A case of delayed bleeding of the chest wall after VATS treated with transcatheter arterial embolization.

We report a case of delayed bleeding after video-assisted thoracic surgery (VATS) that was successfully treated with transcatheter arterial embolization. An 81-year-old woman underwent a pleural biopsy via VATS for pleural dissemination of lung cancer. The postoperative course was good, but 8 days later she was hospitalized for swelling in the right axilla and was admitted to our hospital with a diagnosis of delayed postoperative hemorrhage. Gauze compression was performed, and the patient was discharged without exacerbation of hematoma. However, 4 days later, she was hospitalized for rapidly worsening swelling and pain. Chest computed tomography at the time of rebleeding showed an increase in the hematoma and extravasation in the peripheral right lateral thoracic artery. The patient was immediately treated with emergency angiography, and coil embolization was performed. After this treatment, the patient has done well and there has been no subsequent recurrence of bleeding.

Can Lateral Thoracic Artery Preservation Improve Results in Large PMMC Flaps? - Our Experience of 61 Cases from Northern India.

Introduction: Pectoralis major myo-cutaneous (PMMC) flap continues to be a widely used tool to reconstruct oral cavity defects. But an unreliable and unstable vascular supply can lead to complications like flap loss, Oro-cutaneous fistula and wound dehiscence. Preservation of the lateral thoracic artery (LTA) has been suggested to improve the vascularity of the skin paddle. The present study aspires to compare the complications and flap related outcomes after preserving or sacrificing the LTA while reconstructing oral cavity defects with bi-folded PMMC flap. Materials and Methods: Retrospective analysis of the data of 61 male patients who were reconstructed with bi-folded PMMC flaps between January 2022 and September 2022 was done. 36 patients were reconstructed using a PMMC flap where the LTA was sacrificed, whereas in 25 patients the LTA was preserved. Data was analyzed in terms of patient factors and flap related complications. Results: The overall complication rate including major/minor complications was 44.26% with flap detachment at 22.95% being the commonest complication observed. 13.11% patients developed an Oro-cutaneous fistula and partial and complete flap loss were seen in 9.83% and 4.91% respectively. LTA preservation was significantly associated with only decreased flap detachment rates (p value < 0.05). No significant association was noticed between other flap related complications and LTA preservation. Conclusion: Reconstructing larger defects with a PMMC flap where the LTA is preserved can help improve the vascularity of the flap and decrease various major/minor flap related complications. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04123-3.

Application of a modified lateral thoracic artery perforator flap in partial breast defects.

Background: Breast cancer has become the most frequently diagnosed cancer in the world. Detection at an early stage, frequently allows women to benefit from breast conserving surgery. However, some patients are not satisfied with the breast shape after breast-conserving surgery, and autologous tissue flaps are needed to fill the defect in the resection area. The modified lateral thoracic artery perforator (LTAP) flap isn't one of the commonly used flaps in breast surgery and has the advantages of a reliable blood supply, simple operation and few postoperative complications. In this study, we aimed to evaluate the feasibility and effectiveness of a modified LTAP flap for repairing partial breast defects after breast-conserving surgery. Methods: In this study, we retrospectively analyzed the clinical data of 126 patients treated with LTAP flaps to repair local breast defects at Affiliated Hospital of Guangdong Medical University between January 2020 and June 2021. Data were collected on the demographic characteristics of these patients, tumor size and location, type of axillary lymph node surgery, availability of adjuvant chemotherapy and radiotherapy, and postoperative complications. Results: The median weight of the tumor specimen was 185 g (range, 170-320 g), and this glandular tissue accounted for 30% to 40% of the total breast volume. The average flap size was 10.5 cm ×2.5 cm (length range, 8-15 cm, width range: 2-4 cm). The minimum follow-up time was 6 months, with an average of 10 months (range, 6-22 months). The mean operative time was 130 minutes (range: 90-180 minutes), and the mean hospital stay was 3 days (range, 2-5 days). All modified LTAP flaps survived completely without donor site complications. None of the patients required revision surgery on the postoperative breast. Conclusions: The modified LTAP flap is a reliable method for repairing partial breast defects after breast-conserving surgery. It has the advantages of a simple operation, a reliable blood supply, fewer postoperative complications, and a high flap survival rate. It is especially suitable for Asian women with small breast volumes and can achieve good breast contouring effects.

An unusual combination of a bilateral aberrant suprascapular artery with neurovascular structures variants.

PURPOSE: The report describes a bilateral suprascapular artery (SPSA) of atypical origin in coexistence with neurovascular aberrant structures. METHODS: The variants were identified in a 91-year-old formalin-embalmed male cadaver, derived from a body donation program after a signed informed consent. RESULTS: The left-sided SPSA emanated from the 1st part of the axillary artery, coursed between the brachial plexus lateral and medial cords, accompanied by the suprascapular nerve, and passed below the superior transverse scapular ligament. Ipsilateral coexisted variants were the lateral thoracic artery multiplication, the subscapular trunk formation, and the musculocutaneous nerve duplication. In the right supraclavicular area, a SPSA duplication was identified. The main artery emanated from the thyrocervical trunk in common with the transverse cervical artery and the accessory SPSA emanated from the dorsal scapular artery. Both SPSAs coursed over the superior transverse scapular ligament, while the suprascapular nerve ran below the ligament. CONCLUSIONS: The current study reported a bilateral aberrant SPSA, originating from the AA 1st part (left side) and from the dorsal scapular artery (right side), which coexisted with adjacent neurovascular structures' variants. The left SPSA atypically coursed below the superior transverse scapular ligament. Such an unusual combination of variations, present bilaterally in the current study, may be challenging for radiologists and surgeons.

A single centre experience of local perforator flaps in oncoplastic breast surgery; a cross-sectional study.

Background & objectives: Various oncoplastic techniques have emerged over the years to preserve breast cosmesis and symmetry without compromising the principles of tumor excision. One of the newer techniques for breast volume replacement to achieve symmetry and cosmesis is the use of fasciocutaneous pedicled chest wall perforator flaps or local perforator flaps (LPF). The objectives of this study were to document the details of the surgical procedure as well as patient-reported satisfaction and well-being following the procedure using a validated BREAST-Q tool among Pakistani women. Materials & methods: This cross-sectional study was conducted from March 2019 to February 2021 enrolling 25 female patients who underwent breast conservative surgery using LPF for breast tumors at The Aga Khan University Hospital, Karachi. Data related to the procedure was collected on a pre-designed proforma. Cosmetic outcomes and patient satisfaction were evaluated using 2 scales from BREAST-Q BCT domain version 2.0. The questionnaire was self-administered by the patients during their routine follow-up in the clinic. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Mean (SD)/median (IQR) were computed for quantitative variables and frequency and percentages were calculated for qualitative variables. 2 sample t-test was applied. P-value ≤0.05 was considered significant. Results: 25 patients underwent LPF with a mean age of 47 ± 13.1 years. 8 LICAP, 7 AICAP, and 10 LTAP flaps were performed. Two postoperative complications of wound site erythema were encountered. 23 women were eligible for the BREAST-Q survey. Median (IQR) postoperative satisfaction with breasts and physical well-being chest (equivalent Rasch transformed score) was 100 (41) and 76 [18] respectively. We found high satisfaction with breasts and comparable physical well-being among Pakistani women after LPF surgeries. Conclusion: Local perforator flaps in oncoplastic breast-conserving surgery are a good option showing high satisfaction with breasts and physical well-being in Pakistani women.

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.

Unexpected haemorrhage from lateral thoracic artery following the removal of a pleural drainage tube.

Pulmonologists must be aware of the possible arterial bleeding even during the removal of a safely inserted drain.

Assessment of breast arteries and lymph nodes by 3D MR angiography enhancement imaging: feasibility and pilot clinical results.

BACKGROUND: Conventional dynamic contrast enhanced (DCE) magnetic resonance (MR) hardly achieves a good imaging performance of arteries and lymph nodes in the breast area. Therefore, a new imaging method is needed for the assessment of breast arteries and lymph nodes. METHODS: We performed prospective research. The research included 52 patients aged from 25 to 64 between June 2019 and April 2020. The isotropic e-THRIVE sequence scanned in the coronal direction after DCE-THRIVE. Reconstructed images obtained by DCE-THRIVE and the coronal e-THRIVE were compared mainly in terms of the completeness of the lateral thoracic artery, thoracodorsal artery, and lymph nodes. We proposed a criterion for evaluating image quality. According to the criterion, images were assigned a score from 1 to 5 according to the grade from low to high. Two board-certified doctors evaluated images individually, and their average score was taken as the final result. The chi-square test was used to assess the difference. RESULTS: The coronal e-THRIVE score is 4.60, which is higher than the DCE-THRIVE score of 3.48, there are significant differences between the images obtained by two sequences (P = 1.2712e-8). According to the score of images, 44 patients (84.61%) had high-quality images on the bilateral breast. Only 3 patients' (5.77%) images were not ideal on both sides. The improved method is effective for most patients to get better images. CONCLUSIONS: The proposed coronal e-THRIVE scan can get higher quality reconstruction images than the conventional method to visualize the course of arteries and the distribution of lymph nodes in most patients, which will be helpful for the clinical follow-up treatment.

An unusual case of asymmetrical combined variations of the subclavian and axillary artery with clinical significance.

In a Greek Caucasian male cadaver, a combination of the following arterial variations were observed: an aberrant right subclavian artery originating as a last branch of the aortic arch and coursed posterior to the oesophagus, a right non-recurrent laryngeal nerve, an atypical origin of the left suprascapular artery from the axillary artery, an unusual emersion of the lateral thoracic artery from the subscapular artery and a separate origin of the left thoracodorsal artery from the axillary artery. According to the available literature the corresponding incidences of the referred variants are: 0.7% for the aberrant right subclavian artery, 1.6-3.8% for the origin of the suprascapular artery from the axillary artery, 3% for the origin of the left thoracodorsal artery from the axillary artery and 30% for the origin of the lateral thoracic artery from the subscapular artery. Such unusual coexistence of arterial variations may developmentally be explained and has important clinical significance.

An atypical biceps brachii and coracobrachialis muscles associated with multiple neurovascular aberrations: a case report with clinical significance.

Neural and vascular variations in the axilla and upper limb area are usually paired, but coexistence of muscular aberration on top of this is uncommon. The current case report emphasizes on the unilateral coexistence of a three-headed (tricipital) biceps brachii muscle, a two-headed coracobrachialis with an accessory muscle bundle joining the superficial and deep heads of coracobrachialis muscle. On the ipsilateral side of the 72-year-old male cadaver, a connecting branch originated from the musculocutaneous nerve and joined the median nerve after surpassing the accessory muscle bundle. A large diameter subscapular trunk originated from the 2nd part of the axillary artery and after giving off the 1st lateral thoracic artery trifurcated into a common stem which gave off the 2nd and 3rd lateral thoracic arteries, the circumflex scapular artery and a common branch that gave off the 4th and 5th lateral thoracic arteries and the thoracodorsal artery, as the ultimate branch. All lateral thoracic arteries were accompanied by multiple intercostobra- chial nerves. Documentation of such muscular and neurovascular variants and their embryologic origin increases awareness of their potential impact on diagnosis and treatment of upper limb pathology. To the best of our knowledge, the currently reported cadaveric observations seem to constitute a unique finding.

Abnormal Communication between Lateral Thoracic Artery and Anterior Circumflex Humeral Artery - a Case Report.

Variations in the branching pattern of axillary artery are observed by many anatomists all over the world. A unique bilateral variation in the axillary artery was observed during the routine dissection of the upper limbs on an approximately 65 year old male cadaver. An abnormal communicative channel was observed between lateral thoracic artery and anterior circumflex humeral artery. It passed between the two roots of median nerve. Arterial anomalies in the upper limb are due to defective remodelling of vascular plexus of the upper limb bud during embryogenesis. Knowledge of variations in axillary artery is quintessential for surgeons, radiologists and anaesthesiologists to avoid treacherous complications during procedures.

Massive Hemoptysis with a Fungus Ball-like Shadow in an Old Tuberculosis Cavity That Was Shown to Be a Clot by Bronchoscopy.

Development of aspergilloma is common in cases with a fungus ball-like shadow in cavities due to old tuberculosis. Some reports have shown that blood clots tend to appear as a fungus ball-like shadow. A 71-year-old man with a history of pulmonary tuberculosis presented with a fungus ball-like shadow in an old cavity and hemoptysis. There was no evidence of aspergillus infection on various examinations. We confirmed a blood clot and aneurysm of an artery under direct vision by bronchoscopy. A lateral thoracic artery aneurysm was detected by angiography. Transcatheter arterial embolization was performed. After treatment, the artery aneurysm disappeared.

The surgical anatomy of the vascularized lateral thoracic artery lymph node flap-A cadaver study.

BACKGROUND: One promising surgical treatment of lymphedema is the VLNT. Lymph nodes can be harvested from different locations; inguinal, axillary, and supraclavicular ones are used most often. The aim of our study was to assess the surgical anatomy of the lateral thoracic artery lymph node flap. MATERIALS AND METHODS: In total, 16 lymph node flaps from nine cadavers were dissected. Flap markings were made between the anterior and posterior axillary line in dimensions of 10 × 5 cm. Axillary lymph nodes were analyzed using high-resolution ultrasound and morphologically via dissection. The cutaneous vascular territory of the lateral thoracic artery was highlighted via dye injections, the pedicle recorded by length, and diameter and its location in a specific coordinate system. RESULTS: On average, 3.10 ± 1.6 lymph nodes were counted per flap via ultrasound. Macroscopic inspection showed on average 13.40 ± 3.13. Their mean dimensions were 3.76 ± 1.19 mm in width and 7.12 ± 0.98 mm in length by ultrasonography, and 3.83 ± 2.14 mm and 6.30 ± 4.43 mm via dissection. The external diameter of the lateral thoracic artery averaged 2.2 ± 0.40 mm with a mean pedicle length of 3.6 ± 0.82 cm. 87.5% of the specimens had a skin paddle. CONCLUSIONS: The lateral thoracic artery-based lymph node flap proved to be a suitable alternative to other VLNT donor sites.

Variation in the Branching Pattern of Third Part of Axillary Artery- A Case Report.

Anatomical variation of the branching pattern of axillary artery is very common. The knowledge of this variation is often useful during different surgical and interventional procedures. Variations include typically of Lateral Thoracic Artery (LTA) and Posterior Circumflex Humeral Artery (PCHA). The present case has been reported to document the variation of LTA and PCHA. The axilla of a 65-year-old embalmed female cadaver was routinely dissected for educational purpose in the Department of Anatomy, AIIMS, New Delhi, India. Cunnighams Manual of Dissection was followed during the whole dissection procedure. We found that the third part of axillary artery gave rise to a common trunk which divided into PCHA and LTA. The PCHA curved backwards around the humeral neck and made anastomosis with the anterior circumflex humeral artery. The LTA supplied serratus anterior and the pectoral muscles and made anastomosis with intercostal arteries. The axillary nerve accompanied PCHA while the thoracodorsal nerve accompanied LTA. The rare anatomical variation of the branching pattern of axillary artery is assumed to be helpful in the surgical procedures and various therapeutic interventions of the upper limb.

Tetrafurcation of the subscapular artery. Anatomical and clinical implications.

Anatomic variations of axillary artery branches are commonly encountered during radiological investigation and surgical operations. Their existence can confuse interpretation of radiological results and lead to undesired complications during surgery. In this report authors describe a rare case of a subscapular arterial trunk that gave origin to thoracodorsal, circumflex scapular, posterior humeral circumflex, and lateral thoracic artery. Such a variation might cause undesired sequelae during trauma management and a variety of common flap harvesting operations including latissimus dorsi, scapular and parascapular flaps. Furthermore it presents embryological interest as it gives insight to embryologic development of axillary area.

A new lateral thoracic artery perforator flap design with multiple vascular territories in rats.

BACKGROUND: To describe a new design for an extended lateral thoracic artery (LTA) perforator flap and investigate its anatomical, dynamic, and potential territories. MATERIALS AND METHODS: To assess vascular territories, rats were randomized according to LTA perforator flap type into the surgical groups A, hemidorsal island flap; B, entire dorsal island flap; and C, reduced-size dorsal island flap. RESULTS: On postsurgical day 7, the surviving flap areas were 95%, 92%, and 89% in groups A, B, and C, respectively. Necrosis most commonly occurred in the contralateral LTA territories in groups B and C. The immunoreactivities of intercellular adhesion molecule 1 and vascular endothelial growth factor receptor 2 in dynamic territories, as choke vessel markers, were increased. CONCLUSIONS: We clarified the LTA perforator flap nomenclature and defined its pedicle course and anastomosing patterns; furthermore, we demonstrated that the LTA perforator did not anastomose with its counterpart because of its unidirectional, oblique, and craniocaudal course. The LTA perforator flap was found to be a good model comprising multiple vascular territories and exhibiting continuous necrosis.

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.

Lateral thoracic artery perforator-based flap: a new experimental model.

BACKGROUND: The aim of this study was to describe a new experimental perforator-based flap in rats, supplied by lateral thoracic artery perforator. METHODS: Through out the study, two control and two experimental groups were created consisting of six rats in each group. In the first control group (group 1), mid-axillary line and the fourth intercostal space intersection were used as the center of the flap. A 3 × 2 cm flap was designed and elevated above the cutaneous maximus muscle by transecting all connections with the muscle. In the second control group (group 2), the flap was extended caudally, and 3 × 6 cm flap was designed. Then, the flap was elevated in the same manner as it was described for group 1. In the first experimental group (group 3) 3 × 2 cm flap and in the second experimental group (group 4) 3 × 6 cm flap were designed like control groups. The flaps were islanded on a single musculocutan perforator arising from lateral thoracic artery. The surviving skin paddle areas were calculated on postoperative day 7. RESULTS: The flap viability was calculated 0% for control groups (groups 1 and 2), 100% for the first experimental group (group 3), between 33.3% and 37.7% for the second experimental group (group 4; mean ± standard deviation, 34.76% ± 1.92%). CONCLUSIONS: This new lateral thoracic artery perforator-based flap has a constant anatomy and reliable survival pattern. Also, easy harvesting and the possibility of designing two flaps per animal make this new flap an appealing model for pathophysiological or pharmacologic researches.

Preoperative color Doppler ultrasound assessment of the lateral thoracic artery perforator flap and its branching pattern.

The anatomy of the lateral thoracic artery perforator flap remains controversial, but this region is extremely useful as a reconstructive donor site. In this report, we describe the usefulness of the preoperative color Doppler ultrasound evaluation for the harvesting of the lateral thoracic artery perforator flap, and we clarify its branching pattern. Twenty-seven patients underwent the preoperative color Doppler ultrasound assessment before perforator flaps were harvested. We evaluated the branching pattern and the diameter of the flaps by direct observation. All flaps were successfully transferred, and it was found that the branching pattern of the lateral thoracic perforator is divided into three groups: the superficial branch, the medial branch, and the deep branch. Their appearance ratios were 48.1% (13/27), 14.8% (4/27), and 81.5% (22/27), respectively. The lateral thoracic artery perforator flap has a great deal of anatomical variation, and vessels with relatively small diameters compared to those of other flaps. This is why flaps from this region are not currently popular. This study revealed the superiority of the color Doppler ultrasound for preoperative planning of the lateral thoracic artery perforator flap elevation. Furthermore, the branching pattern and the diameters of the different branches were specified.

The lateral thoracic artery passing through duplicated axillary vein: a case report.

The axillary vein is a large-blood vessel that lies on the medial side to the axillary artery. The veins of the axilla are more abundant than the arteries and their variations were extremely common. During educational dissection, a rare form of the axillary vein accompanying arterial variation was founded in left arm of 70-year-old female cadaver. The axillary vein was divided into two large veins, anterior and posterior axillary veins according to their anatomical position. The lateral-thoracic artery arose from the second part of the axillary artery and passed through the gap of duplicated axillary vein. Before the lateral-thoracic artery passed through the gap of duplicated axillary vein, the lateral-thoracic artery gave-off an additional branch, which descended superficial to the anterior axillary vein. It surrounded the anterior axillary vein as annular form and the diameter of surrounded part of the anterior axillary vein became narrow. This novel case was reported and its clinical implications of such a variant were discussed.