Hemodialysis Reliable Outflow (HeRO) graft creation in upper extremities abandoned due to stent obstruction via recanalization and HeRO outflow component insertion across stent interstices

Background: The purpose of this study was to assess the feasibility and outcomes of recanalization and subsequent HeRO graft outflow component insertion across stent interstices in patients with an otherwise abandoned upper extremity. Methods: Over a 10-year period, 15 patients underwent central venous recanalization by interventional radiology across the interstices of one or more occluded stents for the purpose of subsequent HeRO graft creation. A tunneled central venous catheter was left across the stent and occlusions with tip in right atrium. On a later date, the catheter was used for rapid guidewire access for HeRO graft implantation in the OR by vascular surgery. Procedural and clinical outcomes were determined by retrospective review. Primary and secondary HeRO graft patency rates were estimated with the Kaplan-Meier technique. Results: The technical success rates of recanalization across stent interstices was 100% (15/15). Between one and four overlapping stent walls were traversed. The technical success of the patients who underwent attempted HeRO graft implantation with outflow component traversing across stent interstices was 91% (11/12). No major complications were encountered with either recanalization or HeRO graft implantation. The primary and secondary HeRO patency rates at 12 months were 64% and 80%, respectively. Conclusion: HeRO graft insertion across stent interstices is feasible and can provide effective permanent AV access; thus, the presence of stents across the subclavian and brachiocephalic veins should not be considered a contraindication.

An Efficient Assisted Bidirectional Glenn Design With Lowered Superior Vena Cava Pressure for Stage-One Single Ventricle Patients

Recently, the assisted bidirectional Glenn (ABG) procedure has been proposed as an alternative to the modified Blalock–Taussig shunt (mBTS) operation for neonates with single-ventricle physiology. Despite success in reducing heart workload and maintaining sufficient pulmonary flow, the ABG also raised the superior vena cava (SVC) pressure to a level that may not be tolerated by infants. To lower the SVC pressure, we propose a modified version of the ABG (mABG), in which a shunt with a slit-shaped nozzle exit is inserted at the junction of the right and left brachiocephalic veins. The proposed operation is compared against the ABG, the mBTS, and the bidirectional Glenn (BDG) operations using closed-loop multiscale simulations. Both normal (2.3 Wood units-m2) and high (7 Wood units-m2) pulmonary vascular resistance (PVR) values are simulated. The mABG provides the highest oxygen saturation, oxygen delivery, and pulmonary flow rate in comparison to the BDG and the ABG. At normal PVR, the SVC pressure is significantly reduced below that of the ABG and the BDG (mABG: 4; ABG: 8; BDG: 6; mBTS: 3 mmHg). However, the SVC pressure remains high at high PVR (mABG: 15; ABG: 16; BDG: 12; mBTS: 3 mmHg), motivating an optimization study to improve the ABG hemodynamics efficiency for a broader range of conditions in the future. Overall, the mABG preserves all advantages of the original ABG procedure while reducing the SVC pressure at normal PVR.

Persistent left superior vena cava and its clinical correlation - A cadaveric study

Background: Presented is a case of persistent left superior vena cava draining into the right atrium through coronary sinus and finally opens into right atrium. Abnormalities of the vascular system are more commonly seen due to its importance in circulation. Persistent left superior vena cava is rare but important congenital vascular anomaly. It results when the left superior cardinal vein caudal to the innominate vein fails to regress.The venous anomaly of a persistent left superior vena cava (PLSVC) affects 0.3%–0.5% of the general population. Normally the superior vena cava is a single vascular structure formed by the union of right and left brachiocephalic veins which are in turn formed by the union of internal jugular and subclavian veins of corresponding side, draining the head and neck as well as the superior extremity. Aims and Objective: To evaluate the accuracy of persistent left superior vena cava and to find out the opening of PLSVC and formations of both SVC. Materials and Methods: During routine dissection of Thorax, we have opened the thoracic cage and take out the Heart. during that we found separate SVC and then we did the study on this PLSVC in the Department of Anatomy, Jaipur National University Institute for Medical Sciences and Research Centre (JNUIMSRC) Jaipur and National Institute of Medical Sciences and Research (NIMS & R). Results: We found persistent left superior vena cava in two cadavers out of 30 cadavers (6.66%) one was 64-year-old male cadaver and another 72-year-old male cadaver. Both the vena cavae were formed as of brachiocephalic veins of the corresponding side. The persistent left superior vena cava opened into the enlarged coronary sinus that drained into the right atrium between the opening of inferior vena cava and right atrio-ventricular orifice. Conclusion: It has important clinical implications in certain clinical interventions. It may complicate placementof cardiac catheters or pacemaker leads.

Primary angiosarcoma of superior vena cava: an unexpected diagnosis after an oncological emergency

Angiosarcoma (AS) is a rare malignant tumour representing 1%–2% of all sarcomas. Primary AS of superior vena cava (SVC) was reported in two cases worldwide. We report a 69-year-old woman with neck discomfort, headache and dyspnoea for 3 months. CT angiography showed thrombosis in SVC and brachiocephalic veins resulting in an SVC syndrome. The patient began anticoagulant therapy and underwent balloon angioplasty with clinical improvement. Additionally, a positron emission tomography scan confirmed the presence of a mediastinal mass involving the SVC locally. The tumour was excised and a prosthesis was placed on the SVC. Histology revealed a heterogeneous tumour matrix, either myxoid and composed by fusiform cells with vimentin, homogeneous CD31 and a 30% Ki67 immunoexpression, supporting the diagnosis of an AS. Due to multiple complications, the patient never started chemotherapy, and after tumour recurrence, she died within 5 months after diagnosis.

Superior vena cava syndrome

Summary: The superior vena cava syndrome (SVCS) is caused by compression, invasion, and/or thrombosis of the superior vena cava and/or the brachiocephalic veins. Benign SVCS is separated from malignant SVCS. SVCS comprises a broad clinical spectrum reaching from asymptomatic cases to rare life-threatening emergencies with upper airway obstruction and increased intracranial pressure. Symptoms are correlated to the acuity and extent of the venous obstruction and inversely correlated to the development of the venous collateral circuits. Imaging is necessary to determine the exact underlying cause and to guide further interventions. Interventional therapy has widely changed the therapeutic approach in symptomatic patients. This article provides an overview over this complex syndrome and focuses on interventional therapeutic methods and results.

A Giant Intrathoracic Goiter

Intrathoracic goiter is a relatively rare benign finding, leading often to dyspnea and dysphagia. Imaging methods are of a great importance for the diagnosis. Surgery and total thyroidectomy are the treatment of choice. We present a case of a 72-year-old woman with dysphagia, shortness of breath and fatigue. We observed an increase in both thyroid lobes with retrosternal evolution, descending to the pulmonary artery to the right, and to the aortic arch to the left, with compression of the trachea, brachiocephalic veins and vena cava superior. We performed total thyroidectomy through combined cervical-anterior thoracic right-sided access. Surgical treatment for intrathoracic goiter with or without clinical symptoms is always indicated and should be performed as soon as possible.

Ultrasound-guided supraclavicular brachiocephalic vein catheterization in children: Syringe-free in-plane technique with micro-convex probe

Central venous catheterization of children is often a challenging procedure due to small anatomical structures. Ultrasound guidance has been shown to reduce complications and improve cannulation success as compared with the landmark-based technique. In-plane techniques allow for longitudinal visualization of the vessels and real-time visualization of needle track during its advancement. When in-plane and syringe-free techniques are combined, advancement of the guidewire can also be visualized. We aim to introduce our supraclavicular approach for brachiocephalic vein cannulation in pediatric patients. A syringe-free and in-plane technique is used to cannulate the patients. The subclavian, jugular, and the brachiocephalic veins were visualized by endocavity micro-convex ultrasound probe as a Y shape during the cannulation procedure. We present a case series of successful cannulation by using this technique.

Cerebral Hemodynamics in Chronic Disorders of Cerebral Circulation

The experience of using different methods of magnetic resonance study of the arterial and venous parts of the vascular bed of the head and neck is analyzed, and the feasibility and possibility of simultaneous assessment of the state of the brain and the study of the anatomy of the cerebral bed are shown. 87 patients with chronic cerebral ischemia (CCI) on the background of hypertension (GB) were examined, of the 36 women and 51 men aged from 46 to 72 years. All patients underwent standard neurological examination, MRI of the brain with venography (MRV) of the brachiocephalic veins and venous sinuses of the brain, duplex scanning (DS) in the modes of color Doppler mapping and pulsed Doppler of extra- and intracranial vessels. Comparative assessment of brain MRI results in patients with CCI revealed diffuse changes in the signal intensity from the white matter of the brain (periventricular, subcortical leucoarea, LA), single or multiple ischemic foci of 115 mm, external and internal cerebral atrophy (CA). the feasibility and the possibility of a one-stage assessment of the state of the brain and the study of the anatomy of the cerebral bed are substantiated. The need for an extended magnetic resonance study of the vascular system in the defeat of the arterial bed of the brain is due to certain anatomical and functional relationships between the arterial and venous sections.

Mediastinal Epithelioid Hemangioendothelioma Invading Superior Vena Cava: A Case Report and Review of Literature

Introduction: Epithelioid Hemangioendothelioma (EHE) is a rare vascular neoplasm. Common locations of EHE are the bone, soft tissue, liver, and lung, but the mediastinal location is extremely rare. Few cases of mediastinal EHE, invading the Superior Vena Cava (SVC) have been reported. </P><P> Case Presentation: We report a case of a 21-year-old man with EHE invading the SVC, which was incidentally detected on performing chest radiography. A contrast-enhanced chest Computed Tomography (CT) scan demonstrated a well-defined, oval mass located on the right side of the anterior mediastinum. The mass showed homogeneous enhancement with punctate calcifications, and it invaded the SVC at the confluence area of the right and left brachiocephalic veins. Conclusion: Mediastinal EHE invading the SVC may present as a homogeneously enhancing mass with punctate calcifications. It should be added to the differential diagnosis of tumors of the mediastinum. Accurate preoperative diagnosis of EHE is critical for surgical planning; therefore, knowledge of the radiologic features of EHE is important.