PURPOSE: To assess the usefulness of the ultrasound-guided subclavian vein catheterization in difficult patients. MATERIALS AND METHODS: We tried subclavian vein catheterization in 18 patients in which conventional blind technique failed(N=9) :or was complicated by hemothorax or pneumothorax(N=3) :or was prohibited by respirator care(N=4) and severe thoracic deformity(N=2). Initially, the patency of subclavian vein was evaluated with ultrasonography, and then, the puncture of the subclavian vein was performed under the guidance of ultrasonography. Under the fluoroscopy, the patency of the proximal subclavian vein and the superior vena cava was evaluated after contrast-media injection and a catheter was inserted into the subclavian vein and accurately positioned at the superior vena cava. RESULTS: Successful catheterization was performed in 17 patients. In the remaining one patient, we did not perform catheterization because of bilateral subclavian vein thrombosis detected during the procedure. There were no procedure-related complications. CONCLUSION: Ultrasound-guided subclavian vein catheterization is an easy and safe method even in difficult cases.
Catheterization* ; Catheters* ; Fluoroscopy ; Hemothorax ; Humans ; Punctures ; Subclavian Vein* ; Thrombosis ; Ultrasonography ; Vena Cava, Superior ; Ventilators, Mechanical

PURPOSE: We postulated that the success rate for subclavian venous catheterization could be enhanced by improving body positioning. The purpose of this study was to determine the optimal positioning. The ideal position should result in the largest antero-posterior diameter of the subclavian vein and the shortest depth from the skin to the subclavian vein. METHODS: We used 7.5MHz linear probe. Eighteen adult volunteers underwent ultrasound imaging of the right subclavian vein while supine in the following eight positions: NP/PO/AT, NP/PO/AN, NP/PX/AT, NP/PX/AN, LP/PO/AT, LP/PO/AN, LP/PX/AT, LP/PX//AN (neutral head position, NP; head turned to left, LP; on pillow, PO; off pillow, PX; arm traction, AT; neutral arm position, AN). We checked the antero-posterior diameter of the subclavian vein and the depth from skin to the subclavian vein in each position. Statistical significance was determined using Wilcoxon's signed rank test. RESULTS: The antero-posterior diameter of the subclavian vein in NP/PX/AN position is largest and in LP/PO/AN position is smallest (p=0.01). The difference of the depths from skin to the subclavian vein in each positions is not significant statistically. CONCLUSION: There was no statistically significant effect of head position on the antero-posterior diameter of the subclavian vein or on the depth from the skin to subclavian vein. Arm traction did not result in an increase in the anteroposterior diameter. Positioning on the pillow likewise conferred no advantage in the antero-posterior diameter. The most optimal position for subclavian venous catheterization was the neutral head position without pillow between the scapulas and without the arm retracted position.
Adult ; Arm ; Catheterization* ; Catheterization, Central Venous ; Catheters* ; Head ; Humans ; Scapula ; Skin ; Subclavian Vein ; Traction ; Ultrasonography ; Volunteers

Central venous catheterization is common in the emergency department for monitoring of CVP (central venous pressure), fluid administration, and drug infusions. However, the insertion of a central venous catheter is a technically challenging procedure with known risks and complications. A 94-year-old woman was transferred to an emergency department due to difficulties in removing the guidewire during central catheter insertion through the right subclavian vein. A focused bedside ultrasound showed that the guidewire was improperly positioned in the right internal jugular vein. Upon computed tomographic evaluation, the guidewire perforated the right subclavian vein, looped in the mediastinum, reentered the right internal jugular vein toward the right jugular foramen, and was removed by surgery. In conclusion, as catheter and guidewire entrapment are well-known potential complications of central venous catheterization, when resistance is encountered at any stage of central venous catheterization (especially when removing the entrapped catheter or guidewire) the procedure should be stopped and evaluated with imaging assistance. Clinicians should be aware of more complicated sequelae caused by blunt removal of an entrapped catheter and guidewire, despite its low probability.
Catheterization ; Catheterization, Central Venous* ; Catheters ; Central Venous Catheters* ; Emergencies ; Female ; Humans ; Jugular Veins ; Mediastinum ; Patient Harm ; Subclavian Vein ; Ultrasonography

Paget-Schroetter syndrome is synonymous with spontaneous or effort-induced thrombosis of the axillosubclavian vein that is characterized by swelling and pain on upper extremity. Though axillosubclavian thrombosis represents only 1 - 2%, its frequency of diagnosis has increased over the past years due to improvement of ultrasonography. Although the cause of catheter and drug-related cases is clear, several studies have invested the etiology of Paget- Schroetter syndrome, a condition more commonly seen in the young and otherwise healthy individual. Factors often cited include compression of the vein by the anatomic structure, stress, or excessive effort to the extremity, and repetitive shoulder-arm motion. In the view of treatment, thrombolysis by direct infusion of urokinase has proven to be superior to surgical thrombectomy and is now treatment of choice. We successfully treated a 30-year-old man who suffered from swelling and pain on the right upper extremity by using direct urokinase infusion on thrombosis of subclavian vein. This is very rare disease in plastic and reconstructive surgery, thus diagnosis will seldom be made on clinical evaluation. It should be included in the differential diagnosis of upper extremity swelling compared with lymphedema.
Adult ; Catheters ; Diagnosis ; Diagnosis, Differential ; Extremities ; Humans ; Lymphedema ; Plastics ; Rare Diseases ; Subclavian Vein ; Thrombectomy ; Thrombosis ; Ultrasonography ; Upper Extremity ; Upper Extremity Deep Vein Thrombosis ; Urokinase-Type Plasminogen Activator ; Veins

We experienced a case of deep vein thrombosis after spine surgery in the prone position with a central venous catheter (CVC). Posterior lumbar interbody fusion was performed on a 73-year-old female patient who was diagnosed with spinal stenosis. Accordingly, in the operation room under general anesthesia, two-lumen CVC were inserted into the left subclavian vein. The surgery was performed in the prone position with a Wilson frame. On the next day, there was a sudden occurrence of severe edema in the patient's left arm. By ultrasonography and computed tomography scanning, extensive deep vein thrombosis was observed in the left subclavian vein. The existence of a factor affecting blood flow such as the prone position may increase the risk of thrombus formation. Therefore, careful perioperative evaluation should be implemented.
Aged ; Anesthesia, General ; Arm ; Catheterization* ; Catheters* ; Central Venous Catheters ; Edema ; Female ; Humans ; Prone Position* ; Spinal Stenosis ; Spine* ; Subclavian Vein ; Thrombosis ; Ultrasonography ; Upper Extremity Deep Vein Thrombosis ; Venous Thrombosis*

BACKGROUNDS: The internal mammary artery graft (IMAG) showed a gradual transition in the phasic flow pattern from predominant systolic velocity proximally at the origin from the subclavian artery to the predominant diastolic velocity distal to the anastomosis with coronary artery. IMAG without significant stenosis showed a typical pulsed Doppler flow pattern similar to that of coronary artery characterized by a predominant diastolic component. On the other hand, patients with occluded IMAGs or IMAGs with severe stenosis, low velocity profiles were recorded during diastole with an increase in the systolic component. OBJECTIVES: Identifying abnormal graft flow intraoperatively could allow for immediate graft revision. The aim of this study was to test the feasibility of using a new ultrasound 15 MHz linear array transducer. METHODS: In six patients (M:F=4:2, mean age=69+/-11 yrs), a 15 MHz linear array probe with a sterile cover was placed directly on native coronary arteries and grafts after anatomosis. 2-dimensional image, color and pulsed Doppler signals of native coronary arteries, IMA, saphenous vein and penetrating intramyocardial coronary arteries (PICA) were observed. RESULTS: 1) 2-dimensional image and color flow signals of all grafts and native coronary arteries were visualized. 2) The flow pattern of pulsed Doppler signals of all native coronary arteries including PICA were diastolic dominant. 3) The diastolic dominant pattern typical of a patent grafts on pulsed Doppler were obtained at anastomosis site of graft vessels. 4) The intimal thickening of right coronary artery was also visualized on 2-dimensional images. CONCLUSION: A new echo Doppler probe can be useful for intraoperative assessment of graft flow during bypass surgery.
Blood Flow Velocity ; Constriction, Pathologic ; Coronary Artery Bypass ; Coronary Vessels* ; Diastole ; Echocardiography ; Hand ; Humans ; Mammary Arteries ; Monitoring, Intraoperative ; Pica ; Saphenous Vein ; Subclavian Artery ; Transducers* ; Transplants* ; Ultrasonography

BACKGROUND: The purpose of this retrospective and prospective study is to evaluate the efficiency of ultrasound (US) guidance as a method of decreasing the malposition rate of central venous catheterization (CVC) in the emergency department (ED). METHODS: We retrospectively enrolled 379 patients who underwent landmark-guided CVC (Group A) and prospectively enrolled 411 patients who underwent US-guided CVC (Group B) in the ED of a tertiary hospital. Malposition of the CVC tip is identified when the tip is not located in the superior vena cava (SVC). In Group B, we performed US-guided intravascular guide-wire repositioning and then confirmed the location of the CVC tip with chest radiography when the guide-wire was visible in any three other vessels rather than in the approached vessel. In the case of a guide-wire inserted into the right subclavian vein (SCV), the left SCV and both internal jugular veins (IJV) were referred to as the three other vessels. The two subject groups were compared in terms of the malposition rate using Fisher's exact test (significance = p < 0.05). RESULTS: There were 38 malposition cases out of a total of 790 CVCs. The malposition rates of Groups A and B were 5.5% (21) and 4.1% (17), respectively, and no statistically significant difference in malposition rate between the two groups was found. In Group B, the malposition rate was decreased from 4.1% (17) to 1.2% (5) after the guide-wire was repositioned with US guidance, which led to a statistically significant difference in malposition rate (p < 0.01). CONCLUSIONS: The authors concluded that repositioning the guide-wire with US guidance increased correct placement of central venous catheters toward the SVC.
Catheterization, Central Venous* ; Central Venous Catheters* ; Emergencies ; Humans ; Jugular Veins ; Prospective Studies ; Radiography ; Retrospective Studies ; Subclavian Vein ; Tertiary Care Centers ; Thorax ; Ultrasonography ; Vena Cava, Superior

OBJECTIVE: To evaluate the technical feasibility of intranodal lymphangiography and thoracic duct (TD) access in a canine model.MATERIALS AND METHODS: Five male mongrel dogs were studied. The dog was placed in the supine position, and the most prominent lymph node in the groin was accessed using a 26-gauge spinal needle under ultrasonography (US) guidance. If the cisterna chyli (CC) was not opacified by bilateral lymphangiography, the medial iliac lymph nodes were directly punctured and Lipiodol was injected. After opacification, the CC was directly punctured with a 22-gauge needle. A 0.018-in microguidewire was advanced through the CC and TD. A 4-Fr introducer and dilator were then advanced over the wire. The microguidewire was changed to a 0.035-in guidewire, and this was advanced into the left subclavian vein through the terminal valve of the TD. Retrograde TD access was performed using a snare kit.RESULTS: US-guided lymphangiography (including intranodal injection of Lipiodol [Guerbet]) was successful in all five dogs. However, in three of the five dogs (60%), the medial iliac lymph nodes were not fully opacified due to overt Lipiodol extravasation at the initial injection site. In these dogs, contralateral superficial inguinal intranodal injection was performed. However, two of these three dogs subsequently underwent direct medial iliac lymph node puncture under fluoroscopy guidance to deliver additional Lipiodol into the lymphatic system. Transabdominal CC puncture and cannulation with a 4-Fr introducer was successful in all five dogs. Transvenous retrograde catheterization of the TD (performed using a snare kit) was also successful in all five dogs.CONCLUSION: A canine model may be appropriate for intranodal lymphangiography and TD access. Most lymphatic intervention techniques can be performed in a canine using the same instruments that are employed in a clinical setting.
Animals ; Catheterization ; Catheters ; Dogs ; Ethiodized Oil ; Fluoroscopy ; Groin ; Humans ; Lymph Nodes ; Lymphatic System ; Lymphography ; Male ; Needles ; Punctures ; SNARE Proteins ; Subclavian Vein ; Supine Position ; Thoracic Duct ; Ultrasonography

OBJECTIVE: To assess whether ultrasonographic examination compared to chest radiography (CXR) is effective for evaluating complications after central venous catheterization. METHODS: We performed a prospective observational study. Immediately after central venous catheter insertion, we asked the radiologic department to perform a portable CXR scan. A junior and senior medical resident each performed ultrasonographic evaluation of the position of the catheter tip and complications such as pneumothorax and pleural effusion (hemothorax). We estimated the time required for ultrasound (US) and CXR. RESULTS: Compared to CXR, US could equivalently identify the catheter tip in the internal jugular or subclavian veins (P=1.000). Compared with CXR, US examinations conducted by junior residents could equivalently evaluate pneumothorax (P=1.000), while US examinations conducted by senior residents could also equivalently evaluate pneumothorax (P=0.557) and pleural effusion (P=0.337). The required time for US was shorter than that for CXR (P < 0.001). CONCLUSION: Compared to CXR, US could equivalently and more quickly identify complications such as pneumothorax or pleural effusion.
Catheterization, Central Venous* ; Catheters* ; Central Venous Catheters* ; Diagnostic Imaging ; Observational Study ; Pleural Effusion ; Pneumothorax ; Prospective Studies ; Radiography ; Subclavian Vein ; Thorax ; Ultrasonography*

OBJECTIVE: The purpose of this study was to evaluate the fistulographic features of malfunctioning axillary loop-configured arteriovenous grafts and the efficacy of percutaneous interventions in failed axillary loop-configured arteriovenous grafts. MATERIALS AND METHODS: Ten patients with axillary loop-configured arteriovenous grafts were referred for evaluation of graft patency or upper arm swelling. Fistulography and percutaneous intervention, including thrombolysis, percutaneous transluminal angioplasty and stent placement, were performed. Statistical analysis of the procedure success rate and the primary and secondary patency rates was done. RESULTS: Four patients had graft related and subclavian venous stenosis, two patients had graft related stenosis and another four patients had subclavian venous stenosis only. Sixteen sessions of interventional procedures were performed in eight patients (average: 2 sessions / patient) until the end of follow-up. An interventional procedure was not done in two patients with central venous stenosis. The overall procedure success rate was 69% (11 of 16 sessions). The post-intervention primary and secondary patency rates were 50% and 63% at three months, 38% and 63% at six months and 25% and 63% at one year, respectively. CONCLUSION: Dysfunctional axillary loop-configured arteriovenous grafts almost always had subclavian venous and graft-related stenosis. Interventional treatments are helpful to overcome this and these treatments are expected to play a major role in restoring and maintaining the axillary loop-configured arteriovenous loop grafts.
Adult ; Aged ; Angioplasty, Balloon/*methods ; Arteriovenous Shunt, Surgical/*methods ; Blood Vessel Prosthesis Implantation/*methods ; Chronic Disease ; Constriction, Pathologic/therapy/ultrasonography ; Female ; Follow-Up Studies ; Graft Occlusion, Vascular/*therapy/ultrasonography ; Humans ; Kidney Failure, Chronic/*complications/therapy ; Male ; Middle Aged ; *Renal Dialysis ; Subclavian Vein/ultrasonography ; Survival Analysis ; Treatment Outcome ; Vascular Patency