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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3657_Библиотеки_им_академика_М_И_Перельмана.pdf
70
b
Y. J. El-Abd and K. D. Hagspiel
Fig. 6.4 (continued)
involve either an accessory or replaced artery; an accessory
artery is one in addition to the standard anatomy, while a
replaced artery describes an alternate origin of the artery that
substitutes the standard anatomy. The most commonly
encountered variants include (1) replaced or accessory right
hepatic artery originating from the SMA, (2) replaced or
accessory left hepatic artery originating from the left gastric
artery, and (3) replaced common hepatic artery originating
from the SMA (and less commonly from the left gastric
artery or directly from the aorta).
The pulmonary arterial system is responsible for carrying
deoxygenated blood from the right side of the heart to the
lungs, where gaseous exchange occurs and oxygenated blood
is returned to the left side of the heart by means of the pulmonary veins. We will limit our study to the pulmonary
arteries, as they are frequently imaged when patients are
being evaluated for pulmonary embolism (Fig. 6.5). The
right ventricle pumps blood through the pulmonic valve into
the main pulmonary artery (MPA), which then divides into
the right pulmonary artery (RPA) and left pulmonary artery
(LPA). There can be signicant variation in pulmonary artery
anatomy, and our discussion covers the classical anatomy.
The RPA courses laterally and divides into the upper lobar
artery and interlobar artery. The upper lobar artery has three
divisions, which are the anterior, apical, and posterior segmental arteries, and supplies the upper lobe. The interlobar
artery gives off the right middle lobar artery, which divides
into a medial and lateral segmental artery, and then continues
inferiorly as the lower lobar artery. The lower lobar artery
has ve divisions supplying the lower lobe, which are the
superior segmental artery and the four basal segmental arteries
(anterior, posterior, medial and lateral). The LPA follows a
similar branching pattern as the RPA, except there is no middle lobar artery. In its place, the lingular artery arises from
the left interlobar artery and then divides into a superior and
inferior segmental artery.
Similar to some of the other anatomic regions already
reviewed, there can be signicant variation of the internal
iliac artery branching between patients (Fig.6.6). Classically,
however, the internal iliac artery has a posterior and anterior
division. The posterior division is comprised by three
branches, which includes the iliolumbar artery (coursing
superiorly and supplying the iliopsoas muscles complex), the
superior gluteal artery (usually the largest caliber artery
extending laterally and supplying the gluteal muscles), and
the lateral sacral artery (coursing inferiorly and supplying
the sacrum). The anterior division includes a variable number of key branches but often includes the inferior gluteal
artery, the internal pudendal artery (which supplies various
pelvic structures), the obturator artery (which courses
through the obturator foramen and supplies various structures of the upper leg), the middle rectal artery (supplying a
Main pulmonary
Right pulmonary
Right interlobar pulmonary
artery (Descending branch
segmental
a
b
Right pulmonary
Right ventricular
Right ventricl
outflow trac
Superior Vena
Cava
artery
6 The IR Road Map: Vascular Anatomy Overview
71
Anterior segment
Posterior segment
Right middle
lobe artery
Lower lobar artery
Apical segment
of the RPA)
Medial
segment
Lateral
segment
Lateral
basal
artery
Posterior
Basal segmental
Anterior
basal
arteries (RLL
basal
branches)
artery
Medial
basal
Left pulmonary artery
Apical segment
Posterior segment
Anterior segment
Superior branch (courses
posteriorly)
Lower lobar artery
Superior segment
Inferior segment
Anterior basal
Medial basal
Lateral basal
Posterior basal
Lingular
artery
Basal
arteries
(LLL
branches)
Left pulmonary
artery
Main pulmonary
artery
Expected level of
the pulmonic valve
t
e
Fig. 6.5 Pulmonary arteries. (a) Artist illustration. (b) CT pulmonary angiogram. (c) 3D reconstruction of the right pulmonary artery in (b), lateral
projection (A, anterior; P, posterior). (d) 3D reconstruction of the left pulmonary artery in (b), lateral projection
72
c
d
Posterior segmental
Lower lobar artery
Lateral basal
Medial basal
Posterior basal
segmental artery
segmental artery
segmental artery
Superior segmental
artery
artery
Apical segmental
Posterior segmental
Upper lobar artery
Superior segmental
artery
Interlobar artery
Posterior basal
segmental artery
segmental artery
Lateral basal
artery
artery
Anterior segmental artery
Y. J. El-Abd and K. D. Hagspiel
Medial segmental artery
(of the right middle lobe)
Lateral segmental artery
(of the right middle lobe)
Lower lobar artery
Anterior basal segmental
artery
Medial basal
segmental artery
Apical segmental
artery
Anterior segmental
artery
Inferior segmental
artery (of the lingula)
Superior segmental
artery (of the lingula)
Anterior basal
segmental artery
Fig. 6.5 (continued)
Superior vesical
Internal pudendal artery
Anterior division
a
b
6 The IR Road Map: Vascular Anatomy Overview
73
Iliolumbar artery
Internal iliac
(hypogastric) artery
Common iliac
artery
External iliac
artery
Obturator artery
artery
Inferior vesical
artery
Posterior division
Superior gluteal
artery
Inferior gluteal artery
Lateral sacral artery
Middle rectal
artery
Uterine artery
Fig. 6.6 Internal iliac artery. (a) Artist illustration, female. Illustrated here is the classic anatomy of the internal iliac artery in a female patient. (b)
CTA pelvis, male
portion of the rectum), the inferior vesical artery (supplying
a portion of the urinary bladder), and, depending on the
gender of the patient, either the uterine or the prostatic arteries. As shown here, the uterine arteries are often identiable
by their tortuous course. The prostatic arteries demonstrate
signicant variation between patients, of which the most
commonly seen variants are covered later in this book (refer
to Chap. 29 for more information).
The arterial blood supply to the upper extremity begins
with the subclavian artery (Fig.6.7). As the subclavian artery
courses through the thoracic outlet and past the lateral edge
of the rst rib, it becomes the axillary artery. The axillary
74
Common palmar
a
b
Left axillary
artery
Left subclavian
artery
Left common
carotid artery
Right
brachiocephali
artery
Aortic arch
Fig. 6.7 Arteries of the upper
extremity. (a) Artist illustration.
(b) CTA of the upper extremity,
upper arm. (c) CTA of the upper
extremity, forearm and hand
Y. J. El-Abd and K. D. Hagspiel
Subclavian artery
Axillary artery
Circumflex
humeral arteries
Deep brachial
(profunda)
artery
Interosseous
artery
Ulnar artery
Superficial
palmar arch
Brachial artery
Radial artery
Deep palmar
arch
digital arteries
Proper palmar
digital arteries
Left ulnar
artery
Left radial
artery
Left deep
brachial artery
Left brachial
artery
Left humeral
circumflex
c
artery
Long thoracic
artery
c
Left princeps
pollicis artery
Left radial
artery
Left interosseous
Left brachial
artery
6 The IR Road Map: Vascular Anatomy Overview
Fig. 6.7 (continued)
75
Left proper
digital arteries
Left common
digital arteries
Superficial
palmar arch
Left ulnar
artery
artery
artery gives off the humeral circumex arteries and then
continues through the axilla until it reaches the inferior
border of the teres minor muscle, at which point it becomes
the brachial artery. The brachial artery provides a deep
brachial branch (profunda) that supplies the muscles of the
upper arm. The brachial artery then divides into the radial
and ulnar arteries near the region of the antecubital fossa.
These arteries course distally and form the deep (radial
artery) and supercial (ulnar artery) palmar arches, with the
common digital arteries arising from the supercial palmar arch.
The radial artery gives off a single artery to the thumb, the
princeps pollicis artery. The common digital arteries divide
into the proper digital arteries (PDA) with the 2nd through
5th digits having an ulnar and a radial PDA each. Note the
ulnar artery arises from a common trunk with the interosseous artery, which supplies various muscles of the forearm.
The interosseous artery does not cross the wrist.
The arterial blood supply to the lower extremities begins
with the common iliac artery, which divides into the external
and internal iliac arteries (Fig.6.8). The external iliac artery
continues to the inguinal ligament, at which point it becomes
the common femoral artery. Since the inguinal ligament
cannot be seen on angiography, this transition is dened by
the origins of the inferior epigastric artery medially and deep
circumex iliac artery laterally. The common femoral artery
then divides into the deep femoral (profunda femoris) artery
and the supercial femoral artery (SFA). The deep femoral
artery supplies the muscles of the thigh. The SFA courses
through the adductor canal and becomes the popliteal artery
at the adductor hiatus. The popliteal artery gives off the
geniculate and sural arteries, which supply the various
structures of the knee and calf, respectively. The popliteal
artery then divides into the anterior tibial artery and the tibioperoneal trunk, which gives rise to the posterior tibial
artery and peroneal (bular) artery. The anterior tibial artery
crosses the ankle and becomes the dorsalis pedis artery.
The posterior tibial artery also crosses the ankle and supplies
the medial and lateral plantar arches. The peroneal artery
terminates above the ankle joint. Both the dorsalis pedis
artery and the distal posterior tibial artery can be palpated on
physical exam.
The central veins of the chest are responsible for returning
venous blood from the head, neck, and upper extremities to
the right side of the heart (Fig.6.9). The blood from the head
and neck is drained by the internal jugular (IJ) and external
jugular (EJ) veins. As the IJ vein courses inferiorly, it merges
with the subclavian vein, becoming the brachiocephalic
(innominate) vein. The right and left brachiocephalic veins
meet to form the superior vena cava (SVC), which drains
directly into the right atrium. Note the external jugular veins
inserting into the central portion of the subclavian vein, usually just peripheral to the juncture of the brachiocephalic
vein. Another important structure is the azygos vein. This
vein is formed from intercostal and lumbar veins, draining
76
ab
Common iliac
artery
External iliac
artery
Internal iliac
artery
Right anterior
tibial artery
(lateral runoff
vessels)
Y. J. El-Abd and K. D. Hagspiel
Inferior
epigastric
artery
Deep iliac
circumflex artery
Common
femoral artery
Deep femoral
(profunda) artery
Lateral femoral
circumflex artery
Superficial femoral
artery
Popliteal artery
Tibioperoneal
(TP) trunk
Peroneal (fibular) artery
(middle runoff vessel)
Posterior tibial artery
(medial runoff vessel)
Dorsalis pedis artery
Lateral plantar
arch
Medial plantar
arch
Fig. 6.8 Arteries of the lower extremity. (a) Artist illustration. (b) Contrast-enhanced MRA of the lower extremities
the posterior thoracic and abdominal walls and spinal canal.
It courses superiorly to the right of the spine and drains
directly into the SVC.In cases of central venous obstruction
and in portal hypertension, the azygos vein can serve as an
alternate drainage pathway. Conversely, in cases of low SVC
obstruction, ow in the azygos vein can reverse to carry
blood in the SCV to the IVC.
The systemic veins of the abdomen and pelvis are responsible for returning venous blood from the liver, kidneys, adrenal glands, reproductive tract and pelvic organs, and the lower
extremities to the right side of the heart (Fig.6.10). The major
branches include the paired common iliac veins draining the
lower extremities, the paired renal veins, and the hepatic veins
more superiorly, all of which drain into the inferior vena cava
(IVC). The IVC then courses superiorly across the diaphragm
before draining into the right atrium. The gastrointestinal tract
and spleen do not drain directly into the IVC; rather, they drain
into the portal venous system which directs blood ow into the
liver, where it is processed by hepatocytes before draining into
the hepatic veins and then the IVC.
The portal venous system receives the veins of the
visceral abdominal organs and spleen and drains into the
liver (Fig.6.11). The hepatic blood reenters the systemic cir-
culation via the hepatic veins. The main portal vein is formed
by the conuence of the superior mesenteric vein (SMV) and
the splenic vein. The main portal vein divides into the right
and left portal veins supplying their respective lobes of the
liver. The inferior mesenteric vein usually empties into the
splenic vein or the portal conuence. It can be difcult to
identify on imaging due to its relatively small size. When the
portal venous system pressures are elevated (portal hypertension), there can be redirection of blood through naturally
occurring portosystemic anastomoses in the body, found
between the left gastric vein and esophageal veins, the
superior rectal vein and middle/inferior rectal veins, and the
paraumbilical vein with various subcutaneous veins of the
abdomen. Pathologic dilation of these venous anastomoses
due to increased blood ow can result in gastroesophageal
varices, hemorrhoids, and caput medusae, respectively. A
specic type of portosystemic shunt that is encountered and
treated by interventional radiologists is a splenorenal shunt,
in which portal hypertension causes reversal of splenic
venous blood ow into dilated gastric varices, which then
drain into the left renal vein by a gastrorenal shunt.
The venous drainage of the extremities is divided into
the supercial and deep systems (Fig.6.12). Typically, the
Internal jugular
a
b
6 The IR Road Map: Vascular Anatomy Overview
77
veins
subclavian vein
Brachiocephalic
Superior vena
Right
veins
Azygos vein
cava
External
jugular vein
Left
subclavian vein
Axillary
vein
Cephalic
vein
Brachial
vein
Fig. 6.9 Central veins of the chest. (a) Artist illustration. (b) Contrast-enhanced MRV of the neck and chest
78
Right common
iliac vein
Left common
a
b
Right
Middle
Left
Hepatic
veins
Inferior vena cava
Y. J. El-Abd and K. D. Hagspiel
Right suprarenal
(adrenal) vein
Right renal
vein
Right gonadal
vein (ovarian/
testicular)
External iliac veins
Internal iliac veins
Left suprarenal
(adrenal) vein
Left renal
vein
Left gonadal
vein (ovarian/
testicular)
Common iliac
veins
Hepatic veins
Right renal
vein
Left renal
vein
iliac vein
Fig. 6.10 Systemic veins of the abdomen and pelvis. (a) Artist illustration. (b) MRV of the abdomen and pelvis. Note the accessory caudal right
hepatic vein draining segments 5 and 6 of the liver directly into the IVC, a normal variant
a
b
6 The IR Road Map: Vascular Anatomy Overview
79
Liver
Right portal vein
Main portal vein
Right gastric
vein
Superior
mesenteric vein
Left portal
vein
Left gastric
vein
Spleen
Splenic vein
Inferior mesenteric
vein
Fig. 6.11 Portal venous system. (a) Artist illustration. (b) CT abdomen and pelvis, portal venous phase
supercial veins drain into the deep venous system just
before they converge into the central veins. The deep veins
course parallel to the arterial supply. In the upper extremity,
the supercial venous system consists of the basilic vein,
which courses medially and joins the deep brachial veins in
the upper arm, and the cephalic vein, which courses laterally
and empties into the subclavian vein. These supercial veins
often have a common connection in the antecubital fossa
formed by the medial cubital vein. The deep venous system
includes the radial and ulnar veins which course centrally
and merge into the brachial vein. Note that the deep veins at
these levels are duplicated, meaning that there are two