Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports

BACKGROUND

Thrombosis of the central veins is one of the most frequent complications of implanted venous access devices. Among the first cases occurring in our patients, most were associated with left-sided placement of the ports, with catheter tips lying against the external wall in the upper half of the superior vena cava. Some chest radiographs showed lateromediastinal opacities centered on the catheter tip, suggesting a vessel injury. This position allows a narrow contact between the catheter tip and the vessel wall, thus endothelial injuries might result from mechanical and chemical attack.

METHODS

To assess the role of catheter position, we reviewed the routine chest radiographs of 379 patients who received chemotherapy through venous access devices and were followed up at our department between December 1985 and December 1990. Four groups (upper left, upper right, lower left, and lower right) were defined according to the level of the catheter tip (innominate veins or upper half of the vena cava versus lower half of the vena cava or auricula) and to the side of port implantation.

RESULTS

Ten patients developed symptomatic venous thrombosis (superior vena cava in 9 patient, left subclavian vein in 1 patient). A strong correlation existed between catheter position and incidence of thrombosis: upper left, 8/28 (28.6%); upper right, 1/33 (3%); lower right, 1/68 (1.5%); and lower left, 0/250. Since 1988, we have insisted on replacement of malpositioned catheters, and we have observed fewer thromboses (2/191 versus 8/188).

CONCLUSIONS

The current study suggests that patients with left-sided ports and catheter tips lying in the upper part of the vena cava are at high risk for severe thrombotic complications.

Levels of plasma thrombomodulin are increased in atheromatous arterial disease

The plasma thrombomodulin (TM) level depends on the integrity of the endothelium and the clearance of the molecule. In several different pathological conditions, plasma TM levels increase with damage to the endothelium. We studied plasma TM levels in patients with various localizations of atheromatous arterial disease who had normal serum creatinine levels. Two groups of patients had a single symptomatic localization, which was either peripheral occlusive arterial disease (POAD) or ischemic heart disease (IHD) and a third group of patients had multiple symptomatic localizations (polyvascular). We compared the plasma TM levels with the plasma levels of other specific markers of endothelial cell activation such as: prostacyclin (PGI2), tissue-type plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI-1). Plasma TM levels were significantly increased in all three individual groups and when all patients were considered (total patients), as compared with normal controls. When all patients were considered, there was a significant positive correlation between plasma TM levels and t-PA and between plasma TM levels and PGI2. A significant positive correlation was also found between the plasma TM levels and PAI-1 for patients with POAD. Thus, our findings suggest that an increased influx of TM into the plasma may be caused by endothelial cell damage in patients with atheromatous arterial disease. However in our study, the plasma TM levels obtained were similar for all three types of atheromatous arterial disease. Though plasma thrombomodulin is a marker of endothelial cell injury, it cannot be of a clinical interest until its levels are related to the extend of the atheromatous lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

A new radiologic measurement for the diagnosis of Haglund's deformity

The authors describe a new method of radiologic measurement of "Haglund's deformity", based on a radiologic study of 31 feet operated for posterior heel pain and more especially for calcaneal tendinopathies related to deformity of the calcaneus, and on a series of 60 asymptomatic feet. This angular approach requires a lateral weight-bearing view and proved positive in 85% of symptomatic feet, with only 14% of false-positives in the control group. It thus proves markedly superior to previously described radiologic formulations, since it allows not only for the size and site of the deformity of the posterosuperior part of the calcaneus but also for the angle of verticalization of the latter.

Morphologic and histologic study of the ligamentum flavum in the thoraco-lumbar region

The ligamentum flavum, of which there are only a few studies in the literature, has several features discussed in this work. On the macroscopic level, it has a metameric arrangement: it has two layers, superficial and deep, whose fibers are opposite, and it has close relations with the tendons of attachment of some spinal erector muscles. On the microscopic level, its structure is unique for a ligament, because of a predominance of elastic fibers, because of its intrinsic innervation at each level of the spine, and because this innervation grows poorer with increasing degeneration. The ligamentum flavum constitutes an active ligament, with an essential biomechanical role. Its injury is probably not without consequences, and therefore there are many technical problems about the surgical interlaminar approach.

Clinical performance of vascular grafts lined with endothelial cells

The replacement of arteries with purely synthetic vascular prostheses often leads to the failure of such reconstructions when small-diameter or low-flow locations are concerned, due in part to the thrombogenicity of the internal graft surface. In order to improve long-term patency of these grafts, the concept of endothelial cell seeding has been suggested because this metabolically active endothelial surface plays major roles in preventing in vivo blood thrombosis and because vascular grafts placed in humans do not spontaneously form an endothelial monolayer whereas they do in animal models. The composite structure resulting from the combination of biologically active cells to prosthetic materials thus creates more biocompatible vascular substitutes. To achieve endothelialization of synthetic vascular grafts, previous efforts aimed at "one-stage" procedure (adding autologous endothelial cells to the graft at the time of implantation) in the 1980's seemed clinically feasible but results of reported clinical trials were controversial and mostly disappointing. An alternative method is an in vitro complete and preformed endothelial lining at the time of implantation: the "two-stage" procedure which implies harvest and culture of autologous endothelial cells. Up to date, the latter approach demonstrated its superiority in terms of significantly increased patency of the grafts that underwent endothelialization eight years earlier.

A contribution to the study of the facial artery, its branches and anastomoses; application to the anatomic vascular bases of facial flaps

The authors present the results of dissection of 40 facial arteries and their collaterals. The study of the collaterals is specifically for the cervical portion of this artery and especially for the three segments of its facial portion. The artery and its collaterals are extremely variable as regards its mode of termination. 4 types of artery are presented: labial, angular, nasal and abortive. The global description of the vascularization of the face and the principal anastomoses leads on to a study of the facial flaps and the plastic surgery of the face.

Laparoscopic surgery for coeliac artery compression syndrome: current management and technical aspects

OBJECTIVES

The study aims to assess the feasibility and midterm outcome of trans-peritoneal laparoscopy for coeliac artery compression syndrome (CACS).

DESIGN

Retrospective chart review involving four European vascular surgery departments and two surgical teams.

MATERIALS AND METHODS

charts for patients who underwent laparoscopy for symptomatic CACS between December 2003 and November 2009 were reviewed. Preoperative computed tomography (CT) angiography and postoperative duplex scan and/or CT angiography were performed.

RESULTS

Eleven consecutive patients (nine women) with a median age of 52 years (interquartile range: 42.5-59 years) underwent trans-peritoneal laparoscopy for CACS. All patients had a history of postprandial abdominal pain; weight loss exceeded 10% of the body mass in eight cases. Preoperative CT angiography revealed coeliac trunk stenosis >70% in all cases. One patient had additional aortitis and inferior mesenteric artery occlusion, while another patient presented with an occluded superior mesenteric artery. Two conversions occurred (one difficult dissection and one aorto-hepatic bypass needed for incomplete release of CACS). The median blood loss was 195 ml (range: 50-900 ml) and median operative time was 80 min (interquartile range: 65-162.5 years). Symptoms improved immediately in 10/11 patients (no residual stenosis) while one remained unchanged despite a residual stenosis treated by a percutaneous angioplasty. Symptoms reappeared in one patient due to coeliac axis occlusion. The mean follow-up period was 35 ± 23 months (range: 12-78 months).

CONCLUSION

Our study demonstrates that trans-peritoneal laparoscopy for treating median arcuate ligament syndrome is safe and feasible. Additional patients and a longer follow-up are needed for long-term assessment of this laparoscopic technique.

Does the motor branch of the long head of the triceps brachii arise from the radial nerve?

Anatomy textbooks say that the motor branch of the long head of the triceps brachii (LHT) arises from the radial nerve. Some clinical observations of traumatic injuries of the axillary nerve with associated paralysis of the LHT have suggested that the motor branch of the LHT may arise from the axillary nerve. This anatomic study was performed, using both cadaver anatomical dissections and a surgical study, to determine the exact origin of the motor branch of the LHT. From the adult cadaver specimens (group I), 20 posterior cords were dissected from 10 subjects (eight embalmed, two fresh) using 3.5x magnification. The axillary nerve was followed from its onset to the posteromedial part of the surgical neck of the humerus and the radial nerve. We looked for the origin of the proximal branch of the LHT by a meticulous double anterior and posterior dissection. From the surgical group (group II), 15 posterior cords were dissected from 15 patients suffering from a C5-C6 injured paralysis, without paralysis of the LHT. During the surgical procedure, we looked for the origins of the motor branch of the LHT with a nerve stimulator. In group I, the motor branch of the LHT arose in 13 cases from the axillary nerve near its origin, in five cases from the terminal division of the posterior cord itself, and in two cases from the posterior cord 10 mm before its terminal division into the radial and axillary nerves. In no case did we find the motor branch of the LHT arising from the radial nerve. In eight cases, we found some accessory branches that arose near the principal branch. In group II, the motor branch of the LHT arose in 11 cases from the axillary nerve near its origin and in four cases from the terminal division of the posterior cord itself. The motor branch of the LHT never originated from the radial nerve. In four cases, we found some accessory branches that arose near the principal branch of the LHT. These results reveal that the motor branch of the LHT seems to originate most often from the axillary nerve. This contribution could be relevant for surgical treatment of traumatic nerve injuries.

A note on the anastomoses between the hypoglossal nerve and the cervical plexus

A series of 80 dissections was performed to define the anastomoses between the cervical plexus and the hypoglossal nerve (XII), the superior anastomosis between the trunk of XII and the ansa of the atlas from the cervical plexus; the ansa cervicalis, traditionally known as the ansa of the XIIth cranial nerve or hypoglossal ansa, formed by the direct junctional anastomosis of the descending branch of XII and the internal descending branch of the cervical plexus. The origins, form, branches and chief relations are defined in in the present study.

Percutaneous cryotherapy of vascular malformation: initial experience

The present report describes a case of percutaneous cryotherapy in a 36-year-old woman with a large and painful pectoral venous malformation. Cryoablation was performed in a single session for this 9-cm mass with 24 h hospitalisation. At 2- and 6-month follow-up, the pain had completely disappeared, and magnetic resonance imaging demonstrated a significant decrease in size. Percutaneous cryoablation shows promise as a feasible and apparently safe method for local control in patients with symptomatic venous vascular malformations.

A contribution to the study of the accessory nerve: surgical implications

The anatomy of the accessory n. is defined in the light of 100 dissections with particular regard to the following aspects: its relations with the internal jugular v.; its participation in the innervation of the sternocleidomastoid m.; its location in relation to the anterior and posterior borders of that muscle and to the anterior border of the trapezius; and its branching and anastomoses in the supraclavicular fossa.

The intraorbital arrangement of the anterior and posterior ethmoidal foramina

This study, instigated by surgical observations, and mainly carried out on the dry bone, attempts to analyse both the depth and variability of the anterior and posterior ethmoidal foramina through which pass the ethmoidal aa. The surgical implications of this study relate not only to ligation of the ethmoidal aa. in certain cases of epistaxis, their embolisation and the endonasal microsurgery of the ethmoid, but also to the surgery of the anterior cranial fossa. The study is based on 200 anatomic observations.

Experimental evaluation of a gelatin-coated polyester graft used as an arterial substitute

Protein coating and endothelial cell preseeding have been proposed and studied as improvements to arterial prostheses. In this paper, an impervious polyester vascular graft which had been coated with cross-linked gelatin was compared to a porous one over a period of up to 8 months in dogs. This evaluation involved in vivo methods using radio tracers to study patency and thrombogenicity and in vitro controls of the healing processes. The main advantages offered by coated grafts over uncoated include the absence of preclotting and better biointegration.

Safety and efficacy of embolization using Onyx® of persistent type II endoleaks after abdominal endovascular aneurysm repair

PURPOSE

To retrospectively evaluate the safety and efficacy of embolization of persistent type II endoleaks occurring after abdominal endovascular aneurysm repair (EVAR) using ethylene vinyl alcohol copolymer (Onyx^®).

MATERIAL AND METHODS

Between 2008 and 2016, 28 consecutives patients (25 men, 3 women) with a mean age of 75.3years±9 (SD) (range: 59-90years) were treated for 29 persistent type II endoleaks with increasing aneurysm size>5mm occurring after EVAR. A total of 35 embolization procedures were performed using Onyx^®, via a transarterial route (n=25) or direct puncture (n=10), with or without additional metallic coils. The endpoints were to evaluate the clinical efficacy, corresponding to the stabilization or decrease of aneurism size, and the technical efficacy, corresponding to the ability to complete the embolization.

RESULTS

No severe complications were observed during and after embolization. The primary and secondary clinical efficacies were 75% (21/28) and 96.4% (27/28), respectively. Overall primary technical efficacy rate was 58.6% (17/29), greater for transarterial technique (72.8%) than for direct puncture (14.3%) (P=0.01). Secondary technical efficacy was 72.4% (21/29), with no differences between transarterial (81.8%) and direct puncture (42.8%) (P=0.06).

CONCLUSION

Embolization with Onyx^® of type II endoleaks after EVAR appears a safe and effective procedure.

Anatomic basis of the sural fascio-cutaneous flap: surgical applications

Studies of the fascio-cutaneous vascularization and innervation of the leg seem incomplete. After reviewing the classical findings, the authors report on their anatomic study 15 dissections. Perforating pedicles, originating from the peroneal artery (3 to 5) and posterior tibial artery (4 to 5) destined for the skin and fascia of the posterior aspect of the leg were constantly found. This study suggests the possibility of a distally based sural fascio-cutaneous flap, a flap which has been successfully constructed clinically.

A contribution to the study of the innervation of the sternocleidomastoid muscle

Studies on the innervation of the sternocleidomastoid muscle have shown the highly variable arrangement of the nerve fibers originating from the accessory nerve (eleventh cranial pair) and cervical nerves which supply the muscle. The results of 100 dissections described in this study confirmed these variations and led to propose a classification of the innervation of the sternocleidomastoid according to three main types. The classical "anastomotic" type of innervation (also referred to as Maubrac's type of innervation) was the most frequent, although present in only half of all cases. Innervation of the sternocleidomastoids in symmetrical fashion was an exceptional finding. The functional attributes of these anatomical variations are discussed.

The supra-transverse intermetatarsocapital bursa: a description and its relation to painful syndromes of the forefoot

Very many painful syndromes of the forefoot remain without a satisfactory explanation; although this region contains quite specific structures, it has suffered from the application of analogies with disorders of the hand. Among these specific components, the presence of the supra-transverse intermetatarsocapital bursa provides an explanation of such clinical entities as the acute syndrome of the second intermetatarsal space and gives fresh impetus to the debate on the etiopathogenesis of Morton's metatarsalgia. On the basis of 25 dissections, the authors studied the region between the metatarsal heads, confirming the presence of these bursae and specifying their site and size and particularly their relations with the common plantar digital nerve at its bifurcation into collateral nerves.

Association of primary varicose veins with dysregulated vein wall apoptosis

BACKGROUND

Disordered programmed cell death may play a role in the development of superficial venous incompetence. We have determined the number of cells in apoptosis, and the mediators regulating the intrinsic and extrinsic pathways in specimens of varicose vein.

METHODS

Venous segments were obtained from 46 patients undergoing surgical treatment for primary varicose veins. Controls samples were obtained from 20 patients undergoing distal arterial bypass grafting surgery. Segments of the distal and proximal saphenous trunk as well as tributaries were studied. Cell apoptoses and mediators of the mitochondrial and trans membrane pathway were evaluated with peroxidase in situ apoptosis detection, Bax and Fas detection, caspase-9 and 8 detection in the medial layer.

RESULTS

Disorganised histological architecture was observed in varicose veins. Primary varicose veins also contained fewer peroxidase in situ-positive cells than control veins (2.6% S.D. 0.2% versus 12% S.D. 0.93%, P=.0001, Mann-Whitney u test), fewer Bax positive cells (2.1.% S.D. 0.3% versus 13% S.D. 0.9%, P=.0001) and fewer Caspase 9 positive cells (3.2% S.D. 1% versus 12% S.D. 1.3%, P=.0001). Similar findings were observed in saphenous trunk, main tributaries and accessory veins. In patients with recurrent varicose veins in whom the saphenous trunk had been preserved showed similar findings to primary varicose veins. Residual varicose veins contained fewer peroxidase in situ-positive cells than healthy veins (3.2% S.D. 0.6% versus 11% S.D. 2%, P=.0001), fewer Bax positive cells (2.2% S.D. 0.3% versus 12% S.D. 0.7%, P=.0001) and fewer Caspase 9 positive cells (2.6% S.D. 0.6% versus 12% S.D. 1%, P=.0001). Immunohistochemical detection for Fas and caspase 8 remained equal was the same in the varicose vein and control groups.

CONCLUSION

Apoptosis is down regulated in the medial layer of varicose veins. This dysregulation is attributable to a disorder of the intrinsic pathway and involves the great saphenous vein trunk, major tributaries and accessory veins. This process may be among the causes of primary varicose veins.

[Secondary aortoduodenal fistulas: report of 7 cases]

PURPOSE

Aortoduodenal fistulas are the most frequent aortoenteric fistulas. They may be primary (occurring after aneurysms of the native aorta) or secondary (occurring after aortic prosthesis). Aortoduodenal fistulas are a rare complication of aortic prostheses. They may be caused by prosthesis infection or due to inadequate prosthesis.

METHODS

We report seven observations that emphasize issues pertaining to either diagnosis or therapy.

RESULTS

The delay of occurrence is variable, with a mean of 3 years as reported in the literature. Clinical picture includes upper digestive tract hemorrhage, sometimes fever, abdominal pain or mass. Though difficult, diagnosis can be achieved through gastric endoscopy or CT-scan. Additional diagnostic procedures are often not useful and should not be numerous. Surgical procedures help guide the diagnosis and constitute the main part of the treatment with suture of the duodenum and vascular prosthesis. According to previous works, our observations including prolonged follow-up of the patients suggest that the best vascular treatment is extra-anatomic axillo-bifemoral bypass, while simple suture and prosthesis replacement lead to poor results.

CONCLUSION

Mortality related to aortodigestive fistulas is high (five out of seven patients in the present study) and requires prevention, including more particularly delicate surgery and antibiotic therapy in case of any episode of infection. Aortoduodenal fistulas must be suspected whenever a patient with aortic prosthesis has digestive bleeding or unexplained fever.

Percutaneous cryoablation of symptomatic venous malformations as a second-line therapeutic option: a five-year single institution experience

PURPOSE

To report the mid-term outcomes of percutaneous cryoablation (PCA) performed as second-line therapeutic option of venous malformations (VM).

MATERIAL AND METHODS

From 2011 to 2015, PCA was offered in 24 patients (mean age: 31 years, range: 12-64) as second-line treatment for recurrence of symptoms after sclerotherapy and when resection was not possible (due to lesion location or previous failure) or refused by the patient. Adverse effects were recorded, disease-free survival (DFS) and local tissue control (LTC) rates were calculated based on symptoms and volume evolution.

RESULTS

Mean follow-up was 18.7 months (6-48). Nine (37.5%, 9/24) adverse effects occurred and three (12.5%, 3/24) were severe. Mean pain assessed by visual analog scale (VAS) was 41.7 mm (0-80) before treatment and 20.3 mm (0-80) (p=0.01) after. Mean volume decreased significantly after treatment from 22.4 cm³ (0.9-146) to 8.35 cm³ (0-81.3) (p<0.001). Pain recurred in nine patients and size of one lesion increased. The DFS and LTC rates were 54% [95%CI: 22.94-77.27] and 93.33% [61.26-99.03] at 24 months, respectively. Only VM volume >10 cm³ was associated with a higher risk of local recurrence (p=0.05).

CONCLUSION

PCA as second-line treatment appears to be safe and effective for local control of VM according to mid-term results.

KEY POINTS

• Percutaneous cryoablation of venous malformations appeared well tolerated. • Size of venous malformations decreased significantly after percutaneous cryoablation (p<0.001). • Pain decreased significantly after percutaneous cryoablation of venous malformations (p=0.01).

Evaluation of an in vitro endothelialized vascular graft under pulsatile shear stress with a novel radiolabeling procedure

OBJECTIVE

To improve the hemocompatibility of vascular grafts, endothelial cell (EC) seeding of biomaterials prior to implantation is critical. The current in vitro study was designed to investigate such a feasibility on a collagen-coated heparin-bonded graft and to evaluate cell detachment upon pulsatile shear stress.

MATERIALS AND METHODS

Endothelial cells (EA-hy-926) were seeded onto grafts. The endothelialization of the grafts was evaluated by the [3H]-thymidine incorporation, scanning electron microscopy (SEM) and histological examinations. After in situ EC radiolabeling with a novel 99mTc technique, the prostheses were exposed to pulsatile shear stress (0.27 N/m2), mimicking the shear rate occurring in a superficial femoral artery, for 3 h in a flow circuit and EC loss quantified by gamma camera detection.

RESULTS

Complete EC coverage was achieved after 5 days. Three hours of artificial perfusion resulted in a low EC loss (12.9+/-0.8%, n = 7). SEM shows EC withstanding shear stress in valleys of prosthesis circumvolutions.

CONCLUSIONS

These satisfactory results could be explained by the high affinity of EC for heparinized surfaces in addition to cell surface receptors involved in adhesion to collagen.

Anterior innervation of the proximal tibiofibular joint

Mucoid cysts compressing the common peroneal nerve have been reported. Whether these cysts are schwannoma or are synovial in nature is the subject of controversy in the medical literature. To contribute to this debate, the present study was designed to detail the anterior innervation of the proximal tibiofibular joint. We dissected 10 knees of five fresh cadavers after staining the tibiofibular joint under fluoroscopic guidance. Through a lateral approach near the fibular head, the common peroneal nerve was isolated then dissected distally to determine whether it or its branches ramified over the proximal tibiofibular joint. In all 10 legs, only one collateral branch was observed on the common peroneal nerve proximal to its terminal division. This collateral sent a branch to the proximal tibiofibular joint before penetrating the tibialis anterior muscle. The articular branch coursed in a superior and posterior direction approximately 1 cm to attain the tibiofibular joint. In no specimen did the deep or superficial peroneal nerves send a twig to the tibiofibular joint. This study confirms and clarifies prior descriptions of the innervation of the anterior aspect of the proximal tibiofibular joint. It clarifies the mechanisms of compression of the common peroneal nerve by synovial cysts that originate from the proximal tibiofibular joint and provides anatomical landmarks that should facilitate complete resection of these cysts.