Search

Computed tomography angiography (CTA) was performed under general anaesthesia on a 7-month-old toy poodle that was referred with the chief complaints of salivation and neurological symptoms. The CTA revealed a rare form of posthepatic portosystemic shunt (PSS) via the suspected persistent left umbilical vein communicating with the internal thoracic vein in addition to an azygos continuation of the caudal vena cava (CVC). The patient underwent surgery for partial ligation of PSS on Day 4 after the initial examination. On Day 71, after the initial examination, a second surgery was performed for complete ligation. Approximately 10 years have passed since the patient's second surgery, and he is still healthy, and generally in good condition. Although the morphology of the shunt in this case was unusual and was accompanied by an azygos continuation of the CVC, a favourable course of treatment was obtained by ligating the shunt vessel. This case report suggests that CTA can reveal the complex morphological characteristics like our case. Surgical treatment in this case resulted in favourable progress, similar to that in dogs with commonly observed extrahepatic PSS., (© 2024 The Author(s). Veterinary Medicine and Science published by John Wiley & Sons Ltd.)

Intrahepatic interruption of the inferior vena cava (IVC) with continued hemizygous is a very rare abnormality and sometimes it may be accompanied by other cardiovascular abnormalities. Continuation of the hemizygous vein draining into the right atrium through the left superior vena cava (LSVC) is much rarer. In this paper, we have presented a patient who had simultaneous IVC interrupted with persistent LSVC and suffered from Atrioventricular nodal reentrant tachycardia (AVNRT). Finally, radiofrequencies (RF) catheter ablation for AVNRT was successfully performed through a left subclavian vein access., (© 2024. The Author(s).)

Competing Interests: Declaration of competing interest The authors declare that they have no competing interests.

Background: The malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right subclavian vein into the azygos vein is extremely rare. Here, we report a patient with CVC malposition into the azygos vein via the right subclavian vein. We conduct a comprehensive review of the anatomical structure of the azygos vein and the manifestations associated with azygos vein malposition. Additionally, we explore the resolution of repositioning the catheter into the superior vena cava by carefully withdrawing a specific length of the catheter., Case Presentation: A 79-year-old female presented to our department with symptoms of complete intestinal obstruction. A double-lumen CVC was inserted via the right subclavian vein to facilitate total parenteral nutrition. Due to the slow onset of sedative medications during surgery, the anesthetist erroneously believed that the CVC had penetrated the superior vena cava, leading to the premature removal of the CVC. Postoperative contrast-enhanced computed tomography of the chest confirmed that the central venous catheter had not penetrated the superior vena cava but malpositioned into the azygos vein. The patient was discharged 15 days after surgery without any complications., Conclusions: CVC malposition into the azygos vein is extremely rare. Clinical practitioners should be vigilant regarding this form of catheter misplacement. Ensuring the accurate positioning of the CVC before each infusion is crucial. Utilizing chest X-rays in both frontal and lateral views, as well as chest computed tomography, can aid in confirming the presence of catheter misplacement., (© 2024. The Author(s).)

Background: The purpose of this study was to investigate the effect of our revamped MIE-McKeown operation on postoperative gastrointestinal function recovery., Methods: This revamped MIE-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk and with the tubular stomach buried throughout esophageal bed and azygos arch, has been implemented from July 2020 to July 2021 by the same medical team of Gaozhou People's Hospital thoracic surgery for 13 times. Preoperative clinical data, main intraoperative indicators and postoperative complications were observed., Results: All patients had esophageal malignant tumors at the level of middle and lower thoracic non-azygous venous arch, with preoperative clinical stage CT1-2N0M0 stage i-ii. V-vst test was performed on the 7th postoperative day, and 10 patients were found to have no loss of safety/efficacy. There were 2 cases with impaired efficacy and no impaired safety, 1 case with impaired safety. There were 1 cases of pulmonary infection, 1 cases of anastomotic fistula combined with pleural and gastric fistula, 2 cases of hoarseness, 2 cases of arrhythmia, 10 cases of swallowing function were grade i, 2 cases of swallowing function were grade iii, 1 case of swallowing function was grade iv in watian drinking water test one month after operation., Conclusions: Merit of this revamped MIE-McKeown operation is well preserving the integrity of azygos arch of vagus nerve and bronchial artery, and it is technically safe and feasible. No postoperative mechanical obstruction of thoracostomach, huge thoracostomach and gastrointestinal dysfunction occurs., (© 2023. The Author(s).)

Background: Azygos vein aneurysms (AVAs) are extremely rare. The majority of patients have no obvious clinical symptoms, so they are found by physical examination or by chance. There is limited clinical treatment experience that can be referred to, and there are no clear guidelines or research evidence standardizing the surgical and interventional therapy. Here, we report a patient with idiopathic AVA whose three-dimensional reconstruction of the tumor was completed before surgery. On the basis of three-dimensional reconstruction, single-port thoracoscopic resection of the AVA was successfully completed and reported for the first time. The previously reported cases are summarized to provide guidance for the diagnosis and treatment of patients with AVAs., Case Presentation: A 56-year-old man was transferred to our hospital due to "dysphagia". The diagnosis of AVA was made after enhanced computed tomography, gastroscopy, fiberoptic bronchoscopy, and three-dimensional reconstruction. Congenital weakness or degenerative changes causes the vein walls to be extremely thin that the AVA had the risk of ruptur. Furthermore, the patient had symptoms of dysphagia, he received single-port thoracoscopic surgery. After the operation, his dysphagia disappeared. The postoperative pathology confirmed hemangioma. The patient was discharged 3 days after surgery without any complications., Conclusions: AVAs are rare. Preoperative three-dimensional reconstruction can greatly help surgeons clarify the disease diagnosis, formulate the surgical plan, avoid damage to the surrounding vital organs, and reduce intraoperative bleeding. Thoracoscopic surgery to remove AVAs is difficult and has a high risk of bleeding, while more minimally invasive single-port thoracoscopic surgery is also safe and effective for the treatment of AVAs., (© 2023. The Author(s).)

Background: Azygos vein aneurysm (AVA) is a rare thoracic pathological entity that mimics a posterior mediastinal mass. However, the pathogenesis of primary azygos vein aneurysms is not clear and its pathology is still being discussed. Some of the AVA are asymptomatic and usually discovered accidentally by routine physical examination., Case Presentation: We report the case of a 37-year-old woman who had an azygos vein arch aneurysm with no obvious clinical symptoms. With the analysis of clinical features of the case and AVA morphological characteristics, the AVA was found by a chest computed tomography. Then, enhanced chest computed tomography showed a soft-tissue mass (4.9 × 3.7 × 3.2 cm) in the right posterior mediastinum, which was connected to the superior vena cava and significantly enhanced with contrast agent stratification. The density of the tumor in the delayed stage was the same as that in the azygos vein. The patient underwent video-assisted thoracoscopic surgery. Histopathological evaluation of the surgical biopsy specimen proved to be a completely thrombosed aneurism of the azygos vein arch., Conclusions: AVA is a rare pathology that must be taken into consideration during the differential diagnosis of right posterior mediastinal masses. Thoracoscopic surgery is one of the most preferred treatment options for azygos vein aneurysm., (© 2022. The Author(s).)

Background: Ipsilateral shoulder pain (ISP) is a common problem after pulmonary surgery. We hypothesized that phrenic nerve block (PNB) at the azygos vein level, near the location of the surgical operation, would be effective for reducing ISP. Our primary aim was to assess the effect of PNB on postoperative ISP, following video-assisted thoracic surgery (VATS)., Methods: This prospective, randomized, patient-blinded, single-institution trial was registered at the University Hospital Medical Information Network (UMIN000030464). Enrolled patients had been scheduled for VATS under general anesthesia with epidural analgesia. Patients were randomly allocated to receive infiltration of the ipsilateral phrenic nerve at the azygos vein level with either 10 mL of 0.375% ropivacaine (PNB group) or 0.9% saline (control group) before chest closure. Postoperative ISP was assessed using a numerical rating scale (NRS, 0-10) at rest at 2, 4, 8, 16, and 24 hours. The incidence of ISP was defined as the proportion of patients who reported an NRS score of ≥1 at least once within 24 hours after surgery. In the primary analysis, the proportion of patients with ISP was compared between PNB and control groups using the χ2 test. NRS values of ISP and postoperative incision pain within 24 hours were investigated, as was the frequency of postoperative analgesic use. Incision pain was assessed using an NRS at the time of ISP assessment. Finally, the incidence of postoperative nausea and vomiting and shoulder movement disorders were also evaluated., Results: Eighty-five patients were included, and their data were analyzed. These patients were randomly assigned to either PNB group (n = 42) or control group (n = 43). There were no clinically relevant differences in demographic and surgical profiles between the groups. There was no significant difference in the incidence of ISP (the control group 20/43 [46.5%] versus the PNB group 14/42 [33.3%]; P = .215). The severity of ISP was lower in the PNB group than in the control group (linear mixed-effects model, the main effect of treatment [groups]: P < .001). There were no significant differences between groups in terms of postoperative incision pain. The frequency of postoperative analgesic use was significantly higher in the control group (Wilcoxon rank sum test, P < .001). Postoperative nausea and vomiting did not significantly differ between the 2 groups. There were no changes in the range of shoulder joint movement., Conclusions: Azygos vein level PNB did not significantly affect the incidence of ISP after VATS., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

Chylothorax is defined as the accumulation of chyle in the pleural space, mainly by damaging to the thoracic duct. 99m Tc-Dextran is a relatively new tracer for lymphoscintigraphy. A 40-year-old woman had recurrent chylothoraxes after thymoma resection and ligation of the thoracic duct owing to intraoperative suspected thoracic duct injury. She underwent lymphoscintigraphies using 99m Tc-sulfur colloid and 99m Tc-dextran, respectively, to identify the possible leakage site of the thoracic duct. The images showed increased 99m Tc-dextran but unimpressive 99m Tc-sulfur colloid activity at the leakage site. Based on the results, this patient received surgery anastomosing the thoracic duct and the azygos vein., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In this study, we describe an intrathoracic microsurgical lymphatico-venous anastomosis as an alternative surgical technique for the treatment of refractory chylothorax in an infant. This procedure allowed us to restore enteral nutrition within days of surgery. At 3-year follow-up, there was no recurrence of pleural effusion., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Rationale: The percutaneous catheterization of central veins is widely applied in patients with end-stage renal diseases as a permanent vascular access. To our knowledge, inadvertent placement of a hemodialysis catheter into the azygos vein through the left internal jugular vein is not described., Patient Concerns: A 72-year-old female patient was admitted to the hospital for replacement of another new tunneled hemodialysis catheter due to poor flow in the left internal jugular vein tunneled catheter during hemodialysis., Diagnosis: The catheter tip was incorrectly positioned into the azygos vein as confirmed by conventional anteroposterior and lateral chest radiographs., Interventions: The catheter was removed and replaced under Digital Subtraction Angiography., Outcomes: The catheter tip was finally placed in the proper position., Lessions: The insertion of central vein catheterization is not always in suitable position especially through left jugular vein in hemodialysis patients. DSA technology should be performed to confirm the correct position of the tip and to ensure good blood flow.

Background: Esophageal squamous cell carcinoma with tumor thrombus in the arch of the azygos vein has not been reported to date. Neoadjuvant chemotherapy can decrease the stage in patients with advanced preoperative tumor staging, regaining surgical opportunities and significantly prolonging progression-free survival and overall survival. Herein, we present a case of esophageal squamous cell carcinoma accompanied by tumor thrombus in the arch of the azygos vein, and the patient underwent radical surgery after neoadjuvant chemotherapy., Case Presentation: A 63-year-old male with esophageal squamous cell carcinoma was found to have tumor thrombus formation in the arch of the azygos vein. Four courses of neoadjuvant chemotherapy with the TP regimen (paclitaxel plus nedaplatin) were given. Reexamination revealed a significant reduction in tumor and tumor thrombus volume. Therefore, McKeown radical resection for esophageal cancer and removal of the tumor thrombus in the arch of the azygos vein were performed. Postoperative pathology suggested complete remission of the esophageal tumor and the presence of small focal cancer tissues in the arch of the azygos vein., Conclusion: We report a case of esophageal squamous cell carcinoma with tumor thrombus formation in the azygos vein. We conducted radical resection after 4 rounds of neoadjuvant chemotherapy, and the pathological results revealed complete remission of the tumor. We report our experience addressing this rare case, and we hope to find the underlying mechanism of tumor thrombus formation and whether it has any effects on prognosis in our future study.

Background/aims: Splenectomy is regarded as an effective curative treatment for thrombocytopenia caused by hypersplenism in patients with cirrhosis. However, in clinical practice, thrombocytopenia is not resolved by splenectomy in all patients. This study aimed to evaluate the adverse factors responsible for platelet (PLT) counts below the normal lower limit following laparoscopic splenectomy and azygoportal disconnection (LSD)., Materials and Methods: We retrospectively evaluated the outcomes of 123 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism, who underwent LSD and who had PLT counts <125×109/L (non-normal group) or >125×109/L (normal group) at the postoperative month (POM) 3, between April 2014 and March 2017., Results: Sixteen patients (13.01%) had PLT counts <125×109/L at POM 3 after LSD, while the remaining 107 patients had normal counts. We analyzed 25 perioperative variables in both groups. A logistic multivariate regression identified age (relative risk [RR] 1.082, 95% confidence interval [CI] 1.018-1.150) and longitudinal spleen diameter (RR 0.977, 95% CI 0.955-1.000) as significant independent factors for the PLT count <125×109/L at POM 3. Bivariate correlation analysis showed that age >50 years and longitudinal spleen diameter <160 mm were threshold values for an increased risk of the PLT count <125×109/L at POM 3 after LSD., Conclusion: Age was an independent positive predictor and longitudinal spleen diameter an independent negative predictor of PLT count <125×109/L at POM 3 after LSD.

Thoracic duct ligation is a widely accepted treatment option for chylothorax. This case report describes another treatment approach for recurrent chylothoraxes after thoracic duct ligation. A 40-year-old woman had chylothoraxes after thoracic duct ligation. She underwent a secondary surgery to ligate the thoracic duct. Three days later, the number of chylothoraxes increased compared with presurgery, and we anastomosed the thoracic duct and azygos vein after releasing the thoracic duct ligation. The patient recovered smoothly and was followed up for 2 years. This case shows that anastomosis of the thoracic duct and azygos vein is an alternative surgical approach to treat recurrent chylothoraxes.

During pediatric kidney transplant, surgical challenges occasionally occur. In particular, vascular anastomosis should be considered for children with small body weight < 12 kg, multiple renal arteries, vascular anomaly, and inferior vena cava occlusion. In pediatric patients, a living-donor renal graft is usually donated from a parent. Therefore, the renal artery and vein are too large to be anastomosed with the recipient's internal iliac artery and external iliac vein. In children who are > 12 kg, the renal artery and vein could be anastomosed with the external iliac artery and the external iliac vein. In children who are < 10 kg, the renal artery and vein should be anastomosed directly with the aorta and inferior vena cava. A pediatric transplant surgeon should consider arterial and venous anastomosis sites before transplant surgery. In small children with partial or total inferior vena cava occlusion, the venous anastomosis site should be evaluated. If the graft is placed on the left side, a venous graft must be used as a bridge between the renal vein and inferior vena cava. In 13 kidney transplants in children with inferior vena cava occlusion, 7 were on the left and 6 were on the right side. A patent segment of the inferior vena cava, the left original renal vein, an ascending lumbar vein, an azygos vein, the first graft renal vein, and a portal vein were used for venous anastomosis in 6, 2, 2, 1, 1 and 1 recipient, respectively. One child had graft loss due to renal vein thrombosis and one died of hemorrhage immediately posttransplant. Three had grafts with relatively long-term function, but these were lost due to chronic allograft nephropathy 100, 122, and 137 months posttransplant. However, the other 8 recipients have so far maintained graft function from 6 to 138 months since transplant.

Introduction: Laparoscopic splenectomy and azygoportal disconnection (LSD) has been reported to be safe, feasible, and minimally invasive for cirrhotic patients with portal hypertension. There is still controversy as to whether it is necessary to perform synchronous splenectomy for patients with moderate hypersplenism who undergo azygoportal disconnection for esophagogastric variceal hemorrhage (EGVB)., Methods: We retrospectively evaluated the outcomes in 51 cirrhotic patients with EGVB and moderate hypersplenism (PLT ≥50 × 10 9 /L) who underwent LSD (n = 28) or laparoscopic azygoportal disconnection (LD) (n = 23) between January 2014 and October 2015. Their demographic, intraoperative, and postoperative variables were compared., Results: LSD and LD were successful in all the patients. When compared with LSD, LD had a significantly shorter operation time, less intraoperative blood loss, shorter postoperative hospital stay, fewer days of postoperative body temperature >38.0 °C, lower rate of fever postoperatively, and lower C-reactive protein concentration and procalcitonin concentration on postoperative day (POD) 7 (all P < 0.05). The incidences of portal vein system thrombosis in the LD group on PODs 7, 30, and 90 were significantly lower than those in the LSD group at all the time points (all P < 0.05). According to the postoperative serum proportions of CD4 + and CD8 + and the CD4+/CD8+ ratio (all P < 0.05), the LSD group had significantly lower immune function than the LD group on POD 90., Conclusions: LD is safe and effective for EGVB with moderate hypersplenism secondary to portal hypertension in selected patients., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Connection of the right pulmonary veins to the azygous is an extremely rare variant of partial anomalous pulmonary venous connection. We describe one such case in the setting of an intact atrial septum. Surgical correction in such a situation can be challenging. We describe a successful surgical approach for this unusual variant., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Portal vein system thrombosis (PVST) is an alarming and potentially life-threatening complication of laparoscopic splenectomy and azygoportal disconnection (LSD). The objective of this study was to investigate negative and positive predictors of PVST after LSD in patients receiving anticoagulant regimens with aspirin or warfarin., Methods: Seventy-five consecutive patients who underwent LSD from 2013 to 2014 were retrospectively reviewed. Patients received anticoagulant regimen with warfarin (n = 35) or aspirin (n = 40) according to individual preference. International normalized ratio (INR) and the incidence of PSVT were compared in patients received anticoagulant regimen with warfarin or aspirin on postoperative days (POD) 7, 30, and 90, and factors associated with PVST at these time points were determined by univariate and logistic multivariable regression analyses., Results: Portal vein diameter was an independent negative predictor of PVST on PODs 7, 30, and 90. Anticoagulation with warfarin was an independent positive predictor of PVST on PODs 30 and 90, and INR was an independent positive predictor of PVST on POD 90. Dynamic changes in the incidence of PVST on the day of admission and on PODs 7, 30, and 90 differed significantly between the warfarin and aspirin groups (P = 0.002). No patient experienced perioperative bleeding., Conclusions: Portal vein diameter was an independent negative predictor, while anticoagulation therapy with warfarin and INR were independent positive predictors, of PVST after LSD. Early anticoagulation with warfarin is safe and effective for the prevention of PVST after LSD., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background and Objectives: Given the technical difficulty of laparoscopic splenectomy and azygoportal disconnection (LSD), data are limited that compare the laparoscopic to the open procedure. As the technique becomes more widespread, questions regarding its safety, feasibility, and reproducibility must be addressed. This review assesses the current status of LSD., Methods: We conducted our literature review with a search of the PubMed database. All published series of 5 or more laparoscopic splenectomy and azygoportal disconnection procedures were examined. The demographic, intraoperative, and postoperative data analyzed included number of ports, conversion rate, operative duration, estimated intraoperative blood loss, postoperative hospital stay, and complications., Results: Fifteen articles met the review criteria. Of 412 laparoscopic procedures, traditional laparoscopic splenectomy and azygoportal disconnection (TLSD) was used in 322 patients (78.2%), a modified laparoscopic procedure (MLSD) in 79 (19.2%), and a single-incision laparoscopic procedure (SLSD) in 11 (2.7%). Compared with the traditional and single-incision laparoscopic procedures, the MLSD procedure was associated with shorter operative duration and less blood loss. Furthermore, although the incidence of postoperative portal vein system thrombosis was higher in the laparoscopic than in the open splenectomy with azygoportal disconnection (OSD) procedure, the LSD procedure was associated with less pulmonary infection and pleural effusion and fewer incisional and overall complications than the open procedure. The rate of conversion to an open procedure was 5.4%., Conclusions: LSD is feasible and safe for selected patients when performed by an expert laparoscopic surgeon. It has perioperative advantages over OSD, but studies with longer follow-up periods and larger samples of patients are needed.

The azygos system of veins varies greatly in its mode of origin, but the variation in which the azygos vein is a continuation of the inferior vena cava (IVC) is rare. During an oesophagectomy, the azygos vein typically is transected as a requirement of the surgery. In this case, the enlarged azygos and its arch were a continuation of the IVC. During our procedure, we first established a bypass between the right femoral vein and the jugular vein in case of injury to the azygos vein, and we then performed a McKeown oesophagectomy without transecting the azygos vein. Our experience suggests that an oesophagectomy in cases with an azygos vein continuation of the IVC is feasible. An adequate medical examination and careful reading of the imaging is crucial for the safety of these surgical procedures. An appropriate surgical approach should be selected according to the location of the tumour, the size of the tumour and its anatomical features. The establishment of a veno-venous bypass and protection of the azygos arch in patients whose azygos vein is a continuation of IVC is necessary.

Aims: Inferior vena cava (IVC) interruption is a rare anatomic variant where the azygos vein (AV) drains the blood from the IVC to the upper part of the right atrium via the superior vena cava. Here, we report balloon cryoablation of the pulmonary veins (PVs) via superior access in a patient with atrial fibrillation., Methods and Results: After the first failed ablation attempt due to IVC interruption, balloon cryoablation with a 28-mm Arctic Front Advance cryoballoon (Medtronic CryoCath LP, Quebec, Canada) via superior access was performed; it requires only a single transseptal puncture (TP), and the patient had optimal PV anatomy. Deflectable electrodes were inserted into the right ventricle and coronary sinus from the right femoral vein. The right internal jugular vein was accessed using an SL0 transseptal sheath and BRK needle. The TP was performed under transoesophageal echocardiographic guidance with a Safe Sept wire because the septum was stiff. All PVs were engaged: the left using an ablation catheter before balloon insertion and the inferior following a 'push-up' technique because of a leak above the veins. Cryothermal energy was delivered after checking for occlusion. The procedure lasted 210 min, fluoroscopy time was 78 min, and air-kerma dose was 194 mGy. During the 6-month follow-up, no episodes of atrial fibrillation were detected on several Holter recordings., Conclusions: Successful PV isolation in patients with AV continuation of an interrupted IVC can be safely performed using superior access with balloon cryoablation, after several modifications of standard equipment., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Objectives: An almost universal incidence of developing pulmonary arteriovenous fistulas after the Kawashima operation has been reported. Exclusion of the hepatic venous flow from the pulmonary circulation causes the development of these malformations. Redirection of hepatic venous flow to the pulmonary circulation mostly leads to the regression of the arteriovenous fistulas., Methods: We analyzed 11 patients with arteriovenous fistulas that developed after the Kawashima operation. The hepatic-to-azygos shunts were performed with an off-pump technique through a lateral thoracotomy in all but one. Operative and postoperative data were retrospectively collected., Results: No intraoperative complications occurred, and no patient died in the hospital. Up to 10-year follow-up showed a significant postoperative improvement of patients' oxygen saturation and New York Heart Association class. Apart from 2 re-thoracotomies for bleeding in 1 patient, no complications occurred and no patient died during follow-up. Two other patients underwent reoperation for an undiagnosed additional hepatic vein. The improvement of patients' oxygen saturation and New York Heart Association class persisted during the follow-up period., Conclusions: The surgical connection can be performed safely with an off-pump technique that avoids the risks related to extracorporeal circulation and circulatory arrest. The results at 10 years follow-up confirmed the efficacy and safety of the surgical technique described., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Aim: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy and azygoportal disconnection (MLSD) with intraoperative autologous cell salvage., Methods: We retrospectively evaluated outcomes in 79 patients admitted to the Clinical Medical College of Yangzhou University with cirrhosis, portal hypertensive bleeding and secondary hypersplenism who underwent MLSD without (n = 46) or with intraoperative cell salvage and autologous blood transfusion, including splenic blood and operative hemorrhage (n = 33), between February 2012 and January 2014. Their intraoperative and postoperative variables were compared. These variables mainly included: operation time; estimated intraoperative blood loss; volume of allogeneic blood transfused; visual analog scale for pain on the first postoperative day; time to first oral intake; initial passage of flatus and off-bed activity; perioperative hemoglobin (Hb) concentration; and red blood cell concentration., Results: There were no significant differences between the groups in terms of duration of surgery, estimated intraoperative blood loss and overall perioperative complication rate. In those receiving salvaged autologous blood, Hb concentration increased by an average of 11.2 ± 4.8 g/L (P < 0.05) from preoperative levels by the first postoperative day, but it had fallen by 9.8 ± 6.45 g/L (P < 0.05) in the group in which cell salvage was not used. Preoperative Hb was similar in the two groups (P > 0.05), but Hb on the first postoperative day was significantly higher in the autologous blood transfusion group (118.5 ± 15.8 g/L vs 102.7 ± 15.6 g/L, P < 0.05). The autologous blood transfusion group experienced significantly fewer postoperative days of temperature > 38.0°C (P < 0.05)., Conclusion: Intraoperative cell salvage during MLSD is feasible and safe and may become the gold standard for liver cirrhosis with portal hypertensive bleeding and hypersplenism.

Aim: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy or open splenectomy and azygoportal disconnection for portal hypertension., Methods: This study included 44 patients who underwent modified laparoscopic splenectomy and azygoportal disconnection (MLSD) and 71 who underwent open procedures for portal hypertension. Blood samples were collected before surgery and on days 1, 3, and 7 after surgery. Markers of liver and renal function, C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) were measured, and perioperative variables were compared between the two groups., Results: The modified laparoscopic group showed significantly better and faster recovery, better liver and renal function, and fewer complications than the open group. CRP, IL-6, and PCT concentrations on postoperative days 1, 3, and 7 were significantly lower in the modified laparoscopic group than in the open group., Conclusion: MLSD was associated with lower inflammatory immune responses, less impairment of liver and renal function, and faster and better recovery.

Azygos vein aneurysm is very rare and most cases are detected incidentally. We report a safe resection of azygos vein aneurysm by video-assisted thoracoscopic surgery (VATS) under preoperative evaluation of thrombus by multidetector computed tomography (MDCT). A 60-year old woman presented to our department due to a mediastinal mass revealed by enhanced CT. A dynamic enhanced-CT scan showed a dilated azygos vein with great enhancement in the early phase. Under the diagnosis of azygos vein aneurysm, we analysed the aneurysm by MDCT and confirmed that there was no thrombus within the aneurysm. The resection of the aneurysm by VATS was performed safely. She was discharged 4 days after surgery.

The azygos lobe is a well-known and well-described anatomical variation of the right lung. Primary lung cancer arising from an azygos lobe, however, is exceedingly rare. Only a handful of cases have been previously reported in the literature. We report the first case with operative demonstration of a primary adenocarcinoma arising from an azygos lobe, which was treated with robot-assisted azygos lobectomy.

Background: Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system with a disabling progressive course. Chronic cerebrospinal venous insufficiency (CCSVI) has recently been described as a vascular condition characterized by restricted venous outflow from the brain, mainly due to blockages of the internal jugular and azygos veins. Despite a wide variability among studies, it has been found to be associated with MS. Data from a few small case series suggest possible improvement of the clinical course and quality of life by performing percutaneous balloon angioplasty (PTA) of the stenotic veins., Study Design and Methods: This is a multicenter, randomized, parallel group, blinded, sham-controlled trial to assess the efficacy and safety of PTA. Participants with relapsing remitting MS or secondary progressive MS and a sonographic diagnosis of CCSVI will be enrolled after providing their informed consent. Each participant will be centrally randomized to receive catheter venography and PTA or catheter venography and sham PTA. Two primary end points with respect to efficacy at 12 months are (1) a combined end point obtained through the integration of five functional indicators, walking, balance, manual dexterity, bladder control, and visual acuity, objectively measured by instruments; and (2) number of new brain lesions measured by T2-weighted MRI sequences. Secondary end points include annual relapse rate, change in Expanded Disability Status Scale score, proportion of patients with zero, one or two, or more than two relapses; fatigue; anxiety and depression; general cognitive state; memory/attention/calculus; impact of bladder incontinence; and adverse events. Six hundred seventy-nine patients will be recruited. The follow-up is scheduled at 12 months. Patients, treating neurologists, trained outcome assessors, and the statistician in charge of data analysis will be masked to the assigned treatment., Discussion: The study will provide an answer regarding the efficacy of PTA on patients' functional disability in balance, motor, sensory, visual and bladder function, cognitive status, and emotional status, which are meaningful clinical outcomes, beyond investigating the effects on inflammation. In fact, an important part of patients' expectations, sustained and amplified by anecdotal data, has to do precisely with these functional aspects., Trial Registration: Clinicaltrials.gov NCT01371760.

Objective: To compare the efficacies between transjugular intrahepatic portosystemic shunt (TIPS) and portoazygos devascularization (PAD) in the treatment of portal hypertension with variceal bleeding., Methods: From December 1993 to December 2010, 309 patients with portal hypertension and variceal bleeding were admitted. According to their general conditions and Child-Pugh grades, they were assigned to undergo TIPS (group A, n = 235) or PAD (group B, n = 74). Before operation, compared with the PAD group, the TIPS group possessed worse liver functions, more severe ascites and a greater frequency of bleeding. After operation, the therapeutic efficacies and changes of portal hemodynamics, recurrent variceal bleeding, post-operative encephalopathy and long-term survival were evaluated between two groups., Results: The postoperative portal pressure in the TIPS group ((42.6 ± 7.0) vs (26.3 ± 4.1) cm H2O) decreased much more than that in the PAD group ((38.7 ± 5.2) vs (33.5 ± 5.8) cm H2O, P < 0.01). The rebleeding rates during early postoperation were 0.85% (2/235) and 6.76% (5/74) in TIPS and PAD groups respectively, the occurring rates of hepatic encephalopathy 4.68% (11/235) and 4.05% (3/74) and the rates of operative mortality 1.70% (4/235) and 6.76% (5/74) respectively. Survival rates of 1, 3, 5 and 10 years were 98.30% (231/235) vs 92.24% (69/74), 92.41% (146/158) vs 88.06% (59/67), 80.77% (84/104) vs 79.25% (42/53), 51.43% (36/79) vs 51.85% (14/27) in TIPS and PAD groups respectively., Conclusions: As compared with PAD, TIPS offers the such advantages as less trauma, wider indication, faster hemostasis and satisfactory therapeutic efficacies. Especially for the emergency treatment of a patient with massive variceal bleeding and Child-Pugh C grade liver function, TIPS is a better option than PAD.

We report a case of a shrapnel injury to the right thigh in which a foreign body had lodged in, and moved freely from, the femoral vein to the inferior vena cava and right atrium. However, instead of going into the right ventricle and pulmonary artery, it lodged itself in the superior vena cava-azygous junction. During the entire period, the patient remained asymptomatic and the foreign body was surgically retrieved uneventfully.

We report a resection of an azygos vein aneurysm that formed a thrombus during a 6-year follow-up period. An azygos vein aneurysm is commonly detected as an asymptomatic mediastinal mass. A thrombus could suddenly form without enlarging the aneurysm. Therefore we suggest that even asymptomatic azygos vein aneurysms causing blood stagnation should be resected before they can form a thrombus and cause a pulmonary embolism., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We report a case of locally advanced excavated non-small cell lung cancer with superior vena cava (SVC) syndrome that underwent four cycles of induction chemotherapy. Due to early treatment failure and the impossibility applying radical radiotherapy, a decision was made to perform surgery. The patient underwent right intrapericardial pneumonectomy with en-bloc resection of the SVC, azygos vein and mediastinal lymph nodes. Prosthetic azygo-atrial bypass was then performed. The patient enjoys one year progression-free survival with patent graft and symptomatic relief of SVC syndrome.

A 17-year-old girl visited our hospital for an operation to correct a partial anomalous pulmonary venous return. All the right-side pulmonary veins returned to the azygos vein, which had no connection to the cardiac chamber through the great venous system, such as the superior or inferior vena cava. The azygos vein lacked a normal azygos arch and was connected by multiple connections only to the paravertebral plexus. For the surgical correction, a pericardiostomy was created in the right posterior pericardial wall and azygos vein which was divided at the diaphragm level and was anastomosed to the left atriotomy area through the pericardiostomy site., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Pulmonary arteriovenous malformations are an important but uncommon complication of cavopulmonary connection, particularly in patients with heterotaxy. Absence of hepatic venous effluent in pulmonary arterial blood seems to be a predisposing factor. Pulmonary arteriovenous malformations are most common after superior cavopulmonary anastomosis, but may develop, progress, or persist in 1 lung after Fontan completion if hepatic venous blood streams completely or primarily to the contralateral lung., Methods: Among 53 patients with heterotaxy and inferior vena cava interruption who underwent a modified Fontan procedure from 1985 to 2005, 8 had unilateral streaming of hepatic venous flow and clinically significant pulmonary arteriovenous malformations after hepatic venous inclusion and underwent reconfiguration of the cavopulmonary pathway. In all 8 patients, the hepatic vein-pulmonary artery pathway was contralateral to and offset from the pulmonary artery anastomosis of the single or dominant superior vena cava. Pathway reconfiguration included pulmonary arterial stenting (n = 2), revision of the superior vena cava-pulmonary artery connection (n = 1), construction of a branched hepatic vein-pulmonary artery conduit (n = 2), and surgical or transcatheter construction of a direct hepatic vein-azygous vein pathway (n = 5)., Results: Hepatic vein-azygous vein connection led to improvement in 4 of 5 patients; other approaches typically did not lead to improvement., Conclusions: Resolution of hypoxemia after cavopulmonary pathway reconfiguration in patients with unilateral pulmonary arteriovenous malformations and hepatic venous flow-streaming after Fontan completion supports the importance of hepatic venous effluent in the pathogenesis of pulmonary arteriovenous malformations and the practice of cavopulmonary pathway revision in such patients. Completion or reconfiguration of the Fontan circulation with direct hepatic vein-azygous vein connection may provide the most reliable mixing and bilateral distribution of hepatic venous blood in this population of patients., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Pulmonary arteriovenous malformations caused by abnormal hepatic flow distribution can develop in patients with a single ventricle with an interrupted inferior vena cava. However, preoperatively determining the hepatic baffle design that optimizes hepatic flow distribution is far from trivial. The current study combines virtual surgery and numeric simulations to identify potential surgical strategies for patients with an interrupted inferior vena cava., Methods: Five patients with an interrupted inferior vena cava and severe pulmonary arteriovenous malformations were enrolled. Their in vivo anatomies were reconstructed from magnetic resonance imaging (n = 4) and computed tomography (n = 1), and alternate virtual surgery options (intracardiac/extracardiac, Y-grafts, hepato-to-azygous shunts, and azygous-to-hepatic shunts) were generated for each. Hepatic flow distribution was assessed for all options using a fully validated computational flow solver., Results: For patients with a single superior vena cava (n = 3), intracardiac/extracardiac connections proved dangerous, because even a small left or right offset led to a highly preferential hepatic flow distribution to the associated lung. The best results were obtained with either a Y-graft spanning the Kawashima to split the flow or hepato-to-azygous shunts to promote mixing. For patients with bilateral superior vena cavae (n = 2), results depended on the balance between the left and right superior inflows. When those were equal, connecting the hepatic baffle between the superior vena cavae performed well, but other options should be pursued otherwise., Conclusions: This study demonstrates how virtual surgery environments can benefit the clinical community, especially for patients with a single ventricle with an interrupted inferior vena cava. Furthermore, the sensitivity of the optimal baffle design to the superior inflows underscores the need to characterize both preoperative anatomy and flows to identify the best option., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

In the surgical treatment of lung cancers invading the superior vena cava (SVC), primary closure is preferred for reconstruction when the resected area is small, but the repaired vessel can become constricted. A novel method for SVC repair with azygos flap, which is a longitudinally opened azygos arch, is a facile and effective treatment, and may prevent a reduction in the lumen if the area of tumor invasion is small and close to the azygos arch. When the azygos arch is not invaded by the tumor, this procedure should therefore be considered as one alternative method for SVC reconstruction.

Indwelling pacemaker or defibrillator leads are often extracted with use of a cutting laser sheath. We report embolization of a tined pacemaker lead tip into the azygous vein, with the use of a distal embolization protection device to retrieve the fragment. Creative and non-traditional use of a filter-based device may assist in retrieval of embolized material.

Less than 25 cases of azygous vein lacerations secondary to blunt trauma have been published in the medical literature, most of these injuries were resulting from motor vehicle accidents, but have been described due to falls or assaults. These lesions should be considered as thoracic great vessels injuries and if not recognized promptly carry a high morbidity and mortality. We report a case of a young male involved in a high-speed car collision, admitted to the emergency room in an unstable condition secondary to hypovolemic shock due to azygous vein injury. The patient underwent emergent right antero-lateral thoracotomy followed by sternotomy for surgical control of the vascular injury and resuscitation. Laparotomy and splenectomy were also required, the abdomen was closed. The thoracic cavity was left packed and closure was delayed for 48 h. The patient survived and was transferred to another hospital seven days later.