe aim of this study is to contribute to the literature regarding the anatomy of the venous drainage of the upper extremity.MethodsThe veins of forty upper extremities from twenty one adult cadavers were injected and their axillary regions dissected. The course and pattern of drainage of the venous tributaries in the axillary region were identified and recorded.ResultsThe basilic, brachial, subscapular, lateral thoracic and superior thoracic veins drained mainly into the axillary vein, in common with most textbook descriptions. However, the thoracoacromial veins were observed to drain into the cephalic vein in 70.0% of upper limbs. In addition, a venous channel connecting the distal part and proximal part of the axilla was found along the posterolateral wall of the axilla in 77.5% of the upper limbs. In 95.0% of upper limbs, we discovered a superficial vein which ran from the axillary base and drained directly into the axillary vein.ConclusionThe veins from the inferomedial part of the axilla drain into the axillary vein, whereas the veins from the superolateral part of the axilla drain into the cephalic vein. The venous drainage of the axilla is variable and in common with venous drainage elsewhere, does not necessarily follow the pattern of the arterial supply.

An improved technical trick for identification of the thoracodorsal nerve during axillary clearance surgery: a cadaveric dissection study

BackgroundAccurate anatomical landmarks to locate the thoracodorsal nerve are important in axillary clearance surgery.MethodsTwenty axillary dissections were carried out on ten preserved Sri Lankan cadavers. Cadavers were positioned dorsal decubitus with upper limbs abducted to 900. An incision was made in the upper part of the anterior axillary line. The lateral thoracic vein was identified and traced bi-directionally. The anatomical location of the thoracodorsal nerve was studied in relation to the lateral border of pectoralis minor and from a point along the lateral thoracic vein, 2 cm inferior to its confluence with the axillary vein.ResultsThe lateral thoracic vein was invariably present in all the specimens. All the lateral thoracic veins passed lateral to the lateral border of pectoralis minor except in one specimen, where the lateral thoracic vein passed along its lateral border. The thoracodorsal nerve was consistently present posterolateral to the lateral thoracic vein. The mean distance to the lateral thoracic vein from the lateral border of pectoralis minor was 28.7 ± 12.6 mm. The mean horizontal distance, depth, and displacement, from a point along the lateral thoracic vein, 2 cm inferior to its confluence with the axillary vein to the thoracodorsal nerve were 14.5 ± 8.9 mm, 19.7 ± 7.3 mm and 25 ± 5 mm respectively. The thoracodorsal nerve was found in a posterolateral direction, at a 540 ± 120 angle to the horizontal plane, 95% of the time.ConclusionsThe lateral thoracic vein is an accurate guide to the thoracodorsal nerve. We recommend exploring for the thoracodorsal nerve from a point 2 cm from the confluence of the lateral thoracic vein and the axillary vein for a distance of 25 ± 5 mm in a posterolateral direction, at a 540 ± 120 angle to the horizontal plane.

Abstract P2-01-09: Circulating tumor cells (CTCs) in the venous drainage of the breast in patients with primary breast cancer

Abstract Background: CTCs are shed from tumors and circulate in the peripheral blood after passing through the drainage vein. Axillary lymph node dissection (ALND) provides access to the lateral thoracic vein which flows directly into the axillary vein. In this preliminary study, we evaluated the feasibility of detecting CTCs in the peripheral blood and in the lateral thoracic venous blood for breast cancer patients who underwent ALND. Methods: From June 2016 to March 2017, breast cancer patients who underwent ALND in our institute were eligible for this study. A peripheral blood sample,10ml, was drawn just before the surgery or one day before the surgery. A lateral thoracic venous blood sample was taken from the resected breast just after resection. A blood sample of 0.2ml or more was necessary for CTC isolation. The CTCs in the peripheral blood before surgery (periCTC) and in the blood from the lateral thoracic vein of the resected breast (ltvCTC) were quantitatively examined by using a size-selective CTC isolation platform. Results: A total of 21 patients with median age 51 years (37-75) were enrolled to the study. Of the 21 patients, 38% were premenopausal, 52% had neoadjuvant chemotherapy. Fifty-seven percent were ER and/or PgR positive, 24% were HER2 positive. Fifty-seven percent were stage II disease and 43% were stage III. In 3 patients, we couldn't obtain sufficient blood samples from the lateral thoracic vein. Of the remaining 18 patients, we were able to obtain the median 0.5ml (0.2-2.0) blood samples from the lateral thoracic vein. CTCs were detected in peripheral blood in 15 patients (71%) and median periCTC count was 1 CTC/10ml (0-39). In lateral thoracic venous blood, CTCs were detected in all patients who had sufficient blood samples and the median ltv CTC count was 35.5 CTC/ml (2.5-370). In 5 of 6 patients whom CTCs in peripheral blood samples were not detected, CTCs could be detected in the blood samples from lateral thoracic vein. Conclusion: CTCs can be detected in the peripheral blood and in the blood from lateral thoracic vein in patients with localized breast cancer, and can be detected at a higher rate and at a higher concentration in the blood from lateral thoracic vein than in peripheral blood. Citation Format: Hattori M, Nakanishi H, Yoshimura A, Adachi Y, Iwase M, Gondo N, Kotani H, Sawaki M, Yatabe Y, Iwata H. Circulating tumor cells (CTCs) in the venous drainage of the breast in patients with primary breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-01-09.

Optimization of an Arterialized Venous Fasciocutaneous Flap in the Abdomen of the Rat.

Although numerous experimental models of arterialized venous flaps (AVFs) have been proposed, no single model has gained widespread acceptance. The main aim of this work was to evaluate the survival area of AVFs produced with different vascular constructs in the abdomen of the rat. Fifty-three male rats were divided into 4 groups. In group I (n = 12), a 5-cm-long and 3-cm-wide conventional epigastric flap was raised on the left side of the abdomen. This flap was pedicled on the superficial caudal epigastric vessels caudally and on the lateral thoracic vein cranially. In groups II, III, and IV, a similar flap was raised, but the superficial epigastric artery was ligated. In these groups, AVFs were created using the following arterial venous anastomosis at the caudal end of the flap: group II (n = 13) a 1-mm-long side-to-side anastomosis was performed between the femoral artery and vein laterally to the ending of the superficial caudal epigastric vein. In group III (n = 14), in addition to the procedure described for group II, the femoral vein was ligated medially. Finally, in group IV (n = 14), the superficial caudal epigastric vein was cut from the femoral vein with a 1-mm-long ellipse of adjacent tissue, and an end-to-side arterial venous anastomosis was established between it and the femoral artery. Seven days postoperatively, the percentage of flap survival was 98.89 ± 1.69, 68.84 ± 7.36, 63.84 ± 10.38, 76.86 ± 13.67 in groups I-IV, respectively. An optimized AVF can be produced using the vascular architecture described for group IV.

Venous anomalies of the axilla: a single-institution experience.

Surgical treatment is still the cornerstone in the treatment of breast cancer, a very common neoplasia, particularly affecting the female elderly population. Axillary dissection is crucial in the treatment of some tumours, but variations in axillary vessels anatomy are poorly described in standard anatomy and surgical textbook. We aimed to describe anatomical variations in axillary vessels found in our institutional experience. A prospective 3-year study was conducted in our institution from January 2012 to December 2014. Sixty-one consecutive axillary lymph node dissections (ALNDs) were performed in 61 patients who underwent surgery for stage II and III invasive breast cancer. Anatomical details of axillary vascular anatomy and its variations have been evaluated, described and stored in a prospective database. Sixty-one ALNDs have been performed in the study period. The anatomy of lateral thoracic vein, angular vein and axillary vein was studied and compared with standard anatomical description. Eighteen percentage of venous variations were found out of the 61 dissection performed. Vascular anatomy of axilla is complex and variable. A better knowledge of all possible variations might be helpful in preventing injuries during ALND.

Upper outer boundaries of the axillary dissection. Result of the SENTIBRAS protocol: Multicentric protocol using axillary reverse mapping in breast cancer patients requiring axillary dissection

BackgroundTwo thirds of node-positive breast cancer patients have limited pN1 disease and could benefit from a less extensive axillary lymph node dissection (ALND). Methods172 breast cancers patients requiring an ALND were prospectively enrolled in the Sentibras Protocol of Axillary Reverse Mapping (ARM). Radioisotope was injected in the ipsilateral hand the day before surgery. ALND was standard. Removed lymph nodes were classified into non radioactive nodes and radioactive nodes (ARM nodes). Among ARM nodes, nodes located in the upper outer part of the axilla, above the second intercostal brachial nerve and lateral to the lateral thoracic vein were identified as “zone D ARM nodes”. The main objective was: feasibility of identification of the zone D ARM nodes. Secondary objectives were: metastatic involvement and lymphedema rate. Results100% of patients had ARM nodes identified. The “zone D ARM nodes” were identified in 92% of cases. The rate of metastatic nodes was 60% in the all cohort, 31% in ARM nodes and 9% in zone D ARM nodes. Among those, metastatic rate was 6% in patients undergoing ALND for a positive sentinel node biopsy, 6% in case of primary ALND versus 14% after neo-adjuvant chemotherapy (p < 0.05). After 34 months of median follow up, 27% of interviewed patients had a lymphedema. ConclusionThe ARM technique reliably identifies the “zone D ARM nodes”. These nodes can also easily be identified using knowledge of axillary anatomy. In selected patients, a selective ALND sparing the zone D ARM nodes could be performed.

Head and neck reconstruction by using extended pectoralis major myocutaneous flap.

Pectoralis major flaps have been the workhorse in head and neck region reconstructions till date. However, pectoralis major flaps have disadvantages, including limitations regarding flap range and less stable blood flow than that in free flaps. Here, we report on the safe reconstruction to the oral cavity and neck area by using extended pectoralis major flaps. These flaps include both the normal vessels that feed pectoralis major flaps (the thoracoacromial artery and vein) and the lateral thoracic artery and vein to stabilize blood flow and expand flap survival area caudally. Eight patients who had undergone reconstruction with extended pectoralis major flaps after the resection of head and neck cancers from June 2009 to March 2013. In all cases, the pectoralis major flap was elevated with a vascular pedicle comprising the thoracoacromial artery and vein and the lateral thoracic artery and vein. No blood circulation disorders, such as ischemia or congestion, were observed after the flaps were elevated and moved to the resected areas. All flaps were sutured on without difficulty. The area the flaps were harvested from was closed in a single stage. No postoperative complications such as hematoma, abscess, or fistula were observed. Extended pectoralis major flaps have a wide range and more stable blood flow, so they are thought to be useful in situations in which free flaps cannot be used for a variety of reasons.

Clinical application of sentinel lymph node biopsy based on axillary anatomy in breast cancer: A single institution experience

BackgroundSentinel lymph node biopsy (SLNB), mostly with the use of vital dye or radioisotope, is a method for predicting axillary status in patients with breast cancer. Conventional axillary lymph node dissection (ALND) is used in cases where sentinel lymph node (SLN) is not detected by existing methods, but a series of studies have found that most of SLNs are present in specific anatomical spaces. We attempted to determine the feasibility of SLNB based on axillary anatomy in cases where SLN was not detected by conventional lymphatic mapping methods. MethodsA retrospective analysis involving 208 patients who received anatomical SLNB between January 2003 and December 2010 was performed. Lateral border of the pectoralis major muscle and lateral thoracic vein were defined as the anatomical landmarks, and ALND was performed to at least level II, regardless of the results of frozen section analysis. Pathologic results were used to measure false negative rate and accuracy. Chi-square test and Fisher's exact test were performed to find factors affecting results. ResultsFalse negative rate and accuracy of anatomical SLNB were 21.7% (13/60) and 93.3% (182/195), respectively. T stage, clinical node status, number of dissected SLNs and body mass index were analyzed as factors affecting results, but none of them was found as having a statistically significant influence. ConclusionThese results suggest that anatomical SLNB may not replace ALND in cases where SLN is not detected by conventional lymphatic mapping method, but may be considered as a method for predicting axillary status before conducting a node dissection.

Anatomical variations of the axilla.

PurposeThe present study aimed to measure the thickness of the subcutaneous adipose tissue (SAT) at the site of the surgical incision for axillary lymph node dissection (ALND) and to record potential anatomical variations in the medial cutaneous nerve of the arm (MCNA), the intercostobrachial nerve (ICBN), the lateral thoracic vein (LTV), the lateral thoracic artery (LTA) and the pectoral muscle pedicle (PMP), considering that some details of the anatomy of these structures within the axilla are still unclear.MethodsA prospective study was conducted in 100 consecutive patients with breast cancer who underwent ALND as part of surgical treatment. The anatomy of the dissected axilla was video recorded.ResultsThe SAT thickness ranged from 8 mm to 60 mm, with an average thickness of 25.9 mm. A positive correlation was observed between the SAT thickness and the body mass index (BMI) of the evaluated patients (r = 0.68; p < 0.0001). The MCNA was the anatomical structure that was least commonly observed in the axilla (22% of cases), while the PMP was the most constant element, identified in 100% of cases. All of the studied anatomical structures observed within the axilla showed variation in at least one of the aspects analyzed, i.e., the point of entry and exit, path, number and location of divisions or branches.ConclusionThe present study demonstrated wide variation in thickness of the SAT overlying the axilla and identified the existence of broad normative anatomical variation of the axilla.Electronic supplementary materialThe online version of this article (doi:10.1186/2193-1801-3-306) contains supplementary material, which is available to authorized users.

Morphological study of lymphatic drainage and lymph nodes of mammary glands in doe

Direct relations between human and animal cancers are not completely understood, but the fact that metastasis is identical it’s well recognized. The investigation of lymphatic metastasis in mammary neoplasia or in malignant melanoma in rabbits requires a good knowledge of the topography of main superficial lymph nodes that drains superficial structures. This study aims to perform a detailed description of the lymphatic drainage and the topography of lymph nodes that drain the mammary glands in doe. Using colored solution injection technique, we study the topography of sentinel lymph nodes that drain the mammary glands in ten rabbits. Macroscopically and histological analyses were performed. Lymphatic drainage of the thoracic and cranial abdominal mammary gland (T and A1) was achieved by ventral accessories axillary lymph nodes, in a variable number, from one lymph node in two subjects, two lymph nodes in five subjects, even three lymph nodes in three subjects. This group of ventral accessories axillary lymph nodes represents a distinct group of axillary lymph center in rabbits, being localized at the dorsal border of pectoral ascendant muscle on the lateral thoracic vein trajectory. Caudal abdominal and inguinal mammary glands (A2 and I) drainage was achieved by mammary lymph nodes, belonging inguinofemoral lymph center. They are willing in dorso-lateral part of last mammary gland, embedded in adipose tissue, two lymph nodes on each side. Results presented in this study encourage the use of induced mammary tumor in rabbits as an animal model to study the lymphatic metastatic spread in mammary neoplasia. Also, the data obtained can be used to differentiate the lymph nodes which drain superficial structures in rabbits and improvement of surgical treatment in case of developing mammary tumors.

Cephalic Vein Harvest for Deep Inferior Epigastric Perforator Salvage

Sir: The need for venous flow augmentation is relatively common in deep inferior epigastric perforator flap surgery, particularly so in irradiated internal mammary vessels and the presence of a dominant superficial venous system. Sbitany et al.1 showed in their large series of 1201 free deep inferior epigastric perforator and transverse rectus abdominis musculocutaneous flaps that 11 of these flaps (0.9 percent) exhibited intraoperative venous congestion. Previously described recipient venous sources include the lateral thoracic vein,2 external jugular vein,3 thoracodorsal vein, intercostal vein, cephalic vein,4 and basilic vein. By far the most commonly used is the cephalic vein, which is the first-choice vessel in our practice, as it has consistent anatomy, lying in the subcutaneous tissue above the brachial fascia on the anterolateral aspect of the arm. If the contralateral deep inferior epigastric perforator flap is used, the superficial inferior epigastric vein will lie in the upper lateral quadrant of the flap after inset. This is ideally placed for anastomosis after a cephalic vein turndown. Previous relevant techniques described include the deltopectoral groove, infraclavicular fossa, and anterior axillary skin incision.5 These incisions lead to visible scarring. The indication for venous augmentation is based on multiple intraoperative factors such as the flap perfusion when islanded on the abdomen, the tension or turgor of the superficial inferior epigastric vein, and the degree of flap venous congestion after anastomosis. We do not routinely perform augmentation in all cases; we do so only when there is a need for improving venous outflow. An L-shaped incision is marked out on the medial aspect of the arm with the vertical passing parallel to but posterior to the anterior axillary fold (Fig. 1). The length of the horizontal limb varies according to the length of cephalic vein required. This in turn depends on the type of mastectomy scar. A longer length will be required for a periareolar skin-sparing mastectomy when compared with a more traditional horizontal/oblique mastectomy incision. With careful dissection, the cephalic vein is easily identified sitting on top of the brachial fascia. The vein is then dissected out cranially, ligating any branches in the process. Using optimal retraction, our incision allows the vein to be followed into the deltopectoral groove. It is easier to follow the vein from distal to proximal into the deltopectoral groove in the chest rather than identifying the vein from under the mastectomy flap and dissecting laterally. The vein is then turned down through a subcutaneous tunnel from the flap recipient site. This novel incision has been performed in seven cases over the past 2 years. We have had no donor-site morbidity, although bruising in the upper arm is common. The upper arm incision is a novel aesthetically pleasing technique, which is simple and easily performed. Dissecting the vein from lateral to medial allows for easy identification of the vein under the mastectomy flap. The resulting scar is not seen when standing with arms by the side, and heals well (Figs%. 2 and 3). This technique averts the need for visible deltopectoral incisions or multiple stab incisions in the upper arm when a greater length is required. It is often particularly useful in irradiated axillae, whereby dissection of the cephalic vein in the deltopectoral groove can often be challenging.Fig. 1: Illustrations depicting the upper arm incision.Fig. 2: A well-hidden scar in the patient while standing.Fig. 3: A closeup of the healed scar.DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.

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.

Thrombophlebitis Resembling Mondor’s Disease: A Case Report

INTRODUCTION: Mondor’s disease (MD) is a rare benign breast condition characterized by thrombophlebitis of the superficial veins in the subcutaneous fat of the breast or anterior chest wall. The etiopathogenesis of MD remains controversial and, in the absence of a proven pathophysiological mechanism, a multifactorial phenomenon has been postulated. Various authors have associated the disease with local trauma, including biopsy or surgery, cancer, muscular strain, tight clothing, radiation and large pendulous breasts. Inflammatory and infectious agents have also been proposed as etiologic factors. The thoracoepigastric, superior epigastric and lateral thoracic veins are the most commonly involved, especially the last of these. Although the internal mammary vein receives drainage from the medial aspect of the breast, it is rarely affected. Bilateral involvement is unusual too. We report a case of bilateral thrombophlebitis resembling Mondor’s disease involving the lateral thoracic veins and the internal mammary veins, with multiple simultaneous or separate recurrences in both breasts. CASE REPORT: A 44-year-old Brazilian woman presented at the outpatient clinic of the Fortaleza General Hospital (HGF). On physical examination, the patient presented very large pendular breasts and a 35 cm long subcutaneous, ulcerated cord-like induration in the inner quadrants of the right breast. Several old scars were observed bilaterally in the topography of the thoracic lateral veins and internal veins. Dilated superficial veins were observed in both breasts. The patient was submitted to mammography and sonography, but no lesions were detected. DISCUSSION: The classical form of MD is lateral, unilateral and self-limited thrombophlebitis of the mammary veins. In contrast, in our patient MD affected the lateral thoracic veins and the internal mammary veins bilaterally, with multiple recurrences. Despite all efforts, the main cause was not identified, as with many other cases reported in the literature. In fact, other case reports have associated large and pendular breasts with MD. The major clinical significance of MD is that the condition can mask malignant lesions. No specific treatment is needed in most cases and and follow-up is strongly recommended.