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Variations of the Subclavian Arterial Branching Pattern and Maximization of Its Juwan Ryu Western University, [email protected]

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Variations of the Subclavian Arterial Branching Pattern and Maximization of Its Juwan Ryu Western University, Jryu22@Uwo.Ca Western University Scholarship@Western Masters of Clinical Anatomy Projects Anatomy and Cell Biology Department 2016 Variations of the Subclavian Arterial Branching Pattern and Maximization of its Juwan Ryu Western University, [email protected] Follow this and additional works at: https://ir.lib.uwo.ca/mcap Part of the Anatomy Commons Citation of this paper: Ryu, Juwan, "Variations of the Subclavian Arterial Branching Pattern and Maximization of its" (2016). Masters of Clinical Anatomy Projects. 14. https://ir.lib.uwo.ca/mcap/14 Variations of the Subclavian Arterial Branching Pattern and Maximization of its Supraclavicular Surgical Exposure (Project format: Integrated) by Juwan Ryu Graduate Program in Anatomy and Cell Biology Division of Clinical Anatomy A project submitted in partial fulfillment of the requirements for the degree of Master’s of Science The School of Graduate and Postdoctoral Studies The University of Western Ontario London, Ontario, Canada © Juwan Ryu 2016 Abstract The subclavian artery (SCA) is an important vessel with several branches. However, significant pattern variations exist. Characterizing SCA branches and its relationships to landmark structures like the anterior scalene muscle (ASM) is important in surgery. Computed Tomography Angiograms from 55 patients were retrospectively analyzed using Aquarius iNtuition. Measurements were taken of: distance of origin of SCA branches from the aorta and the ASM-VA origin distance. Only 13 SCAs (12.9%) exhibited the highest prevalence in typical branching pattern. VA originated 1st in 80.2% of SCAs, with ITA arising 2nd (41.3%), TCT 3rd (47.3%), CCT 4th (43.6%) and DSA 5th branch (56.9%). Average VA-ASM distance was 14.14mm with 94.9% of VAs originating within 30mm proximal to the medial border of ASM. The subclavian artery branching order and pattern may present significant variation from the typical order. ASM is reliably positioned proximal to VA and may be used as a landmark for VA. Keywords Subclavian artery, Morphological variations, Anterior scalene muscle landmark, Branching patterns, Vertebral artery, Supraclavicular triangle, Shoulder manipulations ii List of Abbreviations SCA Subclavian Artery CCA Common Carotid Artery VA Vertebral Artery ITA Internal Thoracic Artery TCT Thyrocervical Trunk CCT Costocervical Trunk DSA Dorsal Scapular Artery CTA Computed Tomography Angiogram ASM Anterior Scalene Muscle SCT Supraclavicular Triangle iii Acknowledgments First and foremost, I would like to thank Dr. Adam Power. I still remember what you told me: “There are those who crumble under the face of hardship and harsh words. And there are those who face defeat, say “I got to do better”, and pick themselves up.” During the times when I had misplaced my focus, your words of motivation helped to set my course straight and take ownership of this project. You have inspired me beyond words, gave me a chance to reflect on myself, and pushed me to become better. I will continue to remember the lessons that you’ve taught me as I step forward as a student, and a person. Secondly, I would like to give tremendous thanks to Oonagh Scallan. From the outset, you have been a wonderful source of help, and your enthusiasm and eagerness have inspired me to strive to become a student of your caliber. This project would not be complete without you! Third, I want to express my sincere gratitude to my supervisory committee, Dr.Marjorie Johnson and Dr.Tim Wilson. You have both welcomed my questions with open doors and smiling faces at all times, and guided me within this research project, as well as outside, in the classroom and in the anatomy lab. Lastly, I want to thank the Department of Clinical Anatomy. Kevin Walker and Haley Linklater, thank you for keeping me company and your enormous help down in the morgue. To the second year graduates, especially Jackie Yang, there is no other group of people that I would rather choose to work alongside if I had to do it all over again. A big thank you to my mom, dad and sister for your encouragement and support throughout this program, both financially, and morally. J iv Table of Contents Abstract ............................................................................................................................... ii Keywords ............................................................................................................................ ii List of Abbreviations ......................................................................................................... iii Acknowledgments .............................................................................................................. iv Table of Contents ................................................................................................................ v List of Tables ..................................................................................................................... ix List of Figures .................................................................................................................... xi List of Appendices ........................................................................................................... xiv Chapter 1 ............................................................................................................................. 1 Introduction and Literature Review .................................................................................... 1 Introduction ............................................................................................................. 1 Anatomical Introduction ......................................................................................... 1 1.2.1 Aorta and Supra-Aortic Vessels .................................................................. 1 1.2.2 Prevalence of Subclavian Arterial Branches ............................................... 2 1.2.3 Subclavian Arterial Branching Pattern ....................................................... 4 Aortic Aneurysms and Stent-Graft Interventions ................................................... 5 1.3.1 Introduction to Aortic Aneurysms .............................................................. 5 1.3.2 Interventions to Aortic Aneurysms ............................................................. 6 1.3.3 Landing Zones and SCA Coverage ............................................................. 7 1.3.4 Subclavian Reconstruction .......................................................................... 9 1.3.5 Difficulties with SCA Reconstruction ........................................................ 9 Anatomical Boundaries of the Supraclavicular Triangle ...................................... 10 1.4.1 Anatomical Contents ................................................................................. 11 1.4.2 Bony Landmarks and features .................................................................. 14 v 1.4.3 The Effect of Positioning on the Supraclavicular Window ...................... 15 Rationale of Study ................................................................................................. 18 Chapter 2 ........................................................................................................................... 20 Retrospective Computed Tomography Angiogram Characterization on the Subclavian Arterial Branching Pattern ................................................................................................ 20 Introduction ........................................................................................................... 20 2.1.1 Purpose of Study ....................................................................................... 20 2.1.2 Objectives ................................................................................................. 21 Methods and Materials .......................................................................................... 22 2.2.1 Patient Selection ........................................................................................ 22 2.2.2 Morphologic Analysis of the Subclavian Artery using Aquarius iNtuition ................................................................................................................... 22 2.2.3 Patient Measurements ............................................................................... 24 Results ................................................................................................................... 29 2.3.1 Subclavian Arterial Branches ................................................................... 29 Discussion ............................................................................................................. 35 2.4.1 Interpretation of Results ............................................................................ 35 2.4.2 Limitations ................................................................................................ 39 Conclusions ........................................................................................................... 40 Chapter 3 ........................................................................................................................... 41 Investigation of the Relationship of Vertebral Artery origin to the Position of the Anterior Scalene Muscle ................................................................................................................. 41 Introduction ........................................................................................................... 41
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