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Samerchua A, Leurcharusmee P, Supphapipat K, Unchiti K, Lapisatepun P, Maikong N, Kantakam P, Navic P, Mahakkanukrauh P. Optimal techniques of ultrasound-guided superficial and deep parasternal intercostal plane blocks: a cadaveric study. Reg Anesth Pain Med 2024; 49:320-325. [PMID: 37460213 DOI: 10.1136/rapm-2023-104595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/04/2023] [Indexed: 05/10/2024]
Abstract
INTRODUCTION The optimal techniques of a parasternal intercostal plane (PIP) block to cover the T2-T6 intercostal nerves have not been elucidated. This pilot cadaveric study aims to determine the optimal injection techniques that achieve a consistent dye spread over the second to sixth intercostal spaces after both ultrasound-guided superficial and deep PIP blocks. We also investigated the presence of the transversus thoracis muscle at the first to sixth intercostal spaces and its sonographic identification agreement, as well as the location of the internal thoracic artery in relation to the lateral border of the sternum. METHODS Ultrasound-guided superficial or deep PIP blocks with single, double, or triple injections were applied in 24 hemithoraces (three hemithoraces per technique). A total volume of dye for all techniques was 20 mL. On dissection, dye distribution over the first to sixth intercostal spaces, the presence of the transversus thoracis muscle at each intercostal space and the distance of the internal thoracic artery from the lateral sternal border were recorded. RESULTS The transversus thoracis muscles were consistently found at the second to sixth intercostal spaces, and the agreement between sonographic identification and the presence of the transversus thoracis muscles was >80% at the second to fifth intercostal spaces. The internal thoracic artery is located medial to the halfway between the sternal border and costochondral junction along the second to sixth intercostal spaces. Dye spread following the superficial PIP block was more localized than the deep PIP block. For both approaches, the more numbers of injections rendered a wider dye distribution. The numbers of stained intercostal spaces after superficial block at the second, fourth, and fifth intercostal spaces, and deep block at the third and fifth intercostal spaces were 5.3±1.2 and 5.7±0.6 levels, respectively. CONCLUSION Triple injections at the second, fourth, and fifth intercostal spaces for the superficial approach and double injections at the third and fifth intercostal spaces for the deep approach were optimal techniques of the PIP blocks.
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Affiliation(s)
- Artid Samerchua
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Prangmalee Leurcharusmee
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Excellence in Osteology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kittitorn Supphapipat
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kantarakorn Unchiti
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Panuwat Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Naraporn Maikong
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Perada Kantakam
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pagorn Navic
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pasuk Mahakkanukrauh
- Excellence in Osteology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Le TP, Le AT, Huynh TND, Huynh KQ, Dao TH, Desgranges P, Bosc R. Duplex Imaging Assessment of the Internal Mammary Arteries in Women after Unilateral Mastectomy and Radiotherapy for Breast Cancer. Ann Vasc Surg 2024; 100:15-24. [PMID: 38110082 DOI: 10.1016/j.avsg.2023.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/03/2023] [Accepted: 10/19/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The effects of incidental radiation exposure on internal mammary arteries remain unclear. The present study was designed to test the hypothesis by comparing diameter and blood flow of the irradiated and nonirradiated internal mammary arteries, using Duplex ultrasound imaging. METHODS The study was designed as a single-center, transversal, comparative study. The main outcomes were diameter and volumetric blood flow of the internal mammary arteries. The Wilcoxon rank-sum test was used to assess the differences between the irradiated and nonirradiated internal mammary arteries with regard to the diameter and volumetric blood flow. RESULTS The diameter (median [interquartile range]) of the irradiated internal mammary arteries (0.170 mm [0.160, 0.180]) was smaller than that of the contralateral nonirradiated ones (0.180 mm [0.170, 0.200], P < 0.0001) and that of the internal mammary arteries in the control group (0.180 mm [0.170, 0.190], P < 0.0001). Similarly, blood flow (median [interquartile range]) of the irradiated internal mammary arteries (52.4 ml/min [37.78, 65.57]) was smaller than that of the contralateral nonirradiated ones (62.7 ml/min [46.87, 84.17], P < 0.0001), as well as of the left (56.7 ml/min [46.88, 72.58], P = 0.02) and the right internal mammary arteries in the control group (61.0 ml/min [47.47, 74.52], P = 0 0.0009). CONCLUSIONS The data indicate that the irradiated internal mammary arteries in patients with a history of total mastectomy followed by radiotherapy for breast cancer had significantly smaller diameter and blood flow compared to the nonirradiated internal mammary arteries.
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Affiliation(s)
- Thanh-Phong Le
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam; L'École Doctorale Sciences de la Vie et de la Santé (Doctoral School of Life and Health Sciences), University of Paris-Est, Creteil, France.
| | - Anh T Le
- Oncology Center, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tan N D Huynh
- Department of Diagnostic Ultrasonography, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Khanh Q Huynh
- Oncology Center, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Thu-Ha Dao
- Department of Imaging, Henri Mondor Hospital, Creteil, France
| | - Pascal Desgranges
- L'École Doctorale Sciences de la Vie et de la Santé (Doctoral School of Life and Health Sciences), University of Paris-Est, Creteil, France; Department of Vascular Surgery, Henri Mondor Hospital, Creteil, France
| | - Romain Bosc
- L'École Doctorale Sciences de la Vie et de la Santé (Doctoral School of Life and Health Sciences), University of Paris-Est, Creteil, France; Department of Plastic, Esthetic and Reconstructive Surgery, George- Pompidou Hospital, Paris, France
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Kerai A, Modi P, Shackcloth M, Schache AG, Shaw RJ. Head and neck reconstruction in the vessel depleted neck using robot-assisted harvesting of the internal mammary vessels. Br J Oral Maxillofac Surg 2023; 61:368-372. [PMID: 37246020 DOI: 10.1016/j.bjoms.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 05/30/2023]
Abstract
We report a novel technique of robot-assisted harvesting of the internal mammary vessels to provide effective recipient vessels in a patient with bilateral vessel depleted neck (VDN). A 44-year-old with a Notani grade III osteoradionecrosis (ORN) of the anterior mandible underwent robot-assisted (Da Vinci® Surgical System, Intuitive Surgical) harvesting of the left internal mammary vessels (LIMA, LIMV). Reconstruction of the mandibular defect was done with a virtually planned composite fibular free flap and microvascular anastomosis of the peroneal vessels to the LIMA and LIMV. Successful reconstruction of the anterior mandible was achieved with excellent recipient arterial diameter and length, devoid of any significant thoracic morbidities resulting from robot-assisted harvesting of the internal mammary vessels. Robot-assisted harvesting of internal mammary vessels is a viable alternative to an open approach. The advantages in tissue handling, vessel length, and favourable profile of complications may extend the indications for this otherwise 'niche' solution in the VDN.
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Affiliation(s)
- Ashwin Kerai
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK
| | - Paul Modi
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Andrew G Schache
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK; Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Richard J Shaw
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK; Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
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Sakai S, Yuzaki I, Nagashima H, Kajita H, Kiuchi T, Ishii N, Matsuzaki K, Takatsume Y, Kishi K. A Novel Dissection Method of the Internal Mammary (Thoracic) Artery: Anastomotic Vessel of the DIEP Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4960. [PMID: 37101613 PMCID: PMC10125686 DOI: 10.1097/gox.0000000000004960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/06/2023] [Indexed: 04/28/2023]
Abstract
Deep inferior epigastric perforator flaps are commonly used for breast reconstruction using autologous tissue. For such free flaps, the internal mammary artery provides stable blood flow as the recipient for anastomosis. We report a novel dissection method of the internal mammary artery. First, the perichondrium and costal cartilage of the sternocostal joint are dissected with electrocautery. Then, the incision on the perichondrium is extended along the cephalic and caudal ends. Next, this C-shaped superficial layer of perichondrium is elevated from the cartilage. The cartilage is incompletely fractured with electrocautery, with the deep layer of perichondrium intact. Then, the cartilage is completely fractured by leverage and removed. The remaining deep layer of perichondrium is incised at the costochondral junction and shifted aside, revealing the internal mammary artery. The preserved perichondrium creates a rabbet joint to protect the anastomosed artery. This method not only enables a more reliable, safer dissection of the internal mammary artery, but also allows reusage of the perichondrium as underlayment in the setting of anastomosis, and coverage for the incised rib edge, protecting the anastomosed vessels.
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Affiliation(s)
- Shigeki Sakai
- From the Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ikki Yuzaki
- From the Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hayato Nagashima
- From the Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Kajita
- From the Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomoki Kiuchi
- Department of Plastic and Reconstructive Surgery, International University of Health and Welfare Hospital, Tokyo, Japan
| | - Naohiro Ishii
- Department of Plastic and Reconstructive Surgery, International University of Health and Welfare Hospital, Tokyo, Japan
| | - Kyoichi Matsuzaki
- Department of Plastic and Reconstructive Surgery, International University of Health and Welfare Hospital, Tokyo, Japan
| | - Yoshifumi Takatsume
- Yoshifumi Takatsume, PhD. Department of Anatomy, Keio University School of Medicine, Tokyo, Japan
| | - Kazuo Kishi
- From the Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
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Zangpo D, Nakane H, Iino M. Vascular anatomy and their variations in Situs inversus totalis using postmortem computed tomographic angiography. Anat Cell Biol 2023; 56:155-159. [PMID: 36537136 PMCID: PMC9989793 DOI: 10.5115/acb.22.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/09/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
Studies describing the vascular systems and their variations in Situs inversus totalis (SIT) from a whole-body computed tomographic (CT) angiography perspective are lacking. We report a case of SIT in which postmortem CT angiography (PMCTA) was performed as a part of the forensic death investigation and incidentally detected several vascular variations in it. The PMCTA procedure was performed using the multiphase PMCTA protocol. Almost all major vessels were visualized, indeed in a completely reversed pattern. Contrast mixture flow interruptions were noted in the right coronary arterial branches suggesting possible blockage, upon which autopsy revealed >90% vessel occlusions at several locations. As such the cause of death was due to ischemic heart disease. Anomalous origins of the right internal mammary artery; abnormal left thyrocervical trunk and variations in the drainage of testicular veins were noted. Our findings might be helpful to clinicians and add to the body of literature on SIT.
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Affiliation(s)
- Dawa Zangpo
- Division of Forensic Medicine, Graduate School of Medicine, Tottori University, Yonago, Japan
| | - Hironobu Nakane
- Department of Anatomy, Graduate School of Medicine, Tottori University, Yonago, Japan
| | - Morio Iino
- Division of Forensic Medicine, Graduate School of Medicine, Tottori University, Yonago, Japan
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Ziolkowski NI, Sun KZ, McMillan C, Ryzynski A, Snell L, Lipa JE. Simulating the IMA Recipient Site for DIEP Flap Surgery: A New Model for Dynamic Microsurgery Simulation with Real-Time Respiration and a Pilot Study. J Reconstr Microsurg 2022; 39:254-263. [PMID: 35477116 DOI: 10.1055/s-0041-1740957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Breast reconstruction (BR) using autologous free flaps has been shown to have numerous psychosocial and quality-of-life benefits. Unfortunately, the microsurgical learning curve is quite steep due to some unique operative challenges. Currently, there is no realistic simulation model that captures real-life respiratory excursion and the depth of internal mammary vessels within the compact recipient site. The purpose of this study was to delineate intraoperative measurements of depth and motion, describe the resulting simulation model, and conduct a pilot study evaluating the simulator as an educational resource. METHODS This is a single-center, ethics-approved study. For the intraoperative measurements, all consecutive patients undergoing free flap BR using internal mammary vessels as recipients were recruited. Patient and intraoperative factors as well as intraoperative measurements were recorded. A dynamic model was developed based on intraoperative parameters. For the pilot study, plastic and reconstructive surgery trainees were recruited to complete a hand-sewn internal mammary artery (IMA) anastomosis using the new simulator and completed objective questionnaires pre- and postsimulation. Subjective feedback was recorded and themes determined. RESULTS Fifteen operative sites were analyzed. Flap pocket was found to be between 4 and 5 cm in depth with vertical excursion of 3.7 ± 1.0mm and a respiratory rate of 9 to 14 breaths/minute. Previous radiation, rib space, body mass index (BMI), blood pressure, heart rate, tidal volume, and respiratory rate showed no correlation to vessel depth/excursion. Laterality, rib space, BMI, radiation, vitals, and tidal volume had no correlation with vessel movement. Twenty-two trainees were included in the pilot. An increase in confidence and mixed results for anxiety was reported. CONCLUSION This study reports a novel microsurgical simulation model that provides a realistic deep inferior epigastric perforator free flap BR IMA anastomosis experience. It replicates movement of vessels in situ with real-time respiratory excursion and similar physical structures of the internal mammary system. This model shows promising results for increased use in microsurgical education.
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Affiliation(s)
| | - Kimberly Z Sun
- Department of Surgery, Section of Plastics, Joseph Brant Memorial Hospital, Burlington, Ontario, Canada
| | - Catherine McMillan
- Department of Surgery, Division of Plastic & Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Agnes Ryzynski
- Sunnybrook Canadian Simulation Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laura Snell
- Department of Surgery, Division of Plastic & Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Joan E Lipa
- Department of Surgery, Division of Plastic & Reconstructive Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Agnihotri G, Mitra A. A study on origin, termination, and course characteristics of internal thoracic artery relevant to coronary surgeries and reconstructive procedures. Tzu Chi Med J 2022; 34:348-352. [PMID: 35912049 PMCID: PMC9333097 DOI: 10.4103/tcmj.tcmj_195_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives: The internal thoracic artery is a favored vessel for coronary artery bypass grafting and is utilized for breast reconstructive surgeries. Our study focuses on the origin, termination, and course characteristics of the internal thoracic artery. A comprehension of these morphological features and possible variations will definitely aid a clinician in appropriate harvesting of the artery for clinical procedures. Materials and Methods: 200 thoracic halves (from 100 embalmed adult human cadavers of either sex) were obtained from the department of anatomy. The origin, course characteristics, termination levels, and patterns for the internal thoracic artery were studied. Results: The internal thoracic artery originated from the first part of subclavian artery. The most common course pattern observed was medial concavity (88.5%). In 10% of cases, a tortuous course was observed. No artery with lateral concavity or rectilinear course pattern was documented. The artery terminated in the sixth space in 93.5% of cases. In 98% of cases, bifurcation in termination was observed. Trifurcation in termination was also observed in 2% of cases. The average length of variant artery (third terminating branch) was documented to be 5.5 cm. Conclusion: The increased utilization of the internal thoracic artery for coronary bypass arterial surgery and its role in sternal wound healing has made it imperative for clinicians to keep in mind its anatomical characteristics and local variations. This knowledge definitely will improve prognosis and decrease intraoperative/postoperative complications in patients undergoing coronary surgeries, percutaneous subclavian catheterizations, and reconstructive procedures.
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López-de la Cruz Y, Quintero-Fleites YF, Nafeh-Abi-Rezk MS, Chávez-González E. Fisiología y anatomía quirúrgica de la arteria mamaria interna: ¿qué debe saberse durante su disección esqueletizada? CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Kowalczyk KA, Majewski A. Analysis of surgical errors associated with anatomical variations clinically relevant in general surgery. Review of the literature. TRANSLATIONAL RESEARCH IN ANATOMY 2021. [DOI: 10.1016/j.tria.2020.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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10
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Nanthakumar H, Iwanaga J, Dumont AS, Tubbs RS. A rare cadaveric case of a duplicated internal thoracic artery. Anat Cell Biol 2020; 53:366-368. [PMID: 32727954 DOI: 10.5115/acb.20.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/20/2020] [Accepted: 06/05/2020] [Indexed: 11/27/2022] Open
Abstract
The internal thoracic artery (ITA) arises from the subclavian artery and terminates as the musculophrenic and inferior epigastric arteries. During routine cadaveric dissection, an aberrant left ITA was discovered. A medial and a lateral branch of the ITA branched directly off the subclavian artery as opposed to bifurcating at the 6th or 7th intercostal space. To our knowledge, this is the first reported case of this particular ITA variation arising from the third part of the subclavian artery. Additionally, such a variant might also be considered a high bifurcation of the ITA. Our report examines this variation and its potential implications for coronary artery bypass grafts where the ITA is commonly used.
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Affiliation(s)
- Harry Nanthakumar
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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Nanthakumar H, Iwanaga J, Dumont AS, Tubbs RS. A rare cadaveric case of a duplicated internal thoracic artery. Anat Cell Biol 2020; 53. [PMID: 32727954 PMCID: PMC7527130 DOI: 10.25373/ctsnet.7611560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The internal thoracic artery (ITA) arises from the subclavian artery and terminates as the musculophrenic and inferior epigastric arteries. During routine cadaveric dissection, an aberrant left ITA was discovered. A medial and a lateral branch of the ITA branched directly off the subclavian artery as opposed to bifurcating at the 6th or 7th intercostal space. To our knowledge, this is the first reported case of this particular ITA variation arising from the third part of the subclavian artery. Additionally, such a variant might also be considered a high bifurcation of the ITA. Our report examines this variation and its potential implications for coronary artery bypass grafts where the ITA is commonly used.
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Affiliation(s)
- Harry Nanthakumar
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA,Corresponding author: Joe Iwanaga Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA 70112, USA E-mail:
| | - Aaron S. Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - R. Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA,Department of Anatomical Sciences, St. George’s University, St. George’s, Grenada, West Indies
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Muto M, Satake T, Masuda Y, Kobayashi S, Tamura S, Kobayashi S, Ohtake T, Maegawa J. Absent Internal Mammary Recipient Vein in Autologous Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2660. [PMID: 32309101 PMCID: PMC7159964 DOI: 10.1097/gox.0000000000002660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022]
Abstract
The internal mammary vessels (IMA/Vs) have been used as the first-choice recipient vessels for microsurgical anastomosis and flap inset in autologous breast reconstruction owing to their ease of access and use compared with the thoracodorsal vessels (TDA/Vs). Herein, we report two cases of deep inferior epigastric perforator flap breast reconstructions in which the recipient internal mammary vein (IMV) was lacking. In the first case, a 50-year-old patient underwent delayed two-stage reconstruction, and in the second, a 45-year-old patient underwent delayed reconstruction because of capsular contracture following breast implant reconstruction. Neither patient received preoperative radiation therapy. During IMA/V preparation, we could not find the internal mammary vein (IMV) around the internal mammary artery (IMA) despite careful dissection. No internal mammary lymph node adenopathy and vascular encasement from metastasis were noted. Intraoperative indocyanine green angiography revealed absence of IMV, which was presumed to be congenital. Therefore, microsurgical anastomosis was performed to connect the deep inferior epigastric vessels to the thoracodorsal vessel. The postoperative course was uneventful in both cases. Although many anatomical studies have revealed different locations, diameters, branching patterns, and perforators of the IMA/V, absent IMV has been reported very rarely. In autologous breast reconstruction, plastic surgeons should be prepared for the possibility of the absence of IMV.
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Affiliation(s)
- Mayu Muto
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Toshihiko Satake
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Yuma Masuda
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Saya Kobayashi
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Shihoko Tamura
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Shinji Kobayashi
- Department of Plastic and Reconstructive Surgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Tohru Ohtake
- Department of Breast Surgery, Fukushima Medical University Hospital, Fukushima, Fukushima, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
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Abstract
Internal mammary artery, by far, is the gold standard and first conduit for surgical revascularization especially when it comes to bypassing a lesion in the left anterior descending coronary artery. Several factors behind using this artery have been established, including but not limited to, the anatomical location, the course and flow, the elastic nature of the artery as well as the physiological characteristics that make this conduit to yield excellent long-term patency rates. This review aims to thoroughly examine current literature and establish the facts behind using this conduit in our daily surgical revascularization practice.
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Zhang Q, Xiao Q, Guo R, Xiu B, Li L, Chi W, Gu Y, Wu J. Applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases. Gland Surg 2019; 8:477-485. [PMID: 31741878 DOI: 10.21037/gs.2019.08.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Internal mammary vessels (IMVs) are widely used recipient vessels in abdominal free flap breast reconstructions. Rib sparing technique is an alternative method with less damage in IMVs exposure. This study aims to investigate the factors influencing the selection of IMVs, as well as analyze the applicability and related factors of rib sparing technique in abdominal breast reconstruction. Methods Medical records of 215 patients who underwent abdominal free flap reconstruction from November 2006 to December 2017 in Fudan University Shanghai Cancer Center (FUSCC) were analyzed. Intercostal space (ICS) was measured from preoperative chest computed tomography scan. Factors influencing the choice of recipient vessels and rib sparing were analyzed. Surgery time, hospitalization and complications were assessed. Results Among all 218 flaps, 172 flaps used IMVs as the recipient vessels while 46 used other vessels. patients with immediate reconstruction (P=0.005) and axillary lymph nodes dissection (ALND) (P<0.001) were less likely to use IMVs. Patients' body mass index (BMI) and radiotherapy history showed no statistically significant differences between the two groups (P=0.338 and 0.811). In IMVs group, 62% cases used rib sparing technique. Compared with rib resection group, patients with rib sparing were taller (P=0.047) and with a wider ICS (2.65±0.54 vs. 2.25±0.38 cm, P<0.001). Rib sparing group had a shorter surgery and postoperative hospitalization time, as well as a lower complication rate, but the differences were not statistically significant (P=0.120, 0.450 and 0.612). Conclusions IMVs were used more frequently as the recipient vessels in abdominal free flap breast reconstructions, especially when axillary operation was not performed at the same time. Rib sparing technique had the potential to decrease surgery time, hospitalization days and complications rate. It could be applied in most of the patients with IMVs exposure, particularly in taller patients and patients with a wider ICS. Preoperative chest computed tomography scan can be used to assess the ICS width to provide operational suggestions.
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Affiliation(s)
- Qi Zhang
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qin Xiao
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Rong Guo
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Bingqiu Xiu
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Lun Li
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiru Chi
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yajia Gu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Jiong Wu
- Department of Breast Surgery, Breast Cancer Institute, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.,Collaborative Innovation Center for Cancer Medicine, Shanghai 200032, China
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15
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Shin D, Sung KW, Fan KL, Park TH, Song SY, Roh TS, Lew DH, Lee DW. Expanding the use of internal mammary artery perforators as a recipient vessel in free tissue transfer: An anatomical analysis by computed tomography angiography in breast cancer patients. Microsurgery 2019; 39:509-514. [PMID: 30830973 DOI: 10.1002/micr.30446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 01/25/2019] [Accepted: 02/22/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND The internal mammary artery (IMA) perforator has assumed recent prominence as recipient vessels in free autologous breast reconstruction. However, anatomical understanding is unclear, due to limited cadaver and clinical studies. We evaluated the usability of these vessels by evaluating perforator size, dominance, laterality, interspace location, and relationship with breast volume. METHODS A retrospective review assessed 197 female patients with breast cancer who had undergone computed tomography angiography (CTA) of the chest wall. The average age and body mass index (BMI) of patients was 49.0 ± 6.5 years and 24.2 ± 5 .8 kg/m2 , respectively. The average volume of breasts was 437 ± 190 mL. Our analysis focused on the anatomy of IMA perforator and its relationship to volume and BMI. RESULTS A total of 377 hemi-chest evaluations were performed. Most patients (95.5%) had sizeable perforating artery identified on CTA. Among all sizeable perforators identified, the mean diameter of the most dominant arterial perforator was 1.8 ± 0 .8 mm. The right hemi-chest had significantly larger perforators than the left (1.9 ± 0 .9 mm vs. 1.7 ± 0 .7 mm, p = 0.002). The first intercostal space (ICS) had a slightly greater of perforators than second ICS (34.6% vs. 29.8%, p = 0.172). However, second ICS had a greater number of most dominant perforators compared to first ICS (38.9% vs. 34.7%, p = 0.357). Perforators from first ICS emerge medial to the sternal edge and breast footprint. When dividing groups with 0-1 versus 2-3 reliable perforators, breast volume was significantly higher in the later (422.0 mL vs. 461.2 mL, p = 0.019). CONCLUSION These results are expected to encourage microsurgeons to use the IMA perforator by providing a clear anatomical roadmap.
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Affiliation(s)
- Dongwoo Shin
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Ki Wook Sung
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Tae Hwan Park
- Department of Plastic and Reconstructive Surgery, Bundang CHA Medical Center, Seongnam, Gyeonggi-do, South Korea
| | - Seung Yong Song
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Tai Suk Roh
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Dae Hyun Lew
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Won Lee
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, South Korea
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16
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Hijikata S, Miyamoto T, Yamaguchi T, Yamaguchi J, Iwai T, Watanabe K, Sagawa Y, Masuda R, Miyazaki R, Miwa N, Hara N, Nagata Y, Nozato T. Hemorrhagic shock due to branch injury of the left internal thoracic artery two days after pericardiocentesis. J Cardiol Cases 2018; 18:5-8. [DOI: 10.1016/j.jccase.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 02/03/2018] [Accepted: 02/28/2018] [Indexed: 11/26/2022] Open
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17
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Thimmappa ND, Vasile JV, Ahn CY, Levine JL, Prince MR. MRA of the skin: mapping for advanced breast reconstructive surgery. Clin Radiol 2018; 74:13-28. [PMID: 29499911 DOI: 10.1016/j.crad.2017.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 12/20/2017] [Indexed: 01/02/2023]
Abstract
Autologous breast reconstruction using muscle-sparing free flaps are becoming increasingly popular, although microvascular free flap reconstruction has been utilised for autologous breast reconstructions for >20 years. This innovative microsurgical technique involves meticulous dissection of artery-vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap; however, due to unpredictable anatomical variations, preoperative imaging of the donor site to select appropriate perforators has become routine. Preoperative imaging also reduces operating time and enhances the surgeon's confidence in choosing the appropriate donor site for harvesting flaps. Although computed tomography angiography has been widely used for preoperative imaging, concerns over excessive exposure to ionising radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made magnetic resonance angiography, the first choice imaging modality in our centre. Magnetic resonance angiography with specific post-processing of the images has established itself as a reliable method for mapping tiny perforator vessels. Multiple donor sites can be imaged in a single setting without concern for ionising radiation exposure. This provides anatomical information of more reconstruction donor site options, so that a surgeon can design a flap of tissue centralised around the best perforator, as well as a back-up perforator, and even a back-up flap option located on a different region of the body. This information is especially helpful in patients with a history of scar tissue from previous surgeries, where the primary choice perforator is found to be damaged or unsuitable intraoperatively. In addition, chest magnetic resonance angiography evaluates recipient site blood vessel suitability including vessel diameters, course, and branching patterns. In this article we provide a broad overview of various skin flaps, clinical indications, advantages and disadvantages of each of these flaps, basic imaging technique, along with advanced sequences for visualising tiny arteries in the groin and in the chest. Post-processing techniques, structure of the report and how automation of the reporting system improves workflow is described. We also describe applications of magnetic resonance angiography in postoperative imaging.
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Affiliation(s)
- N D Thimmappa
- Radiology, University of Missouri, Columbia, MO, USA.
| | - J V Vasile
- Division of Plastic and Reconstructive Surgery, Northern Westchester Hospital, Mt. Kisco, USA; New York Eye and Ear Infirmary of Mount Sinai, Plastic Surgery, New York, NY, USA
| | - C Y Ahn
- Plastic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - J L Levine
- New York Eye and Ear Infirmary of Mount Sinai, Plastic Surgery, New York, NY, USA
| | - M R Prince
- Radiology, New York-Presbyterian Hospital, Columbia University, NY, USA; Radiology, Weill Cornell Medical Center, NY, USA
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18
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Casadesús JM, Aguirre F, Carrera A, Boadas-Vaello P, Serrando MT, Reina F. Diagnosis of arterial gas embolism in SCUBA diving: modification suggestion of autopsy techniques and experience in eight cases. Forensic Sci Med Pathol 2018; 14:18-25. [PMID: 29460254 DOI: 10.1007/s12024-018-9951-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2018] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to suggest modifications of autopsy techniques in order to improve post-mortem diagnosis of arterial gas embolism (AGE) based on multidisciplinary investigation of SCUBA diving fatalities. Five adult human cadavers from the voluntary donation program of the Human Anatomy Laboratory, and eight judicial autopsied bodies of SCUBA divers from the Forensic Pathology Service were assessed. Before performing any autopsies, we accessed the diving plan and the divers' profiles for each case. We then introduced a new dissection procedure that included identification, isolation, and manipulation of carotid, vertebral and thoracic arterial systems. The dissected vascular structures that allowed optimall isolation of the systemic arterial circulation were identified and ligated. In three of the eight judicial cases, we had a strongly suggestive history of arterial gas embolism following pulmonary barotrauma (PBt/AGE). In these cases, the additional arterial dissection allowed us to clearly diagnose AGE in one of them. The autopsy of the rest of the cases showed other causes of death such as asphyxia by drowning and heart attack. In all cases we were able to reject decompression sickness, and in some of them we showed the presence of artefacts secondary to decomposition and resuscitation maneuvers. These results allow us to suggest a specific autopsy technique divided into four steps, aimed at confirming or excluding some evidence of dysbaric disorders according to a re-enactment of the incident. We have demonstrated the presence of large volumes of intravascular air, which is typical of PBt/AGE.
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Affiliation(s)
- Josep M Casadesús
- Institute of Legal Medicine and Forensic Sciences of Catalonia, (Division of Girona, Spain), Av. Ramón Folch, 4-6, 17001, Girona, Spain. .,Research Group on Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain. .,Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, 17003, Girona, Spain.
| | - Fernando Aguirre
- Special Group for Underwater Activities (GEAS) of the Spanish Civil Guard, C/Torroella s/n, 17258, Estartit, Spain
| | - Ana Carrera
- Research Group on Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain.,Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, 17003, Girona, Spain
| | - Pere Boadas-Vaello
- Research Group on Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain.,Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, 17003, Girona, Spain
| | - Maria T Serrando
- Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, 17003, Girona, Spain.,ICS-IAS Girona Clinical Laboratory, Av. Dr. Castany s/n, 17190, Salt, Spain
| | - Francisco Reina
- Research Group on Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, University of Girona, Girona, Spain.,Department of Medical Sciences, Faculty of Medicine, University of Girona (Spain), Av. Emili Grahit 77, 17003, Girona, Spain
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19
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Stirling AD, Murray CP, Lee MA. The arterial supply of the nipple areola complex (NAC) and its relations: an analysis of angiographic CT imaging for breast pedicle design. Surg Radiol Anat 2017; 39:1127-1134. [PMID: 28432407 DOI: 10.1007/s00276-017-1858-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/13/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE To investigate the blood supply to the nipple areola complex (NAC) on thoracic CT angiograms (CTA) to improve breast pedicle design in reduction mammoplasty. METHODS In a single centre, CT scans of the thorax were retrospectively reviewed for suitability by a cardiothoracic radiologist. Suitable scans had one or both breasts visible in extended fields, with contrast enhancement of breast vasculature in a female patient. The arterial sources, intercostal space perforated, glandular/subcutaneous course, vessel entry point, and the presence of periareolar anastomoses were recorded for the NAC of each breast. RESULTS From 69 patients, 132 breasts were suitable for inclusion. The most reproducible arterial contribution to the NAC was perforating branches arising from the internal thoracic artery (ITA) (n = 108, 81.8%), followed by the long thoracic artery (LTA) (n = 31, 23.5%) and anterior intercostal arteries (AI) (n = 21, 15.9%). Blood supply was superficial versus deep in (n = 86, 79.6%) of ITA sources, (n = 28, 90.3%) of LTA sources, and 10 (47.6%) of AI sources. The most vascularly reliable breast pedicle would be asymmetrical in 7.9% as a conservative estimate. CONCLUSION We suggest that breast CT angiography can provide valuable information about NAC blood supply to aid customised pedicle design, especially in high-risk, large-volume breast reductions where the risk of vascular-dependent complications is the greatest and asymmetrical dominant vasculature may be present. Superficial ITA perforator supplies are predominant in a majority of women, followed by LTA- and AIA-based sources, respectively.
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Affiliation(s)
- Aaron D Stirling
- Mark Lee Plastic Surgeon, St John of God Hospital, Subiaco, Perth, WA, 6008, Australia. .,Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Dublin, Ireland.
| | - Conor P Murray
- Mark Lee Plastic Surgeon, St John of God Hospital, Subiaco, Perth, WA, 6008, Australia.,Envision Medical Imaging, Cambridge St, Subiaco, Perth, WA, 6008, Australia
| | - Mark A Lee
- Mark Lee Plastic Surgeon, St John of God Hospital, Subiaco, Perth, WA, 6008, Australia
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20
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Determining the best recipient vessel site for autologous microsurgical breast reconstruction with DIEP flaps: An anatomical study. J Plast Reconstr Aesthet Surg 2017; 70:781-791. [PMID: 28259642 DOI: 10.1016/j.bjps.2017.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/25/2016] [Accepted: 01/31/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The deep inferior epigastric perforator (DIEP) flap is a reliable and reproducible technique for autologous microsurgical breast reconstruction. Several recipient vessels sites for microvascular anastomosis have been described such as the internal thoracic vessels, the thoracodorsal vessels, and the circumflex scapular vessels. Nonetheless, the choice of the recipient site depends mainly on individual operator's experience and preferences, and currently the best recipient vessel site is under debate. This anatomical observational study aimed to determine whether anatomy could address this dilemma by determining the best vessel diameter to match the donor with these three recipient sites. METHODS Our series reports 80 dissections of the three anatomical regions of interest. Forty formalin-preserved female cadavers were dissected bilaterally. Internal vessels diameter measurements were recorded with a vascular gauge ranging from 1.0 to 5.0 mm with successive half-millimeter graduations. RESULTS The median diameter of the deep inferior epigastric (DIEA), internal thoracic (ITA), circumflex scapular (CSA), and thoracodorsal arteries (TDA) were: 2.0, 2.5, 2.5, and 1.5 mm, respectively. The median diameter of the deep inferior epigastric, internal thoracic, circumflex scapular, and thoracodorsal veins were: 3.0, 3.0, 3.0, and 2.5 mm, respectively. At the individual level, the perfect match between DIEA and ITA was significantly more frequent than between DIEA and TDA (p = 0.002), and it was more frequent between DIEA and CSA than between DIEA and TDA (p = 0.009). CONCLUSIONS This study supports the use of the internal thoracic pedicle as the first recipient vessel choice, which should be considered, at least anatomically, as the best one with the closest diameter matching with the donor pedicle.
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21
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Cook JA, Tholpady SS, Momeni A, Chu MW. Predictors of internal mammary vessel diameter: A computed tomographic angiography-assisted anatomic analysis. J Plast Reconstr Aesthet Surg 2016; 69:1340-8. [DOI: 10.1016/j.bjps.2016.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/20/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
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22
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Picichè M. Noncoronary Collateral Myocardial Blood Flow: The Human Heart's Forgotten Blood Supply. Open Cardiovasc Med J 2015; 9:105-13. [PMID: 27006713 PMCID: PMC4768666 DOI: 10.2174/1874192401509010105] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 03/20/2015] [Accepted: 04/22/2015] [Indexed: 11/22/2022] Open
Abstract
The “noncoronary collateral circulation” (NCCC) or “noncoronary collateral myocardial blood flow”
(NCCMBF), reaches the heart through a micro-vascular network arising from the bronchial, esophageal, pericardial,
diaphragmatic, and aortic arteries. The left and right internal thoracic arteries (ITAs) along with their collateral branches
also serve as a source of NCCMBF-a feature seen in other mammals. Under certain circumstances the ITAs have a high
potential for developing collateral branches. In the case of severe Leriche syndrome or with chronic obstruction of the
abdominal aorta, the ITAs can serve as the main or even sole source of blood supply to the lower limbs. It is also possible
for the ITAs to develop angiographically visible branches that directly connect with the coronary arteries. In ischemic
conditions there is a functional, ischemia-reducing extracardiac coronary artery supply via natural ipsilateral ITA
anastomosis. To date we know little about NCCMBF and its potential benefits in clinical applications, which makes this a
challenging and intriguing field of research. This paper reviews all available data on noncoronary collateral blood supply
to the human heart.
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Affiliation(s)
- Marco Picichè
- Cardiac Surgery Department, San Filippo Neri Hospital, Via Martinotti 20, 00135, Rome, Italy
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23
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Chow WT, Rozen WM, Patel NG, Ramakrishnan VV. Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review. Microsurgery 2015; 37:66-70. [PMID: 26368338 DOI: 10.1002/micr.22496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 07/08/2015] [Accepted: 08/21/2015] [Indexed: 11/10/2022]
Abstract
Selecting potential recipient vessel options for free flap anastomosis is an important consideration in microsurgical breast and chest wall reconstruction. In these settings, the most common comprise the internal mammary and thoracodorsal vessels, although alternative anastomotic sites have also been described. On occasion, consideration of these alternatives becomes a necessity. The use of five separate recipient vessels is highlighted in a unique case of recurrent locally advanced breast cancer requiring multiple complex reconstructions using free tissue transfer. A 56-year-old lady presented for delayed breast reconstruction one year after radical mastectomy for locally advanced lobular breast cancer. Despite wide resections, local chest-wall recurrence five times necessitated five microsurgical reconstructions, using separate recipient pedicles: internal mammary vessels, thoracodorsal vessels, serratus branch of thoracodorsal vessels, intercostal vessels and thoracoacromial vessels. All flaps survived completely, without donor or recipient complications. There has not been a subsequent recurrence at 6 months since last reconstruction. The purpose of this report is to present the first reported case of microsurgical chest wall reconstruction using five separate free flaps requiring anastomosis to multiple recipient vessels for anterior chest wall coverage, to present a literature-based and clinical review of the regional vascular anatomy of the anterior chest wall, and to present an operative approach algorithm. In such complex cases, this understanding can facilitate a streamlined approach to management. © 2014 Wiley Periodicals, Inc. Microsurgery 37:66-70, 2017.
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Affiliation(s)
- Whitney T Chow
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, CM1 7ET, UK
| | - Warren Matthew Rozen
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, CM1 7ET, UK.,Department of Surgery, Monash University, Monash Medical Centre, Clayton Victoria, 3168, Australia
| | - Nakul Gamanlal Patel
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, CM1 7ET, UK
| | - Venkat V Ramakrishnan
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, CM1 7ET, UK
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Khoo A, Rosich-Medina A, Woodham A, Jessop ZM, Di Candia M, Malata CM. The relationship between the intercostal distance, patient height and outcome in microsurgical breast reconstruction using the second interspace rib-sparing internal mammary vessel exposure. Microsurgery 2014; 34:448-53. [DOI: 10.1002/micr.22238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 02/11/2014] [Accepted: 02/14/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Anna Khoo
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Anais Rosich-Medina
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Amandine Woodham
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Zita M. Jessop
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Michele Di Candia
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Charles M. Malata
- Department of Plastic and Reconstructive Surgery; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Cambridge Breast Unit; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
- Professor of Academic Plastic Surgery; Postgraduate Medical Institute at Anglia Ruskin University, Cambridge and Chelmsford; UK
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25
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Demystifying the Use of Internal Mammary Vessels as Recipient Vessels in Free Flap Breast Reconstruction. Plast Reconstr Surg 2013; 132:763-768. [DOI: 10.1097/prs.0b013e31829fe321] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Tan O, Yuce I, Aydin OE, Kantarci M. A radioanatomic study of the internal mammary artery and its perforators using multidetector computed tomography angiography. Microsurgery 2013; 34:277-82. [DOI: 10.1002/micr.22185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 08/09/2013] [Accepted: 08/16/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Onder Tan
- Faculty of Medicine; Department of Plastic Reconstructive and Aesthetic Surgery; Ataturk University; 25240 Erzurum Turkey
| | - Ihsan Yuce
- Faculty of Medicine; Department of Radiology; Ataturk University; 25240 Erzurum Turkey
| | - Osman Enver Aydin
- Faculty of Medicine; Department of Plastic Reconstructive and Aesthetic Surgery; Ataturk University; 25240 Erzurum Turkey
| | - Mecit Kantarci
- Faculty of Medicine; Department of Radiology; Ataturk University; 25240 Erzurum Turkey
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