SUBCLAVIAL ARTERY

From Big Medical Encyclopedia

SUBCLAVIAL ARTERY [arteria subclavia (PNA, JNA, BNA)] — the large vessel supplying with blood occipital shares of hemicerebrums, a medulla, a cerebellum, a cervical part of a backbone and spinal cord, deep muscles of a neck, partially bodies of a neck, a shoulder girdle and an upper extremity.

Anatomy

Fig. 1. Diagrammatic representation of subclavial vessels: 1 — the left general carotid artery, 2 — the left internal jugular vein, 3 — a back scalene, 4 — a front scalene, 5 — an average scalene, 6 — the left subclavial artery, 7 — the left subclavial vein, 8 — an internal chest artery, 9 — an aortic arch, 10 — an upper vena cava, 11 — a brachiocephalic trunk, 12 — the right subclavial vein, 13 — the right subclavial artery, 14 — the I edge, 15 — the right internal jugular vein, 16 — the right general carotid artery; the large vessels adjacent to a breast and edges are shaded.

Both P. and. begin in an upper mediastinum: right P. and. — from a brachiocephalic trunk (truncus brachiocephalicus), and left — directly from an aortic arch; therefore it is longer right and an intrathoracic part it lies behind the left brachiocephalic vein (fig. 1). Item and. pass up and lateralno, forming slightly convex arch, edges bends around a dome of a pleura and a top of a lung. Having reached the I edge, P. and. gets into an interladder interval (spatium interscalenum) formed by adjacent edges of front and average scalenes. In an interladder interval the artery lies on the I edge. Having rounded during the escaping of an interladder interval the I edge, P. and. passes under a clavicle and enters in axillary pole (see) where passes into an axillary artery (a. axillaris).

For orientation in localization of damages of P. and. and the choice of rational quick access to it conditional division of P. is recommended and. on three departments: 1) intrathoracic — from the beginning of a vessel to an inner edge of a front scalene, 2) interladder — from internal to the outer edge of a front scalene, 3) clavicular — from the outer edge of a front scalene to the outer edge of the I edge. P.'s trunks and. differ in constancy of situation. Options of variability of situation P. have practical value and., connected with existence of an additional cervical edge.

P.'s trunks and. the second and third departments have a symmetric arrangement and are projected on both sides on the middle of a clavicle. Bifurcation of a brachiocephalic trunk is usually projected in the field of the upper edge of the right grudinoklyuchichny joint.

According to V. V. Kovanov and T. I. Anikina (1974), corner of an otkhozhdeniye of the left P. and. in 90% of cases does not exceed 90 °, and right in 88% it is equal 30 — 60 °. It is noted that the right P.'s diameter and. it is more than left — in 72% of cases it makes 10 — 12 mm whereas left in 62% — 7 — 9 mm.

Fig. 2. Topography of subclavial vessels: 1 — a thyroid gland, 2 — the left lower thyroid artery, 3 — the left internal jugular vein, 4 — a front scalene, 5 — the left general carotid artery, 6 — the left subclavial artery, 7 — the left subclavial vein, 8 — the I edge, 9 — the left brachiocephalic vein, 10 — a brachiocephalic trunk (arterial), 11 — the right general carotid artery, 12 — the right subclavial vein, 13 — an internal chest artery, 14 — the right internal jugular vein, 15 — the right subclavial artery, 16 — a cross artery of a neck, 17 — the right vertebral artery, 18 — a shchitosheyny trunk.

In the first department on the right to a front wall of P. and. prilezhit the right venous corner which is quite often intimately soldered by a fascia to P. and.; here the artery is crossed by the wandering and phrenic nerves passing ahead of it. Behind the recurrent guttural nerve lies in this area, and medially — the general originates carotid artery (see). Such syntopy of vessels and nerves in this zone creates considerable difficulties at operations on P. and. At the left ahead of P. and. are located the left brachiocephalic vein and chest channel (see). Nerves do not cross P. at the left and., and pass in parallel. In the first department from P. and. the following branches (fig. 2) depart: vertebral artery (. vertebralis), internal chest (. thoracica int.) and shchitosheyny trunk (truncus thyreocervicalis). The vertebral artery departs from P. and. directly at the place of its exit from a chest cavity also goes up, being located behind the general carotid artery, along a long muscle of a neck (m. longus colli) where enters a cross opening of the VI cervical vertebra. Internal chest artery (. thoracica int.) begins from a lower surface of P. and. at the level of an otkhozhdeniye of a vertebral artery. Going down, the internal chest artery passes behind a subclavial vein, enters a chest cavity and, being the covered cross muscle of a breast (m. transversus thoracis) and a pristenochny leaf of a pleura, goes down parallel to edge of a breast on a back surface of cartilages of the I—VII edges. The Shchitosheyny trunk departs from an anterosuperior surface of P. and. before its introduction in an interladder interval; it has length of 1,5 cm and at once is divided into the following branches: lower thyroid artery (. thyreoidea inf.); the ascending cervical artery (a. cervicalis ascendens); superficial branch (of superficialis) or superficial cervical artery (. cervicalis superficialis); a nadlopatochny artery (a. suprascapularis) passing on a front surface of a front scalene.

In the second department from P. and., from its back surface, only one branch — a costal and cervical trunk (truncus costocervicalis) which begins in an interladder interval of P. departs and. and soon is divided into two branches: deep cervical artery (. cervicalis profunda) and the highest intercostal artery (a. intercostalis suprema).

In the third department from P. and. after its exit from an interladder interval only one branch — a cross artery of a neck (a. transversa colli) also departs, edges is divided into two branches: ascending and descending.

Methods of a research

Methods of a research at various defeats of P. and. same, as well as other blood vessels (see. Blood vessels, methods of a research ). The wedge, methods — definition of extent of ischemic disturbances on an upper extremity (decolourization and the venous drawing of skin, trophic frustration, etc.), and also a palpation and auscultation of area of defeat of a vessel are widely used (lack of pulse on peripheral vessels, emergence of systolic or continuous noise, etc.). Assessment funkts, conditions of collateral circulation at P.'s damages and. Korotkova, etc. is carried out on the basis of Genle's tests (see. Collaterals vascular ). Tool researches (termopletizmo-, ostsillo-, a reovazografiya, a floumetriya, an ultrasonic dopplegrafiya, etc.) give the chance to objectively study a hemodynamics in P.'s pool and. Contrast rentgenol, methods allow to find character patol, changes of a vessel (partial or full occlusion, disturbance of an integrity, the nature of aneurism, the size of an aneurysmal bag, way of inflow and outflow of blood in it, etc.), and also to objectively study the available ways of collateral circulation. Radio isotope is less often applied angiography (see).

Pathology

Fig. 3. The roentgenogram of the contrasted gullet at abnormal an otkhozhdeniya of a subclavial artery (right slanting (projection): defect of filling is specified by an arrow) connected with the impression of a wall of a gullet caused by an atypical arrangement of an artery.

Malformations. Along with the angiodysplasias inherent to all blood vessels (see. Blood vessels, malformations ), a significant role in disturbance of blood supply of P. and. play various anomalies. So, some anomalies of an otkhozhdeniye of P. and. cause a prelum of a gullet, a cut it is found radiological in the form of triangular defect of filling of its (fig. 3). Clinically it is shown by continuous difficulty of passing of food on a gullet. Occasionally meets patol, the right P.'s crimpiness and., followed by ischemic frustration on an upper extremity (weakening of pulse on a beam artery, decrease in sensitivity, periodic pains in muscles of a hand, especially at an exercise stress). The same symptomatology is observed in the presence of additional, or so-called cervical, edges, at syndromes of the big and small pectoral muscles which are followed by a prelum of a gleam of P. and. Treatment, as a rule, operational. Forecast favorable.

Damages Item and. are the most frequent type of its pathology. Extremely seldom at a prelum of a thorax P.'s separation is observed and. from an aorta (usually in combination with injury of a backbone, a primary bronchus easy, etc.). The full break of subclavial vessels, a brachial plexus arises at a separation of all upper extremity together with a shovel. Such injury which is observed at: hit of a hand in the rotating device, usually leads to development shock (see); because of falling of ADG of closing of a gleam of the ends of an artery: and veins by the smashed edges of their wall of severe bleeding it can not be observed.

P.'s wounds and. in the Great Patriotic War of 1941 — 1945 made 1,8% of total number of injuries of the main arteries, and in 30,3% of cases also the simultaneous injury of nerves was observed. According to B. V. Petrovsky, at P.'s wounds and. injuries of lungs and a pleura were noted in 77% of cases. More Vg of wounds of P. and. were combined with fire fractures of bones — clavicles, edges, a humeral bone, a shovel, etc. Apprx. 75% of damages of subclavial vessels it was the share of wounds only to an artery, simultaneous wound of a subclavial artery and vein made apprx. 25%; outside bleeding at wound only P. and. it was observed in 41,7% of cases, at the combined wound of an artery and vein in 25,8%. The arising internal bleeding (in a pleural cavity) came to an end, as a rule, with a lethal outcome. Damages of various departments of P. and. have some features. So, wounds in the first department of P. and., is more often together with a vein, are the most life-threatening. At the left P.'s damages and. sometimes there is also an injury and a chest channel (see); damages to the second department are more often., than defeats in other departments, are followed by an injury brachial plexus (see). Pulsing hematoma (see) later wounds of P. and. developed in 17,5% of cases.

In peace time, according to specialized clinics of VMA, P.'s wound and. make 4% among injuries of all arteries, in 50% of cases they are combined with damage of a brachial plexus. Variety of the combined damages of P. and. and other anatomic educations their wedge, manifestations causes the following features. 1. The menacing massive primary bleeding (see), especially at wounds of a vessel in the first department. 2. Frequent arrozivny bleedings, to-rykh suppuration of the wound channel, damage of vascular walls by splinters of shells, osteomyelitis is fragments of bones the reason, at pulsing P.'s hematomas and. can lead to bystry death of the victim. 3. The constant possibility of a rupture of an arterial aneurysmal bag demanding careful overseeing by all changes of its size (suddenness of increase in a bag — a reliable and objective sign of a gap) and a hemodynamics. 4. The created P.'s aneurism and. it is shown by classical signs (see. Aneurism ): emergence systolic (at arterial) or continuous sistolodiastolichesky (at arteriovenous) the noise disappearing at a prelum of the proximal end; change of pulse on a beam artery; emergence at arteriovenous aneurism of the expanded venous drawing on a hand, a shoulder girdle, a chest wall, including and in subclavial area (see); the progressing increase of vegetative frustration (disturbance of sweating, a trophicity of skin, nails, growth of hair, etc.), especially in the presence of paresis, paralyzes and other phenomena of damage of a brachial plexus (see). At arteriovenous aneurism arisen because of constant dumping of an arterial blood into a venous bed patol, blood circulation causes the raised load of a myocardium with development of a cordial decompensation. To Yu. Yu. Dzhanelidze it was established that in a pathogeny and dynamics of her development the so-called fistulose circle, i.e. distance between an aneurysmal bag and cardial cavities matters; than it is shorter (especially at localization of aneurism on P. and., carotid arteries), the quicker there is a cordial decompensation.

At all types of damage of P. and., if the independent stop of bleeding or self-healing of aneurism is not observed, an operative measure is shown.

Fig. 4. The angiogram at a stenosis of a subclavial artery: a subtotal stenosis (it is specified by an arrow) the right subclavial artery with the expressed post-stenotic expansion of a vessel.
Fig. 5. The angiogram at sclerous aneurism of the right subclavial artery: sacculate expansion on border of the first and second departments of a subclavial artery (it is specified by an arrow).

Diseases. Inflammatory process of P. and. — arteritis (see), aortoarteriit — it is clinically shown by an occlusal syndrome (see. Obliterating defeats of vessels of extremities ), the hl results. obr. atherosclerosis. Perhaps diffusion defeat of a vessel, but the most frequent option — occlusion of the first department of P. and. At the same time symptoms of ischemia of a hand develop, and at occlusion and a vertebral artery — symptoms of insufficiency of blood supply of a brain: headache, dizziness, poshatyvaniye, nystagmus (see), etc. At a contrast rentgenol. a research lack of a contrast agent in a gleam of a vessel, break of its shadow at the level of the mouth or sharply expressed stenosis with distally the located post-stenotic expansion (fig. 4) comes to light. The so-called syndrome of a scalene is a consequence of cicatricial and inflammatory processes in cellulose of an interladder interval of a neck. It leads to P.'s occlusion and. in the second department with typical a wedge, a picture of ischemia of a hand (see. Scalene syndrome ). Rather seldom meet sclerous and mycotic (inf. nature or embolic) P.'s aneurisms and. Unlike usual atherosclerotic occlusions, at to-rykh morfol, changes happen generally in an internal cover of a vessel, at sclerous aneurisms the elastic framework of a wall of an artery collapses that promotes its sacculate expansion (fig. 5).

Mycotic aneurisms of P. and. arise at various heart diseases more often (rheumatism, an endocarditis, etc.), are localized in peripheral departments of a vessel. Their aneurysmal bag is filled with trombotichesky weight, from a cut it is possible to sow the same microflora, as from cardial cavities.

Acute thromboembolisms of P. and. usually accompany the stenosis of the mitral valve complicated by thrombosis of the left auricle, to atherosclerosis, a syndrome of a scalene. They begin suddenly and are characterized by rapid development of ischemia of a hand: a cold snap and marble

pallor of skin of a hand, muscle pain, impossibility of active movements, disappearance of pulse on humeral and beam arteries (see. Thromboembolism ).

Treatment of diseases of P. and. conservative (see. Obliterating defeats of vessels of extremities, treatment ) and operational.

Operations

Indications to operation are bleeding, a rupture of the pulsing hematoma or an aneurysmal bag, a stenosis or P.'s occlusion of ampere-second the progressing ischemic and neurologic disturbances of a hand, and at damages of a vertebral artery — brain disturbances (see. Brain, operations ). As a rule, at the same time make various operations on nerves of a brachial plexus and its trunks — neurolysis (see), recovery operations, first of all nervous seam (see).

Inflammatory processes on skin in the area can be a contraindication surgery field (see).

Anesthesia: usually one of types of inhalation anesthesia (see), Neyroleptanalgeziya (see), at the same time according to indications at separate stages of intervention the managed hypotension is applied (see. Hypotonia artificial ); local anesthesia is less often used (see. Anesthesia local ).

Fig. 6. The diagrammatic representation of cuts of skin for access to a subclavial artery: 1 — a section on the Reich, 2 — a section across Dzhanelidze, 3 — a section across Dobrovolskaya, 4 — a classical section, 5 — a section on Petrovsky, 6 — a section on the Lexer, 7 — a section across Akhutin.

More than 20 quick accesses to P. are described and. The classical section, cuts are most widespread on the Lexer, the Reich, Dobrovolskaya, Petrovsky, to Akhutin, Dzhanelidze, etc. (fig. 6). From the middle of the 70th for access to the first department of P. and. began to use widely thoracotomy (see) in a combination to a sternotomy (see. Mediastinotomy ), for access to the second department — over - and subclavial cuts (usually the clavicle is not crossed).

During the carrying out operation on P. and. the following methods are very important. The ligature of an artery is used for a stop of bleeding (see. Bandaging of blood vessels ).

Fig. 7. The scheme of reconstructive operation at pathological crimpiness of a subclavial artery: and — clips are imposed on the proximal and distal ends of the gyrose site of a subclavial artery; — gyrose the site of an artery is resected, its ends are connected by a circular vascular seam (it is specified by an arrow).

Vascular seam (see) on P. and. it is applied at all reconstructive operations, including to connection of various prostheses, transplants, and also at its damage or patol, crimpinesses (fig. 7).

The easiest way — a side vascular seam is seldom possible. A vascular seam of a subclavial artery and vein, the interfastsikulyarny seam of a brachial plexus and its trunks imposed by means of the microsurgical equipment (see. Microsurgery ), allows to achieve in some cases engraftment of a hand at its separation.

Subclavial and carotid shunting, i.e. vshivaniye of the distal end of the first department of P. and. sideways the general carotid artery — rather new operation developed in the 70th. It is applied at a stupid injury with P.'s separation and. at its mouth or limited atherosclerotic occlusions in the same department.

Fig. 8. The scheme of stages of operation of an intimotrombektomiya at atherosclerotic occlusion of the left subclavial artery: and — clips (2) are imposed on the mouth of a subclavial artery and on a wall of an aorta, the longitudinal arteriotomy is made, the raspatory trombotichesky weight is removed (1); — a wall of an artery it is patched from a Dacron (3).

Intimotrombektomiya, or a trombendarteriektomiya (see. Atherosclerosis, surgical treatment of occlusal defeats ) — rather rare, but rather simple operation. After a longitudinal arteriotomy the atherosclerotic plaque and trombotichesky masses together with the site of an internal cover are removed, and defect of a vascular wall is closed by means of a patch from polymeric materials (see) or autoven (fig. 8). Sometimes at the same time it is possible to remove plaques from the sclerosed vertebral artery and to recover its passability.

A resection of an aneurysmal bag — the most radical traumatic aneurisms operation. Passability of an artery at it is recovered by means of a vascular seam or various ways of an angioplasty. At impossibility to remove a bag various options — vnutrimeshkovy sewing up of defect of a vessel and the collaterals falling into a bag across Matas can be used (see. Aneurism ), bypass shunting (see. Shunting of blood vessels ), etc.

In the mid-seventies at limited stenoses of an atherosclerotic origin began to apply P.'s dilatation and. special catheters (see. X-ray endovascular surgery ). The result of operations on P. and. depend not only on intervention on a vessel, but not to a lesser extent on the nature of operation on a brachial plexus and its trunks.



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Of E. Ostroverkhov (An.), M A. Korendyaeev (hir.).

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