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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3860_Библиотеки_им_академика_М_И_Перельмана
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■
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PART II
■
A Systems Approach to
Diagnosis and Management
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J.CynamonVascular Anatomyabove the Diaphragm
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14
■■■
Vascular Anatomy above
the Diaphragm
JACOB CYNAMON
■ Arteries
The right and left coronary arteries arise off the right
and left aortic sinuses. The brachiocephalic artery is the
first branch off the arch, which bifurcates into the right
subclavian and right carotid arteries. Next, the left carotid artery and, last, the left subclavian artery arise directly off the arch. (See Table 14-1 for variants of normal
arch anatomy and Table 14-2 for genetic abnormalities
of the thoracic arch.)
The thoracic aorta is divided into four segments
14-1): the ascending aorta, the aortic arch, the isthmus
(between last great vessel and the attachment of the ductus arteriosus), and the descending aorta. Occasionally,
there is a fusiform dilatation of the proximal descending
aorta, a ductus diverticulum, which should not be confused with a traumatic injury. Usually, there are nine pairs
of intercostal arteries, from the third through the 11th
intercostal spaces. There are many variations to the intercostal anatomy. Most commonly, there are between two
and four bronchial arteries; multiple bronchial arteries
are more common on the left. Bronchial arteries may
arise directly off the aorta or have a common origin with
an intercostal arter y, thus forming an intercostal bronchial trunk.
The right subclavian artery originates off the brachiocephalic artery and the leftsubclavian artery arisesdirectly
off the aortic arch. The subclavian artery becomes the
axillary artery after it crosses the lateral margin of the first
rib. The subclavian artery gives rise to the following: the
vertebral artery, the thyrocervical trunk, the internal
2
1
(Fig.
mammary artery, and the costocervical trunk. There are
variants to this anatomy, such as independent origins of
branches of the thyrocervical trunk or the costocervical
trunk.
The axillar y artery gives rise to several small branches
around the shoulder (Fig. 14-2A), including the superior
thoracic, thoracoacromial, lateral thoracic, subscapular,
and circumflex humoral arteries. There are many variants to this typical anatomy, including absent vessels and
independent origins to vessels that may be normally common trunks. Occasionally (2%), the radial artery may
originate from the distal axillary artery, and even more
rarely (1%), the ulnar artery may originate from the
distal axillary artery.
The axillary artery becomes the brachial artery at the
lateral margin of the terres major muscle (Fig. 14-2A). It
divides into the radial and ulnar arteries at the antecubital fossa. Its major branches include the deep brachial
artery, which is a large vessel arising in the proximal
upper arm and coursing posterolaterally. The deep brachial artery bifurcates into the radial collateral artery and
the medial collateral artery. Variant anatomy includes a
radial artery that originates off the proximal brachial
artery (12%) and an ulnar artery that originates off the
proximal brachial artery (1 to 2%).
The brachial arter y bifurcates a few centimeters below
the elbow joint into the radial and ulnar arteries. The
axial remaining artery is known as the interosseous artery. The ulnar artery undergoes anastomosis with the
median artery and forms a superficial palmer arch. The
radial artery forms a deep palmer arch.
147
148 J. Cynamon
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TABLE 14-1.
Prevalence of Normal Arch Anatomy and
Its Variants
Anatomy Percent
Normal arch 70
Common origin of the brachiocephalic and left common 22
carotid artery
Left vertebral artery directly off the aorta 4–6
Right and left common carotid artery have common ⬍1
origin
Two brachiocephalic arteries ⬍1
All four great vessels have separate origins 0.1
TABLE 14-2. Congenital Variants for the Aortic Arch
Variant Percent
Left aortic arch with aberrant right subclavian artery
Right aortic arch 1–2
60% mirror image branching
35% with aberrant right subclavian and left ductus or
ligamentum arteriosus
Cervical aortic arch is rare, not associated with
intracardiac anomalies
Coarctation, localized narrowing of the aorta
50% isolated
50% associated with congenital cardiac lesions such
as bicuspid aortic valves, patent ductus arteriosus,
ventricular septal defects, aneurysms of circle
of Willis
a
Associated with congenital heart disease, 10 to 15%.
b
Associated with cyanotic heart disease, 98%.
c
Associated with congenital heart disease, 12%.
b
c
a
1
Aorta
A
SVC
IJ
BC
S
IJ
C
IT
BC
S
A
SVC
AP large veins
TC
CC
RV
IM
RS
RC
B
AA
IA
LC
LS
AAr
DA
LAO arch
LV
IM
Isthmus
IA
IA
FIGURE 14-1. Superimposed arteries and veins of the thorax. (A) AP large veins. A, axillary; C, cephalic; BC, brachiocephalic;
IJ, internal jugular; IT, inferior thyroid; S, subclavian; SVC, superior vena cava. (B) LAO arch. AA, ascending aorta; AAr, aortic
arch; B, brachiocephalic artery; CC, costocervical; DA, descending artery; IA, intercostal arteries; IM, internal mammary artery;
LC, left common carotid artery, LS, left subclavian artery; LV, left vertebral artery; RC, right common carotid artery; RS, right
subclavian artery; RV, right vertebral artery; TC, thyrocervical.
B
Thoracoacromial a.
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Anterior circumflex
humeral
Posterior cirumflex
humeral
Radial collateral a.
Vascular Anatomy above the Diaphragm 149
Superior
thoracic
Lateral thoracic
Subscapular
Axillary a.
Brachial a.
Medial collateral a.
Radial
Deep palmer
arch
Deep brachial a.
Interosseous a.
Ulna
Superficial palmer arch
FIGURE 14-2. (A) Arteries of the upper extremity. (
Continued
)
150 J. Cynamon
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Axillary
Cephalic
Basilic v.
Median cephalic v.
Figure 14-2. (
Continued
Median basilic v.
Basilic v.
Dorsal venous
network of the hand
) (B) Veins of the upper extremity.
Antebrachial v.
Cephalic v.
Vascular Anatomy above the Diaphragm
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151
■ Veins
The veins of the upper extremity are composed predominantly of the superficial venous system (Fig. 14-2). The
veins in the forearm are composed of the dorsal venous
network of the hand, the superficial veins of the palm,
the basilic vein, the cephalic vein, the antebrachial veins,
and the median cephalic and basilic veins. There is a
great deal of variation in the venous anatomy of the
upper extremity. The cephalic vein originates dorsally
and laterally. It crosses the elbow joint and enters the
superior aspect of the axillary vein just below the clavicle.
An accessory to the cephalic vein is frequently present.
The basilic vein originates on the ulnar side of the arm
and continues medial to the brachial artery. It joins the
brachial vein to become the axillary vein at the border of
the teri major muscle. The median cubital veins are the
veins that connect the basilic and cephalic veins in the
antecubital fossa. These veins are inconsistent.
The deep veins on the upper arm usually are paired
and follow their respective arteries (Fig. 14-1B). The sub-
clavian vein is a continuation of the axillary vein. As it
crosses the sternum, it joins with the internal jugular vein
to form the brachiocephalic vein. The left brachiocephalic vein (BCV) is longer than the right. The right
and left BCVs join behind the first anterior rib to form
the superior vena cava (SVC). The azygos vein forms at
the L1–2 level. It travels in the anterior aspect of the
posterior mediastinum slightly to the right of midline. It
arches anteriorly to join the superior vena cava just above
the SVC’s entry into the pericardium.
Anterior and also originating at the L1–2 level slightly
to the left of midline, the hemiazygos ascends and joins
the azygos at the T8 level. The accessor y hemiazygos is
the most variable of the azygos hemiazygos system. It
usually lies on the left side of the upper thorax.
REFERENCES
1. Shuford WH, Sybers RG. The aortic arch and its malformations.
Springfield, IL: Charles C. Thomas; 1974.
2. Khan S, Haust MD. Variations in the aortic origin of intercostal
arteries in man. Anat Rec 1979;195:545–552.
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J.E. SilberzweigPulmonary and Bronchial Arteries
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15
■■■
Pulmonary and Bronchial Arteries
JAMES E. SILBERZWEIG
■ PULMONARY ARTERIOGRAPHY
Pulmonary embolism
The most common indication for pulmonar y arteriography is for the diagnosis of pulmonar y embolism. Other
indications for pulmonary arteriography include the diagnosis and treatment of arteriovenous malformations
(AVMs), aneurysms, developmental abnormalities, vasculitis or inflammatory disease, neoplasms, and evaluation
of pulmonary hypertension.
Pulmonary embolism is a common and potentially lethal disorder. Effective treatment of pulmonar y embolism requires rapid and accurate diagnosis. Because the
clinical signs and symptoms of pulmonary embolism are
nonspecific, imaging procedures are used to make the
diagnosis. Chest radiograph findings that may suggest the
presence of pulmonary embolism include wedge-shaped,
pleural-based densities (Hampton’s hump), regional
oligemia (Westermark’s sign), and central pulmonary artery enlargement.
able indicators of pulmonary embolism. Most patients
have vague parenchymal opacification, atelectasis, pleural effusion, or no abnormality. The utility of the chest
radiograph in patients with suspected pulmonary embolism is to identify a nonembolic etiology for the patient’s
symptoms and aid in interpretation of lung ventilationperfusion (V/Q) scintigraphy.
V/Q scintigraphy is the most commonly performed
initial study for the diagnosis of pulmonary embolism;
however, the results of V/Q scintigraphy are indeterminate in most patients. In these patients, the next diagnos-
1
These findings are not, however, reli-
tic test performed is usually pulmonary arteriography,
which serves as the “gold standard” study for making the
diagnosis of acute pulmonary embolism. A negative highquality pulmonary arteriogram excludes clinically significant pulmonary embolism.
Noninvasive imaging techniques such as magnetic
resonance imaging and helical computed tomography
(CT) have been used for evaluation of pulmonar y embolism but are undergoing further investigation.
investigators have concluded that helical CT may be
more useful than V/Q scintigraphy
for pulmonary embolism; however, investigators have indicated that at this time CT cannot replace pulmonar y
arteriography for the diagnosis of pulmonary embolism
because of its limited ability to identify emboli within
subsegmental branches.
Up to 90% of pulmonary emboli arise from the deep
veins of the lower extremities.
thrombosis and pulmonary emboli include immobilization, prior history of thromboembolic disease, recent
surgery or trauma, pregnancy, use of oral contraceptives,
advanced age, cancer, and the presence of a hypercoagulable state. The initial clinical findings of pulmonary embolism are often nonspecific and include dyspnea,
cough, fever, chest pain, and hemoptysis. Massive pulmonary embolism may result in cardiogenic shock. It is difficult to diagnose pulmonary embolism clinically because
the symptoms may mimic other conditions, such as myocardial infarction, congestive heart failure, and pneumonia.
Pulmonary arteriography has high sensitivity and specificity in the diagnosis of pulmonary embolism in addition
to being a safe procedure. The incidence of minor com-
3,4
2
for initial evaluation
6
Risk factors for venous
2–5
Some
153
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