Search

We treated a surgical case of a 47-day-old male infant diagnosed with an unusual type of cor triatriatum sinister (CTS) with left anomalous pulmonary venous drainage to the innominate vein via a vertical vein. After preoperative hemodynamic assessment of pulmonary venous (PV) return, this patient underwent a resection of the fibromuscular membrane between the accessory and the true left atrial chambers, concomitant with vertical vein banding to facilitate a left PV return through a common pulmonary venous collector (CPVC). Catheterization three months after this surgery revealed no obstruction of the PV return to the mitral orifice as well as good growth of the CPVC as a left PV return pathway. The patient has been doing well on aspirin.

Graphical abstract, Highlights • Retroaortic innominate veins are rare in HLHS. • Prenatal echocardiographic diagnosis of congenital heart defects remains crucial. • Perinatal confirmation of anatomy is important in anticipating surgical difficulties.

Supracardiac total anomalous pulmonary venous drainage is commonly associated with a left-sided ascending vein draining into innominate vein. We present a case of a newborn with a right-sided ascending vein, draining into the right superior caval vein with stenosis at the SVC-ascending vein junction, posing a surgical dilemma in corrective surgery. Usage of three-dimensional computed tomographic scan was essential in delineating the anatomy and aiding surgery. The case demonstrates the rarity of this type of cardiac disease and the complications that develop.

Background Repair of the absence of the whole or major parts of pulmonary arteries is a challenge, and the choice of conduit material to reconstruct the pulmonary arteries is under dispute. We used the autologous innominate vein to construct pulmonary arteries. Case presentation l We present a novel technique using the autologous innominate vein as a free graft in a 6-month-old infant with pulmonary atresia and absence of central pulmonary arteries. Double ductus arteriosus were the only source of perfusion of the lungs. The innominate vein was substituted for the central pulmonary artery between the two lung hila. Total repair by using Contegra graft was performed 9 months later. The patient has been followed for 5 years. Conclusions The autologous innominate vein could be used as inter-hilar pulmonary arteries with no calcification and fibrosis in 5-year follow-up.

Background Retroaortic innominate vein is a rare anomaly. It has been reported in patients with congenital anomalies such as Tetralogy of Fallot or right aortic arch. However, isolated retroaortic innominate vein is quite rare. Case presentation A 63-year-old man was transferred to our institution because of Stanford type A acute aortic dissection. Incidentally, we noticed that the left innominate vein coursed under the aortic arch and was directed into the superior vena cava on computed tomography. We performed emergent hemiarch replacement. Conclusions Attention must be paid to the cannulation site for venous uptake and the method of myocardial protection.

Retroaortic course of left innominate vein is a rare venous anomaly which is usually associated with CHD. Isolated retroaortic innominate vein is exceedingly rare with only a handful of reported cases. We report an otherwise healthy newborn with isolated retroaortic innominate vein and right aortic arch, a combination which has previously not been reported.

16p12.2 microdeletion has been associated with congenital heart defects and developmental delay. In this case, we describe the rare association between tetralogy of Fallot with an absent pulmonary valve a right-sided aortic arch and a retro-aortic innominate vein associated with a 16p12.2 microdeletion and epilepsy.

There is continued increase in the rate of cardiac implantable devices and so are complications associated with them which may necessitate their extraction. The common indications for lead extraction are lead infection, lead malfunction, lead upgrade, or retained broken leads. Different methods are used; most common are percutaneous but sometimes cardiac surgical help may be required. We present one such unique case where leads were not approachable through pacemaker pocket and sternotomy was required and stuck leads were extracted via innominate vein, pulling from either end.

Central vein stenosis is frequently seen in patients on maintenance hemodialysis. This results in venous hypertension, swelling of the limb and malfunctioning of arterio-venous (AV) dialysis fistula. Percutaneous intervention of central vein stenosis is technically challenging with high failure rates, complications and repeated interventions. We hereby report a case of end-stage renal disease on maintenance hemodialysis, who presented with malfunctioning dialysis AV fistula following occlusion of left innominate vein. Successful endovascular stenting of left innominate vein was done with favorable short and long term outcomes.

Persistent left superior vena cava (PLSVC) is an uncommon congenital anomaly. We report a case of implantation of cardiac resynchronization therapy - pacemaker (CRT-P) device in a 38-year-old lady with idiopathic dilated cardiomyopathy. After left axillary vein puncture, we faced an unexpected entry of left subclavian to PLSVC draining into the coronary sinus (CS). The target posterolateral vein which had been identified before, seemed to have an acute angle at its entry into the CS. Hence, at this stage we were in a dilemma, whether to switch to the right side or to continue from the same side. We continued the procedure from the left side and completed it successfully after some manipulation and improvisation.

Background To evaluate the feasibility and safety of ultrasound-guided totally implantable venous access port (TIVAP) implantation via the right innominate vein in patients with breast cancer. Methods Sixty-seven breast cancer patients underwent ultrasound-guided implantation of TIVAPs via the right innominate vein for administration of chemotherapy. Clinical data including technical success, success rate for the first attempt, periprocedural, and postoperative complications were recorded and retrospectively studied. Results All patients underwent successful surgery. The success rate of the first attempt was 95.52% (64/67). The operation time was 28 to 45 min, with an average of 36 ± 6 min. Periprocedural complications included artery punctures in 1 (1.50%, 1/67) patient. Prior to this study, the mean TIVAP time was 257 ± 3 days (range 41 to 705 days). The rate of postoperative complications was 4.48% (3/67), including catheter-related infections in 1 case and fibrin sheath formation in 2 cases. Up to the present study, three people had unplanned port withdrawal due to complications, and the TIVAPs for 25 patients were still in normal use. Conclusions The success rate of ultrasound-guided TIVAPs via the right innominate vein is high with low complications, thus safe and feasible. This technique can provide a new option for chemotherapy of breast cancer patients.

Background Any type of radical thymectomy, open or thoracoscopic, always results in a skeletonized left innominate vein (LIV), which is highly expected to form adhesions to the posterior surface of the sternum. Therefore, in case of future sternotomy, the LIV remains highly exposed to trauma. Methods We describe a surgical technique that is expected to protect the innominate vein in case of future sternotomy. Results Our technique is not technically demanding, is easily reproducible, can be applied in both open and thoracoscopic procedures and does not significantly prolong the overall duration or cost of the procedure. Conclusions Our alternative is the only protective measure for the left innominate vein that can be applied in the first operation and in our opinion should be a standard part of the procedure.

Background To compare the efficacy and safety of right internal jugular vein (IJV) approach and right innominate vein (INV) approach for US-guided totally implantable venous access devices (TIVADs), and to explore the advantages and disadvantages of the two approaches. Methods Six hundred and nineteen adult patients had long-term infusion and chemotherapy needs and inconvenience of peripheral venous infusion. Right INV approach was used to implant 339 cases of TIVADs, and right IJV approach was used to implant 280 cases of TIVADs. The success rate of one-time catheterization and the incidence of complications in the two groups were retrospectively analyzed. Results All patients were successfully implanted in TIVAD. The success rates of one-time puncture in INV group and IJV approach group were 98.53% (334/339) and 95.36% (267/280), respectively. There was significant difference between the two groups (P = 0.020). The incidence of perioperative complications and long-term complications in the right INV group were 1.18% (4/339) and 3.54% (12/339), respectively, while those in the right IJV group were 1.43% (4280) and 3.93% (11280). There was no significant difference in the incidence of perioperative or long-term complications between the two groups (P = 0.785, P = 0.799, respectively). Conclusions US-guided TIVADs via the right INV approach and the right IJV approach are both safe and reliable. The right INV approach improves the one-time puncture success rate, as long as the technique is properly operated, serious complications rarely occur.

Right aortic arch (RAA) and retro-aortic innominate vein are rare vascular anomalies. Diagnosis of these anatomical variations can be achieved using fetal echocardiography, post-natal echocardiography and computed tomography scan. RAA can form a vascular ring when associated with other vascular anomalies which may compress the trachea and/or esophagus. On the other hand, the existence of retro-aortic innominate vein can influence the clinical decision-making and surgical strategy. We report a rare occurrence of both RAA and retro-aortic innominate vein in a three-month old girl with a prenatal diagnosis of tetralogy of Fallot and include details of her presentation and successful management.

Although vessel perforation rarely occurs during percutaneous transluminal angioplasty of a central venous stenosis, it can be a rapidly fatal complication when accompanied by pericardial tamponade. The present case report details our experience with this dangerous complication. It also highlights the risk factors for and the pathogenesis of central venous stenosis, the clinical findings associated with inadvertent vessel perforation during an intervention, and anesthetic management strategies for pericardial tamponade resulting from vessel perforation.

Abstract. We report a rare case of large innominate vein aneurysm in a young women clinically presenting with persistent dry cough and retrosternal pressure. Chest X-ray showed a mediastinal widening leading to thoracic computed tomography, MRI, and phlebography. Initial conservative treatment with regular follow-up was performed. Upon aneurysm growth and recurrent pulmonary infection we decided to surgically resect the aneurysm via a minimally invasive approach.

Bilateral partial anomalous venous connections are rare. Here, we present a patient who underwent the modified Warden procedure to reroute the superior vena cava with the partial anomalous veins to the left atrium and reconstruct the innominate vein and superior vena cava with a polytetrafluoroethylene conduit to the right atrial appendage. The procedure was successfully performed without using foreign materials in the pulmonary venous route. Furthermore, it prevented the obstruction of blood flow.

The mixed type of total anomalous pulmonary venous connection is the least common variant, occurring in approximately 5% of all patients. Dual drainage through a common venous confluence is much rarer. Computed tomography to delineate the exact pulmonary venous anatomy is a must in such cases. Correct preoperative recognition and intraoperative confirmation to check the drainage of all 4 pulmonary veins is essential in all cases of total anomalous pulmonary venous connection. We report the case of an adult patient with dual drainage to coronary sinus and left vertical vein to innominate vein.

Introduction: Our experience in minimally invasive procedures and improvement of graft technology enables easy and successful operation carried out even with complex thoracic aortic diseases from limited surgical area. However, it should be more than one incision or cannulation site for such intervention. We aimed to present our experience and results of 23 patients who has ascending aorta and aortic arch pathologies of which we operated with J-shaped partial sternotomy and innominate vein cannulation. Methods: From January 2014 to January 2016, 23 patients with aorta and aortic valve pathologies who underwent aortic surgery with J-shaped partial sternotomy and innominate vein cannulation included. Operation findings, cardiopulmonary bypass (CPB) values, postoperative results, surgical mortality and morbidity rates, late conversion to full sternotomy rates, ICU and hospital length of stay were evaluated. Results: The mean age of the patients was 53.7±12 (range 19-68) and 18 (78.2%) were males. Arcus aorta debranching applied to 4 patients (17.3%) and one of these procedures was frozen elephant trunk procedure (%4.3). Neither mortality nor cerebrovascular accident occurred. Mean CPB peak flow was 4.6±0.4 L/min, mean flow index calculated as 2.01±0.38 L/min/m2 and there was no CPB problem intraoperatively. Innominate vein ligation was carried out in 5 patients but no complication was seen except one who had left arm swelling treated with elevation. Conclusion: Innominate vein cannulation with J-shaped partial sternotomy is a reliable and easily applicable method providing effective utilization of limited operative field not only in ascending aorta and aortic arch operations but also with the advancements of hybrid systems used in descending aorta pathologies.

Objective: Deep venous thrombosis frequently occurs in patients with neoplastic diseases. The risk is increased by approximately seven times in patients receiving chemotherapy or radiation treatment. Upper extremity deep venous thrombosis is uncommon, mainly due to central venous catheters. Thymus gland tumors are rare, representing up to 1% of all primitive tumors. Adjuvant radiotherapy is recommended in presence of residual tumor after surgery. Case Report: We report the case of a patient suffering from thymoma treated with surgery and radiotherapy, who showed echo graphic evidence of hyperechoic, endoluminal, floating formation in the innominate vein, suggestive of thrombosis that was not responsive to anticoagulant therapy. Discussion and Conclusion: This case confirms the difficulty in diagnosing some endoluminal free-floating formations in vascular bed. Recourse to the ex adiuvantibus criterion, consisting in this case in lack of benefits with anticoagulant treatment, should be desirable.

Operation to provide the best exposure of the complex innominate-subclavian vein that sometimes is necessary to correct obstruction or injury to those vessels.

We describe the case of a newborn infant with transposition of the great vessels and a retroaortic innominate vein. This is a previously undescribed association. The decision was made to incorporate the retroaortic innominate vein into the Lecompte procedure at the time of surgery to avoid the risk of superior caval vein syndrome.

Introduction: Arteriovenous fistulae (AVF)-associated reactive angioendotheliomatosis (RAE) is a very rare entity (three previously reported cases in the literature) that can manifest as extremity wounds. RAE’s etiopathology is unknown. Case description: We report a case of severe limb-threatening upper extremity wound with pathology-proven RAE. This lesion was previously refractory to standard wound care. There was no evidence of limb ischemia or steal syndrome, previously deemed to be the underlying cause of AVF-associated RAE in other reports. Conclusions: Successful endovascular treatment of an ipsilateral innominate vein stenosis led to reduction of venous hypertension, resolution of associated arm edema, and subsequent wound healing. We therefore propose that venous engorgement and hypertension from central venous stenosis is the likely underlying cause for AVF-associated RAE. If this rare entity is encountered in the setting of AVF, there is utility in treating the wound as a sentinel lesion and venography should be conducted to rule out central venous pathology. Vascular intervention complements aggressive local wound management and biopsy is requisite for prompt diagnosis.

Purpose To evaluate the risk factors for central vein stenosis after placement of the totally implantable venous access ports (TIVPs) and the clinical relevance of this condition in breast cancer patients. Materials and methods TIVPs were placed in 191 women with breast cancer via the internal jugular vein (IJV) from January 2009 to December 2012 (mean age, 51.42 years) by left-side ( n = 102) and right-side ( n = 89) approaches. Medical records were retrospectively reviewed. The presence of significant central vein stenosis, tip location of the catheter and retrosternal space were evaluated on chest computed tomography images. Statistical analysis was performed. Results Central vein stenosis developed in 1 and 14 patients after placement via the right and left IJV, respectively. Differences in the cumulative incidence of central vein stenosis were statistically significant between left- and right-side approach groups (log rank test p-value: 0.009). In Cox regression analysis, the hazard ratio for central vein stenosis was 9.441 (p = 0.031) in the left-side approach. The distance between the sternum and the left innominate vein was found to be significantly and independently related to the development of central vein stenosis (p = 0.026). The hazard ratio of distances between the sternum and left innominate vein Conclusions The incidence of central vein stenosis in breast cancer patients was higher after placement of TIVPs via the left IJV. When left-side TIVP placement is required in a patient with right-side breast cancer, the possibilities of left innominate vein stenosis should be considered.

Persistent left superior vena cava (PLSVC) represents the most common thoracic venous anomaly and is an important clinical entity for cardiologists and electrophysiologists, among others. In approximately 30% of cases, a bridging innominate vein connects the left superior vena cava to the right. The present report highlights the value of defining the venous anatomy with a case of dual-chamber pacemaker implantation in the PLSVC with the right ventricular lead placed via the innominate vein. Pertinent considerations for device implantation in the setting of this anomaly are discussed and relevant venography reviewed.

Transcatheter interventions for congenital heart anomalies are constantly improving. Although correction of anomalous pulmonary venous connection is routinely achieved through surgery, there are rare instances where the abnormal pulmonary vein has dual connections to both left atrium and the major systemic veins. Under these circumstances catheter based treatment might become a feasible option. We report a case of dual supply vertical vein connected to left upper pulmonary vein and innominate vein which was successfully obstructed by an occluder device leading to improvements in patient’s condition.

The impact of Lecompte’s maneuver on superior vena cava (SVC) has never been mentioned before. We think that in certain anatomical subsets, Lecompte’s maneuver can result in superior vena cava narrowing. We present a case report of patient with Tetralogy of Fallot with absent pulmonary valve with retro-aortic innominate vein who developed SVC thrombosis after Lecompte’s maneuver.

The need for pacemaker and implantable cardioverter defibrillator (ICD) lead revisions and extractions is steadily increasing. Despite the lack of representative studies, the risk of lead extraction is frequently considered to be lower than leaving nonfunctional leads in situ. We report the case of a patient who was referred to our institution for exchange of a malfunctioning ICD lead. The diagnostic work-up revealed a long-segment transmural migration of the ICD lead at the site of the subclavian and innominate vein. Due to the unpredictable risk of vein perforation, we abandoned the extraction procedure.

Cardiopulmonary bypass (CPB) through a left lateral thoracotomy is a useful approach for some congenital heart procedures, although vascular access for the arterial and venous cannulation can be challenging in the selective patients. Six patients underwent successful extracorporeal circulation through a left lateral thoracotomy using the innominate vein for venous drainage. No operative deaths or major complications occurred. Venous drainage solely from the innominate vein was adequate to establish partial bypass without the need for pericardiotomy. Total bypass was established with combined venous drainage from the innominate vein and the main pulmonary artery. Exposure of the systemic atrioventricular valve was excellent through a left thoracotomy. Venous drainage from the innominate vein without using atrial drainage can safely be used for extracorporeal circulation through a left lateral thoracotomy without compromising the procedure and it is a useful approach to congenital heart surgery in selected patients.

This report describes a stenting technique used to anatomically reconstruct superior vena cava (SVC) bifurcation in a patient with benign SVC syndrome. After recanalizing the SVC bifurcation, we exchanged two 0.035-in. wires for two 0.018-in. wires, deployed the SVC stent over these two wires (“train-track” technique), and stented each innominate vein over one wire. However, our decisions to recanalize both innominate veins, use the “buddy-wire” technique for SVC dilation, and dilate the SVC to 16 mm before stent deployment likely contributed to SVC tear, which was managed by resuscitation, SVC stent placement, and pericardial drainage. Here, we describe the steps of the train-track technique, which can be adopted to reconstruct other bifurcations; we also discuss the controversial aspects of this case.

A 41-year-old woman who had been fitted with a pacemaker 18 years prior presented for lead extraction because of device infection. First, we tried laser sheath. However, it cannot cross the binding in the innominate vein. Then we switched to the rotating mechanical sheath. Although it crunched through binding tissue, the progress halted. We removed the sheath and found pieces of calcified tissue in the sheath lumen. After removing the calcified tissue, both leads were extracted using the laser sheath, without complications. The pathological examination revealed a diagnosis of ossified thrombus. Venous thromboses associated with implanted leads can ossify with time, causing difficulties in the extraction of long-standing intravascular leads.

Purpose Ultrasound-guided (USG) central vein cannulation has become very popular among anesthesiologists and critical care physicians in the last decade and it has been advocated as the gold standard practice for internal jugular vein (IJV) catheterization. Methods We report a technique used at our second level hospital for cannulating either subclavian vein or innominate vein using a supraclavicular (SCV) approach under real time ultrasound guidance for elective positioning of long, medium or short-term central venous catheters (CVC). We report one year of practice. Results A total of 347 intravascular devices were positioned; successful USG SCV cannulation with no complication, failure or malposition was reported in 119 cases. Conclusions The SCV approach under ultrasound guidance is feasible and safe.

Recent technical advances in the domains of anesthesia, cardiovascular and thoracic surgery, and synthetic materials manufacturing coupled with more oncological extended tumor indications have unlocked the door to the surgical treatment of pulmonary, mediastinal, or other rare tumors involving intrathoracic vessels. In 1987, Dartevelle et al1 first described a consecutive and large series of patients with mediastinal or lung malignancies and superior vena cava (SVC) involvement treated with SVC resection by using polytetrafluoroethylene tubular grafts for reconstruction. Open surgery requires a high level of technical expertise and vigilant attention to patient selection and perioperative management to minimize complications, which are reported even in highly specialized centers.1,2 During the past decade, operative mortality for these procedures has ranged between 0% and 7.7%, with long-term patency rates of about 70%-100%.3-9 However, proper patient selection is critical for clinical success. We will outline the role of surgery for selected patients with locally advanced but completely resectable non-small cell lung cancers (NSCLC) or mediastinal tumors (MT) involving invading the SVC and/or the innominate vein (IV).

Of 79 patients seen at the University of Minnesota with symptomatic chronic obstruction of the axillary subclavian or innominate vein, 65 were considered surgical candidates. Etiology of the obstruction was as follows: Group A (n=45), previous subclavian effort thrombosis; Group B (n=14), stenosis caused by occupation or sport activities; and Group C (n=6), long segments (4–7.2 cm) of obstruction caused by chronic intraluminal placement of devices (catheters, pacemaker, or defibrillator leads).

Recently, the superior approach with transaction of the superior vena cava was introduced for the repair of supracardiac anomalies in adults. We developed a bidirectional right-angle venous cannula and placed it within the innominate vein to make the modified superior approach with the superior caval transection suitable for neonates and tiny infants. We applied this modified superior approach for the repair of infracardiac forms of total anomalous pulmonary venous drainage. doi: 10.1111/jocs.12472 (J Card Surg 2015;30:278–280)

We present a patient with superior vena cava (SVC) obstruction due to multiple intraluminal pacemaker leads. Previous attempts at balloon dilatation of the SVC and surgical angioplasty did not provide a long-term solution. A Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ, USA) conduit interposed between the innominate vein and right atrial appendage has resulted in symptomatic relief at a follow-up of 6 months.