Subclavius Research Articles

Midclavicle block: An anatomical study.

Recent studies indicate that clavipectoral fascia plane block (CPB) efficacy may stem from injectate distribution to the anterosuperior clavicular periosteum. We conducted an anatomical study combining the CPB with injection within the subclavius muscle. Our hypothesis was that the anaesthetic injectate would fully cover both the anterosuperior and posteroinferior surfaces of the clavicular periosteum in the midclavicular region. Observational human cadaver study. Laboratory of Surgical Neuroanatomy, Unit of Anatomy and Human Embryology of the Faculty of Medicine and Health Sciences, University of Barcelona. Five fresh human cadavers. The cadavers received both a CPB and subclavius muscle injections under ultrasound guidance in 10 clavicular regions. After the procedures on the cadaveric models, an anatomical dissection by planes was performed to evaluate the distribution pattern of methylene blue on the clavicular periosteum. A probabilistic map of the colour spectrum and staining temperature on the clavicular surfaces was generated. Methylene blue stained 37 ± 16% of the anterosuperior surface and 23 ± 13% of the posteroinferior surface of the clavicular periosteum, particularly in the middle third of each surface. Although the staining did not achieve complete circumferential coverage or perfect alignment between the surfaces, the areas exhibited a close relationship, indicating significant distribution and relevant coverage. Our anatomical study demonstrates that the midclavicular block achieves effective distribution around the middle third of the clavicle, although complete circumferential anaesthesia of the clavicular periosteum was not achieved. Although this block may provide periosteal and bone anaesthesia, it does not address other sources of pain, such as muscle spasms and skin components. Additional clinical studies are needed to evaluate the overall efficacy of this dual block technique for clavicle surgery.

Rib-sparing subclavian vein decompression in venous thoracic outlet syndrome

ObjectiveVenous thoracic outlet syndrome (VTOS), a compression syndrome of the subclavian vein at the costoclavicular junction, is commonly treated with first rib resection. This invasive procedure carries a risk of serious complications. The purpose of this single-center cross-sectional study was to evaluate the long-term outcome of non-bony decompression by resection of the subclavius muscle and tendon and to provide a detailed description of the procedure. MethodsPatients who underwent rib-sparing decompression for VTOS between July 2014 and September 2023 were analyzed using clinical and radiological examinations. Patient-reported measures were used to assess functional disability and residual symptoms (DASH) and disease-specific quality of life and symptoms (VEINES-QOL/SYM). ResultsTen patients were included in the study. Seven were treated for Paget-Schroetter syndrome and 3 for McCleery syndrome. At mean follow up of 45.4 (SD 31.0) months, all patients reported significant resolution of initial symptoms with patent vasculature on Doppler ultrasonography. All patients had a Villalta PTS score <4, indicating the absence of post-thrombotic syndrome. A mean DASH score of 3.8 (SD 5.3) indicated minimal functional disability. Patients reported minimal overall impact on their quality of life as reflected by the mean VEINES-QOL score of 92.6 (SD 8.9) and low severity of venous symptoms as indicated by the mean VEINES-SYM score of 92.7 (SD 9.8). ConclusionOur analysis suggests that non-bony decompression with resection of the subclavius muscle and tendon is a safe and effective intervention for definitive treatment of VTOS that is less invasive than first rib resection.

Innervation of the human sternoclavicular joint.

The sternoclavicular joint (SCJ) functions as the basal joint of the entire upper limb and must move in the proper pattern for normal scapular motion. Afferent sensations from joints, such as proprioception and pain sensation, are important for maintaining the proper motion and condition of joints. Detailed anatomical data are useful for discussing injuries or surgeries that impair the afferent nerve to the SCJ. Nerve branches to SCJs were examined on 12 sides, and the subclavian nerve was investigated on six sides to clarify whether it innervates this joint. On seven of the 12 sides, the SCJ was innervated by two nerves, (1) a branch from the medial supraclavicular nerve that ran medially along the clavicle and (2) a branch from the lateral pectoral nerve that innervated the clavicular head and upper part of the sternocostal head of the pectoralis major. This branch ran medially behind the clavicular head of the pectoralis major and reached the SCJ. In the remaining five sides, the SCJ was innervated solely by the branch from the medial supraclavicular nerve. Subclavian nerves ended within the subclavius muscle or periosteum of the clavicle and were separate from the SCJs. Our data on the route of nerve branches to the SCJ suggest that injury or surgery, such as clavicle fracture or resection of the clavicular head of the pectoralis major for myocutaneous flap transfer, can impair the SCJ's afferent nerve supply.

408 Nerve to Subclavius for Neurotization Procedures: An Anatomical Feasibility Study

INTRODUCTION: Injuries to the inferior trunk (IT) of the brachial plexus and its components can be debilitating. As such injuries are prioritized by surgeons during repair, an additional nerve transfer is considered. METHODS: 13 adult cadavers (26 sides) underwent dissection of the nerve to subclavius and proximal brachial plexus. Once the nerve was isolated from origin to termination, the C8 and T1 roots and IT were identified. The distal end of the nerve to subclavius was transected and swung to these roots and the IT. Once the nerves to subclavius were transposed and in a tension-free manner, the length of excess nerve following being brought to each of these nerves was measured. RESULTS: A nerve to subclavius originated from the superior trunk and traveled anterior to the middle and inferior trunks on all sides. The mean diameter of the nerve to subclavius was 0.8 mm and the mean length was 57 mm. After cutting the nerve to subclavius at its entrance into the subclavius muscle, the distal nerve could be transferred tension free to the IT of the brachial plexus and T1 ventral ramus on all sides. The distal nerve to subclavius reached the T1 ventral ramus with an average of 18 mm of additional length and to the C8 ventral ramus with an average of 19 mm. The nerve also could be transferred to the IT of the brachial plexus with an average of 20 mm of additional length. The nerve to subclavius was found to have approximately 3,000 axons. CONCLUSIONS: To our knowledge, use of the nerve to subclavius has previously not been used for nerve transfer procedures. Based on our cadaveric study, this often-overlooked nerve can be easily transposed to other regional nerves such as the IT of the brachial plexus.

Anatomical variation of the median nerve and accompanying subclavius posticus muscle: a cadaveric case report

The median nerve and subclavius muscle are two critical neuromuscular structures of the upper extremity. Although their anatomical variations are well described in the literature, a case report involving both anatomical variations in the same extremity is rare. Here, we report a case involving different anatomical variations in the median nerve formation and aberrant subclavius posticus muscle. During routine dissection, a rare anatomical variation was encountered in the left upper extremity of an adult male cadaver. In this case report, we observed two distinct findings in the left upper extremity of a 66-year-old male cadaver: a variant basilic vein passing between the lateral and medial roots of the median nerve and the presence of the subclavius posticus muscle. To our knowledge, a case involving an unusual basilic vein passing between the lateral and medial roots of the median nerve and an aberrant subclavian posticus muscle in the same extremity has not been reported to date. Knowledge of such variations may be useful for surgeons in avoiding iatrogenic injuries during anaesthetic and surgical procedures around the axilla and arm.

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.

A rare variation of omohyoid and its embryological correlations- A case report

The omohyoid muscle is important in radical neck dissection, as it is a landmark for this operation. Because it divides the anterior and posterior cervical triangles into smaller triangles and its particular relationship to the large cervical vessels, the presence of an anatomical variation of the omohyoid muscle is important. Either belly may be absent or double; and the inferior belly may be attached directly to the clavicle and the superior is sometimes fused with sternohyoid. Variations in the omohyoid muscle might be linked to differences in embryological development, which could influence the muscle’s final form and function. Anderson (Anderson, 1881) theorized that the superior belly of the omohyoid muscle is a true infrahyoid muscle, whereas the inferior belly most likely shares a common embryology with the subclavius muscle. As omohyoid mucle is used to achieve the reconstruction of the laryngeal muscles and bowed vocal folds, the knowledge of the possible anomalies of the omohyoid muscle is important.In the present study, we have found a case with two inferior bellies &amp; aberrant course of superior belly of omohyoid on right side of 40 years female cadaver embalmed with formalin during routine dissection at Department of Anatomy AIIMS Gorakhpur.Omohyoid muscle is closely related to large vessels of neck &amp; brachial plexus, so variations in this muscle are clinically important.

Hypertrophy of the Subclavius Muscle in Conjunction With Atrophy of the Pectoralis Muscles Postmastectomy: A Cadaveric Case Study

BACKGROUND: Musculoskeletal impairments of the upper extremity following mastectomy are well documented, although the cause of these impairments is not always known. CASE PRESENTATION: Asymmetry of the shoulder girdle musculature was found during anterior chest wall dissection of a female cadaver with a history of a left mastectomy at the age of 45 years (age at death: 96 years). The left pectoralis major and minor muscles were markedly smaller than the contralateral pectoralis muscles, whereas the converse was apparent for the subclavius muscles. OUTCOME AND FOLLOW-UP: In situ measurements of the depth of the bellies of the subclavius muscles demonstrated that the left subclavius depth was nearly twice that of the right on the initial donor. Measurements of the length and wet weight of the muscles confirmed both the increased size and mass of the left subclavius. Further research on an additional 21 pairs of subclavius included 2 additional donors with a mastectomy. When pooled with the original donor's data, the combined 3 subclavius pairs following mastectomy showed a statistical difference in mass (a1 = .05, P = .0354) and width (a1 = .05, P = .0014). DISCUSSION: The pattern of atrophy of the pectoralis muscles in our primary case suggests that the medial pectoral nerve was damaged during surgery or during postoperative treatment. How this led to the apparent hypertrophy of the left subclavius muscle is unclear. It is possible that because of the atrophy and associated weakness of the left pectoralis muscles, the left subclavius muscle took on a greater role in shoulder girdle stabilization, increasing in size and mass over time. JOSPT Cases 2023;3(2):127–133. Epub: 13 March 2023. doi:10.2519/josptcases.2023.11561

Neurogenic Thoracic Outlet Syndrome Induced by Subclavius Muscle Hypertrophy: A Case Report

Neurogenic thoracic outlet syndrome (NTOS) is a complex disorder characterized by compression of the brachial plexus, resulting in pain, weakness, and sensory changes in the upper extremity. Traditional surgical treatments, such as first rib resection or anterior scalene muscle resection, can be invasive and associated with significant morbidity. We present a unique case of a patient diagnosed with NTOS who underwent a preoperative magnetic resonance imaging with the shoulder in an abduction position to identify the cause of NTOS. A minimally invasive subclavius muscle resection was subsequently performed, resulting in a dramatic reduction in pain and significant improvement in motor symptoms. This less invasive approach led to a quicker recovery time and reduced morbidity compared to traditional surgical methods. This case report suggests that before surgery, thoroughly investigating the causes of NTOS and selectively performing decompression only on the structures requiring intervention could also be considered a viable treatment option.

Prevalence and anatomy of the anomalous subclavius posticus muscle and its clinical implications with emphasis in neurogenic thoracic outlet syndrome: Scoping review and meta-analysis

BackgroundThe subclavius muscle runs underneath the clavicle. However, there have been a few reports of a duplicated subclavius muscle which is commonly referred to as subclavius posticus muscle due to its orientation being posterior to the proper subclavius muscle. Its occurrence seems to potentially create a narrowing interval at the superior thoracic aperture as it crosses over the brachial plexus. It might also have functional influence on the shoulder girdle. PurposeTo provide comprehensive gross anatomy description of the variant “subclavius posticus muscle” and to investigate its reported clinical implications with emphasis on its involvement in causing brachial plexus compression. Basic proceduresA scoping review with meta-analysis of the gross anatomy of the subclavius posticus muscle was conducted along with investigating its correlation to the thoracic outlet syndrome. Forty-seven articles were pooled through two rounds of the selection process. The relevant information was extracted and meta-analyzed. Main findingsThe scoping review and meta-analysis of the 47 articles revealed a total prevalence of 11/2069 (4.9%); 10/1369 (5.1%) in cadaveric studies, and 1/700 (5.0%) in MRI studies. The subclavius posticus muscle is a short triangular muscle with an average length of 12 cm and an average width of 1 cm. It originates from the sternal end of the first rib in most cases with reported variants of one case originating from the costoclavicular ligament and one case where it was fused with the proper subclavius muscle. Its insertion is more variable: on the superior border of the scapula with variable length in 71.35%, on the coracoid process of the scapula in 25.42%, and on the clavicle in 0.90%. The subclavian nerve seems to be the dominant nerve supply with a 57.6% prevalence, while 25.8% are innervated by the suprascapular nerve. Other reported nerves were the nerve to the myolohyoid (4.5%), accessory phrenic nerve (4.5%), and a direct branch from the brachial plexus (2.0%). The blood supply was reported (only once) to be from the suprascapular artery. However, the venous drainage was not established at all. Principal conclusionsThe subclavius posticus muscle is a variant muscle occurring with a reported overall prevalence of 4.9%. It can compress the brachial plexus as it runs across at the space of the superior thoracic aperture with exquisite contact, and this can lead to a neurogenic thoracic outlet syndrome. It also can be involved in the vascular thoracic outlet syndrome. Lastly, it is important not to omit its potential influence in shoulder joint instability to some extent.

Excellent results seen with both transaxillary and infraclavicular approaches to first rib resection in patients with subclavian vein thrombosis

BackgroundVenous thoracic outlet syndrome (VTOS) is a debilitating condition with several well-documented treatment paradigms. We reviewed the outcomes from a large academic institution of patients who had undergone transaxillary first rib resection with delayed venography (TA) or infraclavicular first rib and subclavius muscle resection with concomitant venography (ICV) for VTOS with subclavian vein thrombosis. MethodsWe performed a retrospective review of the medical records of all patients who had undergone first rib resection and scalenectomy for VTOS with subclavian vein thrombosis at a single academic institution. The demographics, presentation, operative records, and outcomes were collected. Descriptive statistics were used to compare the two groups. ResultsA total of 73 patients had undergone first rib resection for VTOS during the study period. Of the 73 patients, 36 (49%) had presented with thrombosis of the subclavian vein and were included in the present review. Of the 36 patients, 26 (72%) had undergone TA and 10 (28%) had undergone ICV. No significant differences were seen between the two groups in female gender (54% vs 50%; P = 1.00) or age (28.7 years vs 29.5 years; P = .88). A higher percentage of the ICV group had undergone preoperative thrombolysis (70% vs 27%; P = .02). All the patients in the ICV group had undergone intraoperative balloon venoplasty at resection. The mean time from thrombosis to resection was 2.3 months. All of the TA group had undergone venography at 2 weeks postoperatively. Venography had revealed 15 stenotic veins requiring venoplasty, 8 widely patent veins, 1 acutely thrombosed vein, and 3 chronically occluded veins. The time from initial thrombosis to surgical intervention was 10 months for the patent group, 6 months for the stenotic group, and 4 months for the occluded group. In the TA group, 19% of the patients had required chest tube placement intraoperatively for pneumothorax. In the ICV group, complications included postoperative hematoma (n = 1), wound infection (n = 1), and hemothorax (n = 1). The mean length of stay was 1.04 days for the TA group and 2.00 days for the ICV group (P < .0001). The mean follow-up was 10.4 months and 15.8 months for the TA and ICV groups, respectively. No mortalities were reported. No differences in the vein patency rates were seen between the two groups at follow-up (TA, 93%; vs ICV, 100%; P = 1.00). All the patients were asymptomatic at follow-up. ConclusionsThe outcomes for the patients who had undergone TA or ICV for subclavian vein thrombosis were excellent with no mortality and few complications. The subclavian vein patency rates were high, and all the patients were asymptomatic at follow-up.

The relationship between the subclavian vessels and brachial plexus and the overlying clavicle: Anatomical study with application to plate osteosynthesis.

A subclavian artery aneurysm after clavicle fracture and plate osteosynthesis in a suspected case of a screw that was too long led us to investigate body donor cadavers. The aim was to verify clavicle variability, and the course of the neurovascular bundle in relation to the clavicle and to the osteosynthesis plate, in order to clarify safe zones for plate and screw fixation. We used one fresh frozen and 25 embalmed donors for in situ measurements: (1) length and craniocaudal thickness of the clavicle, (2) distances between the sternal end of the clavicle and the center of parts of the neurovascular bundle. The clavicle was 15.15cm long. The mean distances from the sternal end of the clavicle were 5.62 cm to the subclavian vein, 6.75 cm to the subclavian artery and 8.42 cm to the cords of the brachial plexus. The subclavius muscle was 1cm thick. Because of sex differences in length and distances, we recorded the distances between the sternal end and parts of the neurovascular bundle as ratios of clavicle length (at-risk area) to provide sex-independent parameters: 0.379 for the vein, 0.449 for the artery and 0.554 for the nerve. The neurovascular bundle runs below the clavicle between the medial fourth and three fifths of clavicle length. To avoid iatrogenic neurovascular injuries, special caution is necessary during drilling and screwing the osteosynthesis. We also recommend using screws shorter than 1.4cm.

Subclavian Effort Thrombosis: Pathophysiology, Diagnosis, and Management.

Subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome or venous thoracic outlet syndrome, is an uncommon condition that affects individuals with an irregularly narrow thoracic outlet who engage in repetitive overhead motions of the affected arm. Venous injury arises from microtraumas that occur from the repetitive compression of the SCV between the first rib and the overlying clavicle. Additional sources of extrinsic compression can be due to the anterior scalene muscle, subclavius muscle, and costoclavicular ligament. SCV effort thrombosis is a distinct entity from other forms of deep venous thrombosis and requires unique diagnostic and treatment considerations. Early catheter-directed therapy in the form of pharmacomechanical or catheter-directed thrombolysis combined with prompt surgical thoracic outlet decompression offers patients the best chances for early and durable symptom relief.

Pre-injection technique to identify neural elements in the costoclavicular space for brachial plexus block: Where and what to inject?

Sir, We read with interest the captioned letter “Use of a pre-injection technique to identify neural elements in the costoclavicular space for brachial plexus block for upper limb orthopaedic surgery”.[1] We appreciate the authors’ idea of a pre-injection technique to identify the neural elements in the costoclavicular space (CCS), but have few suggestions. The authors have chosen the supraclavicular fossa as their pre-injection site and administered 3 ml of local anaesthetic (LA) with the assumption that it would reach the CCS. However, one should keep in mind that even a small LA volume of 5 ml at the supraclavicular fossa may be associated with hemidiaphragmatic paralysis (HDP).[2] Therefore, we rather recommend a hydro-dissection technique using 0.9% saline at the CCS. In this method, as the needle passes the subclavius muscle and approaches the brachial plexus sheath (paraneural sheath),[3] small aliquots of 1-2 ml of 0.9% saline will be injected [Figure 1a] to appreciate if the injection is intramuscular or just outside the epimysium of the subclavius muscle/paraneural sheath. Once confirmed, the block needle is gently advanced into the paraneural sheath between the lateral and posterior cords [Figure 1b] and a second injection of saline will now separate the tightly clustered cords. This helps to delineate the neural components.Figure 1: (a) Schematic diagram demonstrating hydro-dissection technique with needle tip just outside the subclavius muscle and the brachial plexus sheath at the costoclavicular space (CCS); (b) Schematic diagram demonstrating block needle inside the brachial plexus sheath at the gap/fissure between the lateral and posterior cord of the brachial plexus sheath at the CCS. AA: Axillary artery (1st part); AV: Axillary vein; LC: Lateral cord; MC: Medial cord; PC: Posterior cord; Blue coloured arrows demonstrating the brachial plexus or paraneural sheath around the cords of the brachial plexus at the CCS. Black star (*) demonstrating the gap/fissure between the lateral and posterior cord of the brachial plexus after the saline hydro-dissection techniqueThis hydro-dissection technique is simple, effective, carries no additional risks for HDP and does not require two separate injections. Hence, we recommend it over the pre-injection technique described by the authors at the supraclavicular fossa for identifying the neural elements in the CCS. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The anatomy and variation of the coracoid attachment of the subclavius muscle in humans.

The functions of the subclavius muscle (SM) are described as stabilization of the sternoclavicular joint (SCJ) and resisting elevation of the lateral end of the clavicle. During systematic cadaveric dissections, we observed additional fibrous structures, previously described as variants of the anatomy, extending from the SM and inserting into the coracoid process (CP). Due to the high incidence of these structures in our dissections, we hypothesized that the attachment at the CP is more common than appreciated and that, as a corollary, the function of the SM was (or has been) more complex than simply depressing the clavicle and generating stability at the SCJ. For our investigation, fifty‐two upper extremities of 26 human cadavers were dissected. The SM was demonstrated from costal to clavicular attachment. We documented additional fibrous structures apparently derived from the SM inserting into the CP. Measurements of the length of the SM, the length of its attachment, and the length of the clavicle were taken in situ, with the specimens supine and the upper extremity in the anatomical position. Variations in the anatomy of the SM and its coracoidal attachment were recorded, and potential correlations were investigated. For documentation purposes photographs and video sequences of passive motion of the shoulder girdle of the specimens were taken. In 49 of the 52 specimens we found additional fibrous structures passing from the SM to the CP. We differentiated three types: (1) a strong cord‐like structure; (2) a small or thin cord‐like structure or structures; and (3) a planar twisted sheet‐like structure. The SM and its extension to the CP appears to contribute to a ‘functional scapular suspension system’ together with the other muscles enveloped by the clavipectoral fascia (pectoralis minor, coracobrachialis and the short head of the biceps brachii). This system assists in the control of the position of the scapula in relation to the thorax, particularly in elevated positions of the upper extremity. We speculate that the differentiation of the fibrous structure depends on the functional demands of the individual. Level of Evidence: Basic science study.

Botulinum Toxin Treatment for Thoracic Outlet Syndrome Induced by Subclavius Muscle Hypertrophy

Thoracic outlet syndrome (TOS) is frequently caused by bone abnormalities and congenital or acquired soft-tissue alterations. Among these, isolated Subclavius Muscle (SM) hypertrophy represents a rare condition that could lead to a reduction in costoclavicular space and brachial plexus compression. A 47-year-old forest ranger with a history of gun shooting during animal hunting and training sessions of skeet shooting for 20 years developed TOS due to ultrasonography-detected isolated SM hypertrophy, successfully treated with an ultrasound-guided Botulinum Toxin (BTX)-A injection. In our patient, ultrasonography of the brachial plexus has allowed SM hypertrophy to be recognized and to perform BTX-A injection just in the muscle, with a complete resolution of the symptoms.

Is Routine Postoperative Anticoagulation Necessary in All Patients after First Rib Resection for Paget-Schroetter Syndrome?

Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n=50) and late (n=75) periods. Mean patient age was 28.4 (12-64years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.

Delayed Subclavian Vein Stenosis without Thrombosis Following Clavicle Fracture

Subclavian vein injuries occasionally occur as a sequela of penetrating trauma or vascular access, but have rarely been reported to occur after clavicle fracture. The subclavian vessels are mainly enclosed by the subclavius muscle, the first rib, and the costocoracoid ligament. Therefore, in such cases, subclavian vein injury is rare because of the strcutures surrounding the subclavian vessels. Nevertheless, subclavian vein injuries occasionally show thrombotic manifestations, and thrombosis of the upper limbs constitutes 1-4% of cases of total deep vein thrombosis. Furthermore, to the best of the authors’ knowledge, although vessel injuries have been reported after clavicle or rib fractures and nerve injuries to regions such as the brachial plexus, no case involving delayed presentation of isolated subclavian vein stenosis after clavicle fracture due to blunt trauma has yet been reported.

Variations of the Subclavius Muscle: a preliminary study

Variations of the Subclavius Muscle: a preliminary study

The Anatomy and Variation of the Subclavius Muscle, its Coracoid Attachment, and Relation to the Clavi-coraco-axillary Aponeurosis

The Anatomy and Variation of the Subclavius Muscle, its Coracoid Attachment, and Relation to the Clavi-coraco-axillary Aponeurosis