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Precapillary Systemic-Pulmonary Anastomoses Thorax: first published as 10.1136/thx.18.3.225 on 1 September 1963. Downloaded from Thorax (1963), 18, 225 Precapillary systemic-pulmonary anastomoses MARGARET TURNER-WARWICK From the Institute of Diseases of the Chest, London, S.W3 In normal lungs the bronchial arteries communi- ran distally, lying in convolutions on the wall of cate with the pulmonary arteries through the the bronchus, and ended in ramifications of the capillary bed surrounding the respiratory pulmonary artery. The 'superficial' communica- bronchioles (Miller, 1947). Whether precapillary tions were not described in detail but were believed communications exist in normal lungs is open to to occur between the bronchial arteries lying in question, but their development under abnormal the interlobular septa and branches of the circumstances is generally agreed. Liebow, Hales, pulmonary artery. Harris and Heath (1962), using and Bloomer (1959) have summarized the two histological methods, were unable to confirm main circumstances under which they have been Verloop's finding of 'deep' anastomoses, and other found: (a) obstruction and diminished flow in the workers using injection techniques have also failed pulmonary arteries, and (b) formation of new to demonstrate these anastomoses in normal lung tissue in the lung. (Cudkowicz and Armstrong, 1951; Weibel, 1959). Many different anatomical forms of systemic- pulmonary anastomoses can be found in the lung, ABNORMAL LUNGS (CONGENITAL HEART DISEASE AND but hitherto only a few of these have been ACQUIRED LUNG DISEASE) described in detail owing to the limitations of the Pulmonary stenosis Hales and Liebow (1948) copyright. techniques used. Cast preparations have been of described two forms of anastomoses in lungs from great value in identifying the larger communica- cases of pulmonary stenosis. One type was found tions, but this method has two disadvantages. close to the hilum, where a major bronchial artery Firstly, histological verification of anastomoses is branch connected directly with the accompanying impossible, and close apposition of minute vessels segmental axial pulmonary artery in an end-to-side manner. More end-to-side communica- may be indistinguishable from their actual peripheral http://thorax.bmj.com/ continuity. Secondly, the histological study of tions were also reported, the bronchial artery vessel wall structure and the surrounding tissue joining a lobular branch of the pulmonary artery. is denied. Angiographic studies of whole lungs Pulmonary artery occlusion In experimental have been of limited value because systemic- pulmonary artery ligation in dogs, peripheral pulmonary anastomoses cannot be distinguished anastomoses have been found between bronchial from superimposition of non-communicating artery branches and lobular pulmonary arteries vessels. similar in form to those seen in congenital In the present work a microradiographic pulmonary stenosis (Liebow, Hales, Bloomer, technique has been developed to study the finer Harrison, and Lindskog, 1950; Cockett and Vass, on September 26, 2021 by guest. Protected branches of the bronchial arteries and their sites 1951). of communication with the pulmonary vascular At sites of thrombotic obstruction of the bed. The findings have been verified by serial pulmonary artery Cudkowicz and Armstrong sections. (1953a) have described an entirely different form of anastomosis. Vasa vasorum (from the systemic circulation) were found penetrating the pulmonary THE MORPHOLOGY OF PREVIOUSLY DESCRIBED arterial wall to establish continuity with its lumen. SYSTEMIC-PULMONARY ANASTOMOSES They believed that acquired bronchopulmonary anastomoses seen in many lung diseases were NORMAL LUNGS Verloop (1948) studied the formed in this way. histology of normal lungs and described two forms Bronchiectasis Anastomoses of two types have of anastomoses. 'Deep' communications were been described. A proximal type was found at the described in the neighbourhood of small bronchi, level of the third to sixth generation bronchus where the thick-walled bronchial artery gave rise where the axial pulmonary artery joined the to a thin-walled lateral 'connecting' vessel which accompanying bronchial artery through a distinct 225 Thorax: first published as 10.1136/thx.18.3.225 on 1 September 1963. Downloaded from 226 Margaret Turner-Warwick connecting vessel which linked the parallel arteries RESULTS like the strut of a ladder. More distally, anasto- moses have been found in relation to bronchiectatic CONGENITAL PULMONARY STENOSIS Nine lungs sacs (Liebow, Hales, and Lindskog, 1949; Cockett have been studied from patients with Fallot's and Vass, 1951). tetralogy with severe pulmonary stenosis. Systemic- Many other workers using injection techniques pulmonary connexions were demonstrated in all have demonstrated the presence of broncho- cases, but the number found in individual lungs pulmonary connexions in abnormal lungs by varied considerably. This variability has been noted observing overflow of medium from the systemic before by Hales and Liebow (1948). to the pulmonary circulation, but the morphology The largest anastomoses were found between of these anastomoses was not usually described branches of the systemic arteries lying on the in detail. visceral mediastinal pleura and peripheral pulmonary arteries. The majority of these pleural TERMINOLOGY branches were derived from true bronchial arteries which entered the lung with the main bronchi at In this paper the term 'systemic arterial supply' the hilum and reached the mediastinal surface to the lungs refers to all vessels supplying the lung through the interlobular septa. Thereafter these arising directly or indirectly from the aorta, and branches radiated over the mediastinal surface includes both the bronchial arteries reaching the lying immediately under the visceral pleura. From lung on the posterior wall of the main bronchi at this surface network lateral branches, 200-400 /s the hilum, and the accessory arteries reaching the in diameter, were found which communicated end lung through the hilum and the pulmonary to end with underlying branches of the pulmonary ligament. artery. The pulmonary components of these 'Subpleural systemic-pulmonary anastomoses' anastomoses were larger than the other branches means the precapillary connexions between the of the pulmonary artery in the immediate vicinity; systemic and pulmonary arteries lying immediately this feature simplified the identification of thesecopyright. under the visceral pleura. The systemic component 'isolated' subpleural systemic-pulmonary anasto- may arise either from the bronchial arteries which moses (Fig. la). reach the pleura along the interlobular septa or Anastomoses of identical form were also found from the accessory arteries reaching the pleura between accessory systemic arteries which reached through the pulmonary ligament. the lung through the pulmonary ligament. For 'Intrapulmonary systemic-pulmonary anasto- this reason the greatest numbers of subpleural http://thorax.bmj.com/ moses' means the precapillary connexions between systemic-pulmonary anastomoses were found over the systemic and pulmonary arteries lying within the mediastinal aspect of the lower lobes, in the the substance of the lung. region where these accessory vessels entered the lung. The majority of communications were found within 5 cm. of the hilum, but occasional ones MATERIAL AND METHODS were identified over the entire mediastinal surface. Although the largest anastomoses were about 400 ju A total of 118 lungs have been studied from 64 in diameter, innumerable smaller ones were patients with various lung and cardiac diseases. dissected. In the absence of pleural adhesions. on September 26, 2021 by guest. Protected The systemic arteries to the lung were injected with a suspension of barium sulphate as 80%, 'Micropaque' FIG. 1 (opposite). Fallot's tetralogy. The systemic arteries (Demancey) in 15%1 gelatin. After fixation in 10% only have been injected and the pulmonary arterial bed formalin, sagittal slices of individual lung lobes were filled through systemic-pulmonary anastomoses. (a) cut 0 5 cm. thick and studied using a microradio- Tortuous systemic arterial branches under the visceral graphic technique described previously (Turner- mediastinal pleura of the lung; one branch is shown Warwick, 1961). Using this method, vessels of 30 ju forming an 'isolated' end-to-end anastomosis with a and greater were filled regularly, but capillaries peripheral branch of thepulmonary artery. (b) A bronchial remained uninjected. artery branch is shown leaving its accompanying In 15 normal lungs, no filling of the pulmonary pulmonary artery, running outwards into the surrounding arterial bed occurred after injection of the bronchial lung tissue to communicate with a distant pulmonary arteries, indicating that no precapillary systemic- artery branch. (c) A bronchial artery branch is shown pulmonary anastomoses were present in healthy communicating end-to-end with a lateral branch of the lungs. In abnormal lungs anastomoses were found accompanying pulmonary artery. Serial section con- frequently, and the different morphological types will firmed that the vessel changedfrom systemic to pulmonary be described. type at the point marked in the diagram (level 2). Thorax: first published as 10.1136/thx.18.3.225 on 1 September 1963. Downloaded from Precapillary systemic-pulmonary anastomoses 227 Systemic pleural arteries Pulmonary artery FIC. I a Pulmonary artery copyright. http://thorax.bmj.com/ FiG. l b on
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