Extended radical resection for bulky N2 small cell lung carcinoma
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Keywords:
Surgical oncology
Mediastinal lymph node
Azygos vein
Cardiothoracic surgery
Abstract We investigated the arterial supply to, and the venous drainage from, the caudal mediastinal lymph node (CMN) in 18 anesthetized and exsanguinated sheep. The purpose of this gross anatomic investigation was to determine the CMN's blood supply so that a structural base can be used to interpret studies of the bronchial circulation's role in the pathogenesis of pulmonary edema. In ten sheep, we cannulated the bronchoesophageal artery at its origin from the aorta and injected Microfil. This artery, which branches into cranial and caudal divisions 2–4 mm distal to its origin, supplied the esophagus, trachea, bronchi, and visceral pleura. The CMN is supplied by the caudal division, as it courses between the CMN and aorta. Microfil injected through the thoracic aorta did not enter the CMN when the bronchoesophageal artery was ligated at its origin. These results indicate that only the bronchoesophageal artery supplies the CMN. In eight sheep we cannulated the vein at the head of the CMN (dorsal mediastinal vein) and injected Microfil, both peripherally and centrally. Peripherally, injected veins reached the CMN and esophagus. The dorsal mediastinal vein extended posteriorly to the CMN in three of the eight sheep, eventually emptying into the left azygos vein near the diaphragm. Centrally, the dorsal mediastinal vein joined the left azygos vein near the heart in six of the eight sheep, including the three in which the dorsal mediastinal vein extended posteriorly to the CMN. In the remaining two sheep the dorsal mediastinal vein drained centrally into the right azygos vein. We conclude that the bronchoesophageal artery supplies the CMN and that either the left or right azygos vein drains it.
Azygos vein
Mediastinal lymph node
Dorsal aorta
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Azygos vein
Lobe
Gross anatomy
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Azygos vein
Brachiocephalic vein
Right gastric vein
Left Pulmonary Vein
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The uppermost portion or arch of the azygos vein is frequently ligated and divided in thoracic surgery. The hemodynamic effects arising from this proce dure have not, however, been described previously. The authors assessed such effects by using transesophageal real-time two-dimensional Doppler echography (TE2DD). Nine patients, whose azygos arch had been ligated and divided in the course of surgery for lung cancer, were examined. The intervals between the prior operation and the examination with TE2DD ranged from one to fifty months. By use of a convex array transducer with a frequency of 7.5 MHz, the hemodynamics of both the azygos vein and the intercostal veins, which join the former, were assessed. The esophagopetal portion of the azygos vein could be visualized in color in 6 of 9 cases. In all these 6 cases, the flow direction of the azygos vein was reversed and directed caudally. Blood flow in both the azygos vein and the intercostal veins is normally pulsatile. After ligation, however, it had become constant in 3 of 5 cases analyzed by pulsed Doppler spectrum. The value of mean flow velocity in the azygos vein (9 ± 5 cm/sec) was significantly (p < 0.05) smaller than that of the control group (15 ±5 cm/sec).
Azygos vein
Pulsatile flow
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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.
Azygos vein
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Objective To evaluate the feasibility of demonstrating the fetal azygos vein by spatio-temporal image correlation(STIC) combined with high-difinition flow(HD) imaging during the second gestation. Methods Two hundred fetuses between March 2013 to November 2013 were divided into 2 groups. In study group, STIC and HD were applied to demonstrate the azygos vein on the fetal thoracoabdominal para-midsagittal view, the relationship between the azygos vein and thoracic aorta, the shape, location and modality of archof azygos vein which joins the superior vena cava were observed after post processing.And two-dimensional ultrasound and color Doppler flow imaging(CDFI) was applyed in the control droup. Results 96/100 of the azygos vein was successfully demonstrated in the study group with the rate of 96%,while 85/100 was successfully demonstrated in the control group with the rate of 85%. According to the relationship of the azygos vein with the spine,the proportion of the right type,middle type and left type of the azygos vein was 26.0%,33.9%,40.1%. The azygos vein parallels with the thoracic aorta upside to the level of superior vena cava,and bends forward and joins the superior vena cava. In one case with hepatic segment of inferior vena cava interruption, wthe azygos vein was dilated with similar diameter to the thoracic aorta. Conclusion It is feasible to demonstrate the azygos vein by STIC combined with HD. The diameter, shape, location and manner of azygos vein can be observed.It can hint the diagnosis of disease that results in expansion of azygos vein. It is better than two-dimensional ultrasound combined.
Azygos vein
Thoracic aorta
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We report a case of a "migrating" azygos vein developing after an abrupt spinal deformity adjacent to the azygos arch. A woman with a previously identified azygos lobe had a follow-up chest computed tomography that demonstrated the azygos vein dislocated medially to the fissure in its usual mediastinal position. The azygos lobe was intact. The woman had developed kyphosis angled at the level of the T4 vertebra, where the azygos vein arches anteriorly.
Azygos vein
Vertebra
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Thirty embalmed adult human cadavers irrespective of age, sex and cause of death, were selected for this study over a period of one year to determine the azygos vein formation and drainage patterns. This study revealed four varieties regarding azygos vein formation. In twenty two cases (73.3%), the azygos vein formed by the confluence of the right subcostal and right ascending lumbar vein. It formed by the right subcostal vein with a contribution from the inferior vena cava (IVC) in three cases (10.0%) while, it formed by the right and left subcostal veins in three cases (10.0%) and in two cases (6.7%) formed by the right subcostal vein only. Moreover, in twenty three cases (76.67%), the azygos vein showed usual course and tributaries. Five cases (16.67%) revealed midline azygos vein with independent left lower eight posterior intercostal and subcostal veins. One case (3.33%) showed (H) shape azygos system. Independent double azygos veins were found in one case (3.33%). Based on the results, the azygos vein can take different developmental variations. Such variations are important in mediastinal surgery, imperative for reporting radiologists and have clinical importance. Variations in the formation and drainage pattern of the azygos vein are not clearly described in the literature. In this study the possible causes of these types of variations are discussed in view of the embryological development.
Azygos vein
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The venous system variations are generally explained on the basis of their embryological development. Tributaries of the azygos venous system varies greatly. Variations of azygos venous system and especially of the hemiazygos veins are not clearly described in the literature. In this case, the azygos vein instead of lying on the right side of the vertebral column was in the midline of posterior mediastinum. The left azygos venous line was ill defined and lower left posterior intercostal veins were opening independently into the azygos vein. The left superior intercostal vein was opening into the azygos vein. The accessory hemiazygos vein was ill defined. The origin and termination of the azygos venous system was found normal. These variations are discussed in view of its embryological development. Clinically these variations should be kept in mind while doing mediastinal surgery of large vessels.
Azygos vein
Venous malformation
Posterior mediastinum
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