CAROTID ARTERIES — the pair arteries of elastic type which are carrying out blood supply of the head and the most part of a neck.
General S. and. are differentiated at a germ from a part of ventral aortas between III and IV branchiate arteries. On a further extent ventral aortas between I and III branchiate arteries will be transformed to outside S. and. Internal S. and. develop from the third pair of branchiate arteries and from parts of a dorsal aorta between I and III branchiate arteries.
By the time of the birth internal S. and. forms the first bend in a cavernous sine.
Right general S. and. (and. carotis communis dext.) departs from a brachiocephalic trunk (truncus bra-chiocephalicus) at the level of the right grudinoklyuchichny joint; left the general Page a. (. carotis communis sin.) — from an aortic arch (see), it is 20 — 25 mm longer than right. General S. and. leave a chest cavity through an upper chest opening and go up in fascial okolososudisty vaginas on the parties from a trachea and a gullet, and then — throats and drinks. Lateral-nee the internal jugular vein, a chain deep cervical limf, nodes, between vessels and behind — a vagus nerve, in front — an upper root of a cervical loop are located. The scapular and hypoglossal muscle crosses the general S. and. in an average third (tsvetn. fig.). Kzadi at the level of bottom edge of a cricoid on a cross shoot of the VI cervical vertebra is a sleepy hillock (Shassenyak's hillock), press the general S. to Krom of ampere-second the purpose of a temporary stop of bleeding at its wound. At the level of the upper edge of a thyroid cartilage the general S. and. are divided into outside and internal S. and. Before division the general S. and. branches are not given.
Outside S. and. in proximal department it is covered grudino - a clavicular and mastoidal muscle, further it is in a sleepy triangle and is covered with a hypodermic muscle of a neck. Before the artery gets to a pozadinizh-not maxillary pole, in front of it cross a hypoglossal nerve, a pricker - a hypoglossal muscle and a back abdomen of a biventral muscle. Lie an upper guttural nerve with shi-loyazychny and shiloglotochny muscles more deeply, to-rye separate outside S. and. from internal. Above the muscles which are attached to an awl-shaped shoot, the artery gets into thickness of a parotid gland. Medialny necks of a joint shoot of a mandible it is divided into final branches — a superficial temporal artery and a maxillary artery.
Front branches of outside S. and. are an upper thyroid artery (a. thyroidea sup.), from a cut the upper guttural artery departs (a. laryngea sup.), a lingual artery (a. lingualis) and a facial artery (a. facialis) sometimes having the general beginning with a lingual artery. Back branches of S. and. — grudino - a clavicular and mastoidal artery (a. ster-nocleidomastoidea), krovosnabzhayushchy the muscle of the same name, an occipital artery (a. occipitalis) and a back ear artery (a. auricularis post.). A medial branch — the ascending pharyngeal artery (a. pharyngea ascendens), a final superficial temporal artery (a. temporalis superficialis) and a maxillary artery (a. maxillaris).
Thus, outside S. and. vascularizes head skin, mimic and masseters, sialadens, an oral cavity, a nose and a middle ear, language, teeth, partially firm meninx, a throat, a throat, a thyroid gland.
Internal Page a. (. carotis int.) begins from bifurcation of the general carotid artery at the level of the upper edge of a thyroid cartilage and rises to a base of skull. In a neck internal S. and. is in structure of a neurovascular bunch together with an internal jugular vein (v. jugularis int.) and vagus nerve (n. vagus). Medially the artery is bent around by an upper guttural nerve, in front — the facial vein, a back abdomen of a biventral muscle, a hypoglossal nerve cross, from to-rogo in this place the upper root of a cervical loop departs. Right at the beginning internal S. and. lies knaruzh from outside S. and., but soon comes over to the medial side and, going vertically, is located between the throat and muscles which are attached to an awl-shaped shoot. Further the artery is bent around by a glossopharyngeal nerve.
In shank bore S. and. passes through the sleepy channel where it is accompanied nervous also by veniplexes (plexus caroticus int. et plexus venosus caroticus int.). According to the course of the sleepy channel internal S. and. does the first bend forward and inside, then in a sleepy furrow the second bend — up. At the level of the Turkish saddle the artery is bent kpered. Near the visual channel internal S. and. forms the fourth bend up and kzad. It lies in this place in a cavernous sine. Having passed through a firm meninx, the artery is located in subarachnoid space on a lower surface of a brain.
Conditionally internal S. and. divide into four parts: cervical (pars cervicalis), stony (pars petrosa), cavernous (pars cavernosa) and brain (pars cerebralis). The first branches departing from internal S. and. in the sleepy channel, caroticotympanic branches are (rr. caroti-cotympanici), to-rye pass in the tubules of a pyramid of the same name of a temporal bone and krovosnabzhat a mucous membrane of a drum cavity.
In a cavernous sine the artery gives a number of the small branches vascularizing its walls, a trigeminal node and initial parts of branches of a trifacial. After escaping of a cavernous sine the eye artery (a. ophthalmica), a back connecting artery depart from an internal carotid artery (a. communicans post.), front fleecy artery (. choroidea ant.), average brain artery (. cerebri med.) and front brain artery (. cerebri ant.).
Internal S. and. vascularizes a brain and its firm cover (see. Cerebral circulation), an eyeglobe with the auxiliary device, skin and muscles of a forehead.
Internal S. and. has an anastomosis from outside S. and. through a dorsal artery of a nose (a. dorsalis nasi) — a branch of an eye artery (a. ophthal-mica), an angular artery (a. angularis) — a branch of a facial artery (a. facialis), a frontal branch (of frontalis) — a branch of a superficial temporal artery (a. temporalis superficialis), and also with the main artery (and. A-silaris), formed of two vertebral arteries (aa. vertebra-les). This anastomosis is of great importance for blood supply of a brain at switching off of an internal carotid artery (see the Brain, blood supply).
General S.'s innervation and. and its branches it is carried out by the postganglionic fibers departing from upper and average cervical nodes of a sympathetic trunk and forming a texture around vessels — plexus caroticus communis, plexus caroticus ext., plexus caroticus int. The average cardiac nerve departs from an average cervical node of a sympathetic trunk, to-ry participates in the general S.'s innervation and.
Gistol. structure of a wall of S. and. and its blood supply — see Arteries. With age in S.'s wall and. there is a growth of connecting fabric. After 60 — 70 years in an internal cover focal thickenings of collagenic fibers are noted, the inner elastic membrane becomes thinner, limy deposits appear.
Methods of a research
by the Most informative methods of a research C. and. are arteriography (see), an electroencephalography (see), ultrasonic investigation (see. Ultrasonic diagnosis), a computer tomography (see the Tomography computer), etc. (see Blood vessels, methods of a research).
Pathology is caused by malformations of S. and., damages and a number of diseases, at to-rykh the wall of arteries is surprised.
Malformations meet seldom and usually have character patol. crimpinesses and S.'s petlistost and. Form and crimp frequency of S. and. happen different; it is most often observed patol. general and internal S.' crimpiness and. (fig. 1, a). Besides, various variations and S.'s anomalies meet and. So, sometimes carotid arteries have the general trunk (truncus bicaroticus) departing from an aortic arch. The brachiocephalic trunk can be absent, then right the general sleepy and right subclavial arteries depart from an aortic arch independently. Also topographical options connected with anomalies of development of an aortic arch (see) meet.
In rare instances from the general S. and. thyroid arteries depart top and bottom (aa. thyroid eae sup. et, inf.), the pharyngeal ascending artery (a. pharyngea ascendens), a vertebral artery of fa. vertebra-lis). Outside S. and. can directly begin from an aortic arch. In exceptional cases it can be absent, at the same time its branches depart from the artery of the same name passing on the other hand or from the general S. and. Number of branches of outside S. and. can vary. Internal S. and. very seldom is absent on one party; in this case it is replaced by branches of a vertebral artery.
In some cases at malformations of S. and., followed by disturbance of blood supply of a brain, operational treatment is shown (see below).
Damages are possible as a result of a gunshot wound of S. and., its injuries, napr, a knife or at operative measures on a neck, are also followed by massive acute blood loss, thrombosis and education пульсирз^ющей hematomas with the subsequent development of false aneurism (see).
At an operative measure concerning S.'s wound and. in the beginning bare its proximal department, and then distal. Only after crossclamping by atraumatic clips of proximal and distal departments of an artery bare area of a wound, impose ligatures above and lower than the place of damage, a side vascular seam or a patch. In cases of formation of a posttraumatic carotid and cavernous anastomosis make operations on its switching off (see. Arterio-sinusnye of an anastomosis , carotid and cavernous anastomosis).
Stage treatment of fighting damages of S. and. it is carried out by the same principles, as at damages of other blood vessels (see Blood vessels, fighting damages. stage treatment).
Diseases. The diseases leading to defeat of a wall of S. and., various forms of nonspecific arteritis, atherosclerosis, a fibromuscular dysplasia and extremely seldom syphilitic aortitis are (see).
At patients with rheumatic heart disease with thrombosis of the left ear or left ventricle of heart in the presence of a ciliary arrhythmia, and also at patients with the postinfarction macrofocal cardiosclerosis complicated by aneurism of heart and a ciliary arrhythmia S.'s thromboembolism can be observed and., edges sometimes is followed by focal brain symptomatology (see. Thromboembolism ).
Nonspecific arteritis (see. Takayasu syndrome ) occupies one of the central places among defeats of a brachiocephalic trunk (fig. 1,6). According to B. V. Petrovsky, I. A. Belichenko, V. S. Krylov (1970), it occurs at 40% of patients with occlusal defeats of branches of an aortic arch, and no more than 20% from them have S.'s defeat and. Nonspecific arteritis is observed at women by 3 — 4 times more often than at men; usually it arises aged up to 30 years, however meets also at children's, and advanced age. Its etiology is completely not found out. In a crust, time consider that nonspecific arteritis is a general disease of allergic and autoallergichesky character with tendency to defeat of a wall of arterial vessels of muscular and elastic type. Defeat of all layers of a wall of an artery comes to the end with a productive panarteritis, tromboendovaskulity, with disorganization and disintegration of an elastic framework and a full obliteration of a vessel. Quite seldom final stage of development of nonspecific arteritis of S. and. formation of true aneurism as a result of destruction of an elastic membrane of a vessel against the background of arterial hypertension is. Most often the proximal department of the general S. is surprised and., and internal and outside S. and. remain passable. In patol. process at nonspecific arteritis other arteries can be also involved (see. Arteritis , Arteritis giant-cell ).
S.'s atherosclerosis and. occurs at men by 4 — 5 times more often than at women. A wedge, the displays of a disease caused by their stenosis or occlusions develop, as a rule, at aged people of 40 — 70 years. Morfol. a picture at atherosclerosis (see) it is characterized by adjournment of lipids in an internal cover of a vessel, formation of atherosclerotic plaques with the subsequent their calcification and an ulceration. At an ulceration of an atherosclerotic plaque the artherothrombosis and embolisms of a peripheral bed are quite often observed by atheromatous masses. Owing to destruction of an elastic framework of a vessel true aneurisms can develop. The important factor promoting development of true aneurisms of S. and., existence at the patient of arterial hypertension is. Most often at the ateroskl to a rose the stenosis sleepy are * teriya in the field of the general S.'s division develops and. on internal and outside (fig. 1, c), and also in ekstrakranial-ny departments of internal S. and. Due to the system developmental character of atherosclerosis only one S.'s defeat extremely seldom comes to light and. The bilateral process leading to occlusion and also existence of an atherosclerotic stenosis and occlusions in an aorta and the main arteries of other bodies is more often observed.
There are messages on S.'s defeat more and more and. as the fibromuscular dysplasia which is observed at women at the age of 20 — 40 years. Nek-ry researchers connect this disease with an inborn dysplasia of smooth muscle cells of a wall of an artery, others — are inclined to consider this disease acquired. Morphologically at a fibromuscular dysplasia the fibrosis of a muscular layer of a wall of an artery, sites of a stenosis alternating with sites of aneurysmal expansions are found. In some cases it is found or stenosing, or aneurysmal forms of a fibromuscular dysplasia. The most often fibromuscular dysplasia is observed in ekstrakranialny departments of S. and., and quite often there is a bilateral defeat.
S.'s stenosis and. it can be caused by also ekstravazalny factors, among to-rykh the most frequent the tumor of carotid gland — a hemodektom is (see the Paraganglioma). It is extremely seldom possible to observe an ekstravazalny prelum of S. and. the tumors of a neck and cicatricial processes which are a consequence of an inflammation and injuries in this area.
Feature of the stenosing defeats of a brachiocephalic trunk, and in particular S. and., discrepancy between a wedge, manifestations of disturbance of blood supply of a brain and expressiveness of the stenosing process in arteries is. It is caused by great compensatory opportunities for cerebral circulation, feature to-rogo existence of a set of collateral ways is (see Collaterals vascular). Critical extent of narrowing of S. and., at a cut there can come the phenomena of insufficiency of blood supply of a brain, reduction of its gleam more than for 75% is. However such degree of a stenosis of S. and. and even its occlusion not always result in acute insufficiency of blood supply of a brain about a wedge, a picture of disturbance of cerebral circulation (see). At S.'s defeats and. distinguish four a wedge, stages of ischemia of a brain: I \asimptom-ny, II — tranzitorny, III — hron. brain vascular insufficiency, IV — the residual phenomena of disturbance of cerebral circulation. Treatment of occlusal and stenotic defeats of S. and. depends on a stage of the ischemia of a brain which is important for definition of indications to an operative measure (see below).
B 30 — are the 40th 20 century the only interventions, to-rye were carried out during the narrowing and full occlusion of S. and., there were operations on a sympathetic nervous system. First successful recovery internal S.'s thrombosis operation and. executed in 1953 t. M. De Veca. In the USSR the first similar operation was manufactured in 1960 by B. V. Petrovsky. Recovery operations on S. and. at their pathology became feasible in connection with development of an angiography, anesthesiology, reconstructive surgery of vessels, development of new atraumatic tools, improvement of methods of protection of a brain against ischemia.
On S. and. perform alloyed and recovery operations. Refer bandaging of an artery in a wound to alloyed or on an extent (see Bandaging of blood vessels) and a resection of an artery. The side and circular vascular seam, patch of an artery, intimtromb-ektomiya with the subsequent vascular seam or a patch, prosthetics and continuous bypass shunting of an artery are among recovery operations.
Operations on S. and. carry out in position of the patient on spin with the roller under shovels, turn the head of the patient aside, opposite to the party of operation. The section of skin is carried out on an inner edge grudino - clavicular sostsevid-ache muscles from a mastoid to the handle of a breast (fig. 2). In nek-ry cases when intervention on proximal departments of the general carotid artery is necessary, carry out in addition partial sternotomy (see. Mediastinotomy ).
The right choice of anesthesia and protection of a brain against ischemia is very important. For the solution of a question of a possibility of operation on S. and. without protection of a brain against ischemia data on a condition of a blood-groove in a villiziyevy circle matter (an arterial circle of a great brain, T.), S.'s crossclampings received by means of functional trials and. (see. Training of collaterals ) at an ultrasonic floumetriya (see. Ultrasonic diagnosis). Special significance is attached at the same time to a condition of the collateral vessels connecting the right and left S.'s systems and. If is exposed to reconstruction only struck, but passable S. and. (at occlusion another), protection of a brain against ischemia is shown.
On the eve of operation sick appoint neuroleptics, tranquilizers and antihistaminic drugs. In 40 min. prior to operation intramusculary enter 0,3 mg! kg of Promedolum, 0,2 mg! kg of Seduxenum, 0,5 mg! kg of Pipolphenum and 0,3 — 0,5 mg of atropine. This premedication renders good tranquilizing effect and promotes smooth carrying out induction. For induction use a technique of the combined introduction anesthesia Seduxenum and fentanyl: against the background of inhalation of nitrous oxide and oxygen in the ratio respectively 2:1 enter fractionally in 2 — 3 min. on 2 — 3 mg of Seduxenum, to-ry possesses anti-hypoxemic action. After the first dose of Seduxenum enter 0,004 mgyg fentanyl. Sufficient degree of anesthesia comes usually after introduction of the general dose of Seduxenum of 0,17 — 0,2 mg! kg. Just before an intubation of a trachea enter 0,004 mg/kg of fentanyl. Duration of induction makes 11 — 13 min. Anesthesia is supported by Ftorotanum (0,25 — 0,5 about. %) and mix of nitrous oxide with oxygen in the ratio 2:1 in combination with fractional administration of fentanyl. During anesthesia exercise constant control of EEG. Before operation within 5 min. probno press S. and. below the site of defeat; at the same time carry out constant registration of EEG (see Elektroentsefalografiya), reo-encephalograms (see the Rheoencephalography) and an elektromanometriya distalny a clip. At normal indicators of EEG, reoentsefalo-grams and pressure in an artery distalny a clip, equal 40 mm of mercury. and more, use of methods of protection of a brain is inexpedient. Emergence on EEG of incorrectly alternating teta-waves or decrease in a voltage of all registered potentials is the indication to acceptance of additional measures of protection of a brain from ischemia.
There are two essentially various ways of protection of a brain against ischemia: 1) preservation of a blood-groove in a brain by means of internal or outside shunting by synthetic tubes or prostheses for S.'s reconstruction and.; 2) reduction of oxygen consumption by tissues of a brain at the expense of a local hypothermia. For this purpose use a kraniotserebralny hypothermia (see the Hypothermia artificial) by means of the device «Cold-2f». Begin it right after induction, reducing temperature to 30 — 31 ° in outside acoustical pass that corresponds to temperature of a brain 28 — 29 °. For blockade of thermal control and removal of vasoconstriction in addition to total curarization enter Droperidolum in a dose of 2,5 — 5,0 mg. At a stage of reconstruction of arteries carry out also measures for improvement of a blood-groove and supply of a brain with oxygen at the expense of the moderate hypercapnia and hypertensia got by increase rs02 and reduction of depth of anesthesia.
Because the hypothermia leads to significant increase in viscosity of blood and deterioration in perfusion of fabrics, carry out transfusions of solutions of glucose, a reopoliglyukin, Polyglucinum, trying to obtain decrease in a hematocrit to 30 — 35%. After carrying out the main stage of an operative measure of the patient warm at first through a helmet of the device «Cold-2f», and then warm air by means of the hair dryer. During this period pay attention to correction of a possible metabolic acidosis (see) owing to the increasing consumption by fabrics of oxygen in connection with fervescence. Active warming is made gradually to 36 °. Further warming of the patient up to the standard temperature happens in intensive care unit. Carry out prevention of a gipertermi-chesky syndrome to this period (see) and cerebrospinal hypertensia by introduction of Suprastinum and Droperidolum. If hypertensia remains, despite use of the specified means, apply nitroglycerine in the form of 1% of spirit solution under language to pressure decrease, about 0,6 mg (4 drops). The ABP level is supported at normotonik at the preoperative level, and hypertensive persons — at the level of 150/90 have 160/95 mm of mercury.
At recovery operations the arteriotomy is carried out after crossclamping of an artery atraumatic clips proksimalny and distalny patholologically the changed site. S.'s arteriotomy and. can be longitudinal (most often), cross or slanting depending on character patol. process and purpose of operation. The size of a section of an artery depends on the estimated volume of intravascular intervention. Most often an operative measure on S. and. carry out at an atherosclerotic stenosis or full occlusion. Most often at this pathology make an intimtromb-ektomiya — a trombendarteriektomiya (see Atherosclerosis, surgical treatment of occlusal defeats, the Thrombectomy). Carry out a longitudinal arteriotomy in the place of narrowing and delete an atherosclerotic plaque together with the changed internal cover of a vessel. The great value is attached at the same time to prevention of a wraparound of an otsloyenny internal cover of a vessel in - the distal end of a wound. For this purpose after crossing of an internal cover in transverse direction it is fixed seams to other layers of a vascular wall. If S.'s diameter and. in a zone of an intimtrombekto-miya it is rather big, the section of an artery is sewn up with a side seam (see. Vascular seam). Otherwise for the purpose of prevention of narrowing coal mine C. and. close by means of a patch from an autovena or a vascular prosthesis.
When atherosclerosis with calcification is led to final fracture of a wall of an artery, it is more preferable to make a resection of the stenosed site with the subsequent autovenozny prosthetics of a remote part of a vessel since at use of synthetic vascular prostheses various complications are much more often observed (thrombosis of a prosthesis, suppuration with the subsequent arrosive bleeding and a so-called vygnaivaniye of a prosthesis). As plastic material usually use the site of a big saphena of a leg.
At nonspecific arteritis of S. and., when patol. process covers all layers of a wall of an artery and it is not possible to execute operation of an intimtrombekto-miya, the most preferable and safe continuous bypass autovenozny shunting is considered (see Shunting of blood vessels). For successful functioning of the shunt the proximal anastomosis of an artery and an autovena impose in the place which is not struck patol. process. A distal anastomosis of an autovena with S. and. quite often impose the end in the end. If for S.'s reconstruction and. the artificial vascular prosthesis is applied, it is necessary to pay special attention to care of a hemostasis and drainage of a wound for prevention of formation of para-prosthetic hematomas, to-rye can be the cause of inflammatory infiltrates and suppurations.
More than in 30% of operations to recover the main blood stream in S. and. it is impossible. In these cases it is necessary to be limited to the intervention improving collateral circulation — excision of a segment of the thrombosed (obliterated) internal S. and. across Lerish. In nek-ry cases recommend to carry out also a gangliectomy (see).
In recent years there are messages on use of a method of the dosed internal dilatation of ekstrakranialny departments of S. and. by a transdermal puncture of a femoral artery on Seldingera (see. Seldingera method ) and the subsequent carrying out a catheter with the cylinder which is inflated on its end in a branch of an aortic arch under X-ray television: control (see. X-ray endovascular surgery). The main advantage of this method consists in an opportunity to avoid an operative measure at patients with high risk of operation (advanced age, existence of serious, associated diseases).
The most frequent complications arising during operations on S. and., development of heart failure and arterial hypotension is (see Hypotension arterial). Treatment of heart failure (see) is carried out by cardiac glycosides, diuretic drugs, small doses of nitroglycerine, sometimes in combination with Isadrinum (Isoproterenolum) or a dopamine, according to indications apply artificial ventilation of the lungs (see. Artificial respiration ) with positive pressure at the end of an exhalation. The most serious complication — emergence or deepening in the postoperative period nevrol. symptoms owing to ischemia of a brain, an embolism or thrombosis of vessels (see the Stroke). Repeated operation in case of thrombosis or an embolism quite often leads to full regress nevrol. symptoms. In case of ischemia of a brain in the postoperative period all efforts shall be bent on prevention and treatment of wet brain (see Hypostasis and swelling of a brain). The encouraging results at the same time are received thanks to use of hyperbaric oxygenation (see).
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M. D. Knyazev; H. V. Krylova (An., embr.), M. H. Seleznyov (anest.).