DOCSLIB.ORG

Deltopectoral Flap, One Should Be More Inclined to Delay Groove, Its Reliability Is Therefore Diminish- the Flap As Delaying Or Supercharging the Ed (Figure 4B)

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text

Load more

OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY DELTOPECTORAL AND CERVICODELTOPECTORAL FASCIOCUTANEOUS FLAPS FOR HEAD AND NECK RECONSTRUCTION Johan Fagan, Ottie van Zyl Fasciocutaneous flaps raised from the Common carotid artery anterior chest wall below the clavicle are Innominate artery well suited to reconstructing skin defects in Internal mammary artery the head and neck region in terms of prox- imity, skin texture and skin colour. Bakam- jian first described the deltopectoral (DP) flap in 1965 as a head and neck recon- 1 Perforating branches structive option . The DP flap is a pedi- cled axial fasciocutaneous flap based on the internal mammary artery perforator arteries (IMAP) (Figure 1) although the perforator(s) are usually not identified, dissected, nor mobilized. However, if the Superior epigastric artery flap is raised as an island flap with Figure 1: Perforators originate from the complete division of the skin pedicle and internal mammary artery the perforators are dissected out, it be- comes an internal mammary artery perfo- rator flap (IMAP flap); the IMAP flap will be discussed in a separate chapter. 1st rib Surgical anatomy 2nd rib Paired internal mammary (IMA) arteries Perforators arise from the subclavian artery and course inferiorly on the inside of the rib cage ap- proximately 1cm lateral to the sternum (Figure 1). The perforating branches of the IMA emerge about 7mm lateral to the sternum through five or six intercostal spaces; they are 0.25-3.5mm in diameter (Figures 1, 2, 3). The so-called “principal Sternum perforator” traverses the 2nd intercostal space; the mean diameters of this artery and vein are just over 1.8mm 2. The vessels subsequently course laterally to provide blood supply to the pectoralis major mus- Figure 2: Left half of sternum: Perforators cle and overlying skin; the 2nd - 4th perfo- emerge approximately 7mm lateral to ster- rators send branches to the breast. num 2 The blood vessels to the fasciocutaneous The DP flap that is located medial to the flap run in a plane superficial to the fascia deltopectoral groove (junction between that covers the pectoralis major and deltoid pectoralis and deltoid muscles) has a muscles; hence the importance of raising reliable axial blood supply and can be these flaps in a plane deep to the deltoid transferred with a high probability of and pectoral fasciae. survival. Figure 3: Perforator branch of IMA 3 Figure 4a: 1st angiosome: yellow; 2nd angiosome: blue; 3rd angiosome: red Three angiosomes (arterial/vascular terri- tories) are included when extending a DP flap laterally over the deltoid (Figure 4a): • 1st Angiosome: IMA perforators ex- tend from the lateral border of the sternum up to close to the deltopectoral groove (This area also receives some blood supply from musculocutaneous perforators arising from the pectoralis major muscle) • 2nd Angiosome: A small, but variable region of skin below the clavicle and medial to the deltopectoral groove is supplied by the thoracoacromial artery via a small direct cutaneous artery Figure 4b: Typical outline of a DP flap rd • 3 Angiosome: The area over the del- (yellow); deltopectoral groove (blue); toid muscle is supplied by musculo- lateral extension of flap (red); incision to cutaneous perforators arising from the gain additional length (green); axis of deltoid branch of the thoracoacromial rotation (red star) artery and the anterior circumflex humeral artery More dominant supply vessels to the 2nd and 3rd angiosomes increase the risk of As one moves laterally and away from the necrosis in the 3rd/distal angiosome once IMA source-perforators the pressure 4 these supply vessels are divided and the gradient diminishes. Taylor showed with flap becomes dependent only on the ves- the angiosome concept that the blood sels from the 1st angiosome. The further supply of the main angiosome and adjacent nd laterally the flap is raised the more random angiosome (2 angiosome) is reliable, but and unreliable the vascular supply and the that an additional angiosome, such as that less reliable the flap becomes. If very large over the deltoid muscle, is at risk of under- deltoid perforators are therefore encoun- going ischaemic necrosis. Once a DP flap tered when elevating the distal part of the is extended lateral to the deltopectoral flap, one should be more inclined to delay groove, its reliability is therefore diminish- the flap as delaying or supercharging the ed (Figure 4b). 2 flap lateral to the deltopectoral groove im- Advantages proves survival of its distal part (see later). • Provides large area of skin cover Deltopectoral Flap (Figure 4) • Better colour and texture match com- pared to free tissue transfer flaps from The DP flap has largely been supplanted distant sites by the pectoralis major, free tissue trans- • Less bulky than pectoralis major flap fer and, to a lesser extent, latissimus dorsi • Technical simplicity flaps. It may however be useful in specific situations when other options are unavaila- Disadvantages ble or have been exhausted e.g. recon- struction of cervical skin defects; skin • Limited arc of rotation cover of an exposed carotid artery (Figures • Fasciocutaneous pedicle limits the 5a, b); closure of a pharyngocutaneous fis- reach of the flap tula; or (staged) hypopharynx reconstruct- • Unsightly donor defect especially if tion (very rarely). Contraindications inclu- skin graft is required (Figure 6) de an internal mammary artery that has previously been used for coronary artery bypass surgery; and prior trauma or surgery (mastectomy, pacemaker, pectora- lis major flap) to the anterior chest wall. Figure 6: Scarring from skin grafts and flap contracture band of the neck Anaesthesia and preparation • General anaesthesia • Paralysis acceptable as there are no major nerves are in the surgical field • Supine position with padding/bag un- der the shoulders • Prepare and drape the anterior chest wall, shoulder and neck • Prepare and drape the thigh for a possi- ble skin graft Flap design (Figures 4, 7) Figures 5a, b: DP flap used to cover skin defect that caused a carotid blowout • Outline the flap over the anterior chest wall and shoulder (Figure 7) 3 Flap elevation (Figure 8) • Cut through skin and subcutaneous fat and breast tissue onto the (delto)pec- toral fascia • Cut through the (delto)pectoral fascia onto the muscle • Suture the skin edges to the fascia • Leave these sutures long at the distal end of flap and hold onto them when elevating the flap Figure 7: Closing a pharyngocutaneous • Use a scalpel (not diathermy) to elevate defect after laryngectomy (pharyngeal mu- the pectoral fascia off the muscle in st cosa has been closed); positions of the 1 order to protect the suprafascial vascu- three perforators and the deltopectoral lar network groove have been marked on the skin • Elevate the flap from lateral to medial just deep to the (delto)pectoral fascia; • The DP flap was originally based on this exposes the muscle fibres of the st rd the 1 - 3 perforators but is now is two muscles (Figure 8) nd rd generally based only on the 2 and 3 • Branches of the thoracoacromial artery perforators which perforate the pectoralis major • Mark the positions of the intercostal muscle laterally are severed during perforators on the skin in the intercos- elevation tal spaces, 1cm lateral to the sternum • Stop elevating the flap about 2cm • A Doppler probe may be used to define lateral to the sternum so as not to injure their positions more accurately (Figure the perforators 7) • Measure the required length of the flap from the top of the defect in the neck to the point of rotation which is based at the most inferior perforator to be used • Note that the point of rotation of the DP flap is located closer to the upper side of the base of the flap due to the Pectoralis major more lax skin along the inferior border Deltopectoral groove of the flap and along the anterior axil- lary fold Deltoid muscle Limits of DP flap Figure 8: Flap has been elevated in a sub- fascial plane to expose pectoralis major • Above: clavicle (unless cervicodelto- and deltoid muscles pectoral rotation flap is used) • Below: 5th intercostal space Flap Inset • Lateral: deltopectoral groove (exten- sion over the deltoid muscle may • The entire flap may be used to cover require delaying the flap) adjacent defects (Figures 9a, b, c) • The flap may also be tubed and passed over an intact bridge of skin, or fash- 4 ioned as an island flap by separating Closure of donor defect the skin off the pedicle in a subcu- taneous plane • Small donor sites can be closed prima- rily by undermining the surrounding skin and inserting a suction or pencil drain (Figure 9c) • Larger donor sites are covered with a split thickness skin graft (Figure 6) Maximising flap survival • Handle the flap atraumatically • Use a scalpel (not diathermy) to raise the flap • Use bipolar cautery for haemostasis Figure 9a: Flap is positioned in its final position to cover the pharyngocutaneous • Avoid injury to the perforating arteries defect; note the back-cut below the 3rd • Avoid tension on the flap during its perforator to increase the length of the flap rotation and inset • If possible, avoid extending the flap beyond the deltopectoral groove • Avoid tracheostomy ties around the neck as they may compress the vascu- lar pedicle Gaining additional length • Cut back over the sternum below and medial to the most inferior perforator (Figures 4, 10) Figure 9b: The skin bridge between the defect and the flap has been divided and elevated to accommodate
Recommended publications
  • Anatomical Variants in the Termination of the Cephalic Vein Stoyan Novakov1*, Elena Krasteva2

    Anatomical Variants in the Termination of the Cephalic Vein Stoyan Novakov1*, Elena Krasteva2

    Institute of Experimental Morphology, Pathology and Anthropology with Museum Bulgarian Anatomical Society Acta morphologica et anthropologica, 25 (3-4) Sofia • 2018 Anatomical Variants in the Termination of the Cephalic Vein Stoyan Novakov1*, Elena Krasteva2 1 Department of Anatomy, Histology and Embryology, 2Department of Propaedeutics of Surgical Di- seases, Medical Faculty, Medical University of Plovdiv * Corresponding author e-mail: [email protected] Jugulocephalic vein is atavistic structure which is very rare. The low incidence of the variations of the cephalic vein in deltopectoral triangle and its position on the anterior surface of the clavicle and the neck doesn’t make it less important for the clinical practice. Phylo- and ontogenesis explain the formation of the above mentioned variations. We followed the pattern of the cephalic vein in its proximal part and termination to describe possible variations. In this long term study on 140 upper limbs of 70 cadavers, 4 or 2,9% of the cephalic veins were variable. The direct empting of the cephalic vein into internal jugular is an exception with few descriptions at the moment. The rareness of this anatomical variation doesn’t make it less important for clinical practice. It is described as a possible obstacle in catheter implantation, clavicle fractures and creation of arteriovenous fistula in patients on hemodialysis. Key words:cadavers, human anatomy variation, cephalic vein, external jugular vein, jugulocephalic vein Introduction Cephalic vein (CV) belongs to the group of superficial veins of the upper limb. It usually forms over the anatomical snuff-box on the radial side of the wrist from the radial end of the dorsal venous plexus.
  • Pectoral Muscles 1. Remove the Superficial Fascia Overlying the Pectoralis Major Muscle (Fig

    Pectoral Muscles 1. Remove the Superficial Fascia Overlying the Pectoralis Major Muscle (Fig

    BREAST, PECTORAL REGION, AND AXILLA LAB (Grant's Dissector (16th Ed.) pp. 28-38) TODAY’S GOALS: 1. Identify the major structural and tissue components of the female breast, including its blood supply. 2. Identify examples of axillary lymph nodes and understand the lymphatic drainage of the breast. 3. Identify the pectoralis major, pectoralis minor, and serratus anterior muscles. Demonstrate their bony attachments, nerve supply, and actions. 4. Identify the walls and associated muscles of the axilla. 5. Identify the axillary sheath, axillary vein, and the 6 major branches of the axillary artery. 6. Identify and trace the cords of the brachial plexus and their branches. DISSECTION NOTES: The donor should be in the supine position. Breast 1. The breast or mammary gland is a modified sweat gland embedded in the superficial fascia overlying the anterior chest wall. Refer to Fig. 2.5A for incisions for reflecting skin of the pectoral region to the mid-arm. Do this bilaterally. Within the superficial fascia in front of the shoulder and along the lateral and lower medial portions of the arm locate the cephalic and basilic veins and preserve these for now. Observe the course of the cephalic vein from the arm into the deltopectoral groove between the deltoid and pectoralis major muscles. 2. For those who have a female donor, mobilize the breast by inserting your fingers behind it within the retromammary space and separate it from the underlying deep fascia of the pectoralis major (see Fig. 2.7). An extension of breast tissue (axillary tail) from the superolateral (upper outer) quadrant often extends around the lateral border of the pectoralis major muscle into the axilla.
  • The Clinical Anatomy of the Cephalic Vein in the Deltopectoral Triangle

    The Clinical Anatomy of the Cephalic Vein in the Deltopectoral Triangle

    Folia Morphol. Vol. 67, No. 1, pp. 72–77 Copyright © 2008 Via Medica O R I G I N A L A R T I C L E ISSN 0015–5659 www.fm.viamedica.pl The clinical anatomy of the cephalic vein in the deltopectoral triangle M. Loukas1, 2, C.S. Myers1, Ch.T. Wartmann1, R.S. Tubbs3, T. Judge1, B. Curry1, R. Jordan1 1Department of Anatomical Sciences, St. George’s University, School of Medicine, Grenada, West Indies 2Department of Education and Development, Harvard Medical School, Boston MA, USA 3Department of Cell Biology and Pediatric Neurosurgery, University of Alabama at Brimingham, AL, USA [Received 19 June 2007; Revised 3 January 2008; Accepted 7 January 2008] Identification and recognition of the cephalic vein in the deltopectoral triangle is of critical importance when considering emergency catheterization proce- dures. The aim of our study was to conduct a cadaveric study to access data regarding the topography and the distribution patterns of the cephalic vein as it relates to the deltopectoral triangle. One hundred formalin fixed cadavers were examined. The cephalic vein was found in 95% (190 right and left) spec- imens, while in the remaining 5% (10) the cephalic vein was absent. In 80% (152) of cases the cephalic vein was found emerging superficially in the lateral portion of the deltopectoral triangle. In 30% (52) of these 152 cases the ceph- alic vein received one tributary within the deltopectoral triangle, while in 70% (100) of the specimens it received two. In the remaining 20% (38) of cases the cephalic vein was located deep to the deltopectoral fascia and fat and did not emerge through the deltopectoral triangle but was identified medially to the coracobrachialis and inferior to the medial border of the deltoid.
  • Bilateral Sternalis Muscles Were Observed During Dissection of the Thoraco-Abdominal Region of a Male Cadaver

    Bilateral Sternalis Muscles Were Observed During Dissection of the Thoraco-Abdominal Region of a Male Cadaver

    Case Reports Ahmed F. Ibrahim, MSc, MD, Saeed A. Makarem, MSc. PhD, Hassem H. Darwish, MBBCh. ABSTRACT Bilateral sternalis muscles were observed during dissection of the thoraco-abdominal region of a male cadaver. A full description of the muscles, as well as their attachments and innervations were reported. A brief review of the existing literature, regarding the nomenclature, incidence, attachments, innervations and clinical relevance of the sternalis muscle, is also presented. Neurosciences 2005; Vol. 10 (2): 171-173 he importance of continuing to record and Case Report. A well defined sternalis muscle Tdiscuss anatomical anomalies was addressed (Figures 1 & 2) was found, bilaterally, during recently1 in light of technical advances and dissection of the thoraco-abdominal region of a interventional methods of diagnosis and treatment. male cadaver in the Department of Anatomy, The sternalis muscle is a small supernumerary College of Medicine, King Saud University, Riyadh, muscle located in the anterior thoracic region, Kingdom of Saudi Arabia. Both muscles were superficial to the sternum and the sternocostal covered by superficial fascia, located superficial to fascicles of the pectoralis major muscle.2 In the the corresponding sternocostal portion of pectoralis literature, sternalis muscle is called "a normal major and separated from it by pectoral fascia. The anatomic variant"3 and "a well-known variation",4 left sternalis was 19 cm long and 3 cm wide at its although in most textbooks of anatomy, it is broadest part. Its upper end formed a tendon insufficiently mentioned. Yet, clinicians are continuous with that of the sternal head of left surprisingly unaware of this common variation.
  • Myofascial Trigger Points of the Shoulder

    Myofascial Trigger Points of the Shoulder

    Johnson McEvoy and Jan Dommerholt Myofascial Trigger Points of the Shoulder Shoulder problems are common, with a 1-year prevalence in developing a more comprehensive approach to shoulder ranging from 4.7% to 46.7% and a lifetime prevalence of rehabilitation. Inclusion of MTrPs in the assessment and 6.7% to 66.7%.1 Many different structures give rise to shoulder management of shoulder pain and dysfunction does not pain, including the structures in the subacromial space, such necessarily replace other techniques and approaches, but it does as the subacromial bursa, the rotator cuff, and the long head of add an important dimension to the management plan. biceps,2,3 and are presented in various lessons. Muscle and spe- cifically myofascial trigger points (MTrPs), have been recog- nized to refer pain to the shoulder region and may be a source TRIGGER POINTS of peripheral nociceptive input that gives rise to sensitization and pain. MTrP referral patterns have been published for the A myofascial trigger point is defined as a hyperirritable spot in shoulder region.4-6 skeletal muscle, which is associated with a hypersensitive Often, little attention is paid to MTrPs as a primary or sec- palpable nodule in a taut band.4 When compressed, a MTrP ondary pain source. Instead, emphasis is placed only on muscle may give rise to characteristic referred pain, tenderness, motor mechanical properties such as length and strength.7,8 dysfunction, and autonomic phenomena.4 MTrPs have been The tendency in manual therapy is to consider muscle pain as described as active or latent. Active MTrPs are associated with secondary to joint or nerve dysfunctions.
  • Radial Medial Head Triceps Branch Transfer to Axillary Nerve by Axillary Approach Acesso Ao Nervo Axilar Por Via Axilar Anterior

    Radial Medial Head Triceps Branch Transfer to Axillary Nerve by Axillary Approach Acesso Ao Nervo Axilar Por Via Axilar Anterior

    THIEME 134 Review Article | Artigo de Revisão Radial Medial Head Triceps Branch Transfer to Axillary Nerve by Axillary Approach Acesso ao nervo axilar por via axilar anterior José Marcos Pondé 1 Lazaro Santos 2 João Pedro Magalhaes 2 Ana Flavia D ’Álmeida 2 1 Department of Neurosciences and Mental Health, Universidade Address for correspondence José Marcos Pondé, MD, PhD, Av. Paulo Federal da Bahia (UFBA), Salvador, Bahia, Brazil VI, 111, Pituba, Salvador, BA, Brazil 41810-000 2 Bahian School of Medicine and Public Health, Salvador, Bahia, Brazil (e-mail: [email protected]). Arq Bras Neurocir 2015;34:134 –138. - Abstract Objective To describe axillary approach for axillary nerve transfer with radial nerve branch in brachial plexus lesions. Methods Six patients aged 24 to 54 (mean 30) years with traumatic superior trunk brachial plexus injury underwent axillary approach between October 2011 and April 2012. On physical examination prior to surgery, they could not perform shoulder abduction, external rotation, or elbow flexion. Surgical approach was made through axillary pathway without any muscular section. The transfer was done with the radial branch to the medial head of triceps. In addition to transfer to axillary nerve, each Keywords patient had spinal accessory nerve transferred to suprascapular nerve and ulnar nerve ► axillary nerve fascicle transferred to musculocutaneous nerve. ► brachial plexus Conclusion Theaxillary approach allowseasyaccesstoaxillarynerveand, therefore, is ► transfer a feasible pathway to transferences involving this nerve. Resumo Objetivo Apresentar via axilar por transferência de nervo axilar com ramo de nervo radial em lesões do plexus braquial. Métodos Seis pacientes com idade entre 24 e 54 anos (média de 30) com lesão braquial traumática do plexus no tronco superior submetidos a via axilar entre outubro de 2011 e abril de 2012.
  • Section 1 Upper Limb Anatomy 1) with Regard to the Pectoral Girdle

    Section 1 Upper Limb Anatomy 1) with Regard to the Pectoral Girdle

    Section 1 Upper Limb Anatomy 1) With regard to the pectoral girdle: a) contains three joints, the sternoclavicular, the acromioclavicular and the glenohumeral b) serratus anterior, the rhomboids and subclavius attach the scapula to the axial skeleton c) pectoralis major and deltoid are the only muscular attachments between the clavicle and the upper limb d) teres major provides attachment between the axial skeleton and the girdle 2) Choose the odd muscle out as regards insertion/origin: a) supraspinatus b) subscapularis c) biceps d) teres minor e) deltoid 3) Which muscle does not insert in or next to the intertubecular groove of the upper humerus? a) pectoralis major b) pectoralis minor c) latissimus dorsi d) teres major 4) Identify the incorrect pairing for testing muscles: a) latissimus dorsi – abduct to 60° and adduct against resistance b) trapezius – shrug shoulders against resistance c) rhomboids – place hands on hips and draw elbows back and scapulae together d) serratus anterior – push with arms outstretched against a wall 5) Identify the incorrect innervation: a) subclavius – own nerve from the brachial plexus b) serratus anterior – long thoracic nerve c) clavicular head of pectoralis major – medial pectoral nerve d) latissimus dorsi – dorsal scapular nerve e) trapezius – accessory nerve 6) Which muscle does not extend from the posterior surface of the scapula to the greater tubercle of the humerus? a) teres major b) infraspinatus c) supraspinatus d) teres minor 7) With regard to action, which muscle is the odd one out? a) teres
  • The Surgical Anatomy of the Mammary Gland. Vascularisation, Innervation, Lymphatic Drainage, the Structure of the Axillary Fossa (Part 2.)

    The Surgical Anatomy of the Mammary Gland. Vascularisation, Innervation, Lymphatic Drainage, the Structure of the Axillary Fossa (Part 2.)

    NOWOTWORY Journal of Oncology 2021, volume 71, number 1, 62–69 DOI: 10.5603/NJO.2021.0011 © Polskie Towarzystwo Onkologiczne ISSN 0029–540X Varia www.nowotwory.edu.pl The surgical anatomy of the mammary gland. Vascularisation, innervation, lymphatic drainage, the structure of the axillary fossa (part 2.) Sławomir Cieśla1, Mateusz Wichtowski1, 2, Róża Poźniak-Balicka3, 4, Dawid Murawa1, 2 1Department of General and Oncological Surgery, K. Marcinkowski University Hospital, Zielona Gora, Poland 2Department of Surgery and Oncology, Collegium Medicum, University of Zielona Gora, Poland 3Department of Radiotherapy, K. Marcinkowski University Hospital, Zielona Gora, Poland 4Department of Urology and Oncological Urology, Collegium Medicum, University of Zielona Gora, Poland Dynamically developing oncoplasty, i.e. the application of plastic surgery methods in oncological breast surgeries, requires excellent knowledge of mammary gland anatomy. This article presents the details of arterial blood supply and venous blood outflow as well as breast innervation with a special focus on the nipple-areolar complex, and the lymphatic system with lymphatic outflow routes. Additionally, it provides an extensive description of the axillary fossa anatomy. Key words: anatomy of the mammary gland The large-scale introduction of oncoplasty to everyday on- axillary artery subclavian artery cological surgery practice of partial mammary gland resec- internal thoracic artery thoracic-acromial artery tions, partial or total breast reconstructions with the use of branches to the mammary gland the patient’s own tissue as well as an artificial material such as implants has significantly changed the paradigm of surgi- cal procedures. A thorough knowledge of mammary gland lateral thoracic artery superficial anatomy has taken on a new meaning.
  • A Detailed Review on the Clinical Anatomy of the Pectoralis Major Muscle

    A Detailed Review on the Clinical Anatomy of the Pectoralis Major Muscle

    SMGr up Review Article SM Journal of A Detailed Review on the Clinical Clinical Anatomy Anatomy of the Pectoralis Major Muscle Alexey Larionov, Peter Yotovski and Luis Filgueira* University of Fribourg, Faculty of Science and Medicine, Switzerland Article Information Abstract Received date: Aug 25, 2018 The pectoralis major is a muscle of the upper limb girdle. This muscle has a unique morphological Accepted date: Sep 07, 2018 architectonic and a high rate of clinical applications. However, there is lack of data regarding the morphological and functional interactions of the pectoralis major with other muscle and fascial compartments. According to the Published date: Sep 12, 2018 applied knowledge, the “Humero-pectoral” morpho-functional concept has been postulated. The purpose of this review was the dissectible investigation of the muscle anatomy and literature review of surgical applications. *Corresponding author Luis Filgueira, University of Fribourg, General Anatomy Faculty of Science and Medicine,1 Albert Gockel, CH-1700 Fribourg, Switzerland, The pectoralis major is a large, flat muscle of the pectoral girdle of the upper limb. It has a fan- Tel: +41 26 300 8441; shaped appearance with three heads or portions: the clavicular, the sternocostal and the abdominal Email: [email protected] head. Distributed under Creative Commons The clavicular head originates from the medial two-thirds of the clavicle (collar bone). The muscle fibers of the clavicular head have a broad origin on the caudal-anterior and caudal-posterior surface CC-BY 4.0 of the clavicle covering approximately half to two-thirds of that surface and converting toward the humerus, resulting in a triangular shape [1].
  • Upper Extremity Venous Ultrasound

    Upper Extremity Venous Ultrasound

    Upper Extremity Venous Ultrasound • Generally sicker patients / bedside / overlying dressings with limited Historically access Upper Extremity DVT Protocols • Extremely difficult studies / senior George L. Berdejo, BA, RVT, FSVU technologists • Most of the examination focuses on the central veins Subclavian/innominate/SVC* Ilio-caval Axillary/brachial Femoro-popliteal Radial/ulnar Tibio-peroneal 2021 Leading Edge in Diagnostic Ultrasound Conference MAY 11-13, 2021 • Anatomic considerations* Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Symptoms / Findings • Incidence of UE DVT low when compared to LE but yield of positive studies is higher ✓Central Vein Thrombosis • Becoming more prevalent with increasing use of UE veins for • Swelling of arm, face and /or neck access • Sometimes asymptomatic http://stroke.ahajournals.org/content/3 • Injury to the vessel wall is most common etiology • Dialysis access dysfunction 2/12/2945/F1.large.jpg ✓Peripheral Vein Thrombosis • Other factors: effort thrombosis, thoracic outlet compression, mass compression, venipuncture, trauma • Local redness • Palpable cord • Tenderness • Asymmetric warmth Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Vessel Wall Injury • Patients with indwelling catheters / pacer wires • Tip of catheter/ wires cause irritation of vein wall 1 Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Anatomy At the shoulder, the cephalic vein travels Deep Veins between the deltoid and pectoralis major • Radial and ulnar veins form
  • Central Venous Access Techniques for Cardiac Implantable Electronic Devices

    Central Venous Access Techniques for Cardiac Implantable Electronic Devices

    Review Devices Central Venous Access Techniques for Cardiac Implantable Electronic Devices Sergey Barsamyan and Kim Rajappan Cardiology Department, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK DOI: https://doi.org/10.17925/EJAE.2018.4.2.66 he implantation of cardiac implantable electronic devices remains one of the core skills for a cardiologist. This article aims to provide beginners with a practical ‘how to’ guide to the first half of the implantation procedure – central venous access. Comparative descriptions Tof cephalic cutdown technique, conventional subclavian, extrathoracic subclavian and axillary venous punctures are provided, with tips for technique selection and troubleshooting. Keywords Implantation of cardiac implantable electronic devices (CIEDs) remains one of the core skills of Pacemaker, pacing, implantation, cardiac cardiologists; most cardiology trainees will require at least basic skills in permanent pacemaker implantable electronic devices, CIED, (PPM) implantation.1 The aim of this article is to provide a guide to the techniques of venous central venous access, techniques access – the first and important part of the implantation procedure. The bulk of the provided instruction is based on our pacing lab experience and references are provided, where necessary, Disclosures: Sergey Barsamyan and Kim Rajappan have nothing to declare in relation to this article. to describe techniques utilised in other centres. No article can be totally comprehensive and cover Review Process: Double-blind peer review. all the subtleties of a procedure. Like for any practical skill, it is possible to give only the core Compliance with Ethics: This study involves a concepts in writing, and nothing can replace hands-on training supervised by an experienced review of the literature and did not involve implanter in a pacing theatre.
  • Cephalic Vein. Detail of Its Anatomy in the Deltopectoral Triangle

    Cephalic Vein. Detail of Its Anatomy in the Deltopectoral Triangle

    Int. J. Morphol., 27(4):1037-1042, 2009. Cephalic Vein. Detail of its Anatomy in the Deltopectoral Triangle Vena Cefálica. Detalle de su Anatomía en el Trígono Deltopectoral Luis Andrés Yeri; Eduardo Javier Houghton; Bruno Palmieri; María Flores; Marcelo Gergely & Jorge E. Gómez YERI, L. A.; HOUGHTON, E. J; PALMIERI, B.; FLORES, M.; GERGELY, M. & GÓMEZ, J. E. Cephalic vein. Detail of its anatomy in the deltopectoral triangle. Int. J. Morphol., 27(4):1037-1042, 2009. SUMMARY: 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. KEY WORDS: Cephalic vein; Deltopectoral triangle; Claviepectoral triangle; Catheterization; Venous access. INTRODUCTION Cephalic vein (CV) is classically described with its way of access (De Rosa et al., 1998; Le Saout et al., 1983; origin in the side corner of the dorsal venous network of the Langard et al., 1985; Nobili, 1976; Povoski, 2000; Viaggio et hand.