Delayed High Output Heart Failure due to Arteriovenous Fistula Complicated with Herniated Disc Surgery

A 36-year-old male presented with progressive exertional dyspnea over months. Physical examination showed jugular venous distension, lung crecipitations, femoral bruit and pitting pedal edema. Echocardiogram showed a dilated right ventricle with severe pulmonary hypertension and a non collapsing inferior vena cava (IVC). On right heart catheterization, IVC oxygen saturation was noted at 92% suggesting arterial mixing; a computed tomography of the abdomen showed a fistula between the right common iliac artery to the right common iliac vein at L4 level and a massive IVC; this was linked to trauma from a disectomy done 16 years ago at L4–L5 level. Endovascular sealing with a 16 × 60 mm bifurcated stent graft (S & G Biotech, Seoul, Korea) was performed which led to complete resolution of the patient’s dyspnea. Iatrogenic vascular injury during lumbar disc surgery, although rare, can lead to high output cardiac failure developing over months to years.     

Role of proximal electrode position in transvenous ventricular defibrillation

Transvenous defibrillation lead systems have been demonstrated to reduce operative morbidity and mortality associated with implantation of cardioverter-defibrillators. To determine the best position for the proximal electrode in transvenous systems, defibrillation thresholds were compared for three positions in a single-pathway, two-lead system. Two defibrillation lead electrodes were transvenously inserted into seven dogs. The distal electrode was positioned in the right ventricular apex. The proximal electrode was randomized to one of three positions: (1) the superior (cranial) vena cava (SVC) at he junction of the right atrium, (2) the left innominate vein at the junction of the SVC, or (3) the external jugular vein. Biphasic defibrillation thresholds for converting electrically induced ventricular fibrillation were determined for the three positions of the proximal electrode in each dog. The innominate vein position resulted in the lowest defibrillation threshold (555±123 V) as compared to the SVC (640±126 V;p=0.0612) and the jugular vein (709±117 V;p=0.0013). Lead impedance gradually increased with increasing dostamce between the two shocking electrodes: 58.4±11.4 Ω for SVC, 76.2±13.8 Ω for innominate vein, and 94.9±10.2 Ω for jugular vein proximal lead electrode position (p<0.05 for all pairwise comparisons). In two-electrode transvenous defibrillation lead systems, positioning the proximal electrode in the left innominate vein produced the lowest defibrillation threshold.     

Clinical implications of left ovarian vein incomplete duplicity with embryonic intersubcardinal anastomosis-derived branches

During the dissection of a female human cadaver a case of a duplex ovarian vein was observed. It was unique in its upper course where it anastomosed with an inferior polar renal vein, which in turn was linked to an upper polar renal vein by means of a joining branch. It is hypothesised that this represent a persistent link between the left subcardinal vein and the left sacrocardinal vein, together with some branches of a venous net, which represent the embryological intersubcardinal anastomosis. The gonadal vein arises from the distal (or postrenal) left subcardinal vein portion; the left renal vein develops from the intersubcardinal anastomosis. The venous net derived from the intersubcardinal anastomosis may represent a bypass system in cases of left renal vein occlusion. Left gonadal vein duplicity may also play an important role in the anatomical basis of idiopathic left ovarian vein syndrome or left varicocele, and can lead to mistakes being made during venous sclerotherapy.     

胎肝血管的三维可视化建模及意义

目的　探讨胎肝血管三维模型的分割方法及其意义。 方法　采用分色和密度差金属造影剂对1例38周新鲜引产正常胎肝进行灌注并铸型,红色环氧树脂填充剂灌注腹主动脉（造影剂为氧化铅）,蓝色环氧树脂填充剂灌注下腔静脉、静脉导管、肝左静脉及肝右静脉外侧支（造影剂为二氧化钛）,紫色环氧树脂填充剂灌注肝中静脉（造影剂为氧化锌）,绿色环氧树脂填充剂灌注肝右静脉内侧支（造影剂为氧化铅）。然后行128层螺旋CT薄层扫描和Mimics软件重建胎肝三维模型。 结果 构建胎肝血管三维模型形态逼真、立体感强。调整mimics阈值间距由大逐步变小,可以有效分割出肝中静脉、肝静脉系及肝固有动脉等血管,能清晰地显示肝内多血管走行及分布情况。 结论　不同密度金属造影剂灌注分割胎肝内多血管方法简便可行,能够为研究者对胎肝血管发生发展及其移植术的研究提供理想技术支持。     

Use of a tunneling technique to achieve a lower defibrillation threshold during implantable cardioverter defibrillator implantation via the right subclavian vein

A 56-yr-old man with aborted sudden cardiac death underwent implantable cardioverter defibrillator (ICD) implantation. While the ICD was being implanted, a left subclavian venogram failed to visualize the left subclavian vein, which was attributed to likely prolonged indwelling of the left subclavian sheath for venous access. Accordingly, the right subclavian vein was punctured and the ICD lead was diverted from the right side area to the active Can in the left pectoral area by tunneling over the sternum for high defibrillation threshold. The approach used in this case may be considered in patients who had difficult left subclavicular venous access and it may be prudent to save the left subclavian vein for ICD implantation in patients with fatal tachyarrhythmia.     

Repeated fracture of pacemaker leads with migration into the pulmonary circulation and temporary pacemaker wire insertion via the azygous vein

Repeated implantation of pacemaker in the same patient is a common occurrence because of the increased longevity of patients. However, repeated lead fracture in the same patient and migration of the pacemaker lead into the pulmonary circulation is rare. We describe a 56-year- old gentleman who had undergone pacemaker implantations thrice due to repeated lead fractures (thrice) and also had migration of the pacemaker lead into the pulmonary circulation. He also had an azygous vein which was noticed while placing the temporary pacemaker wire.     

Skeletal concentrations of lead in ancient Peruvians.

The level of biologic lead (expressed as the ratio of atomic lead to atomic calcium) in bones of Peruvians buried 1600 years ago was found to be 3 x 10(-8), as compared to 2100 to 3500 x 10(-8) in the bones of present-day residents of England and the United States. The ratio of barium to calcium was 2 to 3 x 10(-6) in bones of ancient Peruvians and present-day Americans. Barium and lead have similar morphologic distributions in organisms, so this discrepancy for lead must result from overexposure of present-day people to industrial lead and not from natural variations. The magnitude of this discrepancy has been confirmed by two different lines of investigation not reported in this article. This new evidence suggests that natural interactions of lead in human cells have not yet been determined because reagents, nutrients and controls used in laboratory and field studies have been contaminated with lead far in excess of naturally occurring levels.     

Hepatoportal arteriovenous fistula: morphologic features studied after orthotopic liver transplantation

A 51-year-old woman underwent orthotopic liver transplantation because of a small-duct primary sclerosing cholangitis associated with chronic ulcerative colitis and a hepatoportal arteriovenous fistula. Arteriograms before liver transplantation and specimen arteriograms revealed a convolution of arteries in the right hepatic lobe which communicated with a massively dilated and partly thrombosed portal vein branch. The lesion was probably the result of a previous liver biopsy. Microscopic examination of the fistula and of specimens taken at a distance from the fistula showed prominent intimal fibroplasia of portal vein branches. The vascular changes were so severe that hepatic artery and portal vein branches closely resembled each other on routine sections. We are unaware of such a finding in other conditions and therefore believe that recognition of the described vascular abnormalities in liver biopsy specimens should lead pathologists to comment that an arterioportal fistula might be present.     

预制减压型静脉动脉化皮瓣的临床应用

目的　探讨应用调节皮瓣载荷理论对静脉动脉化皮瓣进行预制减压处理的临床应用效果。 方法　2016 年1月至2017年5月,对临床上24例手指皮肤软组织缺损患者应用预制减压型静脉动脉化皮瓣,皮瓣切取面积最大6.0 cm × 4.0 cm,最小2.0 cm×2.0 cm,术后应用激光闪斑多普勒血流成像仪在不同时间段测量皮瓣血流灌注量,观察皮瓣成活质量及修复效果。 结果　术后24例静脉动脉化皮瓣全部成活,其中1例皮瓣远端出现水疱及皮下瘀血,其余23例皮瓣均无明显水疱形成,无明显肿胀,皮瓣血流灌注量观测发现术后72 h稳定并趋近于生理灌注水平。经过3~24个月随访,发现皮瓣外观满意,质地良好,成活质量好。 结论　预制减压型静脉动脉化皮瓣在静脉回流不充分的情况下,可调节皮瓣的灌注量与回流量达到平衡,进而提高皮瓣成活质量,达到精细修复手部皮肤缺损创面的要求,值得临床推广。     

Fallot's tetralogy presenting with variceal bleed

The erythrocytosis of Fallot's tetralogy may lead to spontaneous thrombosis at any site, but splenic vein thrombosis and variceal bleed is rarely a presentation of Fallot's tetralogy. A case of a 48 years old female with undiagnosed Fallot's tetralogy, presenting with variceal bleed due to splenic vein thrombosis, is reported. It is also interesting to note that the patient survived till this age without any medical or surgical treatment.     

Life without the vein of Galen: Clinical and radiographic sequelae

A thorough understanding of the anatomy of the pineal region, particularly venous drainage, is critical for gaining open surgical access to the pineal gland. The adverse sequelae after intraoperative venous occlusion are assumed to be catastrophic but have been scarcely reported. We report a case of pineocytoma in which the vein of Galen was ligated without postoperative adverse sequelae. Pineal region anatomy with emphasis on deep veins was reviewed in large anatomical studies. There are tremendous anatomical variations in the vein of Galen and its tributaries. Several confounding factors can be encountered during surgery and may lead to accidental sacrifice of the vein of Galen. Survival after focal occlusion of a major deep vein depends on the development of collateral circulation as shown in our case report. Venous drainage remains the cornerstone in the surgical planning of the pineal region. Anatomical variations and venous collaterals undoubtedly contributed to the mixed reports of adverse sequelae after venous sacrifice. Vein of Galen ligation may be survivable but consequences cannot be predicted without a thorough pre-ligation assessment of regional venous collateral drainage. Thorough understanding of the venous anatomy, meticulous planning of the surgical approach and avoidance of the occlusion of the vein of Galen and its major tributaries are key factors to successful pineal region surgery.     

A case of double inferior vena cava with renal,ovarian and iliac vein variation

We encountered a rare case of an anatomic variant of inferior vena cava (IVC) duplication with renal, ovarian and iliac vein variation in an 81-year-old Japanese female cadaver during a student dissection course of anatomy at Aichi Gakuin University School of Dentistry. The two IVCs ran upwards bilaterally to the abdominal aorta. The left IVC joined with the left renal vein (RV) to form a common trunk that crossed anterior to the aorta and ended at the right IVC. We detected a vein [interiliac vein (IiV)] connecting the two IVCs at the level of the aortic bifurcation. The IiV was formed by the union of two tributaries from the left IVC and a tributary from the left internal iliac vein (IIV) and ran obliquely upwards from left to right. Two right ovarian veins, arising separately from the ipsilateral pampiniform plexus, ran vertically in parallel to each other, and each one independently terminated at the right IVC and the right RV. Two right IIVs, connecting each other with small branches, ascended and separately joined the right external iliac vein. The right and left IIVs were connected to each other. These variations cause abnormal drainage, which could lead to clinical symptoms associated with the dysfunction of the vascular and urogenital systems. Here we describe the detailed anatomical features of the area and discuss the related anatomical and developmental aspects.     

Microvascularization of thalamus and metathalamus in common tree shrew (Tupaia glis)

The microangioarchitecture of the thalamus and metathalamus in common tree shrew (Tupaia glis) was studied using vascular corrosion cast/stereomicroscope and SEM technique. The arterial supply of the thalamus and metathalamus was found to originate from perforating branches of the posterior communicating artery, the posterior cerebral artery, the middle cerebral artery, and the anterior choroidal artery. These perforating arteries gave rise to numerous bipinnate arterioles which in turn, with decreasing vessel diameters, branched into a non-fenestrated capillary bed. Venous blood from the superficial parts of the thalamus and metathalamus was collected into the thalamocollicular vein, whereas venous blood from internal aspects of the thalamus was conveyed to the internal cerebral vein. Some venous blood from the most rostral part of the thalamus flowed into tributaries of the middle cerebral vein before draining into the cavernous sinus. Further, the thalamic and metathalamic vascular arrangement was found to be of centripetal type. In addition, thalamic arterial anastomosis was rarely observed. Thus, obstruction of thalamic blood supply could easily lead to thalamic infraction.     

Pacemaker lead endocarditis caused by Achromobacter xylosoxidans

We report the case of a 35-yr-old patient who presented with high fever and chills. He had undergone a patch closure of the ventricular septal defect 18 yr before. One year later, a VVI pacemaker was implanted via the right subclavian vein because of complete heart block. Nine years after that, a new VVI pacemaker with another right ventricular electrode was inserted controlaterally and the old pacing lead was abandoned. Trans-thoracic and trans-esophageal echocardiogram identified the pacemaker lead in the right ventricle (RV) attaching hyperechoic materials and also a fluttering round hyperechoic mass with a stalk in the RV outflow tract. Cultures in blood and pus from pacemaker lead grew Achromobacter xylosoxidans. A diagnosis of pacemaker lead endocarditis due to Achromobacter xylosoxidans was made. In this regards, the best treatment is an immediate removal of the entire pacing system and antimicrobial therapy.     

Left phrenic nerve anatomy relative to the coronary venous system: Implications for phrenic nerve stimulation during cardiac resynchronization therapy

The objective of this study was to quantitatively characterize anatomy of the human phrenic nerve in relation to the coronary venous system, to reduce undesired phrenic nerve stimulation during left‐sided lead implantations. We obtained CT scans while injecting contrast into coronary veins of 15 perfusion‐fixed human heart‐lung blocs. A radiopaque wire was glued to the phrenic nerve under CT, then we created three‐dimensional models of anatomy and measured anatomical parameters. The left phrenic nerve typically coursed over the basal region of the anterior interventricular vein, mid region of left marginal veins, and apical region of inferior and middle cardiac veins. There was large variation associated with the average angle between nerve and veins. Average angle across all coronary sinus tributaries was fairly consistent (101.3°–111.1°). The phrenic nerve coursed closest to the middle cardiac vein and left marginal veins. The phrenic nerve overlapped a left marginal vein in >50% of specimens. Clin. Anat. 28:621–626, 2015. © 2015 Wiley Periodicals, Inc.     

实验性精索青岛脉曲张对生精上皮细胞间连接的影响

Experimental varicoceles were created in adult male Wistar rats by partially occluding the left renal vein. The affect of the varicocele on ipsilateral testis was studied at intervals over 15 weeks via ultrathin sections and freeze-etching replica technique examined under electron microscope. Observations showed that varicocele resulted in injuries of Sertoli-Sertoli cell and Sertoli cell-spermatid junctional complexes. Abnormal changes of Sertoli cell-spermatid junctional complexes might lead to spermiogenic arrest and spermatids slough, while those of Sertoli-Sertoli cell junctional complexes to dysfunction of barrier and abnormal alteration of microenvironment of seminiferous tubule. Probably, this is one of the reasons that the fertility was not improved in some patients even after high level ligation of the internal spermatic vein.     

Adrenal gland hypertrophy in a case of homolateral renal agenesis: case report with special emphasis on adrenal blood supply

Hypertrophic suprarenal gland is an anomaly which can lead to serious complications during adrenalectomy under endoscopy because of abnormal veins of the retroperitoneum. The authors report a rare dissection of a male which presented with this anomaly in a case of homolateral renal agenesis, highlighting this left pseudorenal vein. No abnormality of the genital tract was found. The anatomic features, associated syndromes, implications for endoscopic surgery are outlined and embryologic considerations and discussed.     

数控止血带三种捆扎法对浅静脉的影响及临床效果*

目的：探讨临床中静脉穿刺时止血带的使用最佳方式,达到浅静脉血管最佳充盈度,提高静脉穿刺成功率。 方法：以门诊手术室行非气管插管静脉全麻下无痛手术的成年女性患者为研究对象,选择患者左上肢肘正中静 脉,分别采用3 种止血带捆扎法（ 单根、上双根、上下双根）,使用超声技术分别测量不同捆扎方式下的血管内径、 横截面积、血液流速,记录扎止血带后患者皮肤青紫和手臂麻木开始出现的时间,并进行比较。结果：静脉血管 横截面积比较上双根> 上、下双根> 单根;血管内径比较上双根> 上、下双根= 单根;皮肤青紫、麻木开始出现 的时间比较上双根< 单根< 上下双根,上述差异均有统计学意义。结论：采用上双止血带捆扎法时,血管内径和 面积均为最大,且能够双重阻断静脉回流,静脉血管充盈度最佳。因此,理论上此种捆扎方式最有利于静脉穿刺, 能够提高穿刺成功率。     

The fine structure of the arteriovenous anastomosis and its nerve supply in the human nasal respiratory mucosa

The fine structure of the arteriovenous anastomosis was investigated in the normal human nasal mucosa. The tissues were fixed in 2% osmic acid solution, embedded in Epon and stained with uranyl acetate and lead citrate solutions. It was found that the endothelial basement membrane of the arterial segment of the anastomosis was discontinuous. The anastomosing artery possessed subendothelial cushions of longitudinal smooth musculature which expanded into a thick uniform layer before the artery joined the vein. The fine morphology of these muscle cells did not show epitheloid modification. An elastic membrane of a peculiar structure separated the subendothelial musculature from that of the tunica media. The membrane was continuous with the internal elastic membrane of the proximal artery and with the adventitial elastic mesh of the vein. The anastomosis was supplied by a non-myelinated periarterial nerve plexus which contained cholinergic and adrenergic axons characterized by agranular and fine granular vesicles respectively. The wall of the vein was devoid of musculature and nerves. It mainly consisted of elastic meshes interspersed with bundles of collagen fibers and occasional fibrocytes. It was suggested that the musculature of the tunica media of the artery was controlled by the cholinergic and adrenergic nerves of the autonomic system, and by the sensory nerves in the form of axons reflexes. The subendothelial musculature was controlled by agents carried in blood and was not influenced by the adventitial nerves.