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Operative Anatomy of the Heart Bearbeitet von Denis Berdajs, Marko Turina 1st Edition. 2010. Buch. xv, 543 S. Hardcover ISBN 978 3 540 69227 0 Format (B x L): 21 x 27,7 cm Gewicht: 1597 g Weitere Fachgebiete > Medizin > Vorklinische Medizin: Grundlagenfächer > Anatomie Zu Inhaltsverzeichnis schnell und portofrei erhältlich bei Die Online-Fachbuchhandlung beck-shop.de ist spezialisiert auf Fachbücher, insbesondere Recht, Steuern und Wirtschaft. Im Sortiment finden Sie alle Medien (Bücher, Zeitschriften, CDs, eBooks, etc.) aller Verlage. Ergänzt wird das Programm durch Services wie Neuerscheinungsdienst oder Zusammenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr als 8 Millionen Produkte. 110 3 Coronary Bypass Grafts 3.1 Internal Thoracic Artery rior; in these cases, a vascular ring sometimes sur- rounds the muscle. In the case of a rudimentary first 3.1.1 General Anatomy of the Internal Thoracic rib, the artery always is seen above the uppermost rib. Artery The cervical part is contained in the omoclavicular tri- angle. The artery runs downward and laterally from the 3.1.1.1 Origin and Course of the Internal Thoracic Artery lateral margin of the scalenus anterior to the outer bor- Thethoracicpartoftherightsubclavianarteryorigi- der of the first rib. This is the most superficial segment. nates from the brachiocephalic trunk, just behind the The internal thoracic artery arises from the thoracic sternoclavicular joint, and passes upward in the scale- part of the subclavian artery, just opposite to the thyro- notracheal fossa to the medial margin of the scalenus cervical trunk and medial to the scalenus anterior. In its anterior. initial run off, the artery descends on the pleural cupule The left subclavian artery arises directly from the to cross, after a short course, the sternal third of the aortic arch, just behind the left common carotid artery clavicle and the first rib cartilage, in order to enter the at the level of the fourth thoracic vertebra. In its initial thoracic cavity. Before reaching the first rib, the artery runoff,thearteryascendsinthesuperiormediastinal is crossed by the brachiocephalic vein. Shortly after its cavity to the root of the neck. From the sternoclavicular origin, the phrenic nerve joins the artery from its lateral articulation, the topographies of the left and right sub- aspect. After a short run off, the nerve runs medial and clavian arteries are similar. In the scalenotracheal fossa, ventral to the artery, behind the subclavian vein (Fig. 3.1 the artery winds around the pleural cupule toward the and 3.2). medial border of the scalenus anterior. On the dry-dissected specimen, the right internal The muscular part lies in the subclavian groove of the thoracic artery is inspected from the omoclavicular tri- first rib. Its boundary is formed by the scaleni anterior angle. The right clavicle has been removed and the sca- and medius. This part of the artery forms the highest lenus anterior detached from the first rib. For better part of the arch described by the vessel. In some rare interpretation of the topographical relationships, the variants, the artery passes in front of the scalenus ante- subclavian vein has also been removed. One can see that the artery originates just behind thevenousangleandrunsonthe Phrenic nerve pleural cupule toward the first rib. Scalenus Subclavian Vagal nerve anterior Jugular vein Clavicle vein Pleural cupule The phrenic nerve is presented as a white cord running along the ven- tral aspect of the brachiocephalic trunkand,inthisway,crossesthe internal thoracic artery (Figs. 3.1 and 3.2). The internal thoracic artery may branch off from the cervical part of the subclavian artery (with an inci- dence of 1.4%, as postulated by I Adachi); in this rare instance, the artery can be identified on the lat- eral edge of the scalenus anterior. Fig. 3.1. Origin of the internal thoracic artery Brachial plexus Internal Subclavian artery Insertion of scalenus anterior thoracic artery Superior Ascending cervical artery cervical artery Suprascapular artery 3.1 Internal Thoracic Artery 111 Scalenus anterior Sternohyoid muscle Phrenic nerve Internal thoracic artery Sternum Internal Clavicle jugular vein Vagus nerve Subclavian vein Phrenic nerve Subclavius Superficial cervical artery Cervical pleura Ascending First Rib cervical artery Brachial plexus Subclavian artery Insertion of scalenus anterior Transverse cervical artery Fig. 3.2. Origin of the internal thoracic artery, schematic drawing In this case, the cervical internal thoracic artery traverses the first rib and enters the thoracic cavity in the first intercostal space. Run off of the Internal Thoracic Artery Below the first costal cartilage, the artery descends just vertical to its Internal thoracic branching point. The artery is cov- artery ered by the intercostal cartilage and the internal intercostal muscle. It runsintheconnectivetissueofthe endothoracic fascia on the parietal Superior epigastric artery pleura, as far as the level of the third rib. Below this level, the artery is found upon the transversus thora- cis.Themostfrequentlevelofter- mination of the artery is the sixth intercostal space, where in 90% of cases it divides into two branches Fig. 3.3. Run-offofthe internal thoracic artery and in 10% of cases into three branches (Fig. 3.3). 112 3 Coronary Bypass Grafts Table 3.1 Intercostal Adachi on 52 specimens (mm) Sandmann on Delorme Mignon Our data measured on 50 specimens (mm) space 40 specimens on 30 specimens Male Female (mm) (mm) Left Right I 8–9 (0–16) 8 11 6–20 6 (SD 3.9) 6.4 (SD 3.9) II 13 (8–19) 10 (6–15) 15.3 10–20 13.7 (SD 2.6) 13.9 (SD 2.7) III 12, 13, 14 (16–18) 11 (5–14) 15.6 10–21 14.5 (SD 3.1) 14.8 (SD 2.7) IV 12 (7–16) 10 (6–15) 15.4 8–25 14 (SD 3.6) 14.6 (SD 3.1) V 16.3 (SD 1.7) 16.8 (SD 2.5) Sternal insertion of Manubrium of sternum pectoralis major Transversus thoracis Endothoracic fascia I II III IV Fig. 3.4. Relation between the internal tho- racic artery and the sternum External intercostal muscle Internal thoracic artery/vein Internal intercostal muscle According to our measurements, the artery runs ap- the transversus thoracis and is lateral to the vein. Note proximately 13 mm lateral from the sternal edge. that in the second intercostal space lateral to the vein, a Figure 3.4 shows a superior view of the relationship retrosternal lymphoid gland has been left in situ. A between the lateral sternal edge and the run off of the comparisonofthedistancebetweentheleftandright internal thoracic artery. The intercostal muscles have arteries revealed no significant deviations (Table 3.1). been removed; one can see that the artery runs superfi- The minimal distance was measured at the first inter- cial to the endothoracic fascia. The transversus thoracis costal space. From the second to the fourth intercostal was left in situ. Initially, the artery is medial to the con- space, the distance between the artery and the sternal joined vein (first and second intercostal spaces), then line remains approximately constant. We noted increase just behind the third rib the vein crosses the artery and in this distance at the level of the sixth intercostal space travels more medially. This is particularly obvious in (Fig. 3.4). the third intercostal space. Here, the artery runs along 3.1 Internal Thoracic Artery 113 5 5 5 6 6 6 4 4 4 7 7 11 7 11 1 11 3 1 3 8 1 8 3 8 9 9 9 2 2 10 2 10 10 a b c 5 5 5 6 6 6 7 4 8 4 7 11 11 7 11 1 3 1 8 3 1 8 4 9 9 9 10 2 2 10 10 2 d e f 5 4 6 5 4 6 11 1. Vertebral artery 2. Internal thoracic artery 7 11 1 1 3. Thyrocervical trunk 7 8 3 3 4. Inferior thyroid artery 5. Ascending cervical artery 8 6. Superficial cervical artery 9 7. Suprascapular artery 8. Transverse cervical artery 2 9 2 9. Costocervical trunk 10 10. Supreme intercostal artery 11. Deep cervical artery g 10 h Fig. 3.5. Variants of the origin of the internal thoracic artery Morphological variants of the origin of the internal tho- ers likewise together (Fig. 3.5b). In the third variant racic artery cannot be discussed without emphasizing (8.3%), the internal thoracic artery and the suprascapu- its relationships with the vertebral artery, and the costo- lar artery share a common origin (Fig. 3.5c). In the cervical and thyrocervical trunks. Adachi’s classifica- fourth variant (4.1%), the transverse cervical artery tion scheme distinguishes several frequently occurring originates separately and the other arteries branch off anatomical types with respect to origin from the sub- together (Fig. 3.5d). All of the vessels may arise from a clavian artery. In the most common (normal) type common trunk (3.3%; Fig. 3.5e). The internal thoracic, (45.5%), the vertebral and the internal thoracic arteries, suprascapular, and transverse cervical arteries can arise and the costocervical and thyrocervical trunks arise as separately, the others having a common origin (3.3%; separate branches (Fig. 3.5a). In the second variant Fig. 3.5f). The internal thoracic and the inferior thyroid (19%), the internal thoracic artery and the transverse arteries can have separate origins, with the others aris- cervical artery arise from a common trunk, and the oth- ing together (3.3%; Fig. 3.5g).Thetransversecervical.
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