Brachial insertion of fully implantable venous catheters for chemotherapy: complications and quality of life assessment in 35 patients / Inserção braquial de cateteres venosos totalmente implantáveis para quimioterapia: complicações e avaliação da qualidade de vida em 35 pacientes

ABSTRACT Objective To prospectively evaluate the perioperative safety, early complications and satisfaction of patients who underwent the implantation of central catheters peripherally inserted via basilic vein. Methods Thirty-five consecutive patients with active oncologic disease requiring chemotherapy were prospectively followed up after undergoing peripheral implantation of indwelling venous catheters, between November 2013 and June 2014. The procedures were performed in the operating room by the same team of three vascular surgeons. The primary endpoints assessed were early postoperative complications, occurring within 30 days after implantation. The evaluation of patient satisfaction was based on a specific questionnaire used in previous studies. Results In all cases, ultrasound-guided puncture of the basilic vein was feasible and the procedure successfully completed. Early complications included one case of basilic vein thrombophlebitis and one case of pocket infection that did not require device removal. Out of 35 patients interviewed, 33 (94.3%) would recommend the device to other patients. Conclusion Implanting brachial ports is a feasible option, with low intraoperative risk and similar rates of early postoperative complications when compared to the existing data of the conventional technique. The patients studied were satisfied with the device and would recommend the procedure to others.

RESUMO Objetivo Avaliar prospectivamente segurança perioperatória, complicações precoces e grau de satisfação de pacientes submetidos ao implante de cateteres centrais de inserção periférica pela veia basílica. Métodos Foram acompanhados prospectivamente e submetidos ao implante de cateteres de longa permanência de inserção periférica, entre novembro de 2013 e junho de 2014, 35 pacientes consecutivos com doença oncológica ativa necessitando de quimioterapia. Os procedimentos foram realizados em centro cirúrgico por uma mesma equipe composta por três cirurgiões vasculares. Os desfechos primários avaliados foram as complicações pós-operatórias precoces, ocorridas em até 30 dias após o implante. A avaliação do grau de satisfação foi realizada com base na aplicação de um questionário específico já utilizado em estudos prévios. Resultados Em todos os casos, a punção ecoguiada da veia basílica foi possível, e o procedimento foi concluído com sucesso. As complicações precoces observadas incluíram um caso de tromboflebite de basílica e um de infecção de bolsa, ambos tratados clinicamente sem necessidade de retirada do dispositivo. Dos 35 pacientes interrogados, 33 (94,3%) recomendariam o dispositivo para outras pessoas. Conclusão A implantação do port braquial é uma opção factível, com baixo risco intraoperatório e taxas semelhantes de complicações pós-operatórias imediatas quando comparada a dados já existentes da técnica convencional. Os pacientes estudados apresentaram-se satisfeitos com o dispositivo e recomendariam o procedimento para outras pessoas.

Formações venosas superficiais da fossa cubital: aspectos de interesse para a prática da Enfermagem / Superficial venous formation of the cubital fossa: aspects of interest for nursing practice / Formaciones venosas superficiales de la fosa cubital: aspectos de interés para la práctica de Enfermería

O objetivo deste estudo é contribuir para o conhecimento que auxilie o profissional de enfermagem na identificação dos tipos mais comuns de formações venosas da região da fossa cubital e, ainda, enfocar a importância de estar sempre atento aos casos pouco comuns como o aqui relatado. Através de uma revisão bibliográfica, constatamos que as formações venosas dessa região podem ser classificadas em 5 tipos mais comuns, sendo o tipo II o mais frequente. Constatamos ainda, que a VICo é o local de punção mais indicado, seguido pela VIB. Descrevemos também uma variação anatômica, onde observamos ausência de comunicação entre VC e VB no nível da fossa cubital e VIA drenando na VB, estando presente a VCA.

The aim of this study is to contribute to the knowledge to assists the nursing staff to identify the most common types of venous formations of the cubital fossa region, and also focus on the importance of always being alert to unusual cases as that reported here. Through a literature review, we found that the venous formations of this region can be classified into five common types, bring the Type II the was most frequent. We also found that MCV is considered the best puncture site, followed by MBV. We also describe an anatomical variation, in which we observed the absence of communication between BV and CV at the level of cubital fossa draining into BV and MVF, with the presence of the ACV.

El objetivo de esta investigación es contribuir al conocimiento que auxilie al profesional de enfermería en la identificación de los tipos más comunes de formaciones venosas de la fosa cubital, además de advertir sobre la importancia de fijar la atención a los casos poco comunes, como lo aquí reportado. A través de la revisión bibliográfica, clasificamos las formaciones venosas de esta región en cinco tipos más comunes, siendo lo más frecuente el Tipo II. La utilización de la VICo se recomienda como el mejor sitio de punción, seguido por la VIB. Además, describimos una variación anatómica, donde se observó la ausencia de comunicación entre VC y VB a nivel de fosa cubital y VIA drenando en VB, con presencia de la VCA.

Acute Upper Limb Ischemia due to Cardiac Origin Thromboembolism: the Usefulness of Percutaneous Aspiration Thromboembolectomy via a Transbrachial Approach

OBJECTIVE: To evaluate the usefulness of percutaneous aspiration thromboembolectomy (PAT) via a transbrachial approach in patients with acute upper limb ischemia. MATERIALS AND METHODS: From July 2004 to March 2008, eleven patients with acute upper limb ischemia were enrolled in this study. They were initially treated with thrombolysis (n = 1), PAT (n = 6), or both (n = 4) via a femoral artery approach. However, all of the patients had residual thrombus in the brachial artery, which was subsequently managed by PAT via the transbrachial approach for removal of residual emboli. RESULTS: Successful re-canalization after PAT via a transbrachial approach was achieved in all patients. Two patients experienced early complications: one experienced a massive hematoma of the upper arm due to incomplete compression and was treated by stent deployment. The other patient experienced a re-occlusion of the brachial artery the day after the procedure due to excessive manual compression of the puncture site, but did not show recurrence of ischemic symptoms in the artery of the upper arm. Clinical success with complete resolution of ischemic symptoms was achieved in all patients. CONCLUSION: PAT via a transbrachial approach is a safe and effective treatment for patients with acute upper limb ischemia.

Entrapment of the median nerves and brachial arteries in the lower arms bilaterally and additional origin of biceps brachii muscle: case report / Compresión bilateral del nervio mediano y de la arteria braquial en la parte distal del brazo y origen adicional del músculo bíceps braquial: reporte de caso

Neuro-vascular entrapments associated with variations observed in the origins of muscles in the arm are not uncommon. Though additional heads of biceps brachii muscle and extra fibres of brachialis muscles have been demonstrated earlier, bilateral additional heads of the biceps are rarely seen, especially with entrapment of the median nerve and the brachial arteries in both the arms. The present study reports conspicuous heads of the biceps brachii originating extensively from the medial inter-muscular septum, sharing its origin with the brachialis muscle. The extra origins of the muscle formed long musculo-aponeurotic tunnels. The tunnels measured eight centimeters in length extending from the lower arm to the cubital-fossa. Both the median nerve and the brachial arteries passed through the tunnel. The lower aspect of the left tunnel exhibited origins of fibres belonging to the superficial flexors of the forearm. The neuro-vascular structures did not give any branches in the tunnel. Awareness of such variations can aid clinicians in diagnosing and treating such neuropathies and vascular compromise.

No es infrecuente observar atrapamientos neuro-vasculares asociados con variaciones en el origen de los músculos del brazo. A pesar de haberse observado cabezas adicionales del músculo bíceps braquial y fibras extra del músculo braquial raramente estas cabezas adicionales bilaterales han sido causantes de la compresión del nervio mediano y de la arteria braquial. En este trabajo presentamos las cabezas del músculo bíceps braquial originándose en gran parte en el tabique intermuscular medial compartiendo su origen con el músculo braquial. Los orígenes adicionales del músculo forman largos túneles músculo fasciales. Los túneles miden 8 cm de longitud, y se extienden desde la parte inferior del brazo hasta la fosa cubital. Tanto el nervio mediano como la arteria braquial pasan por el túnel. La parte inferior del túnel izquierdo dio origen a fibras pertenecientes al músculo flexor superficial del antebrazo. Las estructuras neurovasculares no otorgaron colaterales en el túnel. El conocimiento de estas variaciones puede ayudar a los clínicos en el diagnóstico y el tratamiento de neuropatías y compromiso vascular.

Multiple arterial variations in the right upper limb of a caucasian male cadaver / Múltiples variaciones arteriales en el miembro superior derecho de un cadáver caucásico masculino

Anatomical variations of the arterial patterns in the upper limb have been describe in many anatomical studies, but the occurrence of four variations in a ipsilateral upper limb is rare. These arterial variations were observed in the right upper limb of a 65 -year old Caucasian male cadaver during routine dissection in the anatomy department, College of Medicine at the King Saud University, Riyadh. These arterial variations include: 1) a large common trunk of the axillary artery giving origin to subscapular artery, profunda brachii artery, common circumflex humoral artery and superior ulnar collateral artery, 2) superficial brachial artery; 3) superficial brachioulnar artery, and 4) the radialis indicis branch from superficial palmar arch. Appreciation of variations in the upper limb vessels is important due to increasing number of procedures both diagnostic and therapeutic as in breast cancer surgery, flap harvesting and arteriogaphy.

En numerosos estudios se han descrito las variaciones anatómicas de los patrones arteriales en el miembro superior, sin embargo, la aparición de cuatro variantes ipsilaterales en un miembro superior es poco frecuente. Estas variaciones arteriales fueron observadas en el miembro superior derecho de un cadáver caucásico masculino de 65 años de edad, durante la disección de rutina en el Departamento de Anatomía de la Facultad de Medicina de la Universidad de King Saud, en Riad. Estas variaciones arteriales incluyen: 1) un gran tronco común de la arteria axilar dando origen a las arterias subescapular, braquial profunda, braquial común y colateral ulnar superior; 2) la arteria braquial superficial; 3) la arteria braquioulnar superficial y 4) la rama radial del índice desde el arco palmar superficial. La observación de variaciones en los vasos del miembro superior es importante debido al número cada vez mayor de procedimientos diagnósticos y terapéuticos, como en la cirugía del cáncer de mama, la recolección de colgajos y arteriografías.

Resección transaxilar de la primera costilla con apoyo endoscópico en el síndrome de salida de tórax: una opción quirúrgica segura / Endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe surgical option

Introducción: La resección transaxilar con apoyo endoscópico es una técnica quirúrgica novedosa en el manejo del síndrome de salida de tórax que permite identificar con seguridad el paquete vasculonervioso y las diferentes estructuras. Nuestro objetivo fue valorar los resultados de morbilidad y mortalidad del tratamiento quirúrgico en el síndrome de salida de tórax con esta técnica. Material y métodos: Estudio longitudinal prospectivo de 22 intervenciones quirúrgicas de resección transaxilar de la primera costilla, con apoyo endoscópico a pacientes con síndrome de salida de tórax, entre enero de 2000 y enero de 2009, en un hospital privado de la cuidad de Puebla, México. De ellos, 16 mujeres y seis hombres, con edad promedio de 35 años. Encontramos 16/22 (72.7 %) pacientes con síntomas neurológicos y 6/22 (27.3 %) con síntomas venosos; entre ellos, 2/22 (9.09 %) presentaban trombosis venosa de esfuerzo axilosubclavia. Resultados: Entre las 22 intervenciones encontramos bandas fibrosas en 8/22 pacientes (36.3 %): 1/22 (4.5 %) con una banda cervical tipo 1 y costilla cervical grado II, 1/22 (4.5 %) con banda cervical tipo 2 y costilla cervical grado I, 2/22 (9.09 %) con banda tipo 3, 1/22 (4.5 %) con banda tipo IV, 1/22 (4.5 %) con banda tipo V y 2/22 (9.09 %) con banda tipo VII y trombosis axilosubclavia. Después del procedimiento, 20/22 (90.9 %) pacientes manifestaron mejoría total y 2/22 (9.1 %), parestesias leves. No hubo complicaciones por lesiones nerviosas, vasculares o pleurales. Conclusiones: La técnica escrita provee un margen de seguridad amplio y mejora la visibilidad, disminuyendo las complicaciones quirúrgicas.

BACKGROUND: Endoscopic-assisted transaxillary first rib resection is a novel approach in the management of thoracic outlet syndrome (TOS) and allows us to safely identify the neurovascular package and different structures. Our main objective is to assess the results of morbidity and mortality of the surgical treatment in TOS with this technique. METHODS: We carried out a prospective, longitudinal study with 22 surgical interventions of transaxillary first rib resection with endoscopic support in patients with TOS from January 2000 to January 2009 in a private hospital located in Puebla, Mexico. There were 16 females and six males with a mean age of 35 years. We found 16/22 (72.7%) patients with neurological symptoms and 6/22 (27.3%) with venous symptoms; 2/22 (9.09%) patients had effort thrombosis of the axillary-subclavian vein. RESULTS: Of the 22 interventions, we found fibrous bands in 8/22 patients (36.3%); 1/22 (4.5%) with type 1 cervical band and cervical rib grade II, 1/22 (4.5%) with type 2 cervical band and cervical rib grade I, 2/22 (9.09%) with band type 3, 1/22 (4.5%) with band type IV, 1/22 (4.5%) with band type V and 2/22 (9.09%) with band type VII and axillary-subclavian thrombosis. After the procedure, 20/22 (90.9%) patients showed total symptom improvement and 2/22 (9.1%) patients had mild paresthesias. There were no complications from nerve, vascular or pleural damage. CONCLUSIONS: This technique provides an ample margin of safety and improves visibility, reducing surgical complications.

Cephalic vein: detail of its anatomy in the deltopectoral triangle / Vena cefálica: detalle de su anatomía en el trígono deltopectoral

The cephalic vein shows a scarce description, especially in the deltopectoral triangle, and its ending in the axillary vein. Some established considerations such as "superficial vein, located in the deltopectoral groove, accompanied by braches of the thoraco-acromial artery, which ends in the deltopectoral triangle in the shape of fan arch" should be reevaluated. Procedures difficulties in the la catheterization deserve for a more accurate description. A descriptive, prospective study is performed. The goal is to determine the anatomy of the cephalic vein in the deltopectoral triangle, with a special focus on the characteristics concerning its path and type of termination. Findings show that the cephalic vein is deeply placed and has a different path than that of an arch (circumference segment on a level) with a retro pectoral path and an acceptable diameter, thus useful and safe in the catheterization processes.

La vena cefálica ha sido poco descrita en el triángulo deltopectoral y su terminación en la vena axilar. Algunas consideraciones la señalan como "la vena superficial, situada en el surco deltopectoral, acompañada de ramas de la arteria toraco-acromial, que termina en el trígono deltopectoral en forma de arco de ventilador" por lo que debe ser reevaluado. Debido a las dificultades en los procedimientos de cateterización la vena cefálica merece una descripción más exacta. Se realizó un estudio descriptivo prospectivo con el objetivo de determinar la anatomía de la vena cefálica en el trígono deltopectoral, dando especial atención a sus trayecto y tipo de terminación. Los resultados demostraron que la vena cefálica está localizada profundamente en el surco deltopectoral, presenta un trayecto distinto a un arco (segmento de la circunferencia de un nivel) siendo este trayecto retropectoral y un diámetro aceptable, por lo tanto, útil y seguro para los procesos de cateterización.

Venas superficiales de la fosa cubital: aspectos anátomo-clínicos y antropológicos / Superficial veins of the cubital fossa: anatomo-clinic and anthropologic aspects

Es bastante frecuente el acceso a las venas superficiales de la fosa cubital, siendo uno de los sitios más utilizados para punción venosa. Aunque es un procedimiento simple, es invasivo y a veces doloroso. La disposición de las venas superficiales de la región cubital ha sido descrita por numerosos autores y en diversos grupos étnicos, describiéndose variaciones y diversas padronizaciones. Las venas superficiales de la fosa cubital se han descrito formando una M, N, Y y W. Numerosos estudios, en distintas razas y grupos étnicos han demostrado similitudes y diferencias en la disposición de las venas superficiales de la fosa cubital. En 1908 Berry & Newton determinaron que en el 83% de los hombres británicos la vena cefálica del antebrazo (VCA) y la vena basílica del antebrazo (VB A) eran conectadas por la vena mediana del codo (VMCo). Okamoto (1922) en hombres japoneses, determinó 3 Tipos de padrones venosos: Tipo I donde la VCA origina la VMCo, no existe la vena cefálica accesoria del antebrazo (VCAA), y la VCA no se duplica; Tipo II, caracterizado por la duplicación de la VCA y un Tipo III, que incluye la VCAA que drena en la VCA. En hombres blancos y negros Charles (1932) señaló que la distribución más frecuente (cerca de 70% de los casos), era aquella donde la VCA y la VB A eran conectadas por la VMCo. Soller et al. (1962, 1964) en africanos de África Occidental, distinguieron tres tipos de formaciones venosas. Grupo I. Disposición clásica, tipos en M o aparentes (38,1%). Grupos II y III descritas como disposiciones de tipo embrionario constituyen el 62% de los casos. Halim & Abdi (1974) en hindúes, observaron tres tipos: 1) Tipo I. La VCA y la VBA son conectadas por la VMCo; Tipo II. La VCA drena en la VBA; la vena mediana del antebrazo (VMA) drena en la VCA. Tipo III. No existe comunicación entre la VCA y la VBA en la fosa cubital y la subdividen en Tipos IIIA y III B. Wasfi et al. (1986) describieron ...

Access of the cubital fossa to the superficial veins is very frequent, this being one of the most frequent vein puncture sites. Although it is a simple procedure, it is invasive and at times painful. The disposition of the superficial veins of the cubital area has been described by numerous authors and in diverse ethnic groups, describing many variations and various patterning. The superficial veins of the cubital fossa have been independently described, forming an M, N, Y or W. Numerous studies in different races and ethnic groups have demonstrated similarities and differences in the disposition of the superficial veins of the cubital fossa. In 1908 Berry & Newton determined that in 83% of British men the cephalic vein of the forearm (CVF) and the basilic vein of the forearm (BVF) were connected by the median cubital vein (MCV) Okamoto (1922) in Japanese men, determined 3 types of venous patterns. Type I where the CVF originates the MCV, the accessory cephalic vein (ACV) does not exist, and the (CVF) does not duplicate; Type II is characterized by the duplication of the CVF and a Type III, that includes the ACV which drains in the CVF. In white and black men Charles (1932) indicated that the most frequent distribution (nearly 70% of the cases), was that where the CVF and the BFV were connected by the MCV. Soller et al. (1962, 1964) in Africans from West Africa, distinguished three types of venous formations. Group I classic dispositions, types in M or apparent (38.1%) Groups II and III described as dispositions of the embryological type constitute 62% of the cases. Halim & Abdi (1974) observed 3 types in Hindus types: 1) Type I. The CVF and the BVF are connected by the MCV; Type II. The CVF drains in the BVF: the median vein of the forearm (MVF) drains in the CVF. Type III. There is no communication between the CVF and the BFV in the cubital fossa and it is subdivided in Types III A and III B. Wasfi et al. (1986) described ...

Índice Tornozelo-Braquial (ITB) determinado por esfigmomanômetros oscilométricos automáticos / Assessing Ankle-Brachial Index (ABI) by using automated oscillometric devices

FUNDAMENTO: Índice Tornozelo-Braquial (ITB) é essencial na prática clínica, mas dificuldades técnicas na sua execução pelo padrão de referência Doppler vascular (DV) tornam-no ainda pouco utilizado. OBJETIVO: Avaliar aplicabilidade da determinação do ITB com uso de esfigmomanômetros oscilométricos automáticos (EOA) e sugerir a utilização dos índices delta-Bráquio-Braquial (delta-BB) e delta-ITB como marcadores de risco cardiovascular. MÉTODOS: Estudo descritivo e observacional de 247 pacientes ambulatoriais (56,2 por cento feminino, média 62,0 anos) submetidos à determinação do ITB com aferição simultânea da pressão arterial (PA) em membros superiores (MMSS) e inferiores (MMII) utilizando-se dois EOA (OMRON-HEM705CP). Nos casos em que não foi possível aferir PA em pelo menos um dos MMII utilizou-se DV. Os pacientes divididos em Grupo N (ITB normal: 0,91 a 1,30) e Grupo A (ITB alterado: <0,90 ou >1,30) tiveram comparados entre si os valores de delta-ITB (diferença absoluta ITB/MMII) e delta-BB (diferença absoluta PAS/MMSS). RESULTADOS: Utilizando-se EOA foi possível determinar ITB em 90,7 por cento. Com dados do Grupo N determinaram-se valores de referência (VR) no percentil 95 de delta-ITB (0-0,13) e delta-BB (0-8 mmHg). Quando comparado com o Grupo N, o Grupo A apresentou prevalência mais elevada tanto de delta-ITB (30/52 contra 10/195; Razão de Chances: 25,23; p<0,0001) como de delta-BB (13/52 contra 7/195; Razão de Chances: 8,95; p<0,0001) acima dos VR. CONCLUSÃO: O ITB pode ser determinado na maioria das vezes com EOA. Delta-ITB e delta-BB acima dos VR estiveram significativamente mais prevalentes nos portadores de ITB alterado e podem ser sugeridos como marcadores de risco cardiovascular em futuros estudos epidemiológicos.

BACKGROUND: Assessing Ankle-Brachial Index is an essential procedure in clinical settings, but since its measurement by the gold standard Doppler Ultrasonic (DU) technique is impaired by technical difficulties, it is underperformed. OBJECTIVE: The aim of this study was to assess the efficacy of an automated oscillometric device (AOD) by performing Ankle-Brachial Index (ABI) assessments and to suggest delta brachial-brachial (delta-BB) and delta-ABI as markers of cardiovascular risk. METHODS: In this observational and descriptive study, 247 patients (56.2 percent females, mean age 62.0 years) had their arterial blood pressure (ABP) measured for ABI calculation. Two AOD (OMRON-HEM705CP) devices were used for simultaneous measurements of the ABP, first of the two arms and then of the arm with higher systolic ABP and a leg, first the left and then the right one. When leg ABP measurements were not possible, ABI determination was performed by using the standard Doppler Ultrasonic (DU) technique. Patients were designated to Group N (normal ABI: 0.91 to 1.30) or Group A (abnormal ABI: <0.90 or >1.30). Other indexes were also calculated: delta-BB (absolute difference in mmHg of systolic ABP between arms) and delta-ABI (absolute difference of ABI between legs) and the results were compared. RESULTS: In most patients (90.7 percent), it was possible to determine the ABI. Group N data allowed calculation of the 95th percentile reference values (RV) of delta-BB (0 to 8 mmHg) and delta-ABI (0 to 0.13). When compared to Group N, Group A had a significantly higher prevalence of high values greater than the RVs of delta-ABI (30 of 52 and 10 of 195, respectively; Odds Ratio = 25.23; p<0.0001) and delta-BB (13 of 52 and 7 of 195, respectively; Odds Ratio = 8.95; p<0.0001). CONCLUSION: In most patients, the ABI could be measured by AOD. Both indexes, delta-BB and delta-ABI greater than the RVs, were significantly more prevalent in patients with abnormal ABI ...

Variations of the Superficial Brachial Artery in Korean Cadavers

The superficial brachial artery (SBA), a branch of the axillary artery, is one of the most common arterial variations in this area. While it is more vulnerable to accidental arterial injection or injury, it could be useful for the nourishment of a medial arm skin free flap. To analyze the relationship between the SBA of axillary origin and segmental variation of the axillary artery, we dissected 304 arms of Korean cadavers. We found an SBA of axillary origin in 12.2% of cadaveric arms. Unilateral occurrence was detected in 16 cadavers and bilateral in 10. SBAs gave rise to radial and ulnar arteries in the cubital fossa (8.9%), continued in the forearm as the radial artery (2.3%), or ended in the upper arm (1.0%). The SBA ended as ulnar artery was not found in any of the cadavers. The bifurcation of the SBA into the radial and ulnar arteries, presence of an SBA that ends in the upper arm, and the lack of continuation as the ulnar artery are characteristics of SBAs in Korean cadavers.

Formaciones Venosas de la Fosa Cubital en el Individuo Mapuche: Estudio Bioscópico / Venous Formations in the Cubital Fossa of Mapuche: Bioscopy Study

Las venas superficiales de la fosa cubital constituyen uno de los sitios más importantes para punción venosa. La disposición de esas venas presenta numerosas variaciones y, la disposición de ellas no ha sido estudiada en el grupo étnico mapuche. Debido a esto, y considerando a este grupo como el mayor conglomerado étnico de América del Sur, efectuamos este estudio. Fueron analizadas las venas superficiales de la fosa cubital, en 300 miembros superiores (150 derechos y 150 izquierdos) de individuos de ambos sexos (30 hombres y 120 mujeres), chilenos del grupo étnico mapuche, con edades entre 15 y 84 años. El estudio fue realizado en las postas rurales adyacentes a la ciudad de Temuco. Basados en la clasificación de del Sol et al. (1988) para las formaciones venosas de la fosa cubital, obtuvimos los siguientes resultados: Tipo I (38,7%), la vena cefálica (VC) se divide en vena intermedia basílica (VIB) y vena intermedia cefálica (VIC), uniéndose a la vena basílica (VB) y vena cefálica accesoria (VCA), respectivamente. La VIB era de mayor calibre y la vena intermedia del antebrazo (VIA) drenaba, generalmente, en la VB; Tipo II (28,3%), la VC origina la vena intermedia del codo (VICo), que se une a la VB. No existe VCA, siendo la VICo de mayor calibre y la VIA drena en la VB; Tipo III (24%), no existe comunicación entre la VB y VC a nivel de la fosa cubital. La VIA drena en la VB; Tipo IV (4,3%), la VC drena en la VB y la VIA drena en la VC; Tipo V otras disposiciones, donde se incluye la M clásica (1%) que resulta de la división de la VIA. La utilización de las VIC y VC se recomienda cuando ellas tienen un calibre semejante a la VIB o a la VICo ya que los riesgos de punción de otras estructuras anatómicas importantes, como ramos anteriores del nervio cutáneo medial del antebrazo o arteria braquial, son mínimos.

The superficial veins of the cubital fossa constitute one of the most important sites for vein puncture. The availability of those veins present numerous variations, and the availability of these has not been studied in the Mapuche ethnic group. In view of the above, and considering this group as the greatest ethnic conglomerate in South America the study took place. The superficial veins of the cubital fossa were analized in 300 superior members (150 right and 150 left) in subjects of both sexes (30 men and 120 women) Chileans of the Mapuche ethnic group between 15 and 84 years of age. The study was realized in rural clinics near the city of Temuco. Based on the classification of del Sol et al. (1988) for the vein formation of the cubital fossa, the following results were obtained: type I (38.7%), the cephalic vein (VC) is divided in the intermediate basilic vein (VIB) and intermediate cephalic vein (VIC), joining thebasilic vein (VB)and accessory cephalic vein (VCA) respectively. The VIB was of a major caliber and the intermediate vein of the forearm (VIA) generally drained in the VB, Type II (28,3%), the VC originates the intermediate vein of the elbow (VICo), that joins the VB. VCA does not exist, th VICo being of a mayor caliber and the VIA drains in to VB, Type III (24%) no communication exists between the VB and VC at the level of the cubital fossa, the VIA drains into VB, Type IV (4,3%), the VC drains in the VB and VIA drins in the VC; Type V other dispositions where the classic M is included (1%) which results in the division of the VIA. The use of the VIC and VC is recommended when they have a similar caliber to that of the VIB of VICo. Because the puncture risks of other important anatomic structures, such as anterior branches of the medial cutaneous nerve of the forearm or brachial artery are minimal.

Confiabilidade da medida da dilatação fluxo-mediada da artéria braquial pela ultra-sonografia / Reliability of brachial artery flow-mediated dilatation measurement using ultrasound

OBJETIVO: Determinar a confiabilidade das medidas dos diâmetros basal (DBAB) e pós-oclusão (DPOAB) da artéria braquial e da dilatação fluxo-mediada da artéria braquial (DILA), assim como quantificar o erro típico dessas medidas (ETM). MÉTODOS: A consistência interna (2 medidas intradias) foi determinada em 10 voluntários, enquanto a estabilidade (2 medidas interdias) foi determinada em 13 voluntários aparentemente saudáveis e não-fumantes. As imagens da artéria braquial foram obtidas pelo aparelho de ultra-sonografia bidimensional com Doppler, utilizando transdutor de 14 MHz. As distâncias entre as interfaces íntima-luz foram medidas antes e após interrupção do fluxo sangüíneo durante 5 minutos por manguito posicionado no braço. O DILA foi considerado o porcentual de aumento do DPOAB em relação ao DBAB. RESULTADOS: A ANOVA não identificou diferenças significativas entre as medidas intradias e interdias. Para o DILA, os coeficientes de correlação intraclasse entre as medidas intradias e interdias foram R = 0,7001 e R = 0,8420, respectivamente (p < 0,05). Os coeficientes de variação foram 5,8 por cento e 12,4 por cento e os ETM relativos 13,8 por cento e 14,9 por cento, respectivamente para medidas intra e interdias. A análise dos gráficos de Bland-Altman apontou que as variáveis não apresentaram erro heterocedástico. CONCLUSÃO: A medida do DBAB, DPOAB e do DILA por meio de técnica manual pela ultra-sonografia apresenta alta confiabilidade tanto para os valores intradias quanto interdias, possibilitando seu uso para diagnóstico e monitoramento da função endotelial.

OBJECTIVE: To determine the reliability of the baseline (BBAB) and post occlusion (POBAD) brachial artery diameters, brachial artery flow-mediated dilatations (BAFMD) measurements, and to quantify the typical error of the measurements (TEM). METHODS: Internal consistency (2 measurements on the same day) was determined in 10 volunteers, whereas stability (2 measurements on separate days) was determined in 13 volunteers. All the volunteers looked healthy and were nonsmokers. The brachial artery images were obtained using a two dimensional Doppler ultrasound instrument: a 14 MHz transducer was used. The distances between the intima-lumen interfaces were measured before and after the blood flow had been stopped by means of a cuff on the arm for five minutes. BAFMD was considered as the percentile increase of POBAD in relation to BBAD. RESULTS: ANOVA did not identify any significant differences between the measurements taken on the same and separate days. For BAFMD, the intraclass correlation coefficients between the measurements taken on the same and separate days were: R = 0.7001 and R = 0.8420, respectively (p < 0.05). The variation coefficients were 5.8 percent and 12.4 percent and the relative SMEs were 13.8 percent and 14.9 percent, respectively, for the measurements taken on the same and separate days. Analysis of the Bland-Altman graphs indicated that the variables did not present heteroscedastic errors. CONCLUSION: The BBAD, POBAD and BAFMD measurements using the manual ultrasound technique were highly reliable for both the same and separate day measurements and therefore can be used to diagnose and monitor endothelial function.

A familial case of cleidocranial dysostosis presenting upper limb ischemia

CONTEXTO: A isquemia do membro superior não é tão comum quanto a isquemia do membro inferior, mas quando não diagnosticada ou diagnosticada de forma errada determina grave seqüela e até perda da extremidade. RELATO DE CASO: O caso de uma paciente com isquemia do membro superior, devida a disostose cleidocraniana, é apresentado. Esta é uma causa extremamente rara de compressão do segmento arterial subclávio-axilar que evoluiu para trombose arterial. Somente dois casos foram previamente relatados na literatura com esta condição e nesta forma de apresentação.

Ergotamine-Induced Upper Extremity Ischemia: A Case Report

Ergotamine-induced limb ischemia is an extremely rare case. We present a case of a 64-year-old man, who developed ischemia on the right upper extremity due to long-term use of Ergot for migraine headache. Angiography revealed diffused, smooth, and tapered narrowing of the brachial artery. The patient was successfully treated with intravenous nitroprusside.

Acceso venoso percutáneo braquial: Su utilidad en el cateterismo diagnóstico e intervencionista en cardiopatías complejas / Brachial percutaneous venous access: Its usefulness in the diagnostic and interventionist catheterism of complex cardiopathies

Introducción: El acceso venoso a la vena cava superior es obligatorio en pacientes portadores de anastomosis tipo Glenn. En cardiopatías complejas, es habitual la repetición de cateterismos, encontrando frecuentemente dificultades de acceso femoral. Para evitar la punción venosa yugular interna, potencialmente peligrosa, hemos utilizado la vena mediana basílica como acceso inicial. Objetivo: Valorar la efectividad y seguridad de la vía venosa braquial en pacientes, que precisan cateterismo cardíaco. Material y métodos: Se intentó la punción en 37 pacientes. Edad media 10 años (3.1-33.5). Todos ellos postoperados de cardiopatías complejas y con un promedio de 2.45 cirugías y 3.6 cateterismos por paciente. 40% de los pacientes: trombosis femoroilíaca bilateral. Técnica: Compresión venosa axilar, punción venosa basílica y canalización con introductor 4 a 6F. Resultados: Acceso efectivo: en 34 de los 37 pacientes (91.8%). En todos se realizó cateterismo diagnóstico, en 3, prueba pronóstica de oclusión y en 6 -angioplastía de rama pulmonar. Complicaciones: 2 obstrucciones tardías de la vena mediana basílica derecha (6%). Conclusiones: La punción venosa braquial es una técnica alternativa útil que permite acceso a cava superior y cavidades derechas a partir de los 3 años de edad, asociándose a un bajo porcentaje de complicaciones. Ciertas dilataciones vasculares pueden realizarse por esta vía.

Venous access through the superior caval vein is mandatory to study the pulmonary arteries in patients with a Glenn anastomosis. In complex congenital heart disease, repeat catheterizations may lead to iliac vein thrombosis and superior access is needed. In order to avoid the internal jugular venous puncture, we have used puncture of the antecubital vein as an elective access. Material: Brachial puncture was attempted in 37 patients. Mean age: 10 years (3.1-33.5). 2.45 heart surgeries and 3.6 cardiac catheterizations per patient had been previously performed in this group. 40% of patients had bilateral iliac vein thrombosis. Technique: Axillary vein external compression, venous puncture and introduction of 4-6 F sheath. Results: Venous access through brachial vein was achieved in 34 of 37 pts (91.8%). Diagnostic catheterization was done in all, balloon test occlusion of the pulmonary valve in 3 and pulmonary artery branch dilation in 6 pts. Complications: 2 late thrombosis of the right brachial vein (6%). Conclusions: Antecubital venous puncture is an alternative and useful technique that allows easy catheterization of superior caval vein, pulmonary artery and right heart chambers. It is associated with minor complication rate, avoiding internal jugular vein puncture. Certain therapeutic procedures can be performed through such route.

Omentopexy for limb salvage in Buerger's disease: indications, technique and results.

Buerger's disease is a limb-threatening condition occurring in the young and productive age group and its management has always been a challenging problem. A large number of medical and surgical options have been suggested, but the quest for an ideal solution to this problem continues. Omentopexy for Buerger's disease is an attractive option, which is rapidly gaining popularity. We discuss the historical aspects, technical considerations and results of omental transfer for this limb-threatening condition. In doing so, the relevant literature on the subject has been extensively reviewed. In all published series, there has been marked improvement in intermittent claudication and rest pain. Ischaemic ulcers have healed and the progression of gangrene has stopped. If carried out with the complete understanding of the anatomy of the omental vascular arcade, the results of omentopexy are gratifying, thus avoiding amputation and conserving the limb.

Transposición de vena basílica en el brazo, para acceso vascular en pacientes sin lecho venoso superficial / Transposition of basilic vein of the arm, for vascular access in patients without superficial veinbed

La provisión de acceso vascular duradero, en pacientes con insuficiencia renal en hemodiálisis, sin lecho venoso superficial, es difícil. Tradiocionalmente, se recurre al uso de prótesis vascular. Entre mayo de 1998 y abril de 1999, se confeccionan 8 fístula arteriovenosas humerobasílicas con transposición subcutánea de la vena basílica en el brazo, en igual número de pacientes con antecedentes de múltiples accesos vasculares ocluidos; dos pacientes con accesos vasculares protésicos trombosados (PTFE). Hubo 100 por ciento de utilización de vena basílica. Cinco pacientes de sexo masculino, y tres, femenino. con edad promedio de 40 años (rango: 23-65 años). Entre las complicaciones destacan: hematoma (1), linforrea (1), edema del brazo (2), estenosis de vena basílica (1), aneurisma (1). Una fístula se ocluyó a los 30 días. Ningún paciente se infectó. Al 30/6/99 se mantienen permeables y funcionales 6 fístulas. En nuestra breve experiencia, y por razones económicas y mayor duración, consideramos a la fístula arteriovenosa humerobasílica con transposición venosa subcutánea, nuestra primera alternativa en este tipo de pacientes. Los accesos vasculares protésicos corresponden a la última alternativa

Trombosis venosa profunda del miembro superior / Deep venous thrombosis of upper extremity

Aunque los fenómenos trombóticos venosos profundos de los miembros superiores ocupan menos del 5 por ciento de todas las trombosis venosas profundas, recientemente en nuestra práctica clínica hemos observado un incremento de estos casos, principalmente asociados al empleo de catéteres venosos centrales, razón por la cual decidimos hacer una revisión del tema y de la casuística de los autores.

Changing etiological spectrum of acute peripheral vascular injuries: a clinico-epidemiological study

The overall incidence of acute peripheral vascular injuries is on a rise in civilian practice which is largely attributable to frequent use of firearms, terrorist violence and high speed road traffic accidents. This study reveals the clinical and operative details of 19 patients with peripheral vascular trauma which necessitated surgical intervention from August 1998 to February 2000. Present study also aims to highlight an emerging change in the etiological spectrum of vascular injuries with an alarming contribution by the drug addicts [15.7%], which demands a multi-disciplinary approach. An understanding of modes of presentation of vascular trauma with early diagnosis and appropriate treatment are essential for all surgeons to maximize the chances of limb salvage. Time is the prime factor in determining the final outcome of vascular repair

Gangrena venosa de membro superior / Venous gangrene of the upper extremity

Os autores relatam o caso de uma paciente de 59 anos de idade que procurou o serviço médico com queixas de dor em hemitórax direito, tosse seca de longa data que piorou nos últimaos três meses. A tomografia computadorizada de tórax revelou a presença de nódulo pulmonar. Logo após a realização do exame apresentou edema, dor e cianose no membro superior esquerdo,com diagnóstico de trombose por dúplex scan de veias subclávias e jugulares bilateralmente. Evoluiu para síndrome compertimental do membro superior esquerdo. Foi realizado fasciotomia que aliviou os sintomas até o quinto dia pós operatório, quando voltou a apresentar piora clínica do membro que evoluiu para gangrena. Ocorreu deterioração do quadro pulmonar, chegando a óbito antes da amputação do membro