Superior Epigastric Vein Research Articles

Mondor's Disease Superficial Thrombophlebitis of the Chest Wall: Case Report of a Rare Condition

Introduction: Superficial thrombophlebitis of the chest wall is referred to as Mondor's disease (MD). Other atypical locations such as abdominal, inguinal and penile regions have been described in the literature [1]. In the thoracic region, the veins mainly affected are the thoracoepigastric vein and the superior epigastric vein. Its incidence is low and it generally occurs in the middle-aged people [2]. It is a benign, self-limited lesion whose treatment is usually conservative. The resolution of the clinical picture in most cases occurs within 4 to 8 weeks [2, 5]. Clinical Case: A 41- year-old female patient, no personal pathologic history. She went to the doctor for medical consultation due to the presence of a lump in the right submammary region after thoracic trauma with a car seat belt in a traffic accident of 12 days of evolution. She reported pain and progressive increase of the lump size. Physical examination revealed the presence of a venous lump in the right chest and abdominal wall, 1 cm in diameter, solid, painful on palpation, extending from the right submammary region to the right side with a length of 13 cm. Based on the clinical and ultrasound study, a diagnosis of Mondor's disease was made. An initial conservative management was decided with the use of anti- inflammatory drugs, analgesics and clinical and ultrasound monitoring at 4 weeks. Conclusion: Mondor's disease is a clinical disease of infrequent occurrence; its diagnosis is based mainly on a detailed clinical history and can be complemented with color Doppler ultrasound. Being a self-limited disease, the treatment with the highest success rates is conservative, reserving surgery in cases of difficult pain treatment.

The position of ‘shunt restriction’ along an arterialized vein affects venous congestion and flap perfusion of an arterialized venous flap

Restriction of arteriovenous (AV) shunting has been shown to enhance peripheral perfusion and also reduce venous congestion of an arterialized venous flap. Thus, this study is designed to investigate the effect of 'shunt-restriction' location on venous congestion and flap perfusion in a 'shunt-restricted' arterialized venous flap (AVF). Abdominal flaps based on the thoracoepigastric vessels of Sprague-Dawley rats were raised. The inferior epigastric vein was repaired to the femoral artery in order to create an AVF. The superior epigastric vein was preserved for drainage. Microcirculation and laser Doppler flowmetry results were compared between AVFs with 'shunt restriction' at a proximal third (SR-proximal) distance and 'shunt restriction' at a distal third (SR-distal) distance. Bidirectional sluggish flow was detected at the proximal part of venous flaps in both groups. Unidirectional normal flow was observed in more capillaries of the distal flaps in the SR-proximal group. In the middle of the flaps, blood flow was sluggish and intermittent in the veins and was absent in most capillaries of the SR-distal group. The flow was prompt and unidirectional in more capillaries of the SR-proximal group. Using laser Doppler flowmetry, the average perfusion of the whole SR-proximal flaps was found to be higher than that of SR-distal flaps (p=0.017). The average flux at the middle and distal portions of the SR-proximal group was significantly higher than those of the SR-distal group (p=0.049). 'Shunt restriction' at the proximal third of the AV shunt resulted in enhanced perfusion and reduced venous congestion in an AVF.

CD4+ lymphocytes improve venous blood flow in experimental arteriovenous fistulae

The role of immune cells in arteriovenous fistulae (AVF) maturation is poorly understood and has received, until quite recently, little attention. This study examines the function of T lymphocytes in AVF vascular remodeling. Experimental fistulae were created in athymic rnu nude rats lacking mature T lymphocytes and euthymic control animals by anastomosing the left superior epigastric vein to the nearby femoral artery. Blood flow rates, wall morphology, and histologic changes were assessed in AVF 21 days after creation. The effect of CD4(+) lymphocytes on AVF maturation in athymic animals was analyzed by adoptive transfer of cells after fistula creation. The absence of T lymphocytes compromised blood flow in experimental fistulae. Histopathologic inspection of AVF from athymic rats revealed that T-cell immunodeficiency negatively affected venous vascular remodeling, as evidenced by a reduced lumen, a thick muscular layer, and a low number of inflammatory cells compared with control animals. Adoptive transfer of CD4(+) lymphocytes from euthymic rats into athymic animals after fistula creation improved blood flow and reduced intima-media thickness. These results point at the protective role of CD4(+) lymphocytes in the remodeling of the AVF vascular wall.

Comment to: Selective high ligation of the saphenofemoral junction decreases the neovascularization and the recurrent varicose veins in the operated groin by Mariani F, Mancini S, Bucalossi M, Allegra C. Int Angiol 2014 Jul 16 [Epub ahead of print

The classical radical high ligation (RHL) performed with the Babcock technique is defined as the traditional gold standard technique: superficial tributaries dissection, followed, when possible, back to the secondary branch points, division and ligation; GSV ligation flush to the junction. In the present study the authors analyze, as an alternative, the selective high ligation (SHL) of the Junction with 5/12 years follow-up. The rationale is that SFJ tributary veins coming from the abdominal wall have an important role in draining the venous flow to the deep veins or to the opposite vein network, particularly when the venous abdominal flow is modified for physiological condition (i.e. pregnancy) or external compression or obstruction (i.e. deep venous thrombosis) . In SHL the veins coming from the abdominal wall, as the superior epigastric vein (SEV) or the superior iliac circumflex vein (SICV), are spared, while the superior external pudendal vein (SEPV) and the others tributaries which have an acute angle with the saphenic axis or a T branch from the thigh, are carefully isolated and ligated with 2/0 or 3/0 non absorbable thread; the GSV is ligated and dissected flush the confluence of the spared tributary veins, usually about 1 cm from the SFJ, to maintain its drainage into the GSV stump. The study included a homogenous cohort of 360 patients (mean aged 51.9 years range 18 to 75 years - CEAP C2S Ep), that underwent unilateral varicose vein surgery from January 2001 to December 2008. The neovascularization and the recurrences in the groin were found in seven patients (1.9%) of the total cases: 3 patients were symptomatic, 4 asymptomatic. The recurrences were due to inadequate groin surgery: the anterior lateral thigh vein, the posterior medial thigh or a T branch of tributaries left, a GSV stump exceeding 1 cm. The GSV stumps and the spared tributaries were open to venous flow; no venous reflux in the groin at Valsalva in standing position was present; the compression ultrasonography of the GSV stump was negative in all the patients. During the past 10 years minimal invasive surgery or endovascular approaches with radiofrequency and endolaser ablation have developed. These techniques leave all or nearly all tributaries of the SFJ and the results in terms of recurrences from the saphenous stump seem to be better than the Babcock’s RHL. The selective high ligation is a reliable technique, decreasing the incidence of neovascularization and recurrent varicose veins in the operated groin.

Hemodynamic Effect of Different Kinds of Venous Augmentation in a Pig Transmidline Flap Model of DIEP Flap

Venous augmentation enhances the viability of the deep inferior epigastric perforator (DIEP) flap. We compared the efficacy of three venous superdrainage procedures on survival area and hemodynamics of the DIEP flap model. In 24 castrated Yorkshire pigs, a true abdominal perforator-based flap was created based on four perforators arising from the deep superior epigastric vessels. Three remaining venous tracts were alternated to represent different venous augmentations of the DIEP flap. Analyzed were flap perfusion, venous blood pressure, and venous blood gas. In control animals, all three supplemental veins were ligated; the ipsilateral superficial superior epigastric vein (SSEV) was retained in the IS (ipsilateral SSZV augmented) group, the contralateral SSEV in the CS (contralateral SSZV augmented) group and the contralateral deep superior epigastric vein (DSEV) in the CD (contralateral DSZV augmented) group. The flap was then returned to its bed, and animals sacrificed on the seventh day postoperatively. DIEP flap survival was then recorded. All four intraoperative parameters showed improved perfusion of the distal flap area under distal venous augmentation. Efficacy was CDSEV > CSSEV > ISSEV > none. Skin islands of the CD and CS groups survived completely. In the IS and control groups, 96.33 ± 3.16% and 84.00 ± 7.55% of skin islands survived, respectively. Test groups were statistically significantly different from the control group but not from each other. Venous superdrainage effectively enhances DIEP flap survival. Benefit was relatively the same for all procedures. An additional venous route should be preserved with large or multiterritory flaps to improve venous congestion.

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.

Transmidline Abdominal Skin Flap Model in Pig: Refinements and Advancements

Abdominal flaps have recently gained considerable popularity in breast reconstruction, and their importance and advantages have been widely accepted. Given the unreliability of the distal parts in these flaps and the advancement of microsurgery, many modifications and improvements have been made. To get a better understanding of these flaps, researchers have encouraged the search for a suitable flap model. The purpose of this study was to clarify the anatomical and physiological features of the transmidline abdominal flap model in pig. We included 16 white female Yorkshire pigs in this study. In six pigs, the vascular anatomy of the abdominal region was studied by multidetector row computed tomographic angiography and anatomic dissection. In the remaining 10 pigs, three kinds of transmidline abdominal flap models were established. The pigs were scanned on the abdominal flap to evaluate the perfusion zones after the true abdominal transmidline flap was created, and then they were sacrificed to determine the flap survival area 7 days after surgery. The results of the study were as follows. (1) The pig's deep inferior epigastric vessels were smaller than deep superior epigastric vessels both in length and diameters. (2) The deep superior epigastric artery always bifurcates into two groups; each group gives off five or six branches. (3) The superficial superior epigastric veins were present, while the superficial epigastric arteries were absent in all the animals included. (4) The linea alba abdominis was tough and lack of vascular structures. The average perfusion units were 197.0±24.2, 103.2±36.4, 138.8±25.4, and 30.2±11.8 from zone I to zone IV. All the flaps underwent partial necrosis. The flap survival area percentage was 85.9±4.1%. The transmidline abdominal skin flap in pig is a reliable and true abdominal flap model for future physiological studies, especially the circulatory dynamics in transmidline abdominal flaps.

Mondor disease: An unusual consideration in a young woman with a breast mass

Mondor disease is a variant of thrombophlebitis involving the thoracoepigastric lateral thoracic and/or superior epigastric veins. This entity was first described more than 100 years ago by Fagge but gained its eponym in 1939 when four cases of subcutaneous angiitis of the chest wall were described by the French surgeon Henry Mondor. All previous reports in the literature describe populations of adult women ranging in age from 21 to 66 years [with a mean of 43 years in one study and 33 years in another]. These reports generally suggest that Mondor disease is a self-limited condition with no increased risk of malignancy or other breast abnormality. However an association between Mondor disease and breast carcinoma has been suggested in a small number of older women. Mondor disease has not previously been described in the adolescent literature; however it is an important consideration in the evaluation of an adolescent with a breast mass or tenderness. (excerpt)

Paraumbilical venous collateral circulations: Color Doppler ultrasound features

Using Color Doppler ultrasonography to trace the dilated paraumbilical vein to its connection with systemic veins in 27 patients, we have found four major pathways: In type 1 (63%), the vein connected with the external iliac vein via the inferior epigastric vein. In type 2 (3.7%), the vein connected with the saphenous vein via the superficial epigastric vein. In type 3 (22.2%), the vein connected with the internal thoracic vein via the superior epigastric vein. Type 4 (11.1%) is a combination of types 1 and 2. A frank caput medusa was not seen, but occult caput medusae were seen in two patients. Turbulent flow was seen at the junction between inferior epigastric and external iliac veins, paraumbilical and superficial epigastric veins, and superficial epigastric and saphenous veins in some patients. Color Doppler ultrasonography is a convenient, noninvasive method for determining the course and associated hemodynamic changes in the paraumbilical collateral circulation. © 1996 John Wiley & Sons, Inc.

Paraumbilical venous collateral circulations: color Doppler ultrasound features.

Using Color Doppler ultrasonography to trace the dilated paraumbilical vein to its connection with systemic veins in 27 patients, we have found four major pathways: In type 1 (63%), the vein connected with the external iliac vein via the inferior epigastric vein. In type 2 (3.7%), the vein connected with the saphenous vein via the superficial epigastric vein. In type 3 (22.2%), the vein connected with the internal thoracic vein via the superior epigastric vein. Type 4 (11.1%) is a combination of types 1 and 2. A frank caput medusa was not seen, but occult caput medusa were seen in two patients. Turbulent flow was seen at the junction between inferior epigastric and external iliac veins, paraumbilical and superficial epigastric veins, and superficial epigastric and saphenous veins in some patients. Color Doppler ultrasonography is a convenient, noninvasive method for determining the course and associated hemodynamic changes in the paraumbilical collateral circulation.

An anatomic study of the venous drainage of the transverse rectus abdominis musculocutaneous flap.

The authors studied the venous drainage of the abdominal wall and its application to the transverse rectus abdominis musculocutaneous flap on 12 cadavers by injecting methylene blue and methyl methacrylate to follow the venous pathways. The nonvascular tissues of the specimens injected with methyl methacrylate were corroded away to show the three-dimensional arrangement of the vessels. We describe the veins of the anterior abdominal wall in relation to the transverse rectus abdominis musculocutaneous flap. The venous drainage of the transverse rectus abdominis musculocutaneous flap when used for breast reconstruction occurs from the cutaneous part of the flap to the inferior deep epigastric veins through vertical perforators that are mainly periumbilical. From there the flow is through the deep superior epigastric veins into the internal mammary vein. The deep inferior epigastric veins were found to have valves that prevent retrograde flow. In designing the flap, its safety is increased if it includes the periumbilical perforators. Thinning the flap should be done at the deep surface to preserve Scarpa's fascia and the superficial epigastric system.