Venous Drainage Research Articles

Microsurgical resection of a ruptured intraventricular arteriovenous malformation in a neonate: considerations in management. Illustrative case.

Arteriovenous malformations (AVMs) are the most common cause of intracranial hemorrhage in children, although they are rarer in neonates. Age, location, lesion architecture, and rupture status define treatment options. Sparse literature exists to guide the management of clinically symptomatic intraventricular AVM rupture in neonates. We highlight the case of a neonate with a ruptured intraventricular AVM to showcase considerations in treatment, discuss surgical technique, and help guide management. An 18-day-old female presented with lethargy in extremis and was found to have new intraventricular hemorrhage. Angiogram revealed a Spetzler-Martin grade 2 AVM with a right posterior choroidal feeder and deep venous drainage within the ventricle. Her age limited radiosurgical and endovascular interventions. She underwent an interhemispheric, transcollosal, intraventricular approach for complete AVM resection. Perioperative care was managed by a multidisciplinary team, successfully mitigating the patient's high risk of hemovascular collapse. Stereotactic radiosurgery, endovascular embolization, and microsurgery are options for AVM obliteration, and multimodal therapy must be tailored to the lesion and patient. Conservative management can also be considered. Each intervention carries risks and varying likelihoods of success. Balancing these outcomes is challenging without definitive, high-quality, evidence-based guidance. The best treatment maximizes the chance of AVM obliteration while minimizing morbidity.

Lung recovery utilizing thoracoabdominal normothermic regional perfusion during donation after circulatory death: The Colorado experience

ObjectiveDonation after circulatory death (DCD) procurement and transplantation after thoracoabdominal normothermic regional perfusion (TA-NRP) remains a novel technique to improve cardiac and hepatic allograft preservation but may be complicated by lung allograft pulmonary edema. We present a single-center series on early implementation of a lung-protective protocol with strategies to mitigate posttransplant pulmonary edema in DCD lung allografts after TA-NRP procurement. MethodsData from all lung transplantations performed using a TA-NRP procurement strategy from October 2022 to April 2023 are presented. Donor management consisted of key factors to reduce lung allograft pulmonary edema: aggressive predonation and early posttransplant diuresis, complete venous drainage at TA-NRP initiation, and early pulmonary artery venting upon initiation of systemic perfusion. Donor and recipient characteristics, procurement characteristics such as TA-NRP intervals, and 30-day postoperative outcomes were assessed. ResultsDuring the study period, 8 lung transplants were performed utilizing TA-NRP procurement from DCD donors. Donor ages ranged from 16 to 39 years and extubation time to declaration of death ranged from 10 to 90 minutes. Time from declaration to TA-NRP initiation was 7 to 17 minutes with TA-NRP perfusion times of 49 to 111 minutes. Median left and right allograft warm ischemia times were 55.5 minutes (interquartile range, 46.5-67.5 minutes) and 41.0 minutes (interquartile range, 39.0-53.0 minutes, respectively, with 2 recipients supported with cardiopulmonary bypass or venoarterial extracorporeal membrane oxygenation during implantation. No postoperative extracorporeal membrane oxygenation was required. There were no pulmonary-related deaths; however, 1 patient died from complications of severe necrotizing pancreatitis with a normal functioning allograft. All patients were extubated within 24 hours. Index intensive care unit length of stay ranged from 3 to 11 days with a hospital length of stay of 13 to 37 days. ConclusionsDespite concern regarding quality of DCD lung allografts recovered using the TA-NRP technique, we report initial success using this procurement method. Implementation of strategies to mitigate pulmonary edema can result in acceptable outcomes following lung transplantation. Demonstration of short- and long-term safety and efficacy of this technique will become increasingly important as the use of TA-NRP for thoracic and abdominal allografts in DCD donors expands.

FRI196 Non-Hemorrhagic Adrenal Infarction in Pregnancy with Tuberous Sclerosis

Abstract Disclosure: A. Mahaldar: None. H. Al Jumaili: None. S.R. Campbell: None. M.Z. Baker: None. Background: Non hemorrhagic adrenal infarction is a rare diagnosis in pregnancy with less than 20 cases reported in literature so far. No cases have been reported in patients with tuberous sclerosis. Most patients present with abdominal pain. Clinical Case: 29 year old woman G2P1 presented at 35 weeks gestation with right upper quadrant pain. She reported two episodes of dizziness in first trimester but otherwise had an uneventful pregnancy prior to presentation. First pregnancy was uncomplicated. Past medical history included asymptomatic tuberous sclerosis. No previous history of blood clots. Physical examination revealed a distended abdomen appropriate for gestational age and right upper quadrant tenderness to palpation. Initial laboratory data was unremarkable except for leukocytosis with WBC 16.6 k/mm3 (4-11 k/mm3). Normal electrolytes and liver function tests. Abdominal ultrasound revealed cholelithiasis without evidence of acute cholecystitis and unremarkable renal findings. CT abdomen pelvis with contrast showed thickening with surrounding stranding of right adrenal gland suggesting acute adrenal infarction and multiple pancreatic cysts. 8 am cortisol was 4.9 mcg/dl (4.1-16.6 mcg/dl) and ACTH was 23 pg/ml (7.2-63.3 pg/ml). Patient had received 2 doses of betamethasone due to concern for preterm delivery at 48 hours and 36 hours prior to this blood draw. Hypercoagulable panel was sent prior to starting enoxaparin. Elevated Factor VIII >150% (50 to 150%) was noted as expected in pregnancy. Lupus anticoagulant was weakly positive with LA sensitive PTT 50.1 (0 to 51.9 sec). Anticardiolipin antibody and beta 2 glycoprotein antibody were normal. Patient was treated with hydrocortisone 15 mg by mouth daily and full dose enoxaparin for anticoagulation. At one month follow up 8 am cortisol was 24 mcg/dl. Hydrocortisone replacement was discontinued. Labor was uncomplicated with vaginal delivery at 38 weeks gestation. Day 1 postpartum at 7:30 AM cortisol was 20.94 mcg/dl. Patient was discharged home in a stable condition with continued anticoagulation with enoxaparin and no further hydrocortisone treatment. Conclusion: We present a case of non hemorrhagic adrenal infarction in a pregnant patient with tuberous sclerosis. Adrenal infarction without hemorrhage is rare. Anatomy of adrenal gland makes it prone to microvascular thrombosis and infarction in a thrombotic state because of single draining vein for venous drainage. Pregnancy as a hypercoagulable state has been previously associated with non hemorrhagic adrenal infarction in few case reports. Whether tuberous sclerosis played any role in our patient’s pathogenesis remains unclear as there are no data or case reports linking the two. In conclusion, the diagnosis of non hemorrhagic adrenal infarction needs to be considered in hypercoagulable or pregnant patients presenting with abdominal pain. Presentation: Friday, June 16, 2023

Comparison of central venous catheter thoracic drainage and traditional closed thoracic drainage following minimally invasive surgery for esophageal carcinoma: a retrospective analysis

ObjectiveTo compare the effectiveness and safety of central venous catheter thoracic drainage (CVCTD) with traditional closed thoracic drainage (TCTD) after minimally invasive surgery for esophageal cancer.MethodsWe conducted a retrospective investigation of 103 patients who underwent minimally invasive esophageal cancer surgery at our institution between January 2017 and December 2019. Among them, 44 patients underwent CVCTD, while 59 received TCTD. We compared the following outcomes between the two cohorts: drainage volume, duration of drainage, postoperative complications (including pleural effusion, pulmonary infection, atelectasis, anastomotic leakage, etc.), length of hospital stay, and postoperative pain assessment.ResultsNo significant differences were observed between the experimental and control groups regarding postoperative thoracic drainage, the timing of postoperative tube removal, or postoperative complications. However, significant disparities were noted in the duration of postoperative hospitalization, drainage tube healing time, and pain threshold among the esophageal cancer patients in both cohorts (p < 0.05).ConclusionCVCTD is a secure and potent alternative to TCTD following minimally invasive surgery for esophageal carcinoma. It potentially contributes to reducing the incidence of postoperative complications while curtailing the duration of hospitalization. Additional research is warranted to substantiate these findings.

Monitoring the cerebral venous drainage in space missions: the Drain Brain experiments of the Italian Space Agency

It is well known that the space environment induces major alterations to various human physiological systems, determining a general deconditioning of the body. Medical research programs aim to keep the astronaut’s health status during the mission, enable their ready operation once they arrive at their destination, and allow their safe recovery when returned to Earth. Among the programs coordinated and supported by the Italian Space Agency (ASI), the experiments called Drain Brain, performed by the University of Ferrara, are particularly relevant in this respect. The project, which began with the collaboration of Samantha Cristoforetti in 2014, has demonstrated the capability of a plethysmograph system to study the cerebral circulation and the venous return from the brain to the heart, onboard the International Space Station (ISS). Demonstrating the progressive reduction of the cross-sectional area of the internal jugular vein, particularly significant between pre-flight data collection and the last assessment after 6 months of flight on the ISS (p&lt;0.001). Over the next two years, thanks to the Drain Brain 2.0 project, crews of the International Space Station will be studied with a new version of the plethysmograph, synchronized with the electrocardiogram, to assess cardiac efficiency and brain drainage in relation to symptoms such as blurred vision, numbness, or the feared onset of jugular thrombosis, that is linked to blood flow slowdown due to the absence of the gravitational gradient. Drain Brain 2.0 will also generate important returns to Earth, closing the virtuous circle of terrestrial application of space research.

Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

Traumatic middle meningeal arteriovenous fistula presenting with long delayed-onset facial nerve palsy without temporal bone fracture: illustrative case.

Traumatic facial nerve palsy (FNP) without temporal bone fracture (TBF) has a delayed onset in some cases; however, long delayed-onset FNP in this setting has not been reported. The middle meningeal vein (MMV) is one of the venous drainage routes from the facial nerve. Herein, the authors describe a rare case of traumatic middle meningeal arteriovenous fistula (MMAVF) presenting with the long delayed-onset FNP without TBF. A 42-year-old man with pulsatile tinnitus and left FNP was admitted to our hospital 4 weeks after head trauma without TBF. Cerebral angiography revealed an MMAVF between the middle meningeal artery and the MMV on the left side. Seven days after admission, the FNP showed slight improvement, and preoperative angiography revealed decreased shunt flow of the MMAVF. Transarterial coil embolization was successfully performed. Postoperative angiography showed no residual fistula. Two weeks after the procedure, there was complete resolution of the FNP. This clinical course was correlated with the angiographic findings, suggesting that the long delayed-onset FNP was caused by the traumatic MMAVF without TBF. In patients presenting with long delayed-onset FNP after head trauma without TBF, the vascular lesion must be evaluated to exclude MMAVF.

Recurrence of arteriovenous malformation in an adult patient after complete resection: illustrative case.

Complete resection of an arteriovenous malformation (AVM) is considered a curative treatment. In this paper the authors discuss two possibilities in the event of hemorrhage after satisfactory resection of an AVM: recurrence or remnant. A 33-year-old female patient was diagnosed with an incidental right frontal AVM that was microsurgically resected and whose postoperative angiography showed no remnant. Eight years later, she presented with an episode of headache and speech arrest. Magnetic resonance imaging showed bleeding in the previous surgical site, and a new angiography revealed the presence of a vascular blush not seen previously. The patient did not show the most frequently associated factors for recurrence described in the literature, which are hemorrhage on presentation and deep venous drainage. In addition, factors related to undetected vascular remnants, such as preoperative hemorrhage and early postoperative angiography, were absent. Considering the characteristics of the case, we believe that the most likely explanation is the development of a de novo vascular formation secondary to factors not yet elucidated. Preexisting views on AVM formation, the curative value of resection, and long-term follow-up in certain patients should be reevaluated.

Standardized Methodology for Duplex Ultrasound Examination of Arteriovenous Access for Hemodialysis: A Proposal of the French Society of Vascular Medicine and the French-Speaking Society of Vascular Access.

Duplex ultrasound (DUS) is an essential tool for characterizing and monitoring arteriovenous (AV) access for hemodialysis. The aim of the work described here, requested by the French Society of Vascular Medicine in collaboration with the French-Speaking Vascular Access Society, is to propose a standardized methodology for performing and documenting DUS, taking into account the variety of AV access techniques and the problems routinely encountered. A steering committee reviewed the literature and selected the relevant references. A draft was prepared, and all items with missing or conflicting data were submitted to a Delphi consensus. The final document was discussed and approved by all participants. The principles of DUS evaluation of AV access consist of examination of the afferent artery, the anastomosis and the entire venous drainage system. DUS uses B-mode ultrasound, color flow, pulsed wave and power Doppler analysis. DUS can be used in a variety of clinical situations, which can directly influence the methodology of the examination and the interpretation of the results. Blood flow should be assessed as it correlates with the risk of thrombosis. The measurement should be adapted to the different anatomical and hemodynamic conditions encountered. Characterization of stenosis should take into account the residual diameter of the drainage vein and its hemodynamic consequences. Other complications can be assessed with a standardized DUS examination. When performed according to a rigorous methodology, DUS of the AV access allows a comprehensive assessment of its functionality and eliminates the need for further invasive diagnostic procedures.

Right subaxillary muscle-sparing thoracotomy for less invasive open-heart surgery: flap-double patch repair of sinus venosus atrial septal defect and partially anomalous pulmonary venous drainage.

Right subaxillary muscle-sparing thoracotomy for less invasive open-heart surgery: flap-double patch repair of sinus venosus atrial septal defect and partially anomalous pulmonary venous drainage.

What the Musculoskeletal Radiologist Needs to Know About the Vascular Anatomy of the Spine and Spinal Cord.

This article describes the vascular anatomy of the spine and spinal cord, highlighting key structures and anatomical variations relevant to musculoskeletal radiologists. It covers the arterial and venous drainage systems, along with examples of vascular conditions affecting the spine. Understanding the vascular anatomy of the spine and spinal cord is crucial for accurate interpretation of imaging studies and safe spinal interventional procedures. Imaging techniques for evaluating vascular pathology of the spine are discussed and compared. Understanding vascular anatomy and the most common vascular disorders will lead to an accurate diagnosis and suggest the appropriate type of study needed for further characterization and/or patient management.

Extracorporeal Circulation and Venous Hemodynamics: A Literature Review on Physiological Foundations to Clinical Applications

The venous system constitutes a vital component of the human circulatory system, facilitating the return of deoxygenated blood from tissues and organs back to the heart. During cardiac surgeries while using cardiopulmonary bypass (CPB), a critical step involves diverting venous blood from a cannula through the heart-lung machine, where it undergoes oxygenation before re-entering the arterial circulation. This process demands careful control and management to ensure safe and effective perfusion throughout the body. This research paper offers an exploration of venous drainage strategies in the context of cardiac surgery and other applications of extracorporeal life support. The PRISMA method was employed as the guiding framework for conducting this review. The investigation utilized a qualitative research design to assess the artificial circulation and venous dynamics. Out of 85 selected journal publications, 63 peer-reviewed and evidence-based research works were shortlisted. Through an examination of existing evidence, the author underscores the significance of precise venous cannulation techniques and drainage approaches, underscoring the influence on hemodynamics, clinical outcomes, and potential complications. The study delves into advanced monitoring methods and future prospects within the realm of venous drainage. The insights presented in this review serve as a valuable resource for evidence-based decision-making, ultimately contributing to improved patient outcomes and elevated surgical practices.

Vascular Anatomy of Segment IV of the Liver in Live Liver Donors.

Studies on the anatomy of the liver have helped surgeries such as liver resection. Liver resection is of significance in liver transplantation. In liver resection, the anatomy of segment IV is very important as it is more prone to ischemia. The primary objective is to study the anatomical variations of the hepatic artery and hepatic vein of segment IV from MDCT images of the hepatic vasculature in living liver donors. This study aims to document the anatomy of the hepatic artery supplying segment IV and its venous drainage in 300 living liver donors. In this retrospective study, 600 MDCT images of hepatic vasculature were observed, and the interpretations were recorded. The origin of the artery to segment IV was documented.The observations of the hepatic vein were tabulated as classified in Nakamura's study. Segment IV artery originates from the left hepatic artery (LHA) in 72% of the cases and the right hepatic artery(RHA) in 23%. Hepatic venous drainage of segment IV comprises type I, type II, andtype III in 14.33%, 53.67%, and30% of cases, respectively. Type I anatomy of the hepatic vein is preferred in both right and left lobe liver transplantationas the drainage from segment IV is safe. Vascularity to segment IV is key in living liver donors, as donor safety is of utmost importance in the case of living donor liver transplantation.

Machine Learning Models for Brain Arteriovenous Malformations Presenting with Hemorrhage Based on Clinical and Angioarchitectural Characteristics

This study aims to develop the best diagnostic model for brain arteriovenous malformations (bAVMs) rupture by using machine learning (ML) algorithms. We retrospectively included 353 adult patients with ruptured and unruptured bAVMs. The clinical and radiological data on patients werecollected. The significant variables were selected using univariable logistic regression. We constructed and compared the predictive models using five supervised ML algorithms, multivariable logistic regression, and R2eDAVM scoring system. A complementary systematic review and meta-analysis of studies was aggregated to explore the potential predictors for bAVMs rupture. We found that a small nidus size of <3cm, deep and infratentorial location, longer filling time, and deep and single venous drainage were associated with a higher risk of bAVMs rupture. The multilayer perceptronmodel showed the best performance with an area under the curvevalue of 0.736 (95% CI 0.67-0.801) and 0.713 (95% CI 0.647-0.779) in the training and test dataset, respectively. In our pooled analysis, we also found that the male sex, a single feeding artery, hypertension, non-White race, low Spetzler-Martin grade, and coexisting aneurysms are risk factors for bAVMs rupture. This study further demonstrated the clinical and angioarchitectural characteristics in predicting bAVMs hemorrhage.

Impact of the type of ductus venosus agenesis and the presence of associated anomalies on prognosis

Objective: The Ductus Venosus (DV) connects the umbilical vein to the inferior vena cava. With a portocaval pressure gradient, the well-oxygenated blood in the ductus venosus accelerates towards the left sidewall of the inferior vena cava, directing the blood preferentially towards cephalic and coronary circulation through the foramen ovale (1). DV serves as a shunt, expanding to protect the heart and brain in hypoxic conditions. Ductus Venosus Agenesis (DVA) is a rare congenital abnormality with a prevalence of 0.03-0.07%. The type of DVA, along with any additional anatomical or chromosomal anomalies in fetuses with DVA, significantly affects the postnatal prognosis. Some fetuses with DVA develop normally, while others may experience growth retardation, heart defects, or other complications. In this study, we aimed to evaluate the frequency of associated anomalies in DVA cases, examine the impact of each type of DVA (intrahepatic and extrahepatic venous drainage) on prognosis, and contribute to the literature on this rare disease. Materials and Methods: We conducted a retrospective study of all cases diagnosed prenatally with DVA at a tertiary center between 2016-2019. Our study reviewed obstetric data, associated anomalies, other systemic anomalies, type of DVA, chromosomal or genetic anomalies, and perinatal and postnatal outcomes. Postnatal infants were followed up to the 6th month. Results: We identified 16 cases with ductus venosus agenesis. The type of DVA (intrahepatic-extrahepatic shunt), presence of chromosomal anomalies, accompanying ultrasonographic findings, and perinatal outcomes were recorded. Generally, in 7 out of the 16 cases, the umbilical vein drained into the portal system (44% - intrahepatic), and in 9 cases, it drained into the systemic venous system. Conclusion: DVA is a rare congenital abnormality with potentially significant implications for affected fetuses and infants. Early diagnosis, careful monitoring, and appropriate management strategies are crucial to optimize outcomes for these patients. There's a need for future research to better understand the underlying etiology and pathophysiology of DVA and to develop more effective treatment options for affected individuals.

Multi-Stage Treatment for Spetzler-Martin Grades III, IV, and V Arteriovenous Malformations: Preoperative Embolization and Microsurgical Resection in a Consecutive Series of 250 Patients.

The treatment of high-grade brain AVMs is challenging and has no guidelines available to date. This study was aimed at reporting the experience of two centers in treating these AVMs through a multi-stage approach consisting of preoperative embolization and microsurgical resection. A retrospective review was performed for 250 consecutive patients with a diagnosis of high-grade brain AVM (Spetzler-Martin grades III, IV, and V) treated in two centers in Germany between January 1989 and February 2023. The analyzed data included demographic, clinical, morphological, and neurological data. A total of 150 cases (60%) were classified as Spetzler-Martin grade III, 82 cases (32.8%) were classified as grade IV, and 18 cases (7.2%) were classified as grade V. Eighty-seven cases (34.8%) presented with hemorrhage. The devascularization percentages achieved were <50% in 24 (9.6%), 50-80% in 55 (22%), and >80% in 171 (68.4%) cases. The average number of sessions was 5.65 ± 5.50 and 1.11 ± 0.32 endovascular and surgical procedures, respectively, and did not significantly differ by rupture status. Death or dependency (mRS score ≥ 3) after the last follow-up was observed in 18.8% of patients and was significantly associated with age > 80 years and poor baseline neurological condition. The complete resection rate was 82.3% and was significantly associated with age > 80 years, large nidus, and deep venous drainage. Permanent disabling neurological deficit after at least 3 months of follow-up was diagnosed in 13.2% of patients and was significantly associated with age > 80 years and infratentorial locations. A multi-stage treatment for high-grade AVMs is feasible for selected cases but comes at a functional cost. The devascularization percentage was not associated with the investigated outcomes. Age > 80 years was associated with poor safety and effectiveness outcomes; consequently, this treatment should be offered only in exceptional circumstances.

Hemodynamic and Hydrodynamic Pathophysiology in Chiari Type 1 Malformations: Towards Understanding the Genesis of Syrinx.

The pathophysiology of this association of type 1 Chiari malformation (CM1) and syrinxes is still unknown. There is an alteration in the dynamics of neurofluids (cerebrospinal fluid, arterial and venous blood) during the cardiac cycle in CM1. Our objective is to quantify CSF or arterial blood or venous blood flow in patients with Chiari syndrome (CS) with and without syrinxes using phase-contrast MRI (PCMRI). We included 28 patients with CM1 (9 with syrinxes, 19 without). Morphological MRI with complementary PCMRI sequences was performed. We analyzed intraventricular CSF, subarachnoid spaces CSF, blood, and tonsillar pulsatility. There is a highly significant correlation (p < 0.001) between cerebral blood flow, cerebral vascular expansion volume and venous drainage distribution. Venous drainage distribution is significantly inversely correlated with oscillatory CSF volume at the level of the foramen magnum plane [-0.37 (0.04)] and not significantly correlated at the C2C3 level [-0.37 (0.05)] over our entire population. This correlation maintained the same trend in patients with syrinxes [-0.80 (<0.01)] and disappeared in patients without a syrinx [-0.05 (0.81)]. The distribution of venous drainage is an important factor in intracranial homeostasis. Impaired venous drainage would lead to greater involvement of the CSF in compensating for arterial blood influx, thus contributing to syrinx genesis.

Venous anatomy of the left ventricular summit region: Insights from high-speed rotational retrograde angiography.

Mapping and ablation through the coronary venous system (CVS) have shown potential for ventricular arrhythmias originating from the left ventricular summit (LVS). Multielectrode catheters and balloons are frequently used for mapping and venous ethanol ablation (VEA). However, there is limited data on the venous size and drainage condition in the LVS region. This study aimed to investigate the morphology, angiographic size, and drainage condition of LV summit veins via high-speed rotational angiography (RA). We measured and analyzed the size of the great cardiac vein (GCV), the anterior interventricular vein (AIV), veins near to the LVS, and other main tributaries of CVS in 102 patients undergoing electrophysiology study. Rotational retrograde angiography of LVS was successfully performed in 81 patients. The diameter of GCV at the level of the Vieussens valve and the distal end of GCV (junction of GCV-AIV) was larger in males than females (6.8 ± 1.1 vs. 5.6 ± 1.2 mm, p < .001; 5.2 ± 0.9 vs. 4.6 ± 0.8, p = .002, respectively) while no significant gender differences were observed in other tributaries. The LV summit veins presented downward drainage direction in half of the patients, indicating potential anatomic adjacency with His bundle. Left anterior oblique (LAO) 45° projection might provide the practical and optimal view of the LV summit veins. The coronary veins of the LVS region present various anatomical morphologies and ostium sizes. We provide a systematic description and angiographic size spectrum of CVS. RA could facilitate assessing the feature of CVS comprehensively.

Craniocervical Junction Dural Arteriovenous Fistula and Pial Arteriovenous Fistula Presenting Concomitantly in Separate Locations with Subarachnoid Hemorrhage

Craniocervical junction dural arteriovenous fistula and pial arteriovenous fistula are rare cerebrovascular lesions. While their pathophysiology is different, both conditions can cause intracranial hemorrhage attributable to venous congestion. We present, to our knowledge, the first case report of craniocervical junction dural arteriovenous fistula and pial arteriovenous fistula presenting concomitantly in separate locations with subarachnoid hemorrhage. This case appears to have been due to increased venous hypertension caused by a merging of the venous drainage of the 2 lesions, resulting in hemorrhage.

Form and Function: Technique for Free Functional Gracilis Harvest With Greater Saphenous Vein for Large Skin Paddle.

Free functional gracilis transfer is a technique for restoration of upper extremity function following brachial plexus injury, as well as muscle loss from traumatic, oncologic, and congenital causes. However, when used for the latter applications, a functional muscle as well as large skin paddle can be required. Historically, skin paddle size was limited by venous outflow of the gracilis flap, using 1 or 2 venae comitantes, and large unreliable skin paddles resulting in partial necrosis. Therefore, to restore form and function, we herein present a technique of free functional gracilis muscle harvest with inclusion of adjacent greater saphenous vein for inclusion of a large skin paddle with 2 venous drainage systems.