Left Cephalic Vein Research Articles

Dextrocardia with complete atrioventricular block—the right clinical approach to pace a heart on the right hemithorax: a case report

BackgroundA heart positioned on the right side of the thorax can be more a complex situation than it seems, also the potentially associated congenital cardiopathies are variable. In this regard, patients with dextrocardia presenting with complete atrioventricular block require a thorough anatomical investigation to map the veno-arterial system and potential cardiovascular defects before proceeding with a permanent pacing procedure.Case presentationA 73-year-old Caucasian woman with no significant medical history presented with syncope. Physical examination showed regular heart sounds with an average heart rate of 35–40 beats per minute and no other relevant physical findings. Chest X-rays revealed a heart positioned in the right hemithorax. A standard electrocardiogram revealed complete atrioventricular block with junctional escape rhythm at nearly 35–40 beats per minute. A transthoracic echocardiogram showed a mirror image dextrocardia without any other remarkable abnormalities. Venogram performed using the left peripheral cephalic vein showed normal venous return into the right atrium positioned on the left side. Surgical intervention consisted of permanent dual chamber pacemaker implantation using the left subclavian vein. Discussion is provided based on the relevant medical literature outlining different potential scenarios with associated cardiac and major vessels abnormalities.ConclusionThis case highlights an atypical presentation of atrioventricular block in a patient with dextrocardia and situs inversus, for whom a successful dual-pacemaker implantation procedure was performed.

Imipramine in dogs: A pharmacokinetic study following oral administration under fasted and fed conditions

This study investigates the pharmacokinetics (PK) of imipramine, a tricyclic antidepressant used in human psychiatric disorders and increasingly considered in veterinary medicine. Despite its longstanding use in canines, prior research on imipramine's PK in dogs is lacking. This study aimed to determine the PK of imipramine in dogs in regards to feeding conditions, and to ascertain whether desipramine (active metabolite) is formed or not. In this study, six male Labrador dogs underwent oral administration (1.5 mg/kg) of imipramine tablets (10 mg each; Tofranil®, Novartis) in both fasted and fed conditions. Dogs were randomly allocated to one of two treatment groups, employing an open, single-dose, two-treatment, two-phase, cross-over design, with a washout period of one week. Blood was drawn from the left cephalic vein to heparinized tubes at 0, 0.25, 0.5, 0.75, 1, 1.5, 2, 4, 6, 8, 10, 24, and 48 h. Plasma concentrations were quantified using a validated HPLC method, and the data were analyzed using PKanalix™ software with a non-compartmental approach.Concentrations of imipramine remained quantifiable up to 1.5 hr after administration under both conditions. Desipramine, in both feeding states, was detectable for a short duration, but not quantifiable. No significant differences were observed in the PK parameters of imipramine between the fasting and fed states. The rapid attainment of maximum concentration (Cmax) occurred within 0.25 h, indicating a swift absorption rate. Notably, the terminal half-life in dogs was remarkably short at 0.25 h, prompting a re-evaluation of dosing strategies. Considering the recommended therapeutic plasma concentrations in humans, the administered dose might result in effective levels for a brief period of time. Future research should explore intravenous administration, multiple-dose studies, and metabolic investigations to further elucidate imipramine's PK in dogs.

A rare variations of the cephalic vein drainage: two cases report.

Throughout the years, anatomic studies have demonstrated numerous variations in the course of the cephalic vein (CV). There are, however, very rare cases of uncommon formation, course or termination of the vein to which our attention should be drawn. During a routine dissections conducted in the Department of Anatomy and Neurobiology, in two formalin-fixed cadavers, the very rare anatomical variants were found. In 80 year-old Caucasian female the right cephalic vein, after crossing the clavipectoral triangle, ascended anterior and superior to the clavicle and drained into the lateral branch of the right external jugular vein, which in turn opened to the right subclavian vein. In the second case, the dissection of 83 year-old Caucasian male cadaver revealed that after passing through the deltopectoral groove, the left cephalic vein run between clavicle and subclavius muscle to terminate in the left subclavian vein. Understanding of the topography, morphology and anatomical variations of the cephalic vein is important not only for the anatomists but for the clinicians and nurses as well. Such knowledge can prevent multiple complications during many invasive procedures including implantation of Cardiac Implantable Electronic Devices, central venous access, arteriovenous fistula creation or even iatrogenic injuries during clavicle or glenohumeral joint surgery.

262 AN UNUSUAL CAUSE OF PACEMAKER MALFUNCTION WITH NON-COMMON ELECTROCARDIOGRAPHIC PRESENTATION AND UNEXPECTED ECHOCARDIOGRAPHIC FINDING

Abstract This clinical case shows the diagnostic challenge and the management of a 79 y-o male with arterial hypertension, tabagism, obesity and a recent hospitalization for infero-lateral STEMI undergoing primary PCI of Right Coronary Artery with 2 DES and following DDDR MRI PM (pacemaker) implantation (through left cephalic vein) due to the development of persistent 2:1 AV block (atrio-ventricular block). One month later, admission at Emergency Department for syncope. The admission therapy included Aspirin plus Clopidogrel, Ramipril, Atorvastatin. Normal parameters were found at laboratory analyses. The electro-stimulator activity evaluation showed a PM malfunction with ventricular capture failure. Thus, the increase of PM output up to electric ventricular capture (8 Volt/120 msec) was performed, but the following Electrocardiogram (ECG) showed a PM-induced rhythm with RBBB-morphology. Then, the bedside Echocardiogram showed an apparent presence of a linear hyper-echogenic image (lead?) into left ventricle with no inter-ventricular septal defect neither inter-ventricular shunt, inter-atrial septal hypermobility with no evident inter-atrial shunt at rest; while a chest Radiography identified the atrial and ventricular leads with no accurate individuation of their position. The patient was admitted in Intensive Cardiac Care Unit with confirmation of intermittent failure to ventricular capture and RBBB-morphology during PM-induced rhythm at telemetry monitoring. Due to Electrocardiographic and (above all) Echocardiographic findings, a strong suspect of abnormal position of the ventricular lead into left ventricle through a possible PFO has been raised. A chest Computed Tomography was performed confirming the anomalous position of the ventricular lead: the atrial lead was in the right atrium whereas the ventricular lead reached the left atrium through an inter-atrial defect/patent foramen ovale (PFO), then crossing the mitral valve up to left ventricle. The PM-lead repositioning was scheduled two days after. With intra-operative fluoroscopy, a further verify of leads position was observed (the ventricular one into left ventricle through PFO and mitral valve, the atrial one mildly displaced upwards) and the leads repositioning was performed. After positioning of temporary stimulator lead in right ventricle, the ventricular lead has been withdrawn from left-side chambers and positioned into septal-apical right ventricle; furthermore, the position of right atrial lead has been optimized (because of frequent spontaneous passage to the left atrium through the PFO, during manual maneuvers). Finally, the optimal stability of the device was obtained, as well as the optimal atrial and ventricular capture during stimulation test. During the observation in Cardiology Unit in following days, the telemetry monitoring and ECG showed a PM-induced rhythm, without capture nor sensing failure. The chest Radiography confirmed the correct position of atrial and ventricular leads. Finally, the pre-discharge transthoracic Echocardiography showed a LVEF 57% with no valvular pathology nor pericardial effusion, and with atrial and ventricular leads into right-side chambers.

281 CARDIAC RESYNCHRONIZATION TERHAPY IN PERSISTENT LEFT SUPERIOR VENA CAVA WITH A BRIDGING INNOMINATE VEIN

Abstract Background The Persistent Left (PL) Superior Vena Cava (SVC) is a congenital malformation of the thoracic venous return that has an incidence of 0.2-3% in the general population and an incidence of about 0.5% in patients undergoing cardiac implantable electronic device. In this case, the placement of the leads, especially for the Right Ventricle (RV) and Left Ventricle (LV) through one of the branches could be challenging. Methods A 66-year-old man with hypertension, diabetes and dyslipidemia, in optimal pharmacologic therapy for congestive heart failure (NYHA II), hospitalized for recurrent syncopal episodes, with extreme sinus bradycardia, first-degree AV block and Left Bundle Branch Block, The patient had a LV hypertrophy and mild global systolic function (LV ejection fraction of 40%) for these we opted for a pacemaker CRT device implantation. Results Isolation of left cephalic vein was used as venous access for right atrium (RA) and RV leads while Seldinger technique via subclavian vein was used as venous access for LV lead. The guidewire through the subclavian vein pointed out the presence of PLSVC. Left subclavian venogram confirmed PLSVC and revealed a bridging innominate vein. To pass through the innominate vein and reach the SVC, a 0.035-inch hydrophilic guidewire was used. A 6Fr-sheath was advanced through the hydrophilic guidewire, subsequently a second metallic guidewire was advanced through the same introducer by removing the dilator. The RV and RA leads were placed respectively on low right interventricular septum and RA appendage passing through bridging innominate vein. Electrical parameters were normal. For the placement of the LV lead a 9.5Fr sheath introducer was advanced over the guidewire through the PLSVC. A venogram showed a lateral and a postero-lateral branch of the coronary sinus with acute angulation. With a 6Fr quadripolar Josephson catheter the postero-lateral branch was entered, eventually a 9Fr peelable outer guide catheter was advanced through the electrophysiology catheter becoming selective with the interested branch. A quadripolar S shaped lead was used, it was advanced into the targeted vein through a 0,014fr hydrophilic guidewire. Adequate electrical parameters and stability were achieved. Conclusion Lead implantation in patient with PLSVC is challenging. Placing the RA and RV leads through SVC ensure a better stability along time. The cannulation of CS is easily achieved by approach via PLSVC while selective vein cannulation can be difficult due to the modified acute angulation.

Abstract 11687: Diagnosis and Management of High-Risk Pulmonary Embolism in a Term Neonate

Case Presentation: A 5 day old, term infant born to a 39-year-old G1P0 with a history of diet-controlled gestational diabetes mellitus presented with hypernatremic dehydration in the setting of poor feeding. On hospital day 2, the infant suffered a bradycardic cardiac arrest requiring 2 minutes of CPR prior to return of spontaneous circulation. An echocardiogram (Figure 1A) revealed moderately depressed right ventricular (RV) function, elevated RV pressure and a large mobile mass extending from the main pulmonary artery (PA) into the left PA with obstruction of flow. D-dimer was markedly elevated at 2740 ng/mL. A subsequent CT angiogram revealed acute pulmonary emboli in the distal left and right branch PAs (Figure 1B). Additional imaging was obtained and showed dural venous sinus, left portal vein and right cephalic vein thromboses. The infant was managed with a heparin infusion and supportive therapy for the RV dysfunction and pulmonary hypertension including mechanical ventilation, inhaled nitric oxide as well as epinephrine and milrinone infusions. Over the course of two weeks, the infant improved clinically with normalization of RV function. Discussion: Neonatal pulmonary arterial thrombosis is an exceedingly rare phenomenon. The majority of cases described in the literature are associated with either an inherited thrombophilia or with underlying congenital heart disease, which were not found to be present in this case. However, this patient presented with severe dehydration and a history of maternal diabetes, both of which are risk factors for neonatal thrombosis. Fortunately, this patient responded to treatment with anticoagulation alone and did not require more invasive therapies, such as surgical thrombectomy or systemic and catheter-directed thrombolysis. Although rare, neonatal pulmonary arterial thrombosis can occur and delays in recognition and treatment may lead to significant RV dysfunction, morbidity, and even death.

P13 COMPLETE ATRIOVENTRICULAR BLOCK IN A 52–YEAR–OLD MAN ASSOCIATED WITH LYMPHATIC CANCER WITH CARDIAC INVOLVEMENT

Abstract A 52–year–old man arrived at the local emergency room for worsening dyspnea and asthenia, present for about a month, but significantly worsening during the night of the access. The ECG (Figure 1) revealed complete AtrioVentricular Block (ABV) with a narrow–QRS junctional escape rhythm, with a heart rate of about 30 beats per minute (bpm). The other vital parameters were within the normal limits and no anomalies were detected on the physical examination. Medium–dose intravenous isoprenaline infusion was immediately started, with an increase in the junctional escape rate up to 50 bpm. The patient also underwent chest x–ray, which showed interstitial thickening in the pulmonary hilus, which was judged to be nonspecific. The blood chemistry was normal and the echocardiogram (Figure 2) did not show any abnormalities. Since there were no apparent reversible causes of the complete AV block, on the next day, a bicameral pacemaker was implanted via the left cephalic vein. The procedure was uneventful and the patient was discharged home two days later, in good general condition. Eight days after the discharge, surgical wound control and pacemaker control were performed, with completely normal parameters. About 15 days after the discharge the patient went back to the local emergency room for dyspnea and fever. Chest Computed Tomography (CT) without contrast medium was performed, which revealed the presence of widespread pathological mediastinal lymphadenopathy. Therefore, the patient was admitted to the internal medicine ward. An in–depth diagnostic was performed first with thoraco–abdominal angio–CT, then with Positron Emission Tomography (PET)–CT (see Figure 3), which revealed the presence of diffuse areas of fixation of the radio–drug (18F–Fluorodeoxyglucose –FDG–), at the ilo–mediastinal, hepatic, pulmonary, retrocrural, retrocaval, iliac, supra and subclavicular, and also cardiac area (activation of interatrial brown fat and between aortic root and the superior vena cava). The patient was therefore transferred to another hospital for diagnostic investigations and lymphoma therapy. In the light of the picture that emerged, the arrhythmological disease was considered to be referred to the cardiac involvement of the oncological disease; to date there are few similar cases described in the literature. Legend of the figures: Figure 1: ECG at the admission Figura 2: Echocardiogram at the admission Figura 3: PET / CT with myocardial areas of 18F–FDG fixation.

Alternant Approach to Manage Patent AVF With Untreatable Venous Hypertension from Central Stenosis

<h3>Introduction and Objective</h3> Arteriovenous fistula (AVF) associated venous hypertension from central venous obstruction is commonly seen to cause dysfunctional dialysis access and severe swelling. It is traditionally managed by a variety of surgical, interventional approaches, but when the central stenosis/occlusion cannot be corrected, focus shifts only to relieve the edema. The most common approach is sacrificing the vein with ligation and starting anew despite risks of non-maturity and/or using a non-autologous conduit. We report a novel approach by translocating a patient's native and "mature" vein to create a new AVF and treat both problems. This minimizes time-to-maturity, quickly establish long-term, autologous vascular access for hemodialysis and simultaneously treat the swollen extremity. <h3>Case Report</h3> 80-year-old female with a functional brachiocephalic AVF had severe and painful venous hypertension due to presumed central vein obstruction. The AVF was created in 2017 and unused until November 2019. It worked for 7 months until developing left upper extremity swelling and pain. She underwent five balloon angioplasty procedures at an outside facility without lasting resolution. In January 2021 her left upper extremity was tense, edematous and significant erythema. The left arm had evolving elephantiasis with Peux D'Orange skin changes, warmth, tenderness, with a distant, but palpable thrill. We attempted resolution via femoral venous access which revealed a >70% stenosis of her subclavian vein close to the innominate junction and near her first rib and clavicle interface. Balloon angioplasty with a 12 × 40mm Conquest balloon at 20 ATM had immediate reversal of her venous hypertension and symptomatic relief. At one month she reported recurrence of swelling and pain. We discussed first rib resection, AVF ligation and/or catheter-only dialysis or starting again. She refused a rib resection. We harvested and excised her large and mature left cephalic vein and translocated it to her right forearm to create a new radial artery to Brachial vein AVF (with a tunneled catheter for acute access). Due to size mismatch, we everted the left cephalic vein to do valvulotomy, and the anastomosis was done in a non-reversed fashion with two end-to-side anastomosis. This simultaneously corrected her venous hypertension and gave her an autologous AVF using her contralateral cephalic vein. At one month, her left upper extremity had complete resolution and the AVF was cleared for access. <h3>Discussion</h3> Venous hypertension and central venous obstruction with a functional AVF can compromise efficient dialysis and be very debilitating leading to AVF ligation and abandonment when it cannot be resolved. This approach offers an accessible technique for salvage of a relatively common AVF complication with high success for cannulation.

595 Penetrating Pelvic Trauma from a Crossbow Bolt: An Unusual Choice of Weapon

Abstract Introduction The crossbow was a popular weapon in medieval times due to their relative ease of use and accuracy but was superseded by firearms around the 16th century. Today, it is legal for adults in the UK to own a crossbow without a licence. Case Report A young adult male victim was brought to a Major Trauma Centre with a single lower left quadrant penetrating wound caused a crossbow bolt that was self-removed immediately after the injury. A 2.5cm entry wound was present with no exit wound. The patient was haemodynamically unstable on arrival and was transferred to theatre without imaging within 16 minutes of arrival. The main operative findings were multiple small bowel serosal tears, a full thickness small bowel injury with no contamination and a left external iliac artery injury with active bleeding which were all repaired primarily. The post-operative recovery course included occlusive left cephalic and antecubital vein thrombi and an extensive non-occlusive left common femoral vein thrombus treated with anticoagulant therapy but was otherwise unremarkable. He was discharged 10 days later with no lasting sequelae at 6-week follow up. Discussion This case highlights a rare but important and likely underreported modality of penetrating injury. Crossbow bolts have low kinetic energy compared to bullets but high penetrative force, thus little energy is transferred to surrounding tissues. Hence the main injuries caused by crossbow bolts are due to direct damage to structures they come into contact with. Although rare, trauma surgeons should be aware of the pattern of injury caused by crossbows.

Diagnosing a hematopoietic malignancy during shoulder arthroplasty: A case report

Introduction. Determining the cause of shoulder pain is usually a challenge as many problems, such as rheumatoid arthritis, osteoarthritis, osteonecrosis, rotator cuff arthropathy, traumatic arthritis, fractures, conditions of cervical vertebra, and neo-plasms, can produce similar symptoms. The diagnosis is usually regarded as incidental, however, chronic lymphocytic leukemia (CLL) diagnosis by the histopathological evaluation performed on lymph nodes excised during a shoulder procedure has not been reported in the literature, to the best of our knowledge. We present a CLL-small lymphocytic lymphoma (SLL) case diagnosed incidentally during reverse shoulder arthroplasty. Case report. A 69-year-old female with a history of left proximal humerus fracture a year prior was presented to our outpatient clinic with left shoulder pain. A proximal humerus non-union was revealed radiographically. The patient underwent reverse shoulder arthroplasty. During surgery, a 2.5 ? 1.5 ? 1 cm sized lymph node was observed near the left cephalic vein. The lymph node biopsy result was reported to be CLL-SLL. The patient had no early postoperative complications and was dis-charged two days after. At her final evaluation, she was free of orthopedic complaints and was consulted with the hematology department to receive CLL-SLL treatment. Conclusion. Elderly patients presenting with non-union should be questioned for vague symptoms; lymph nodes surrounding the non-union site should be examined thoroughly. Any suspicious lymphadenopathy encountered during orthopedic surgery should be excised and sent for pathological evaluation

Arteriovenous Fistula Stenosis: A Case Report

Background: Arteriovenous fistula (AVF) has better rate of patency and lower rate of complication compared to other vascular access for hemodialysis. One priority to be concerned is access failure for hemodialysis access is common findings and correspond with high healthcare cost, morbidity and mortality. Objective: This case report aimed to elaborate the proper management of patient with arterio fistula stenosis. Case Illustration: A man, 64 years old, stage V CKD with AVF in his left arm for hemodialysis access was admitted to our hospital due to difficulty in cannulation during his last hemodialysis. He had AVF For Hemodialysis access for two years. About 1 month before, he undergone surgery for creation of AVF for hemodialysis access in his right arm, but AVF was failed to reach maturation. Based on vascular doppler ultrasound (DUS) done in AVF of the left arm revealed there was stenosis in the juxta-anastomosis site and cephalic venous stenosis. Angioplasty was done in anastomose AVF and implantation of venous stent in the left cephalic vein. Conclusion: For patients on hemodialysis, vascular access is considered as the lifeline. Complications related to Vascular access is associated with morbidity and reduced quality of life. Surgery often difficult to do as readily as a percutaneous approach. In more than 80% of hemodialysis access underwent percutaneous interventions, flow was successfully restored. Based on this success rate, it has replaced surgical revision as the treatment of stenosis AVF.

The Implantation of Totally Implantable Venus Access Ports Way: Cephalic Vein Cut-Down in Oncologycal Patients

Introduction: In an observational and retrospective study we wish to demonstrate that the performance of Preoperative Ultrasound prior to implantation of a Totally Implantable Venous Access Port (TIVAP) using Cephalic Vein Cut-down (CVC) improves the success rate and reduces complications. Method: Between 2008 and 2018, 860 Cephalic Veins (CV) were studied preoperatively with Ultrasound. The Cephalic Vein was not suitable with a diameter less than or equal to 3.3mm. Diameters, procedure times, success rate, follow-ups and complications were studied. Results: An Ultrasound was performed on 860CV, 146 (16.9%) were ruled out for implantation for various reasons. Of the 714CV to study, they belonged to 681 patients (63.3% women), with a mean age of 60.5 years (19-87). Age and colon neoplasia were significantly higher in males (p&lt;0.001). Of the 714 valid cases, in 12 cases (1.7%) there was a spasm of the CV so that the overall success rate was 97.9%, being higher via the LCV (98.5%). The 85.2% were accessed using the Left Cephalic Vein (LCV). The mean diameter was 3.8±0.2mm and the mean procedure time was 25.0±2.6 minutes, being less via the LCV (p&lt;0.02). There were no intraoperative complications, and 1.3% experienced postoperative complications, predominantly Deep Vein Thrombosis (0.8%). There were 26 delayed complications (3.7%), the most frequent being system infection (1.7%) and catheter occlusion (1.3%). 200 TIVAPs (28.6%) were explanted, 24.5% due to end of treatment, 3.2% due to complications and 0.9% due to other causes. Conclusion: The Cephalic Vein Cut-down whit preoperative ultrasound is an excellent via for the implantation of TIVAP with high rate the success, without intraoperative complications and with few postoperative complications.

Tuberculosis Presenting as Multiple Vein Thrombosis in a Hospitalized Man

Tuberculosis (TB) remains an infectious disease with a high prevalence worldwide and represents a major public health issue. Although venous thromboembolism (VTE) is a rare complication of this disease, it may be a potentially life-threatening event. A 58-year-old man was admitted due to hematemesis due to inflammation at the anastomosis site after a gastrectomy years ago. After 3 days in-hospital, he showed a peroneal deep vein thrombosis and superficial thrombosis of left cephalic vein. Although reduced mobility and lack of prophylactic heparin could explain vein thrombosis, a simple etiologic workup was performed and active tuberculosis was diagnosed. This case illustrates a rare and unusual presentation form of tuberculosis, a condition that remains now-a-days one of the leading infectious causes of death worldwide. The association between tuberculosis and VTE is rare, but it should be systematically investigated.

Ultrasound-guided removal of cut intravenous cannula

The most common invasive intravascular procedure is the placement of the intravenous cannula. The use of peripheral venous cannulas may lead to a number of complications that may increase hospital stay, increase the cost of treatment, and decrease patient comfort. Spontaneous fracture and migration of intravenous cannula is a known complication and should be removed immediately. We report a case of a peripheral venous catheter (PVC) piece in the left cephalic vein treated successfully by a surgical approach. Our patient had to undergo intravenous cannulation for treatment of pneumonia and the cannula was cut on the second day by mistake during removal. The cut catheter piece was removed operatively. Inserting and removing a PVC is not always a simple and harmless procedure.

Teaching NeuroImages: Facial swelling and intracerebral hemorrhage from venous hypertension in a dialysis patient.

A 56-year-old woman on hemodialysis through left arm arteriovenous fistula presented with headache, aphasia, and gradually worsening left facial swelling (figure 1A). MRI showed left temporal intracerebral hemorrhage with arterialized veins (figure 2, A and B). Cerebral angiography revealed multiple areas of venous flow reversal suggesting venous hypertension (figure 2C). Fistulogram demonstrated chronic left cephalic vein occlusion with outflow retrograde through the left internal jugular, facial, intracranial, and then centrally through right internal jugular veins. Recanalization of the venous occlusion improved facial swelling (figure 1B). Early recognition of facial swelling may prevent intracerebral hemorrhage in patients with arteriovenous fistula.1,2

Combined vascular and neurologic injury after cephalic vein cutdown approach for ICD implantation

In this article we discuss two cases that highlight possible complications of cardiac device implantation. In particular, our first case involves a patient who, during implantable cardioverter defibrillator (ICD) implantation, sustained injuries to her subclavian artery and vein and subsequently developed a self-resolving neuropraxia of the brachial plexus. In our second case, the patient, also during ICD implantation, had his left cephalic vein nicked during cutdown. Post-op he then developed a hematoma-induced left brachial plexus injury that also eventually self-resolved. A literature search has not shown other incidences of iatrogenic brachial plexus injuries from ICD implantation as described.

Linear atrophy and vascular fragility following ultrasoundguided triamcinolone injection for DeQuervain tendonitis

A 64 year-old woman presented with a one-yearhistory of purpuric, atrophic, linear patches alongthe left lateral forearm. The patient had receivedtwo ultrasound-guided triamcinolone injectionsone year earlier into her left extensor pollicis brevisand abductor pollicis longus tendon sheathsfor DeQuervain tendonitis. In the seven monthsfollowing the second injection, the patient developedatrophy, purpura, and telangiectasias starting at thesite of injection and extending proximally, followingthe course of her left cephalic vein. The patient wastreated initially with amlactin and moisturizing creamcontaining alpha-hydroxy acid cream to aid in dermalrepair. Despite treatment, she continued to haveproximal progression of the atrophy and purpura.A 4mm punch biopsy revealed a normal-appearingepidermis overlying horizontal dermal fibrosis, alongwith atrophic-appearing adipocytes with accentuatedcapillaries in the subcutaneous fat, consistent witha diagnosis of corticosteroid atrophy. These grossand microscopic changes presumably resulted fromlymphatic uptake and spread of the corticosteroidfollowing the injections for tendonitis. Although localatrophy and vascular fragility are well-documentedside effects of corticosteroid injections, linear spreadof these symptoms is rarely reported, and to this pointhas not been demonstrated in the literature followingultrasound-guided steroid injection for DeQuervaintendonitis.

Spontaneous repositioning of a malpositioned peripherally inserted central catheter.

Sir, A 3-year-old female child diagnosed with acute lymphoid leukaemia was scheduled for peripherally inserted central catheter (PICC) insertion for chemotherapy. After administering general anaesthesia, a 3F PICC, 22 cm long, was introduced through the left cephalic vein. The catheter was introduced with the head towards the side of the line, and no difficulty was faced while introducing the catheter. Postprocedure, in the recovery room, a chest X-ray taken showed the catheter tip malpositioned in the internal jugular vein [Figure 1a]. Since the child already had a peripheral venous access, it was decided to use that access for the continuation of the chemotherapy. We opted to re-evaluate the position of the catheter after allowing the child to be active and preferentially in an erect posture rather than redirecting the catheter immediately. An X-ray repeated the next day showed the catheter redirected to the desired position in the superior vena cava without any intervention [Figure 1b]. Figure 1 (a) Malpositioned peripherally inserted central catheter (b) Peripherally inserted central catheter after spontaneous repositioning PICCs are reportedly safe as venous access devices for use in patients receiving chemotherapy and/or parenteral nutrition, with a low-incidence of complications.[1,2,3] It is recommended for antibiotic administration lasting longer than 6 weeks[4] and substituting PICC for central venous catheter may reduce the incidence of catheter-related bloodstream infections in long-stay ICU patients.[5] The PICC is composed of a long, soft and flexible tubing which is introduced mainly through large veins in the cubital fossa or arm. They are made of either silicone (conventional PICCs) or polyurethane (power-injectable PICCs). Polyurethane is a much stronger material than silicone and withstands high injection pressures but at the cost of reduced flexibility. PICCs can stay inside a patient indefinitely until complications such as phlebitis or catheter malposition occur. The regular central catheters are thicker and less flexible compared to PICC. In contrast to the central venous catheter that needs repositioning if malpositioned, PICCs being soft and flexible, can follow the direction of blood flow in the vein and may get spontaneously redirected towards the SVC and right atrium. Hence, we recommend a conservative approach with observation for a period of 24–48 h following the malpositioned placement of a PICC if patient's condition allows. Reassessment of the position after 24–48 h may result in spontaneous redirection and avoidance of another intervention. However, the patient should have an alternative venous access for the continuation of treatment during this period. The malpositioned catheter should be kept patent even during this period by repeated flushing with normal or heparinised saline. Patients should be encouraged to be active and recumbent and/or erect to aid the change of position of the catheter. It may be justifiable to wait for a reasonable period of 24–48 h as the possibility of the introduction of infection cannot be excluded when the catheter tip is redirected through a guide wire. Most patients scheduled for PICC insertion are immunocompromised, and infection is of great relevance in this context. We would suggest the practice of observation for 24–48 h to check for spontaneous catheter repositioning in the management of malpositioned PICC lines. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Phenytoin-Induced Purple Glove Syndrome: A Case Report and Review of the Literature.

To present a case report and literature review of phenytoin-induced purple glove syndrome (PGS). A 54-year-old African American male presented to our hospital's emergency department (ED) following a seizure episode, cardiac arrest, and loss of consciousness. On arrival to the ED, the patient's total phenytoin level was subtherapeutic at 4.1 mcg/mL and his corrected total phenytoin level was subtherapeutic at 5.1 mcg/mL. In the ED, the patient received a loading dose of intravenous (IV) phenytoin 1,000 mg once via the left cephalic vein, at a rate of 50 mg/min, and was admitted to the medicine service. A day following IV phenytoin administration, a nurse noticed an IV fluid infiltration on the skin tissue around the left cephalic vein. The area appeared dark blue and purple in color, swollen, erythematous, and warm to touch. An ultrasound of the left upper extremity was performed and revealed subcutaneous fluid collection without evidence of thrombosis. The Naranjo Adverse Drug Reaction Probability Scale assigned a score of 7, indicating phenytoin as the probable cause of purple glove syndrome (PGS). The patient's PGS was managed with a combination of dry dressing material, left forearm elevation, collagenase topical cream, 0.1% IV bupivacaine, and IV fentanyl. The patient's injury was resolving at the time of discharge to a rehabilitation facility. PGS is a rare complication of IV phenytoin therapy. The risk of PGS for this patient may have been abated by decreasing the phenytoin infusion rate from 50 mg/min to less than 25 mg/min.

Contralateral pneumothorax after cardiac pacemaker implantation.

We report a case of a 73-year-old man, who was scheduled for elective dual chamber pacemaker implantation because of paroxysmal second-degree atrioventricular block. The pacemaker pocket was located in the left infraclavicular fossa. An active fixation ventricular lead was implanted into the right ventricular outflow tract (RVOT) through the left cephalic vein venesection, while another active fixation (Medtronic CapSure 5076MRI) atrial lead was located within the right atrial appendage using left subclavian vein puncture. During the procedure, due to anatomical inconveniences, several attempts at subclavian vein puncture were performed. Difficulties were also encountered during lead introduction through the superior vena cava. At the end of the procedure spontaneous dislocation of the atrial lead occurred. The young doctor repositioned this lead into the free wall of the right atrium (RA). Optimal sensing, pacing, and impedance parameters for both leads were obtained. The day after operation, the patient reported unspecific pain in the upper abdominal region and later strong, intermittent, stabbing pain in the lower chest. These symptoms intensified during inspiration and while lying on left side. The patient negated dyspnoea. On auscultation, normal vesicular breath sounds were heard. Neither pericardial fluid nor signs of RV perforation were found in transthoracic echocardiography (TTE). In the telemetric pacemaker assessment an increased pacing threshold of atrial lead was noticed (from < 0.5 V/0.4 ms during pacemaker implantation to 4.5 V/1 ms in unipolar pacing and 3 V/1 ms in bipolar pacing); no changes in sensing or impedance parameters were found. However, due to the lack of exact assessment of the atrial lead tip positioning, it was impossible to definitively exclude RA perforation (Figure 1 A). The device was reprogrammed to bipolar stimulation, leading to a decrease in reported complaints. Figure 1 A – Echocardiographic study showing parts of the atrial and ventricular lead and no signs of pericardial fluid excess. B – Fluoroscopy after first implantation. C – Fluoroscopy after spontaneous dislocation of atrial lead. D – ... On the next day a lack of atrial lead capture by threshold > 7.5 V/1.5 ms was recorded. Fluoroscopy revealed dislocation of the atrial lead, which was extracted subsequently. New lead was implanted through subclavian vein puncture into the right atrial appendage, obtaining good parameters (Figures 1 B, C). Several hours after reoperation the patient reported resting dyspnoea. Chest radiograph revealed large right-sided pneumothorax (Figure 1 D), which was cured by suction drainage. There are two probable causes of contralateral pneumothorax in the reported case. The first is pleura injury during Seldinger set introduction. Taking into account potential small mediastinal bleeding size, the venous system (especially the extrapericardial part of the superior vena cava) puncture could be done by guidewire (part of the Seldinger set). The second is right atrium, pericardium, and pleura perforation by a primary implanted atrial lead that dislocated or was extracted with subsequent pneumothorax. Because of the lack of fluid excess signs in the pericardial sac (during both physical and radiological examination), the first hypothesis seems more likely. However, contralateral pleural puncture during subclavian vein cannulation cannot be excluded. Treatment by chest tube placement and/or pacing lead reposition or extraction in case of heart perforation seem to provide satisfactory results in most patients with contralateral pneumothorax after pacemaker implantation [1–4]. In some cases a new atrial lead (also epicardial) was implanted and/or atrial or pericardial repair was performed [1, 3].