Leiomyosarcoma in the musculature of large vessel wall

Leiomyosarcoma of the large arteries and veins is rare. In this paper, one case of primary leiomyosarcoma of the axillary vein is reported. The patient, a 66 year old man, was admitted because of a mass in the medial side of right upper arm for three years and increasingly growing. The tentative diagnosis was neurologic fibroma. A local resection was performed and the final diagnosis of leiomyosarcoma of the right axillary vein was established by pathology. So far, there are 86 cases reported in the foreign literature but only one in the Chinese literature. The neoplasm most frequently occurs in the large veins (68 cases) and approximately one half in the inferior vena cava (33/68). 18 neoplasms are originated from the large arteries and of them, 10 from the pulmonary arteries. Primary leiomyosarcoma in large veins is about four times as common as that in arteries. The primary sites in order of incidence: (1) inferior vena cava; (2) pulmonary artery; (3) other large veins and (4) other large arteries.     

Feasibility of bisegmentectomy 7-8 is independent of the presence of a large inferior right hepatic vein

BACKGROUND: Right superior liver resection or bisegmentectomy 7-8 is defined as the anatomical removal of segments 7 and 8 of the liver. According to recent reports, this type of resection requires the presence of a large accessory right inferior hepatic vein to drain the remaining segment 6. However, anatomic studies have shown that segment 6 has multiple veins presenting several anastomosis with the surrounding hepatic veins. Therefore, the maintenance of the veins from segment 5 that ultimately drain into the middle hepatic vein can be enough to assure venous drainage of both segments. METHODS: Describe an alternative technique for bisegmentectomy 7-8 using intrahepatic glissonian access in patients with absence of a large inferior right hepatic vein. RESULTS: The technique was successfully performed in four consecutive patients without immediate or long-term venous or venous related complications. CONCLUSIONS: Bisegmentectomy 7-8 may increase resectability rate in patients with bilateral lesions and may also enhance the opportunity to perform repeated resections in cases of tumor recurrence. Our study confirms the anatomical assumption that bisegmentectomy 7-8 did not result in segmental outflow block even in the absence of a thick inferior right hepatic vein and therefore should be performed more often than reported so far. The absence of this vein should not be a straightforward indication for right hepatectomy in cases where a liver-sparing procedure such as bisegmentectomy 7-8 can be safely employed.     

Value of embolisation of collateral veins from gastric varices before balloon-occluded retrograde transvenous obliteration

Objective: The purpose of our investigation was to determine the safety and usefulness of embolisation procedures in balloon occluded retrograde transvenous obliteration (BRTO) as treatment of gastric varices after portal hypertension. Materials and Methods: Between June 2004 and August 2009, 40 patients underwent BRTO for gastric varices that occurred after portal hypertension in our institution. When large collateral vessels of gastric varices had developed as drainage veins other than the gastro‐renal shunt, these collateral vessels were embolised prior to BRTO. Results: Embolisation was performed for 18 collateral vessels in 16 cases before BRTO. Embolised collateral vessels were the left inferior phrenic vein (n = 14), intercostal vein (n = 3), and ascending lumbar vein communicating with the gastro‐renal shunt (n = 1). Mean number of micro‐coils used was 5.7 in left inferior phrenic veins, 4.7 in intercostal veins and 4 in the ascending lumbar vein. In 36 (90%) patients, contrast‐enhanced abdominal CT after BRTO showed that the gastric varices were well obliterated. The rate of occurrence of cases in which the remnant of the enhanced area in the gastric varices was seen even after BRTO was statistically higher in cases requiring embolisation of collateral vessels than in those who did not (4/16 versus 0/24, P = 0.0199 according to Fisher's exact probability test). Recurrence of gastric varices was determined by endoscopy in 1 (2.5%) case necessitating embolisation of collateral vessels. There were no serious complications. Conclusion: Embolisation of collateral vessels before BRTO is a safe and useful procedure. However, especially in cases having collaterals sufficiently large to require embolisation, careful follow‐up for recurrence of gastric varices is necessary.     

Recurrent varicose veins. Part 1: Evaluation utilizing duplex venous imaging.

There is the need to develop a universally accepted standard investigation for recurrent varicose veins. Duplex venous imaging offers a precise, non-invasive technique to make anatomic and hemodynamic diagnoses. A routine protocol of duplex imaging of recurrent varicose veins is described based on the known recurrent sources of reflux from deep to superficial veins. Results from this protocol indicate that incompetent perforating veins are the most common site of reflux from deep to superficial veins in patients with recurrent postsurgical varicose veins. Other important sites of reflux detected by this method are recurrent communications with the common femoral vein, the saphenopopliteal junction, and incompetent pelvic veins. Duplex imaging is recommended as a safe, non-invasive method of evaluating recurrent varicose veins.     

胃癌合并门静脉癌栓的CT表现

为了提高对胃癌合并门静脉癌栓CT表现的认识,回顾性分析1990年5月23日~2005年9月18日7例经胃镜、手术病理及临床确诊的胃癌合并门静脉癌栓患者的资料。7例患者均行CT平扫加增强检查。CT检查均显示胃病变区胃壁明显不规则增厚,3例患者出现肝转移灶。门脉癌栓栓子发生的部位主要位于门脉主干段(7例),其中2例累及左、右分支;1例累及肠系膜上静脉;1例同时累及肠系膜上静脉和脾静脉。7例患者中有5例癌栓未见明显强化,2例患者增强后癌栓轻度强化。5例患者癌栓的所在门脉主干明显扩张,门脉血流阻断,5例患者扩张的门脉主干周围可见明显强化迂曲的侧枝血管影,其中2例出现大量腹水。研究结果显示,虽然绝大部分门静脉癌栓由原发性肝癌引起,但门静脉癌栓也可以是由进展期胃癌形成,密切结合临床资料,两者鉴别诊断并不困难。     

Early liver metastases in patients with medullary carcinoma of the thyroid gland

In 13 patients who had been thyroidectomized for medullary carcinoma (MCT), basal and pentagastrin-stimulated immunoreactive calcitonin (iCT) concentrations were measured in a peripheral vein and concomitantly in hepatic veins as well as in the superior and inferior caval veins. The basal concentrations of iCT in serum from the antecubital vein ranged from normal values (less than 0.50 micrograms/1) to grossly elevated (greater than 100 micrograms/1). Intravenous pentagastrin injections (0.5 micrograms/kg) stimulated transiently calcitonin secretion in all patients and peak concentrations occurred in peripheral venous blood and in the inferior caval vein after 3 to 5 minutes. In all patients peak iCT values in the hepatic vein occurred at 1 to 2 minutes and were much higher than in samples taken from other veins. Only three patients showed metastases to liver as judged by conventional clinical and laboratory examinations. Two patients with nonthyroid, malignant disease did not show an increase in serum iCT concentration of hepatic veins. The authors conclude that MCT may spread early to the liver. The presence of liver metastases is an important prognostic factor in patient evaluation and can be demonstrated by measuring iCT in hepatic veins before and during pentagastrin stimulation.     

肝尾状叶肿瘤的切除(附5例报道)

目的:探讨肝尾状叶肿瘤的手术切除经验.方法:对我院2001年11月～2002年6月收治的5例累及肝脏尾状叶肿瘤的手术方式作回顾性分析.结果:本组5例均采用右侧路径切断尾状静脉,2例其中游离部分腔静脉,切断尾状静脉4～5支,2例血管瘤和1例肝转移癌患者游离全部肝段下腔静脉,切断全部尾状静脉.5例患者均好转出院.结论:尾状静脉的离断是手术安全的保障.另外解剖肝门板,离断尾状叶的动、静脉分支可以减少手术中的出血量.     

Selective hepatic vascular exclusion and Pringle maneuver: A comparative study in liver resection

Objective

Most liver resections require champing of the hepatic pedicle (Pringle maneuver) to avoid excessive blood loss. But Pringle maneuver cannot control backflow bleeding of the hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from injuries of the hepatic vein. Although total hepatic vascular exclusion (THVE) can prevent bleeding of the hepatic vein effectively, it also may result in systemic hemodynamic disturbance because of the clamped inferior vena cava (IVC). SHVE, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. We compared the effects of selective hepatic vascular exclusion (SHVE) and Pringle maneuver in resection of liver tumors involving the junction of the hepatic vein.

Methods

From January 2000 to October 2005, 2100 patients with liver tumors had undergone liver resections in our department. Among them, tumors of 235 cases adhered to or were close to the junction of one or more hepatic veins. Both SHVE and Pringle maneuver were used to control blood loss during hepatectomy. These 235 cases were divided into two groups: Pringle maneuver group (110) from January 2000 to December 2002 and SHVE group (125) from January 2003 to October 2005. Data were analyzed regarding the intraoperative and postoperative courses of the patients. In the SHVE group, total SHVE (clamping the porta hepatis and all major hepatic veins) was used in 69 cases and partial SHVE (clamping the porta hepatic and one or two hepatic veins) in 56 cases. There were three methods in hepatic veins occlusion: ligating with suture, encircling and occluding with tourniquets and clamping with Satinsky clamps.

Results

There was no difference between the two groups regarding the age, gender, tumor size, cirrhosis and HBsAg rate, ischemia time and operating time. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group. Hepatic veins rupture with massive blood loss occurred in 14 and air embolism in three during the tumor resection, but there was no massive blood loss and air embolism in the SHVE group due to hepatic vein occlusion. Postoperative bleeding, reoperation, liver failure and mortality rate were higher, and ICU stay and hospital stay were longer in the Pringle group than those in the SHVE group.

Conclusion

SHVE is much more effective than Pringle maneuver in controlling intraoperative bleeding. It can prevent massive blood loss and air embolism from hepatic veins rupture and can reduce the postoperative complication rate and mortality rate. Clamping the hepatic veins with Satinsky clamps is much safer and easier than ligating with suture and occluding with tourniquets.     

Diseases Mimicking Thrombosis of the Limb – A Retrospective Radiological Study

To demonstrate misinterpretation of phlebography findings we present 14 cases, which were first diagnosed as deep vein thrombosis, but later turned out to be caused by expansive processes around veins, e.g. popliteal cyst, haematoma, muscle necrosis and abscess.     

Giant Mastoid Emissary Vein: Source of Profuse Bleeding During Mastoid Surgery

The emissary veins are residual connections between intra-cerebral veins and their extra-cranial drainage. Mastoid emissary vein is a rare but definite entity which if not diagnosed preoperatively could be a cause of severe hemorrhage at the time of surgery which may prove to be life threatening. These veins may vary in size from that of a mere thread to that of a wax match or 1/8th–3/8th of an inch. We report one such case of a giant mastoid emissary vein which was opened while operating on mastoid and caused profuse bleeding which could only be controlled by surgical pack.     

直肠癌根治术中骶前静脉大出血的处理

[目的]探讨直肠癌根治术中骶前静脉大出血的原因及纱布填塞压迫法的止血效果.[方法]5例直肠癌患者中3例(1例Miles术、2例Dixon术)因术中解剖层次错误、游离直肠后壁时撕裂骶前静脉引起的大出血,2例因Dixon术中骶前静脉渗血处理不当撕裂骶前静脉引起的大出血,使用纱布填塞压迫法止血.[结果]5例患者均成功止血,顺利完成手术,术后72h去除纱布,无再次继发性出血发生,患者恢复好,随访无不良反应发生.[结论]直肠癌根治术中未掌握正确的解剖层次或骶前渗血处理不当是骶前静脉大出血主要原因;纱布填塞压迫法仍然是目前直肠癌根治术中骶前静脉大出血的最有效方法.     

Budd-Chiari syndrome: successful treatment by percutaneous transluminal angioplasty

Budd Chiari syndrome is a rare disorder. It is caused by obstruction of the hepatic veins. The prognosis is usually dismal, except in the rare case where the obstruction is due to either webs in the hepatic veins or membranous obstruction of the inferior vena cava. Such cases, more common in the Orient, can be treated by percutaneous transluminal angioplasty. We report a case of Budd Chiari syndrome, due to a membranous obstruction in the right hepatic vein, successfully treated by percutaneous transluminal angioplasty.     

Venous complications following petrosal vein sectioning in surgery of petrous apex meningiomas

Objective

Meningiomas involving the petrous apex regularly show a close relationship with the superior petrosal vein which is sometimes obliterated during surgery due to its proximity to the tumour. However, there is no study available so far focusing on the frequency of postoperative venous congestion related complications following petrosal vein obliteration as well as on pre- and intraoperative findings related to them.

Methods

Fifty-nine patients with meningiomas involving the petrous apex were analyzed concerning the intraoperative preservation or sacrifice of the petrosal vein and postoperative complications related to venous occlusion.

Results

When a petrosal vein was occluded, in 9 of 30 cases venous-related complications occurred with a minor venous-congestion phenomenon in seven cases and major complications in two cases. When the petrosal vein complex was preserved, there were no similar complications.

Conclusion

Preservation of the petrosal venous complex, especially of large caliber veins, should be attempted whenever possible to increase the safety of surgery. In cases of petrosal vein obliteration, effective brainstem decompression following tumour removal is essential to minimizing the risk of cerebellar congestion.     

Intersegmental attenuation difference on CT caused by partial Budd-Chiari syndrome secondary to hepatocellular carcinoma: report of two cases

For two patients with partial Budd-Chiari syndrome secondary to hepatocellular carcinoma, dynamic CT was evaluated. The obstructed hepatic veins were both the middle and left hepatic veins in Case 1 and the right hepatic vein in Case 2. The area affected by obstructed hepatic vein(s) was seen as low density on both unenhanced and contrast enhanced CT in Case 1 and as high density on enhanced CT in Case 2. The border of attenuation differences caused by the obstruction of the middle (Case 1) or right (Case 2) hepatic vein was intersegmental planes of the anterior segment of the right lobe, and that caused by the obstruction of the left hepatic vein was the intersegmental plane of the medial third of the left lateral segment. Once intersegmental attenuation difference is recognized on CT, partial Budd-Chiari syndrome should be considered.      

主动脉弓右侧食管癌经左胸后外切口手术的体会

主动脉弓右侧食管癌多采用右胸切口.暴露较好。但因切口多.术后并发症高.有一定缺点。作者采用左侧剖胸7例.计弓上吻合术4例.颈部吻合术3例。术中遇到粘连严重者4例.分离困难时奇静脉损伤3例,采用主动脉弓游离牵开的方法进行处理,取得了满意效果。手术要点:结扎肋间动静脉不宜超过3支;牵拉主动脉弓时用力要缓慢轻柔.不可过急。     

Anatomy and pathophysiology of varicose veins

The venous anatomy of the leg is described with special reference to the superficial venous system. The histologic and histochemical differences between varicose and normal veins are presented. The pathophysiology of varicose veins is related to congential or acquired abnormalities of the deep venous system, venous valves, and/or fascial or vein wall weakness. Increased deep venous pressure may be both proximal and distal in etiology, arising from arteriovenous anastomoses, incompetent communicating veins, or venous obstruction. Primary valvular incompetence arises from venous obstruction (thrombosis), thrombophlebitis, or valvular agenesis. Secondary valvular incompetence occurs from deep venous obstruction or increased venous distensibility (usually secondary to circulating estrogens). Finally, fascial weakness of the vein wall or supporting fascia provided a genetic basis for the pathophysiology of varicose veins. Understanding the anatomy and pathophysiology of varicose veins should lead to a more rational and efficacious treatment.     

Serum p53 antibodies in drainage blood from the azygos vein in patients with esophageal carcinoma

BACKGROUND: Serum p53 antibodies (p53-Ab) have been detected in some cancers. The possible correlation between serum p53-Ab levels in drainage blood from the azygos vein in patients with esophageal carcinoma and prognosis was investigated. MATERIALS AND METHODS: Serum p53-Ab levels were examined in both the peripheral and azygos veins of 57 patients, and in the peripheral vein of 17 healthy volunteers. Serum p53-Ab levels were measured using an enzyme-linked immunosorbent assay. RESULTS: The positive rate of serum p53-Ab in the peripheral vein of the patients was 31.6%, significantly higher than that of the normal volunteers. There were no significant correlations between the clinicopathological features and the serum p53-Ab in either the peripheral or azygos veins. Serum p53-Ab levels in either vein did not correlate with prognosis in the univariate survival analysis, although the levels in the two veins were significantly correlated. CONCLUSION: Serum p53-Ab levels in the azygos vein did not reflect the tumor status or prognosis more directly or accurately than those in the peripheral vein, since levels in the two veins were similar. Therefore, measurement of serum p53-Ab in the azygos vein does not appear to be necessary.     

肝细胞癌相关动静脉瘘的多排螺旋CT表现

背景与目的：临床上相当一部分患者不可能常规作经导管肝动脉造影检查,这往往导致肝细胞癌(hepatocellular carcinoma,HCC)相关的动静脉瘘(arteriovenous fistula,AVF)漏诊,丧失栓塞治疗的机会。本研究旨在探讨HCC相关AVF的多排螺旋CT(muhidetector spiral CT,MDSCT)表现,以提高其诊断与鉴别诊断水平。方法：分析经数字减影血管造影(DSA)检查证实的56例HCC相关AVF的MDSCT薄层动态增强表现。结果：MDSCT显示31例门静脉主干和／或1级分支增强早于肠系膜上静脉或脾静脉,其中1例有左肝静脉提早增强浓密显影并左肝静脉和下腔静脉上端癌栓形成,1例肝动脉晚期HCC病灶周围短暂片状强化、门静脉期变为等密度;18例门静脉主干和／或1级分支显影浓密于肠系膜上静脉或脾静脉;4例门静脉2级及以下分支增强早于门静脉主干,3例门静脉2级及以下分支显影浓密于门静脉主干,伴有肝动脉晚期HCC病灶周围短暂的片状(3例)或楔形(4例)强化,门静脉期变为等密度。49例重中度分流中央型病例,病灶和脾脏强化程度均降低,非癌变肝实质强化程度增加且密度不均。结论：HCC相关AVF具有复杂的MDSCT表现,门静脉和／或肝静脉提早增强、浓密显影是其主要改变。     

Ultrasound-guided venous access: “Wire-loaded puncture” technique for paediatric cancer patients

Ultrasound-guided venous access is becoming a standard technique in many centers worldwide. In small veins and in the pediatric population, successful venous puncture is sometimes followed by resistance in passing the wire. The needle seems to miss the small vein during syringe dismounting, wire mounting and wire advancement through the needle.This work describes a “wire-loaded puncture” technique as a solution for this problem.

Petrosal vein occlusion in cerebello-pontine angle tumour surgery: An anatomical study of alternative draining pathways

Objective

The present anatomic study investigates alternative draining pathways of the petrosal vein territory, which allow compensation in case of surgical sacrifice.

Methods

In eight (four formaldehyde fixed and four alcohol fixed) specimens the petrosal vein complex has been dissected and studied. Three heads have been selectively injected via the superior petrous sinus with colored silicon in two different colors. Thereafter the posterior fossa content was removed epidurally from the skull and further fixed in 4% formaldehyde. The nervous and vascular structures were dissected under microscopic control, measured and photographed. 3D-photographs were elaborated.

Results

The petrosal vein was present in all cases and joined the superior petrous sinus always lateral to the trigeminal nerve as a single trunk. In the selectively injected specimens no passage of the colored silicon mixture to the contralateral venous brainstem territory could be discerned. However, the ipsilateral anastomoses to the deep supratentorial venous system – peduncular, anterolateral pontomesencephalic, lateral mesencephalic veins, and the tectal veins in connection with the pontotrigeminal vein – filled in all cases.

Conclusion

Although the present anatomical model does not reflect physiological aspects of vascular dynamics, we document an apparently compensatory venous blood drainage occurring via anastomotic pathways directed to the ipsilateral supratentorial venous system. These findings represent an interesting aspect for preoperative image-guided planning in cerebello-pontine angle surgery.