BACKGROUND: Internal jugular vein access is an essential part of patient management in many clinical settings and is usually achieved with a blind, anatomical landmark-guided technique. The purpose of this study is to evaluate whether a 2-dimensional ultrasound technique can improve on the traditional method. METHODS: Eighty patients undergoing elective open heart surgery were randomly assigned to an anatomical landmark group or ultrasound group (each n = 40). With the patient in the supine position, the head was rotated 30o to the contralateral side and triangle formed by the clavicle and both heads of the sternocleidomastoid muscle were identified. We accessed the internal jugular vein from the apex of the triangle toward the ipsilateral nipple in the anatomical landmark group. The internal jugular vein and carotid artery were visualized with two-dimensional ultrasound. We compared the number of advances made with the central venous cannulation needle, the time to blood aspiration, complications and failure rate. RESULTS: The failure rate was 22.5% using the anatomical landmark technique and 5% using the ultrasound technique. The vein was entered on the first attempt in 60% of patients using the landmark technique and in 63% using ultrasound (P>0.05). Mean attempts for puncture were 1.9 (anatomical) vs 1.6 (ultrasound-guided) (P>0.05). Complications occurred in 20% of cases using anatomical landmarks and in 5% using ultrasound (P>0.05). The average access time was 26.5 seconds by the anatomical approach and 56 seconds by the ultrasound approach (P< 0.05). CONCLUSIONS: Ultrasound-guided cannulation of the internal jugular vein did not significantly decrease failure rate, access time, complications, and attempts for puncture, nor did it increase the amount of successful first attempts. However an investigation using a larger number of patients will be needed.
Carotid Arteries ; Catheterization* ; Clavicle ; Head ; Humans ; Jugular Veins* ; Needles ; Nipples ; Punctures ; Supine Position ; Thoracic Surgery ; Ultrasonography ; Veins

BACKGROUND: This study evaluated the position and relationship between the right internal jugular vein (IJV) and the surrounding external landmarks using ultrasonography. METHODS: Fifty-four patients undergoing central vein access for cardiac surgery were enrolled in this study. The IJV, carotid artery (CA) and sternocleidomastoid muscle (SCM) at the cricoid cartilage level in 15o trendelenburg position with 30o head rotation were examined using a two dimensional ultrasound transducer of a TEE machine. Images of the vessels and the demographic data of the patients were recorded and analysed. RESULTS: At the level of the cricoid cartilage, the position of the right IJV was medial to middle of the clavicular head of the SCM muscle in 26 cases (48.2%), lateral in 11 cases (20.4%) and just above the middle of clavicular head of the SCM muscle in 17 cases (31.5%). In 43 patients (79.6%), the IJV overlapped the CA anterolaterlly < 5 mm, and these cases were regarded as normal. Ten patients (18.5%) had a medially positioned IJV overlapping the CA more than 5 mm and the IJV was positioned lateral to CA in 1 (2%) patient. The mean ratio of the overlapped diameter and the diameter of the CA was 33.6% and the overlapping ratios were greater than 50% in 10 patients (31.4%). The mean skin-to-vein distance at the angle of 30degrees was 1.82 cm. CONCLUSIONS: In 18.5% of patients positioned in the 15o Trendelenburg position, with their head turned to the left 30degrees, the IJV overlapped the CA medially more than 5 mm, which increased the risk of a carotid puncture using the blind technique.
Carotid Arteries* ; Catheterization ; Cricoid Cartilage ; Head* ; Head-Down Tilt* ; Humans ; Jugular Veins* ; Prospective Studies* ; Punctures ; Thoracic Surgery ; Transducers ; Ultrasonography ; Veins

A 17-yr-old young woman was referred to our hospital with a 2-yr history of claudication of the lower extremities and severe arterial hypertension. Physical examination revealed significantly different blood pressures between both arms (160/92 and 180/95 mmHg) and legs (92/61 and 82/57 mmHg). The hematological and biochemical values were within their normal ranges, except for the increased erythrocyte sedimentation rate (83 mm/hr) and C-reactive protein (6.19 mg/L). On 3- dimensional computed tomographic angiography, the ascending aorta, the aortic arch and its branches, and the thoracic and, descending aorta, but not the renal artery, were shown to be stenotic. The diagnosis of type IIb Takayasu's arteritis was made according to the new angiographic classification of Takayasu's arteritis, Takyasu conference 1994. Percutaneous transluminal angioplasty with stenting was performed on the thoracic and abdominal aorta. After the interventional procedures, the upper extremity blood pressure improved from 162/101 mmHg to 132/85 mmHg, respectively. She has been free of claudication and there have been no cardiac events during 2-yr of clinical follow-up.
Adolescent ; Angiography ; *Angioplasty, Balloon ; Aorta, Abdominal/radiography ; *Aorta, Thoracic/radiography ; Carotid Arteries/ultrasonography ; Female ; Humans ; *Stents ; Takayasu Arteritis/radiography/*therapy/ultrasonography ; Tomography, X-Ray Computed

Anatomical variations of carotid arteries may be related to their development (agenesis, aplasia, hypoplasia) or course (coiling, kinking, tortuosity). Partial or total aberrancies in carotid vessel anatomy rarely occur. We describe the case of a 95-year-old woman presented with sudden onset of confusion and disorientation together with upper limb clonus. Computed tomography (CT)-scan revealed a left frontal brain injury with a not conclusive carotid doppler ultrasound. CT angiography reported a bovine aortic arch with bilateral retroesophageal course of both common carotid arteries and left severe (>70%) internal carotid artery stenosis. The knowledge of anatomical variations of the course of carotid arteries is relevant for possible surgical or endovascular repair or in case of otolaryngology or intubation procedures.
Angiography ; Aorta, Thoracic* ; Brain Injuries ; Cardiovascular Abnormalities ; Carotid Arteries ; Carotid Artery, Common* ; Carotid Stenosis ; Female ; Humans ; Intubation ; Otolaryngology ; Ultrasonography ; Upper Extremity

OBJECTIVES: Early diagnosis of intrauterine growth retardation is important to ensure optimal monitoring and delivery with the introduction of real-time and Doppler ultrasound systems, a noninvasive method of measuring human fetal blood flow has become available. The aim of this study is to compare blood flow velocity waveforms at the fetal descending aorta and umbilical artery in normal and in patients with pregnancy induced hypertension. METHODS: Using a combination of linear array real-time and pulsed Doppler ultrasound, blood flow velocity measurements were carried out at the fetal descending aorta and umbilical artery in 35 normal pregnancies and 18 cases of pregnancy induced hypertensive patients. RESULTS: The mean systolic/diastolic ratio of umbilical artery and aorta was significantly higher in PIH patients than in normal pregnancies(3.8 +/- 0.81 versus 2.97 +/- 0.52, p<0.05) and to predict perinatal morbidity, umbilical velocimetry is more sensitive than that of descending thoracic aorta. CONCLUSION: This study suggests that umbilical artery velocimetry could be used as a marker to predict adverse perinatal outcome.
Aorta ; Aorta, Thoracic* ; Blood Flow Velocity ; Early Diagnosis ; Female ; Fetal Blood ; Fetal Growth Retardation ; Humans ; Hypertension, Pregnancy-Induced ; Pregnancy ; Rheology* ; Ultrasonography ; Umbilical Arteries

A 56-year old female underwent total aortic arch replacement March 1995, because of an expanding chronic Debakey type I aortic dissection. This aortic dissection had an intimal tear at the origin of the right carotid artery. Retrograde and antegrade propagation of dissection resulted in aortic arch blood flow separation and expanding pseudolumen to the abdominal aorta. Sudden anuria (ARF) developed 3 hours later postoperatively and renal doppler ultrasonography and aortography showed diminished blood flow of renal arteries. We performed balloon aortic dilatation but failed. She could be restored good renal flow after intimal flap fenestration resection and thrombectomy of the abdominal aorta. This patient could be discharged in a state of mild CRF after 2 months of ICU care for respiratory and renal failure.
Acute Kidney Injury* ; Anuria ; Aorta, Abdominal ; Aorta, Thoracic* ; Aortography ; Carotid Arteries ; Dilatation ; Female ; Humans ; Middle Aged ; Renal Artery ; Renal Insufficiency ; Thrombectomy ; Ultrasonography, Doppler

BACKGROUND: Carotid atherosclerosis and aortic at herosclerosis are both a predictor of atherosclertic cardiovascular diseases. However, the relationship between carotid and aortic atherosclerosis is not well known. METHODS: We performed B-mode ultrasound examinations of the carotid arteries in 38 consecutive elderly cases(13 men, mean age 69+/-3 years and 25 women, mean age 69+/-5 years) who underwent transesophageal echocardiography, to assess whether atherosclerosis in the carotid artery correlates with thoracic aortic atherosclerosis or may be a marker for it. RESULTS: The incidence of carotid and thoracic aortic atherosclerotic plaques were 44.7% and 50%, respectively. There was a significant relationship between carotid atherosclerosis and thoracic aortic atherosclerosis(r=0.532, p<0.01), and a increase in the extent of aortic atherosclerosis with increasing grades of carotid atherosclerosis. In the entire study cases, the presence of carotid atherosclerosis had a sensitivity 63.2%, specificity 73.7%, positive value 72.6% and negative predictive value 66.7% in detec-ting thoracic aortic atherosclerosis. CONCLUSION: In the Korean elderly, B-mode ultra sound examination of the carotid arteries is a easy and useful technique for the prediction of the presence and severity of thoracic atherosclerosis.
Aged* ; Aorta ; Aorta, Thoracic* ; Atherosclerosis* ; Cardiovascular Diseases ; Carotid Arteries ; Carotid Artery Diseases* ; Echocardiography, Transesophageal ; Female ; Humans ; Incidence ; Male ; Plaque, Atherosclerotic ; Sensitivity and Specificity ; Ultrasonics ; Ultrasonography

PURPOSE: This study was designed to determine the frequency and echocardiographic findings of 22q11.2 deletions in fetuses with cardiac defects on fetal ultrasound or familial backgrounds of 22q11.2 deletions. MATERIALS AND METHODS: We retrospectively reviewed the medical and ultrasonographic records of 170 fetuses that underwent fluorescence in situ hybridization (FISH) analysis for chromosome 22q11.2 deletions between February 2001 and April 2013. RESULTS: Among 145 fetuses with cardiac defects, six (4.1%) had 22q11.2 deletions. Deletions of 22q11.2 were detected in 6 (5%) of the 120 fetuses with conotruncal defects: 5 (8.9%) of 56 with tetralogy of Fallot (TOF) and 1 (5.9%) of 17 with double outlet right ventricle (DORV). No deletions were found in cases of pulmonary atresia, truncus arteriosus, right aortic arch, or transposition of the great arteries. No 22q11.2 deletions were found in non-conotruncal cardiac malformations. Among 25 fetuses with familial backgrounds of 22q11.2 deletions, one (4%) had a maternally inherited 22q11.2 deletion with no cardiac findings. CONCLUSION: Knowledge of the frequency and echocardiographic findings of 22q11.2 deletions might be helpful for prenatal genetic counseling. It is advisable to perform FISH analysis for 22q11.2 deletions in pregnancies exhibiting conotruncal cardiac defects such as TOF or DORV.
Aorta, Thoracic ; Arteries ; Double Outlet Right Ventricle ; Echocardiography ; Fetus ; Fluorescence ; Genetic Counseling ; In Situ Hybridization ; Pregnancy ; Prenatal Diagnosis* ; Pulmonary Atresia ; Retrospective Studies ; Tetralogy of Fallot ; Truncus Arteriosus ; Ultrasonography

Congenital extrahepatic portocaval shunt (CEPS) is a rare anomaly of the mesenteric vasculature in which the intestinal and splenic venous drainage bypasses the liver and drains directly into the inferior vena cava, the left hepatic vein or the left renal vein. This uncommon disease is frequently associated with other malformations and mainly affects females. Here we report a case of pulmonary arterial hypertension associated with CEPS (Abernethy type 1b shunt) in a 20-yr-old man who was incidentally diagnosed during evaluation of multiple nodules of the liver. The patient was treated by inhalation of iloprost (40 microg/day) with improved condition and walking test. Physicians should note that congenital portocaval shunt may cause pulmonary hypertension.
Echocardiography, Doppler ; Humans ; Hypertension, Pulmonary/*diagnosis/drug therapy ; Iloprost/therapeutic use ; Liver/blood supply/radiography ; Magnetic Resonance Imaging ; Male ; Thoracic Arteries/ultrasonography ; Tomography, X-Ray Computed ; Vasodilator Agents/therapeutic use ; Vena Cava, Inferior/*abnormalities/ultrasonography ; Young Adult

Free TRAM flap is considered as the first choice of the breast reconstruction after mastectomy deformity. Complications such as partial flap loss and fat necrosis in reconstructed breasts are less common with free TRAM flap than conventional pedicled TRAM flap or deep inferior epigastric perforator flap(DIEP flap), because free TRAM flap has a robust blood supply by deep inferior epigastric artery. We evaluated the incidence, causes, diagnosis, and treatment of fat necrosis in reconstructed breast using free TRAM flap. A retrospective study was performed in all patients who had undergone free TRAM flap breast reconstruction between 1990 and 2002. Fat necrosis is a clinical diagnosis, usually made by physical examination alone. However we performed mammography and ultrasonography in all patients to rule out the recurrence of tumor, and get the objective and unbiased data. We performed needle biopsy for exclusion of cancer recurrence in selected cases. Of the 92 breasts reconstructed with free TRAM flap, 7 patients(7.6%) had clinically evident fat necrosis, and 2 patients(2.1%) had fat necrosis that was found only by mammography and ultrasonography. The size of fat necrosis in our study was various from 1.0 x 0.7 x 0.5 to 8 x 4 x 3 cm. The lesions of the fat necrosis were usually placed on superomedial and medial part of the reconstructed breast. In case of the fat necrosis, anchoring suture of flap which had been applied for the preservation of flap drooping and ptosis seemed to be related with the location. In addition, use of zone IV of TRAM flap would be associated the occurrence of fat necrosis. We suggest that fixation suture of flap, intraoperative injury of perforator vessel, extensive use of flap (including Zone IV), smoking and obesity, postoperative radiation therapy can be the causes of fat necrosis in the reconstructed breast with free TRAM flap. Fat necrosis is said to be relatively common in patients who were obese or had a history of smoking in literature, but it did not show any significant differences in our study. Five patients underwent excision during nipple-areolar complex reconstruction after 6 months of free TRAM flap breast reconstruction, and 4 patients did not undergo any treatment due to relatively small size. Hardness of fat necrosis became smaller in size, and softened with time. We conclude that the fat necrosis would be decreased if free TRAM flap breast reconstruction was performed with well organized design of flap, sensible assessment of perforators in the flap, careful use of zone IV in thin patient, and careful suture fixation of flap to chest wall.
Biopsy, Needle ; Breast* ; Congenital Abnormalities ; Diagnosis ; Epigastric Arteries ; Fat Necrosis* ; Female ; Hardness ; Humans ; Incidence ; Mammaplasty ; Mammography ; Mastectomy ; Obesity ; Physical Examination ; Recurrence ; Retrospective Studies ; Smoke ; Smoking ; Sutures ; Thoracic Wall ; Ultrasonography