Aberrant branches of the subclavian artery and their relationship with the phrenic nerve and the brachial plexus / Ramas aberrantes de la arteria subclavia y su relación con el nervio frénico y el plexo braquial

SUMMARY: Variations in subclavian artery branches are relatively common and may impact surgical procedures and effects. During educational dissection of a male cadaver, we encountered an extremely rare variation of the right subclavian artery branches. The internal thoracic artery, the thyrocervical trunk, and the costocervical trunk arose from the third part of the right subclavian artery. In addition, the phrenic nerve displaced remarkably laterally by the thyrocervical trunk, and the course of the costocervical trunk was between the upper trunk and the middle trunk of the brachial plexus. These variations may pose a potential risk for nerve compression and increase the risk of arterial and nerve puncture. This case report would bring attention to the possibility of other similar cases, and early detection of these variations through diagnostic interventions is helpful to reduce postoperative complications.

RESUMEN: Las variaciones en las ramas de la arteria subclavia son relativamente comunes y pueden afectar los procedimientos y efectos quirúrgicos. Durante la disección educativa de un cadáver masculino, encontramos una variación extremadamente rara de las ramas de la arteria subclavia derecha. La arteria torácica interna, el tronco tirocervical y el tronco costocervical nacían de la tercera parte de la arteria subclavia derecha. Además, el nervio frénico se desplazaba lateralmente por el tronco tirocervical, y el trayecto del tronco costocervical se encontraba entre el tronco superior y el tronco medio del plexo braquial. Estas variaciones pueden suponer un riesgo potencial de compresión nerviosa y aumentar el riesgo de punción arterial y nerviosa. Este reporte de caso llamaría la atención sobre la posibilidad de otros casos similares, y la detección temprana de estas variaciones a través de diagnósticos es útil para reducir las complicaciones postoperatorias.

Successful endovascular repair with coil embolization of ruptured right internal thoracic artery aneurysm / Reparo endovascular bem-sucedido de aneurisma da artéria torácica interna direita roto com embolização com molas

Abstract Internal thoracic artery aneurysms (ITAAs) are rare with wide variation in clinical presentation and a high risk of rupture. Endovascular techniques are increasingly being used for treatment of such aneurysms over surgical repair in recent times. A 34-year-old male presented with progressive swelling of the right anterior chest wall for 2 weeks and was diagnosed with right internal thoracic artery aneurysm with contained rupture. He underwent successful endovascular repair with coil embolization of ruptured right ITAA. Post intervention computed tomography (CT) angiography confirmed sealing of the ruptured aneurysm with no residual filling of the sac. At six months follow-up he is doing well with complete resolution of hematoma. This case demonstrates that an endovascular approach with coil embolization is a feasible and safe option for treating the rare ruptured ITAAs.

Resumo Os aneurismas da artéria torácica interna (ITAAs) são raros, com ampla variação na apresentação clínica e alto risco de ruptura. As técnicas endovasculares têm sido cada vez mais utilizadas para o tratamento desses aneurismas em relação ao reparo cirúrgico. Um homem de 34 anos de idade apresentou edema progressivo da parede torácica anterior direita por 2 semanas e foi diagnosticado com aneurisma da artéria mamária interna direita com ruptura contida. Ele foi submetido a reparo endovascular bem-sucedido, com embolização de ITAA direito roto. A angiotomografia computadorizada (angioTC) pós-intervenção confirmou o selamento do aneurisma rompido, sem enchimento residual do saco. No seguimento de 6 meses, ele estava bem, com resolução completa do hematoma. Este caso demonstra que a abordagem endovascular com embolização com molas é uma opção viável e segura no tratamento dos raros ITAAs rotos.

Clinical application of lateral thoracic artery perforator flap in breast conserving surgery / 中华医学美学美容杂志

Objective:To explore the clinical application of lateral thoracic artery perforator flap in repairing local defect after breast conserving surgery.Methods:The clinical data of 48 breast cancer patients planned to finish breast conserving surgery were retrospectively analyzed. The patients were divided into plastic breast-conserving group and routine breast conserving group. In the plastic breast-conserving group, 24 patients local defect repaired with the lateral thoracic artery perforator flap. In the routine breast conserving group, 24 patients local defect repaired with the fascial flap around the cutting edge. The operation related indexes and cosmetic effect from two groups were compared.Results:Both groups of patients successfully completed breast conserving surgery. The plastic breast-conserving group patients had significantly increased in operation time, operative blood loss, incision length and drainage tube indwelling time compared with the routine breast conserving group; the differences were statistically significant ( t=6.99, 9.37, 21.74, 8.80, P<0.05). The rate of secondary surgery enlarged was lower than fhat in the routine breast conserving group, and the difference was statistically significant (χ 2=4.76, P<0.05). There were 3 cases in the plastic breast conserving group and 1 case in the conventional breast conserving group. The skin at the edge of the flap was ischemic necrosis in the 4 cases, which healed after dressing change and drainage, and there was no significant difference ( P>0.05). The evaluation of postoperative cosmetic effect showed that the excellent and good rate of the observation group was 91.7%, compared with the routine breast conserving group (58.3%); the difference was statistically significant (χ 2=7.11, P<0.05). All patients were followed up for average 24 months, and local recurrence and distant metastasis were not observed. Conclusions:The lateral thoracic artery perforator flap for filling local defects in the lateral quadrant or central region of breast cancer is feasible, easy to operate, hides incision scar, better cosmetic effect and worthy of clinical promotion.

Effect of thoracic artery blood supply on the accuracy of contrast-enhanced ultrasound in differentiating benign and malignant peripheral pulmonary lesions / 中华超声影像学杂志

Objective:To investigate whether the existence of thoracic artery blood supply in peripheral pulmonary lesions is the key factor affecting the accuracy of contrast-enhanced ultrasound in differentiating benign and malignant lesions.Methods:From June 2020 to December 2021, a total of 170 patients with peripheral pulmonary lesions were consecutively enrolled in Xi′an Chest Hospital, and all patients underwent conventional ultrasound and contrast-enhanced ultrasound(CEUS). Taking ΔAT(lesion-lung arrival time difference ) of 2.5 seconds as the cut-off point for differentiating benign and malignant lesions(ΔAT<2.5 s for benign, ΔAT≥2.5 s for malignant), and the final pathological results as the gold standard, these patiens were divided into correct classification group and wrong classification group, and the main influencing factors of wrong classification were analyzed.Results:Compared with the correct classification group, the proportion of thoracic artery blood supply in the wrong classification group was significantly higher ( P<0.001). After adjusting the dendritic venous reflux, thoracic artery blood supply was an independent influencing factor for CEUS misclassification ( OR=3.531, 95% CI=1.805-6.908, P<0.001). In the patients with thoracic artery blood supply, the sensitivity of the absence of dendritic venous reflux in judging malignant peripulmonary lesions was 75.0%, the specificity was 91.3%, and the area under the ROC curve (AUC) was 0.832 (95% CI=0.715-0.915, P<0.001), while the sensitivity, specificity and AUC of CEUS in judging malignant peripulmonary lesions were 68.7%, 67.4% and 0.659 (95% CI=0.528-0.775, P=0.006), and there was significant statistical difference in the AUC between them( P<0.001). In the group of patients without thoracic arterial blood supply, the sensitivity of the absence of dendritic venous reflux in judging malignant peripulmonary lesions was 82.8%, the specificity was 63.3%, and the AUC was 0.730 (95% CI=0.636-0.811, P<0.001), while the sensitivity, specificity and AUC of CEUS in judging malignant peripulmonary lesions were 62.1%, 81.0% and 0.684 (95% CI=0.587-0.770, P=0.003), and there was no significant difference in the AUC between them ( P=0.425). Conclusions:The presence of thoracic artery blood supply significantly decrease the diagnostic efficiency of CEUS in differentiating benign and malignant of peripheral pulmonary lesions. For peripheral pulmonary lesions with thoracic arterial blood supply, the diagnostic efficiency of dendritic venous reflux is better than CEUS, while for lesions without thoracic artery supply, the diagnostic efficiency of dendritic venous reflux is equivalent to CEUS.

Primer separador retráctil de pulmón para facilitar la disección extrapleural de la arteria torácica interna / First retractable lung spreader to facilitate extrapleural dissection of the internal thoracic artery

RESUMEN La disección de la arteria torácica interna es uno de los procedimientos más definitorios de la cirugía de revascularización miocárdica, pues se ha demostrado que la calidad de vida y la evolución a corto y largo plazo de los pacientes dependerán de las características morfológicas del injerto. Hace más de 25 años se propuso la utilización de un separador pulmonar maleable para facilitar la disección de la arteria torácica interna, especialmente su segmento proximal, pero nunca se ha fabricado ese dispositivo. Se presenta un separador pulmonar manufacturado a partir de dispositivos en desuso, empleados en cirugía coronaria. Se comentan y discuten las principales ventajas demostradas durante más de tres años en cerca de un centenar de pacientes.

ABSTRACT Internal thoracic artery dissection is one of the most defining procedures of coronary artery bypass grafting, as it has been demonstrated that the quality of life and short-long term outcome of patients will depend on the morphological characteristics of the graft. More than 25 years ago, the use of a malleable lung spreader was proposed to facilitate the internal thoracic artery dissection especially its proximal segment, but that device has never been manufactured. A lung spreader, assembled from disused devices, used in coronary artery revascularization is presented. The main advantages confirmed over more than three years in nearly a hundred patients are discussed and commented upon.

An Anatomical Study Of Variations In The Branching Pattern Of Axillary Artery And Its Clinical Significance

Introduction: Variation in the branching pattern of axillary artery is quite common. Accurate knowledge of thenormal and variant arterial anatomy of the axillary artery is important for clinical procedures in axillary andpectoral region. The aim of this study is to find out the incidence and types of variation in the branching patternof axillary artery.Materials and Methods: Dissection of axillary and pectoral region was done on both sides in 25 cadavers in thedepartment of Anatomy, K.P.C. Medical College and Hospital, Kolkata to study the branching pattern of axillaryartery.Results: Variation was present in 16% cases. Among these, 6% variation was present in the second part and 10%variation was present in the third part of axillary artery. Most common variation found was the origin ofsubscapular artery from the second part of axillary artery.Conclusion: Proper knowledge of variations of branching pattern of axillary artery is important for orthopaedic,reconstructive and vascular surgeons to avoid complications during various surgical procedures in axillaryregions and angiographies.

Variant Anatomy Of Internal Thoracic Artery- Clinical Implications

Background: Now a days, Internal thoracic artery (ItA) is being widely used in coronary artery bypass grafting(CABG) and in breast reconstructive surgeries. In addition, the area around its origin is also used for subclavianvein catheterization and introducing a pacemaker.Aim: Aim of the study was to know the normal and variant anatomy of internal thoracic artery in Indian subjectsin order to provide useful data to thoracic surgeons, so as to prevent iatrogenic complications in ItA dissections.Clinical applications related to variations were analysed.Material and Methods: 30 cadavers were dissected to see the mode of origin of internal thoracic artery, diameterat its origin and relation with phrenic nerve and thyrocervical trunk.Results: 55 arteries were showing normal origin and tend to arise opposite the root of thyrocervical trunk.Remaining 5 were arising in common with one or two branches of thyrocervical trunk. Average diameter at itsorigin was 2.8cm on left and 2.6cm on right. Relation with phrenic nerve was variable.Conclusion: During CABG surgery, Breast reconstructive surgery and various interventional procedures, it isimportant to know the variant pattern of ItA so as to avoid iatrogenic complications

A Questionnaire Survey of Regarding the Internal Thoracic Artery Harvesting Targeting Under 40 Cardiovascular Surgeons No.11 / 日本心臓血管外科学会雑誌

Basic procedures that cardiovascular surgeons routinely perform are rarely discussed, despite the great variability among facilities. The aim of this study is to survey the current status of internal thoracic artery harvesting in cardiovascular surgeons aged under 40 years old, and to share the results of this questionnaire investigation regarding basic skills.

Comparison of the Plasma Metabolome Profiles Between the Internal Thoracic Artery and Ascending Aorta in Patients Undergoing Coronary Artery Bypass Graft Surgery Using Gas Chromatography Time-of-Flight Mass Spectrometry

BACKGROUND: The left internal thoracic artery (LITA) has been used as the first conduit of choice in coronary artery bypass grafting (CABG) because of excellent long-term patency and outcomes. However, no studies have examined substances other than nitric oxide that could be beneficial for the bypass conduit, native coronary artery or ischemic myocardium. This study was conducted to evaluate differences in metabolic profiles between the LITA and ascending aorta using gas chromatography-time of flight-mass spectrometry (GC-TOF-MS). METHODS: Twenty patients who underwent CABG using the LITA were prospectively enrolled. Plasma samples were collected simultaneously from the LITA and ascending aorta. GC-TOF-MS based untargeted metabolomic analyses were performed and a 2-step volcano plot analysis was used to identify distinguishable markers from two plasma metabolome profiles. Semi-quantitative and quantitative analyses were performed using GC-TOF-MS and enzyme-linked immunosorbent assay, respectively, after selecting target metabolites based on the metabolite set enrichment analysis. RESULTS: Initial volcano plot analysis demonstrated 5 possible markers among 851 peaks detected. The final analysis demonstrated that the L-cysteine peak was significantly higher in the LITA than in the ascending aorta (fold change = 1.86). The concentrations of intermediate metabolites such as L-cysteine, L-methionine and L-cystine in the ‘cysteine and methionine metabolism pathway' were significantly higher in the LITA than in the ascending aorta (2.0-, 1.4- and 1.2-fold, respectively). Quantitative analysis showed that the concentration of hydrogen sulfide (H2S) was significantly higher in the LITA. CONCLUSION: The plasma metabolome profiles of the LITA and ascending aorta were different, particularly higher plasma concentrations of L-cysteine and H2S in the LITA.

A Case of One-Stage Surgical Treatment of Subclavian Steal Phenomenon Coexisting with Ischemic Heart Disease without Extra-corporeal Circulation / 日本心臓血管外科学会雑誌

A 49-year-old man presented with subclavian steal phenomenon and severe stenosis of LMT. His SSP was composed of severe stenosis of the innominate artery, and the greater part of the blood supply to the right subclavian artery was through the collateral circuit of the vertebral arteries and the internal thoracic arteries. We performed replacement of the innominate artery with a prosthetic graft and coronary artery bypass using LITA in one-stage surgery.

A Cadaveric Study On Lateral Thoracic Artery

Introduction: Lateral thoracic artery is one of the branches of second part of axillary artery which arises near thelateral border of pectoralis minor.Aim and Objectives: To study the variations in the origin of Lateral thoracic artery and note its pattern.Materials and methods: 54 axillae from embalmed cadavers allotted for dissection were used for the study.There were 22 male and 5 female cadavers, with ages ranging from 60 to 80 years, specimens of both sides wereused.Results: The commonest variation was common trunk for Lateral thoracic artery and Thoracodorsal Artery(9.5%).Conclusion: The study was carried out to show important variations in the branching pattern of lateral thoracicartery, in order to orient the surgeons performing reconstructive plastic surgery and modified radial mastectomy.

Scalenus Anterior Muscle With Two Heads Associated With Variation In The Branches Of Subclavian Artery: A Rare Presentation

Arterial variations are quite common. Many studies had elaborated variations in branching pattern of subclavianartery. Present study illustrates a unique feature of scalenus anterior muscle having two heads of origin and acommon trunk for internal thoracic artery (ITA) and thyrocervical trunk (TCT). This rare common trunk passesbetween two heads of right scalenus anterior. Such rare variation was not reported so far. The rarity of suchvariation signifies the necessity of the present study. On the left side all branches arose normally from subclavianartery except dorsal scapular artery which originates from second part itself instead of third part which is aquite common variation. The Internal thoracic artery is widely utilized as a great conduit for MyocardialRevascularization. This common truncal origin is of great surgical importance to Cardiothoracic Surgeons,Cardiovascular Surgeons and Interventional Therapy Radiologists.

Repair of large and medium size facial skin and soft tissue defects by the free expanded deltopectoral flap / 中华整形外科杂志

Objective@#To evaluate the application of the expanded free deltopectoral flap, pedicled with perforation of internal thoracic artery, in the repairment of middle to large facial skin and soft tissue defect.@*Methods@#From June 2015 to December 2017, 11cases diagnosed with facial lesions were included in this study. The tissue defect of 10 cases were caused by burn, and 1 case by superficial tumor. In the first stage, the tissue expander was implanted into the internal thoracic artery supplying area. After the expander was fully expanded, the second surgery, i. e. the resection of facial lesion, was performed. The defect areas of patients, with the range of 9 cm×7 cm to 17 cm×10 cm, were repaired by expanded free deltopectoral flaps.@*Results@#All flaps were survived, with no vascular crisis occurred. The size of flaps ranged from 10.0 cm×9.0 cm to 18.0 cm×11.5 cm. All the patients were satisfied with the outcomes, after 6 to 24 months follow-up. The color and texture of flaps was close to normal. The scars were acceptable.@*Conclusions@#The expanded free deltopectoral flap, pedicled with the perforator of internal thoracic artery, is a promising way to repair middle to large facial skin and soft tissue defect.

Breast reconstruction with pedicled perforator flaps / 中国癌症杂志

Comparing with free perforator flap, pedicled flap is a relatively simpler and safer technique, with lesser donor site morbidity. In recent years, the application of pedicled perforator flaps has emerged as a new option for breast reconstruction. Those pedicled perforator flaps include thoracodorsal artery perforator flap, intercostal artery perforator flap (lateral intercostal artery perforator flap, anterior intercostal perforator flap) etc. Serratus anterior artery perforator flap, superior epigastric artery perforator flap, and lateral thoracic artery perforator flap can also be raised technically. To enhance surgical accuracy, it is necessary to evaluate the location and quality of perforator vessels preoperatively. Proper flap design is of more importance for pedicled flap when compared with it's free flap counterpart. Although free flap approach remains the golden standard in breast reconstruction when considering autologous tissue transplantation, pedicled perforator flap has the apparent merits of minimized surgical trauma, less time-consuming and less stress for reconstructive surgeons.

Idiopathic Internal Thoracic Artery (ITA) Pseudoaneurysm treated with endovascular embolization

A 44-year-old female was diagnosed with an ITA pseudoaneurysm in the right supraclavicular fossa. She was successfully treated with endovascular embolization. The challenges of diagnosis and treatment are discussed.

Octreotide for Treatment of Chylorrhea after Internal Thoracic Artery Harvest / 日本心臓血管外科学会雑誌

<p>Chylorrhea is a rare complication after cardiothoracic surgery, occurring in 0.5-2% of patients. It is extremely rare after coronary artery bypass grafting. The initial management of chylorrhea is conservative, but if it is unsuccessful, surgical intervention is indicated. Recently, some cases treated with octreotide have been reported. We report two cases of chylorrhea after internal thoracic artery harvest treated with octreotide.</p>

Hybrid Coronary Artery Revascularization for Takayasu Arteritis with Major Visceral Collateral Circulation from the Left Internal Thoracic Artery

Coronary arterial involvement in Takayasu arteritis (TA) is not uncommon. Herein, we describe a case of TA with celiac trunk and superior mesenteric artery occlusion combined with coronary artery disease. Bilateral huge internal thoracic arteries (ITAs) and the inferior mesenteric artery provided the major visceral collateral circulation. After percutaneous intervention to the right coronary artery, off-pump coronary artery bypass grafting for the left coronary territory was done using a right ITA graft and its large side branch because of its relatively minor contribution to the visceral collateral circulation.

Fluxometria intraoperatória do enxerto composto de artéria torácica interna esquerda e veia safena magna

Enxerto composto de artéria torácica interna esquerda (ATIE) e veia safena magna (VSM) na revascularização de duas ou mais artérias do sistema coronariano esquerdo (SCE)é uma técnica descrita na literatura desde a década de 1980. Apesar de recentes estudos demonstrarem que a ATIE é capaz de oferecer fluxo sanguíneo adequado, para duas ou mais artérias do SCE, tanto em situação de repouso como estresse, estudos aprofundados devem ser desenvolvidos para aprimorar esse conhecimento. O objetivo deste trabalho é analisar a dinâmica de fluxo sanguíneo neste tipo de enxerto composto, sobretudo no que concerne a adaptabilidade da ATIE eà influência da presença do segmento de VSM sobre o fluxo na ATIE.Em vinte e três pacientes foirealizadoenxerto composto em Y de ATIE e VSM, para revascularizar a artéria interventricular anterior (AIA) e outro ramo do SCE, respectivamente, sem circulação extracorpórea (CEC). O fluxo sanguíneomédio, parâmetros de perviedade do enxerto(fração diastólica e índice de pulsatilidade)e reserva de fluxo coronariano(RFC) foram avaliados por meio de fluxometria por tempo de trânsito (FMTT)em todos os segmentos do enxerto composto, ou seja, nos segmentos proximal e distal da ATIE e no segmento de VSM. As medidas foram realizadas em condição basal, e após estresse farmacológico com dobutamina, bem como sem e com clampeamento temporário a traumático dos segmentos distais do enxerto composto.Estresse farmacológico resultou em aumento dos valores do fluxo sanguíneo em todos os segmentos analisados(p<0,05)...

Composite graft of left internal thoracic artery (LITA) and great saphenous vein (GSV) in the revascularization of two or more arteries of the left coronary system (LCS) is a technique described in literature since the 1980s. Despite recent studies demonstrating that LITA is capable of providing adequate blood flow for two or more LCS arteries, both in basal condition and under stress, deeper studies must be developed to improve this knowledge. The objective of this study was to analyze blood flow dynamics in this kind of composite graft, specially in what concerns to LITA adaptability and to the influence of GSV segment on LITA flow. In 23 patients, a LITA and GVS composite Y-graft was realized to the anterior interventricular artery (AIA) and to another LCS branch, respectively, without extracorporeal circulation. Mean blood flow, as well as parameters of graft patency (diastolic fraction and pulsatile index) and coronary flow reserve(CFR)were evaluated throughtransit time flowmetry (TTFM) in all segments of the composite graft, which are LITA proximal and distal segments, and GSV segment. The measures were realized in basal condition and after dobutamine-induced pharmacological stress, as well as without and with non-traumatic temporary clamping of the distal segments of composite graft. Pharmacological stress resulted in increased values of blood flow in all analyzed segments (p<0,05)...

Total Aortic Arch Replacement in a Patient with a Patent Right Internal Thoracic Artery Graft Crossing between the Sternum and the Ascending Aortic Aneurysm / 日本心臓血管外科学会雑誌

We report a case of 76 year-old woman who had previously undergone coronary artery bypass grafting (CABG) with the right internal thoracic artery (RITA) bypassed to the left anterior descending artery. Six years after CABG, she developed acute type A aortic dissection, and she was medically treated because the false lumen was thrombosed and it was considered that surgical intervention would be high risk for the patent RITA graft crossing between the sternum and the ascending aorta. During follow-up, her aortic aneurysm enlarged to 57 mm in diameter, and finally she was referred to our hospital for surgical intervention. In this case, preservation of the patent RITA graft was thought to be critical because the RITA graft was the only blood source for the left anterior descending artery. Prior to re-median sternotomy, we performed a right anterior minithoracotomy to make sufficient space between the sternum and the RITA graft, and then instituted peripheral cardiopulmonary bypass to decompress the heart. After re-sternotomy, we ensured minimum dissection of the RITA graft, and we successfully accomplished graft replacement of the ascending aorta to the aortic arch without injuring the patent RITA graft. In cases with a patent RITA graft and an ascending aortic aneurysm close to the sternum, our strategy is considered to be efficient for re-median sternotomy.

Excision of a Giant Coronary Artery Aneurysm Located Immediately Proximal to the LAD and Closure of Its Stump with LITA Patch and CABG to LAD / 日本心臓血管外科学会雑誌

A 52-year old man was referred to our hospital for atrial fibrillation ablation therapy. A multislice computed tomography study demonstrated a giant coronary artery aneurysm situated just proximal to the left anterior descending (LAD), LAD stenosis and coronary-pulmonary artery fistula. The fistula was ligated and the aneurysm was resected under cardiopulmonary bypass. The left internal thoracic artery was used as a bypass graft to the LAD as well as a patch for closure of the LAD orifice to avoid left circumflex artery stenosis. We report a rare case of giant LAD aneurysm with coronary-pulmonary artery fistula.