Operative Anatomy of the

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

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Surgery of the aorta is one of the most challenging areas the aortic root are discussed herein. A morphological of cardiac and vascular surgery, from the management description of the ascending aorta, aortic arch, thoracic of emergency situations to the treatment of degenera- aorta, and supraceliac part of the aorta will be provided. tive diseases. To achieve an optimal surgical result, it is A discussion of the abdominal part of the aorta is out- essential not only to have an exhaustive knowledge of side the scope of this book. the pathological mechanisms involved, but also to be The human aorta commences at the upper part of the familiar with the anatomy of the aorta. Hence, we are aortic root at the level of the sinotubular junction, dedicating an entire chapter to this great vessel of the where it is about 3 cm in diameter, and after ascending human body. for a short distance, it arches backward and to the left In this chapter, we will focus on the anatomy of the side, over the root of the left . It then descends with- aorta, but not including the aortic root. In the past, the in the on the left side of the vertebral column, aortic root (also known as the bulb of the aorta) was passes into the abdominal cavity through the aortic hia- considered to be an integral part of the ascending aorta. tus in the diaphragm, and ends by dividing into the However, since the introduction of reconstructive pro- right and left common iliac . Thus, the aorta can cedures of the aortic root, this part of the ascending be described as having several portions: the ascending aorta is now regarded as an independent morphological part, the arch, and the descending part, the latter of and functional unit. The detailed morphology of the which is again divided into the thoracic and abdominal aortic root has been discussed elsewhere (Chap. 5), and aortae. so only the segments of the aorta positioned superior to

Right Right common Brachiocephalic Left Left internal subclavian carotid artery trunk jugular Left vagal nerve

Right internal jugular vein Left sub- Vagal clavian artery nerve Right Right brachioce- brachio- phalic vein cephalic vein

Internal Internal thoracic thoracic artery artery

Trachea Phrenic nerve

Left Superior pulmonary vena cava artery

Superior lobe of right lung

Right superior Phrenic Right Ascending Pulmonary Left superior Superior lobe pulmonary vein nerve auricle aorta trunk pulmonary vein of left lung Fig. 11.1. Supracardiac , with exposure of the great vessels 11.1 The Aortic Arch 457

Right internal jugular vein Left internal jugular vein Right subclavian artery

Right Trachea Left common carotid artery Vagal nerve Vagal nerve Left subclavian artery Right brachiocephalic vein Left brachiocephalic vein Brachiocephalic trunk Internal thoracic Internal thoracic artery artery Pericardiacophrenic Phrenic nerve vein Superior lobe Ascending aorta of left lung

Superior lobe Pulmonary of right lung artery Right auricle Left superior Right superior pulmonary pulmonary vein vein Fig. 11.2. Supracardiac mediastinum, with exposure of the great vessels, schematic drawing

The direction and the topographical positions of the as- habitus. At this level, the ascending aorta is joined on cending aorta are presented on the dry-dissected speci- the right to the superior vena cava and on the left to the menofthesuperiormediastinuminFig. 11.1 and the pulmonary trunk. Anteriorly, the ascending aorta is corresponding drawing (Fig. 11.2), wherein the ascend- covered by the appendage of the right , from the ing aorta is viewed from the anterior aspect. The anteri- left by the pulmonary trunk, and from the right by the or chest wall has been removed and the superior vena cave. The aforementioned fat-tissue con- opened to secure adequate exposure of the anterior sur- densation elevates the epicardium from the anterior face of the heart. In the presented case, the entire anteri- wall of the aorta, forming a semicircular plica, as seen or sheath of the pericardium has been removed, sparing clearly on Fig. 11.1.Thefoldofthetransitionbetween the left and right phrenic nerves on the lateral surfaces the pericardium and the epicardium may be found on of the pericardium. The superior lobes of the right and the superior part of the ascending aorta, just before the leftlungshavebeenretracted.Theinitialpartoftheas- junction with the aortic arch. Note that the ascending cending aorta is positioned behind the infundibulum aorta is contained within the pericardium and is en- (Figs. 11.1 and 11.2). This initial part is viewed from the closed in a tube of serous pericardium, which it shares posterior aspect and is surrounded by the left and right with the . On the presented specimen, atria. Here, the ascending aorta causes a furrow on the this is seen as oblique line running along the anterior surfaces of both atria. The incisure on the right medial wall of the ascending aorta, from right to left, from infe- wall of the right atrium is particularly prominent and is rior to the brachiocephalic artery, inferior toward the seen clearly on the cross section of the mediastinum pulmonary trunk (Figs. 11.1 and 11.2). presented in Fig. 11.3 and the corresponding drawing (Fig. 11.4). Note here that the ascending aorta is inspect- edfromthesuperioraspect.Thesamesituationisseen on Figs. 12.4 and 12.5, wherein the ascending aorta is seen from an inferior view. The part of the ascending aorta positioned inferior to the pulmonary artery is covered by the epicardial fat tis- sue.Thepresenceofthiscondensationoffatischarac- teristic and is found in every heart, independent of the 458 11 Surgical Anatomy of the Aorta

Left Internal thoracic Right Sternocostal Superior Pectoralis auricle artery/vein auricle joint vena cava major

APS RPS Superior lobe Superior lobe LPS

Right superior pulmonary Left superior vein pulmonary Superior vein lobar artery

Right Superior superior lobar artery lobar bronchi

Inferior lobe Superior lobe

Left superior Descending Hemi-azygos Spinal cord, Thoracic Esophagus Azygos lobar bronchi aorta vein dura mater, duct vein epidural space Fig. 11.3. Horizontal cross section of the thorax at the level of the sinotubular junction, superior view

Sternum Pectoralis major Internal Sternocostal joint thoracic artery and vein Right auricle Superior lobe Superior lobe

Superior vena cava Left auricle Right superior Left superior pulmonary vein pulmonary vein Superior Left superior lobar artery lobar bronchi Superior Right superior lobar artery lobar bronchi Esophagus Azygos vein Descending Hemi-azygos vein aorta Inferior lobe Thoracic duct Spinal cord, dura mater, Inferior lobe epidural space

Fig. 11.4. Horizontal cross section of the thorax at the level of the sinotubular junction, superior view, schematic drawing 11.1 The Aortic Arch 459

In the next specimens, the ascend- ing aorta will be viewed from the Left vagal left aspect in order to establish the Brachioce- nerve detailed topography and its rela- phalic trunk Recurrent tionship to the other anatomical laryngeal structures (Figs. 11.5 and 11.6). On nerve Aortic arch the dry-dissected specimen in Fig. Ligamentum Superior 11.5 and the corresponding sche- arteriosum vena cava matic drawing in Fig. 11.6,the Left pulmo- ascending aorta and the aortic root nary artery areseenfromtheleftanterolateral Phrenic nerve, view. The pulmonary trunk has pericardiaco- phrenic vein been dissected so that the superior Right auricle dissection line is positioned infe- Left auricle Ascending rior to its bifurcation into the left aorta Left main and right main pulmonary arteries. trunk The inferior dissection line is posi- Pulmonary Circumflex tioned in the pulmonary root. The root branch sinuses of the pulmonary bulb have Diagonal been removed, leaving only the branch Anterior three intervalvular triangles and interventri- Great cardiac the commissures in situ. Thus, the cular branch vein space behind the pulmonary trunk Right may be investigated. This is effec- tivelythespaceofthetransverse pericardial sinus, which is in- spected from the anterior direction Fig. 11.5. Ascending aorta, left anterior view. Arrows indicate the pericardial transition (Fig. 11.6). Note that the left main stem and the bifurcation have also been brought into the view using this exposure. The appendage of the left atrium has been retracted. Brachiocephalic trunk

In this specimen, it is clear that the Right brachiocephalic vein Common carotid artery pulmonary root and the infundibu- Left subclavian artery lum are positioned in front of the aortic root and the conjoined part Right phrenic nerve of the ascending aorta. Here, the ascending aorta is a direct continu- Superior vena cava ation of the aortic root and the axis Transverse of the left ventricle. From here on, Ascending aorta pericardial sinus thecourseoftheascendingaorta Pulmonary trunk describes a slight curve, which is directed upward, forward, and to Right auricle Right ventricle the right (Fig. 11.5). At the level of the junction between the superior vena cava and the right atrium, the ascending aorta reaches the most extreme right position, from which point the aorta travels in the frontal plane upward and to the left, toward Fig. 11.6. Ascending aorta, anterior view, schematic drawing the aortic arch. The mentioned