[Síndrome de Paget-Schrötter: presentación de cuatro casos]. / Paget-Schrötter syndrome: description of four cases.

Deep vein thrombosis (DVT) of the upper limb is a rare entity, estimated to account for 10% of all cases of DVT. Classically, they are classified into primary (idiopathic, due to subclavian vein compression or exercise related) and secondary (cancer, thrombophilia, trauma, shoulder surgery, associated to venous catheters or due to hormonal causes). The Paget- Schrötter syndrome is a primary thrombosis of the subclavian vein in the subclavian-axillary junction, related either to repetitive movements or to exercise; leading to microtrauma in the endothelium with consequent activation of the coagulation cascade. Clinically, it presents abruptly with pain, edema and feeling of heaviness in the affected limb. The treatment varies from thrombolytics and anticoagulation to surgical intervention, depending on the time of evolution. We present four cases of exercise-related subclavian vein thrombosis.

Síndrome de Paget-Schrötter: presentación de cuatro casos / Paget-Schrötter syndrome: presentation of four cases

La trombosis venosa profunda (TVP) del miembro superior es una entidad poco frecuente, se estima que representa el 10% de todos los casos de TVP. Clásicamente se clasifican en primarias (idiopáticas, por compresión de la vena subclavia o relacionadas con el ejercicio) y secundarias (cáncer, trombofilia, traumatismo, cirugía del hombro, asociadas a catéteres venosos o de causa hormonal). El síndrome de Paget- Schrötter es una trombosis primaria de la vena subclavia en la unión subclavio-axilar, ya sea por movimientos repetitivos o relacionada al ejercicio; llevando a microtrauma en el endotelio con la consiguiente activación de la cascada de coagulación. Clínicamente se presenta de forma brusca con dolor, edema y sensación de pesadez en el miembro afectado. El tratamiento varía desde trombolíticos y anticoagulación a la intervención quirúrgica, dependiendo del tiempo de evolución. Presentamos cuatro casos de trombosis de vena subclavia relacionada con el ejercicio.

Deep vein thrombosis (DVT) of the upper limb is a rare entity, estimated to account for 10% of all cases of DVT. Classically, they are classified into primary (idiopathic, due to subclavian vein compression or exercise related) and secondary (cancer, thrombophilia, trauma, shoulder surgery, associated to venous catheters or due to hormonal causes). The Paget- Schrötter syndrome is a primary thrombosis of the subclavian vein in the subclavian-axillary junction, related either to repetitive movements or to exercise; leading to microtrauma in the endothelium with consequent activation of the coagulation cascade. Clinically, it presents abruptly with pain, edema and feeling of heaviness in the affected limb. The treatment varies from thrombolytics and anticoagulation to surgical intervention, depending on the time of evolution. We present four cases of exercise-related subclavian vein thrombosis.

Ultrasound evaluation of the respiratory changes of the inferior vena cava and axillary vein diameter at rest and during positive pressure ventilation in spontaneously breathing healthy volunteers.

INTRODUCTION: Ultrasound assessment of the inferior vena cava (IVC) has gained favour in aiding fluid management decisions for controlled, mechanically ventilated patients as well as in non-mechanically ventilated, spontaneously breathing patients. Its utility in spontaneously breathing patients during positive pressure non-invasive ventilation has not yet been determined. The use of the axillary vein, as an alternative option to the IVC due to its ease of accessibility and independence from intra-abdominal pressure, has also not been evaluated. The aim of this study was to assess respiratory variation in IVC and axillary vein diameters in spontaneously breathing participants (Collapsibility Index) and with the application of increasing positive end-expiratory pressure (PEEP) via positive pressure non-invasive ventilation (Distensibility Index). METHODS: The IVC and axillary vein diameters of 28 healthy adult volunteers were measured, using ultrasound, at baseline and with increasing PEEP via non-invasive ventilation. The Collapsibility Index and Distensibility Index of these vessels were calculated and compared for each vessel. The association between increasing PEEP levels and the indices was evaluated. RESULTS: Positive pressure delivered via non-invasive ventilation produced a similar degree of diameter change in the IVC and the axillary vein, that is, the Distensibility Index was similar whether measured in the IVC or the axillary vein (P=0.21, 0.47 and 0.17 at baseline, 5 and 10 cmH2O PEEP, respectively). Individual study participants' IVC and axillary veins, however, had variable responses to PEEP; that is, there appeared to be no consistent relationship between PEEP and the diameter changes. CONCLUSION: While the axillary vein could potentially be used as an alternative vessel to the IVC to assess for volume responsiveness in controlled, mechanically ventilated patients as well as in non-mechanically ventilated, spontaneously breathing patients, neither vein should be used to guide fluid management decisions in spontaneously breathing patients during positive pressure non-invasive ventilation.

Venous anomalies of the axilla: a single-institution experience.

AIM: Surgical treatment is still the cornerstone in the treatment of breast cancer, a very common neoplasia, particularly affecting the female elderly population. Axillary dissection is crucial in the treatment of some tumours, but variations in axillary vessels anatomy are poorly described in standard anatomy and surgical textbook. We aimed to describe anatomical variations in axillary vessels found in our institutional experience. PATIENTS AND METHODS: A prospective 3-year study was conducted in our institution from January 2012 to December 2014. Sixty-one consecutive axillary lymph node dissections (ALNDs) were performed in 61 patients who underwent surgery for stage II and III invasive breast cancer. Anatomical details of axillary vascular anatomy and its variations have been evaluated, described and stored in a prospective database. RESULTS: Sixty-one ALNDs have been performed in the study period. The anatomy of lateral thoracic vein, angular vein and axillary vein was studied and compared with standard anatomical description. Eighteen percentage of venous variations were found out of the 61 dissection performed. CONCLUSIONS: Vascular anatomy of axilla is complex and variable. A better knowledge of all possible variations might be helpful in preventing injuries during ALND.

Diagnosis and treatment of effort-induced thrombosis of the axillary subclavian vein due to venous thoracic outlet syndrome.

Venous thoracic outlet syndrome (VTOS) is uncommon but most frequently occurs in young, active, healthy patients. This condition typically presents as subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome. The pathophysiology underlying VTOS is chronic repetitive compression injury of the SCV in the costoclavicular space, resulting in progressive venous scarring, focal stenosis, and eventual thrombosis. Clinical evaluation includes a history and physical examination followed by catheter-based venography, for definitive confirmation of the diagnosis and initial treatment with pharmacomechanical thrombolysis. After restoration of SCV patency, patients are maintained with anticoagulation and surgical therapy is usually planned within 4 to 6 weeks. Surgical management of VTOS can be accomplished via different protocols involving either the transaxillary, infraclavicular or paraclavicular approaches to thoracic outlet decompression. The paraclavicular approach is emphasized in this review, because it affords the surgeon the ability to safely perform complete thoracic outlet decompression (complete anterior and middle scalenectomy, removal of the entire first rib, and resection of the subclavius muscle and costoclavicular ligament), along with definitive management of the damaged SCV (external venolysis, intraoperative venography, and direct vein reconstruction, if needed, using patch angioplasty or bypass grafting), in one operative setting. After surgical therapy, interval anticoagulation and a comprehensive physical therapy and rehabilitation program are important in achieving a return to full function. Current protocols on the basis of the paraclavicular surgical approach have thereby routinely provided patients with lasting symptomatic relief, freedom from indefinite anticoagulation, and the ability to return to unrestricted upper extremity activity.

Focal myositis presenting as pseudothrombophlebitis of the arm.

We described a 21-year-old woman with a diagnosis of Sjögren syndrome that came for consultation with a localized mass over her left arm of fast growth. Lab results were normal; a Doppler ultrasound showed the presence of partial thrombosis in the left axillary vein; a magnetic resonance imaging showed edema on the biceps muscle and the biopsy of the mass disclosed the presence of severe lymphocyte infiltrate within the connective tissue and scarce muscle fibers. Immunostaining showed positive results for antígeno comun leucocitario in spanish (leukocyte common antigen) (ACL) and CD3. Those results are consistent with the diagnosis of focal myositis. The patient was treated with low doses of prednisone and methotrexate, with good response.

[Venous and lymphatic alterations in women with lymphedema after axillary lymphadenectomy in breast cancer treatment]. / Alterações venosas e linfáticas em mulheres com linfedema após linfadenectomia axilar no tratamento do câncer de mama.

PURPOSE: To evaluate changes in the venous axillary-subclavian and lymphatic systems of women with lymphedema after axillary lymphadenectomy for breast cancer treatment. METHODS: This was a case series involving 11 women with unilateral upper limb lymphedema after axillary lymphedenectomy for the treatment of breast cancer. The study was carried out in the Mastology Program of the Clinical Hospital of the Federal University of Goiás, Goiânia, GO, during the period between March 2010 and March 2011. Doppler velocimetry ultrasonography was used to detect the presence of venous changes in the subclavian and axillary veins. Lymphatic changes were evaluated by lymphoscintigraphy in both upper limbs. Fisher's exact test was used for the comparison between limbs. RESULTS: Subclavian vein flow volume in the upper limb with lymphedema was significantly different from that in the contralateral limb (p<0.001), 54.6% of the women had increased flow. In the axillary vein, 45.4% had increased flow and 45.4% had decreased flow, with a statistically significant difference (p<0.01) between limbs. Compared to the contralateral limb, significant lymphatic changes (p<0.05) were also found in the vessel route (not visualized), number of lymphatic vessels (none), axillary lymph nodes (absent) and dermal reflux (present). In the contralateral upper limb without lymphedema, no venous or lymphatic alterations were encountered. CONCLUSION: The women subjected to axillary lymphadenectomy for the treatment of breast cancer presented both venous and lymphatic changes in the upper limb with lymphedema.

Alterações venosas e linfáticas em mulheres com linfedema após linfadenectomia axilar no tratamento do câncer de mama / Venous and lymphatic alterations in women with lymphedema after axillary lymphadenectomy in breast cancer treatment

OBJETIVO: Avaliar as alterações do sistema venoso axilo-subclávio e do sistema linfático em mulheres com linfedema após linfadenectomia axilar para o tratamento do câncer de mama. MÉTODOS: Trata-se de um estudo de série de casos, envolvendo 11 mulheres com linfedema unilateral de membro superior após linfadenectomia axilar para o tratamento do câncer de mama. O estudo foi realizado em hospital universitário do Brasil Central no período compreendido entre os meses de março de 2010 e março de 2011. Avaliou-se a presença de alterações venosas nas veias subclávia e axilar, por meio do exame de ultrassonografia com dopplervelocimetria, e de alterações linfáticas, pela linfocintilografia, em ambos os membros superiores. O teste Exato de Fisher foi utilizado na comparação entre os membros. RESULTADOS: No membro superior com linfedema, detectou-se diferença significativa na veia subclávia, em relação ao membro contralateral, quanto ao volume do fluxo (p<0,001), sendo que 54,6% das mulheres apresentaram fluxo aumentado. Já, na veia axilar, 45,4% apresentaram fluxo aumentado e 45,4% reduzido, com diferença significante (p<0,01) na comparação entre os membros. Também foram observadas alterações linfáticas significativas (p<0,05), em relação ao membro contralateral, representadas pelo trajeto do vaso (não visibilizado), número de vasos linfáticos (nenhum), linfonodos axilares (ausentes) e refluxo dérmico (presente). No membro superior contralateral sem linfedema, não foram encontradas alterações venosas ou linfáticas. CONCLUSÃO: As mulheres submetidas à linfadenectomia axilar para o tratamento do câncer de mama apresentam tanto alterações venosas quanto linfáticas no membro superior com linfedema.

PURPOSE: To evaluate changes in the venous axillary-subclavian and lymphatic systems of women with lymphedema after axillary lymphadenectomy for breast cancer treatment. METHODS: This was a case series involving 11 women with unilateral upper limb lymphedema after axillary lymphedenectomy for the treatment of breast cancer. The study was carried out in the Mastology Program of the Clinical Hospital of the Federal University of Goiás, Goiânia, GO, during the period between March 2010 and March 2011. Doppler velocimetry ultrasonography was used to detect the presence of venous changes in the subclavian and axillary veins. Lymphatic changes were evaluated by lymphoscintigraphy in both upper limbs. Fisher's exact test was used for the comparison between limbs. RESULTS: Subclavian vein flow volume in the upper limb with lymphedema was significantly different from that in the contralateral limb (p<0.001), 54.6% of the women had increased flow. In the axillary vein, 45.4% had increased flow and 45.4% had decreased flow, with a statistically significant difference (p<0.01) between limbs. Compared to the contralateral limb, significant lymphatic changes (p<0.05) were also found in the vessel route (not visualized), number of lymphatic vessels (none), axillary lymph nodes (absent) and dermal reflux (present). In the contralateral upper limb without lymphedema, no venous or lymphatic alterations were encountered. CONCLUSION: The women subjected to axillary lymphadenectomy for the treatment of breast cancer presented both venous and lymphatic changes in the upper limb with lymphedema.

Tratamiento de la trombosis venosa de esfuerzo en el miembro superior / Treatment of effort-induced venous thrombosis of the upper limb

IntroducciónEl correcto tratamiento de la trombosis venosa profunda (TVP) subclavia puede disminuir la secuela a largo plazo.ObjetivoAnalizar el resultado clínico a largo plazo de los pacientes tratados en nuestro servicio de trombosis venosa de esfuerzo en el miembro superior.Material y métodosEstudio retrospectivo (1986-2009). Veintinueve pacientes diagnosticados de TVP subclavia sin antecedente de marcapasos, neoplasia, accesos venosos o de hemodiálisis. Once mujeres y 18 hombres, edad media 38 años. Más de la mitad con trabajos o deportes con sobreesfuerzo de la cintura escapular. Diagnóstico: flebografía y/o ecodoppler. Tratamiento: anticoagulación: 5, fibrinólisis y anticoagulación: 9, cirugía y anticoagulación: 2, fibrinólisis, cirugía y anticoagulación: 13. La fibrinólisis (urokinasa) fue total o parcialmente efectiva en el 77% de los casos (17 de los 22 tratados con urokinasa), en 2 de ellos trombectomía adicional. Cirugía descompresiva en 15 casos: el 59% de los tratados con fibrinólisis; 4 abordajes vía transaxilar, 2 supraclavicular y 9 suprainfraclavicular. En todos los pacientes salvo en uno, resección de primera costilla asociando escalenectomía en todos. Evaluamos la secuela mediante test de calidad de vida QuickDASH y permeabilidad de la vena mediante ecodoppler.ResultadosComplicaciones precoces: una reintervención por sangrado. No complicaciones tardías. Seguimiento medio 126 meses. Siete pacientes perdidos en el seguimiento. A largo plazo, el 68% asintomáticos, de estos, el 73% sometidos a cirugía descompresiva.ConclusionesEn nuestra serie, los pacientes con TVP de esfuerzo sometidos a cirugía descompresiva, presentan un mejor resultado clínico a largo plazo que los no intervenidos(AU)

IntroductionApplying appropriate treatment for subclavian deep vein thrombosis may reduce long-term sequels.ObjectiveTo analyse the long-term clinical results of those patients treated in for upper body stress thrombosis in our Department.Materials and methodsA retrospective study (period 1986-2009) was conducted on 29 patients diagnosed with Venous Thoracic Outlet Syndrome (TOS) without pacemaker, neoplasia, previous vein access, or history of haemodialysis. The subjects included 11 women and 18 men, with a mean age of 38 years. More than half of the study subjects had jobs or took part in a sport activity involving acute stress of pectoral girdle. The diagnosis was made using Duplex Ultrasound With Venography. Treatment consisted of: anti-coagulation: 5; fibrinolysis: 9; surgery: 2; fibrinolysis+surgery: 13. Fibrinolysis was total or partially successful in 77% of cases (17 out of the 22 treated with Urokinase), two of them needing a further thrombectomy. Decompression surgery was used in 15 cases; 59% of the patients who had been treated with fibrinolysis, 4 via transaxillary approach, 2 supraclavicular and 9 supra- and infraclavicular combined. All patients but one had first rib resection, half of them had scalenectomy.ResultsEarly complications: one patient required post-intervention because of bleeding. There were no late complications. Seven patients were lost during follow up (126 months on average). In the long-term, 68% of interviewed patients remained asymptomatic, 73% of of them were subjected to decompression surgery.ConclusionsIn our series, patients who had a venous TOC decompression surgery after extrinsic compression, showed better long-term clinical results than those not operated on(AU)

Estudo anatômico da veia braquial comum como via de drenagem colateral do membro superior / Anatomic study of the common brachial vein as a collateral drainage channel of the upper limb

CONTEXTO: Traumatismos ou tromboses que possam evoluir com alterações da drenagem venosa do membro superior, dependendo do território interrompido, podem ter como mecanismo compensatório uma via colateral de drenagem sem que haja prejuízo para o retorno venoso desse membro. A veia braquial comum apresenta-se como uma alternativa plausível e pouco conhecida. OBJETIVO: Descrever a anatomia da veia braquial comum como via de drenagem colateral no membro superior. MÉTODOS: Utilizamos 30 cadáveres do sexo masculino, cujos membros superiores estavam articulados ao tronco, não importando a raça, formolizados e mantidos em conservação com solução de formol a 10 por cento. Utilizamos como critérios de exclusão cadáveres com um dos membros desarticulado ou alterações deformantes em topografia das estruturas estudadas. RESULTADOS: A veia braquial comum esteve presente em 73 por cento (22/30) dos cadáveres estudados, sendo que em 18 por cento (04/22) dos casos drenou para a veia basílica no seguimento proximal do braço e em 82 por cento (18/22), para a veia axilar. CONCLUSÃO: A veia braquial comum está frequentemente presente e, na maior parte das vezes, desemboca na veia axilar.

BACKGROUND: Trauma and thrombosis that can result in changes in the venous drainage of the upper limb, depending on the vascular territory interrupted, may have as a compensatory mechanism a collateral drainage channel that prevents damage to the venous return of that limb. The common brachial vein is a plausible and little known collateral channel for this purpose. OBJECTIVE: To describe the anatomy of the common brachial vein as a collateral drainage channel of the upper limb. METHODS: We have dissected 30 cadavers of people of different races, whose upper limbs were articulated to the trunk and preserved in a 10 percent formaldehyde solution. The exclusion criteria were disarticulated limbs or deformities in the topography of the studied structures. RESULTS: The common brachial vein was present in 73 percent (22/30) of the cadavers dissected. The common brachial vein drained into the axillary vein in 82 percent (18/22) and into the basilic vein in the proximal segment of the upper limb in 18 percent of the cadavers (04/22). CONCLUSION: The common brachial vein is frequently present, and, in most cases, it drains into the axillary vein.

Axillary vein compression by Langer's axillary arch, an aberrant muscle bundle of the latissimus dorsi.

BACKGROUND: Axillary vein compression is an important differential diagnosis in swelling of the upper extremities besides deep venous thrombosis. CASE REPORT: We present a rare case of axillary vein compression in a 17-year-old female with intermittent swelling and pain of the left arm due to an aberrant muscle bundle of the left latissimus dorsi. After resection of this bundle, which corresponded to Langer's axillary arch, the swelling and pain on the left arm resolved completely. CONCLUSION: In symptomatic patients with axillary vein compression due to Langer's axillary arch, a resection of the muscle bundle is an effective way of treatment.

Effects of Carnoy's solution on blood vessels of the axillary fossa of rats.

Carnoy's solution is applied to reduce the recurrence of odontogenic keratocysts and unicystic ameloblastomas. The deleterious action of this fixative on nerves has been studied but no attention has been paid to its effects on nearby vessels. The aim of this study was to investigate the effects of Carnoy's solution on blood vessels. The rat axillary artery and vein were surgically exposed, soaked with Carnoy's solution and kept in place for 2, 5 or 10 min, depending on the treatment group. The 5-min group was followed for 1, 2 and 3 weeks postoperatively. The vessels in the 2-min and 5-min exposure groups showed histological changes to the vessels, represented by focal loss of the endothelium and hyalinization of the wall. These alterations increased in the 10-min group. The vessels in the 3-week observation period revealed signs of recovery. It is concluded that Carnoy's solution can damage blood vessels but the process is reversible for exposure times less than 5 min.

Operating management of central venous hypertension complicating upper extremity dialysis access.

AIM: To evaluate the importance of surgical bypass between the terminal part of functional arteriovenous shunt (av) for hemodialysis on upper extremity and inner jugular vein in axillosubclavian venous segment obstruction associated with central venous hypertension. METHOD: Retrospective assessment of surgical bypass between central segments of av fistula and ipsilateral/contralateral inner jugular vein using ePTFE graft in 17 patients over a 20 year period (1987-2006). RESULTS: The surgical procedure was not associated with intra- or post-operative complications. Primary cumulative bypass and av fistula function persisted for 26 months on average. CONCLUSION: An accurate bypass to salvage the functional dialysis access associated with central venous hypertension requires careful decision based on clinical and radiological examination. The bypass procedure is beneficial where endovascular treatment is not indicated. Clinical and radiological bypass monitoring is crucial.

A comparison between ultrasound-guided infraclavicular block using the "double bubble" sign and neurostimulation-guided axillary block.

BACKGROUND: Ultrasound-guided infraclavicular block can be performed using the double bubble sign. Previously described, the double bubble sign consists superiorly of the axillary artery (in short axis) superimposed on an inferior bubble created by local anesthetic injection. In this study, we compared this new method of brachial plexus anesthesia to the traditional triple-nerve stimulation axillary block. METHODS: Seventy patients were randomized to receive a single-injection, ultrasound-guided infraclavicular block using the double bubble sign or a triple-stimulation axillary block. RESULTS: Both methods produced similar success rates (89%-91%). However, infraclavicular blocks were associated with a shorter performance time (3.90 +/- 2.27 vs 8.03 +/- 3.92 min; P < 0.001) and lower block-related pain scores (2.70 +/- 2.02 vs 4.17 +/- 2.57 on a 0-10 scale; P = 0.01). CONCLUSION: Compared to triple-stimulation axillary block, ultrasound-guided infraclavicular block using the double bubble sign provided a similar efficacy, a shorter performance time and lower procedural pain scores.

Exercise-induced deep vein thrombosis of the upper extremity. 2. A case series in children.

Upper-extremity deep venous thrombosis (UEDVT) is an increasingly important clinical problem in children. These events are classified as primary or secondary, with the latter being the most common and usually associated with the presence of a central venous line. Among primary UEDVT, the so-called Paget-Schroetter syndrome, effort-related or exercise-induced upper-extremity thrombotic event represents an extremely rare finding that has never been described in a pediatric series. The objective of the second part of this two-part article is to report the first pediatric series in a group of adolescents with this condition from a single center, describing their clinical features, management, and outcome. A retrospective chart review of 6 patients seen between December 2003 and April 2005 was conducted, with a median follow-up of 9 months (range 2-17). Four females and two males, all Caucasian, were enrolled with a median age of 16 years (range 14-17). In all cases, strenuous exercise was present in the month preceding diagnosis and mild trauma was present in only one case (weight lifting). At presentation, all patients had objective swelling of the affected limb for a median of 4 days (range 2-14), and 4 patients had UEDVT of the dominant arm. Thrombophilia investigation revealed that 50% had a combined prothrombotic state at presentation, and all patients were/are being treated with anticoagulation for 6 months (low-molecular-weight heparin followed by warfarin). Continuation of the initial symptoms was present in all cases but one at the 3-month clinic follow-up (last case has yet to reach 3 months of follow-up), and residual moderate to severe postthrombotic syndrome was present in all 3 cases followed for more than 12 months. Of those 3 patients followed for more than 1 year, 2 patients recurred despite having complete resolution of the thrombus after 6 months of anticoagulation, and the third patient underwent surgery with clinical improvement. Adolescents with UEDVT treated only with anticoagulation seem to have a poor outcome.

Exercise-induced deep vein thrombosis of the upper extremity. 1. Literature review.

Paget-Schroetter syndrome or effort-related upper extremity deep vein thrombosis is a rare condition that usually afflicts young healthy individuals, most commonly males. The cause is multifactorial but almost always involves extrinsic compression of the subclavian vein at the thoracic inlet, causing venous stenosis from repetitive trauma. The diagnosis of this condition may be difficult, and its delay may contribute to potential complications including thrombosis progression, pulmonary embolism, thrombosis recurrence, and post-thrombotic syndrome. Similarly, the best therapeutic option has not been established and in the lack of evidence-based guidelines, treatment may be extremely challenging especially in children, in whom long-term complications can be particularly disabling.