Subclavian artery and its branches. Topographic anatomy of the subclavian vein and subclavian artery. Subclavian vein puncture technique. Subclavian artery, surgical tactics for wounds. What causes obstruction of the subclavian artery

The subclavian artery is one of the main human arteries, supplying the head, upper limbs and upper torso of a person. The subclavian artery is paired, that is, there are right and left subclavian arteries. For prevention, drink Transfer Factor. They begin in the anterior mediastinum. The right one originates from the brachiocephalic trunk, and the left one - directly from the aortic arch. Therefore, the left subclavian artery is longer than the right by approximately 4 cm.
The artery forms an upwardly convex arc that goes around the dome of the pleura. Then through the upper aperture of the chest it goes to the neck, leads into the interscalene space, where it lies in the groove of the same name of the first rib and below the lateral edge of this rib passes into the axillary cavity and continues like the axillary artery.
The walls of the subclavian artery consist of three membranes: internal, middle and external. The inner membrane is formed from the endothelium and pidendothelial layer. The middle shell consists of smooth muscle cells and elastic fibers, the ratio of which to each other is approximately the same. The outer shell is formed by loose fibrous connective tissue, which contains bundles of smooth myocytes, elastic and collagen fibers. It contains vascular vessels that provide trophic function.
In the subclavian artery, three sections are topographically distinguished: the first - from the point of origin to the interscalene space, the second - in the interscalene space, and the third - from the interscalene space to the upper opening of the axillary cavity. In the first section, three branches depart from the artery: the vertebral and internal thoracic arteries, the thyrocervical trunk, in the second section - the costocervical trunk, and in the third - sometimes the transverse artery of the neck.
The vertebral artery, whose normal lumen is 1.9 mm–4.4 mm, is considered a branch of the subclavian artery. The vertebral artery is the most significant of the branches of the subclavian artery. It starts from its upper surface, flows into the transverse foramen of the sixth cervical vertebra and lies in the canal, which arose due to the holes in the transverse processes of the cervical vertebrae. The vertebral vein also runs along with the artery. The vertebral artery emerges from the transverse foramen of the first cervical vertebra and runs in its groove. Having passed the posterior atlanto-occipital membrane and the dura mater, the artery then lies through the foramen magnum and the posterior cranial fossa. This is where its intracranial part begins. Behind the pons of the brain, this artery connects with a similar artery on the opposite side, forming the basilar artery, which is unpaired. Continuing its path, the basilar artery is adjacent to the basilar groove and the lower surface of the bridge at its anterior edge.
In the cranial cavity, the following branches depart from the vertebral artery: the anterior spinal artery - right and left, the paired posterior spinal artery and the posterior inferior cerebellar artery, which branches on the lower surface of the cerebellar hemisphere.

Question:

I beg you to answer this question. I did an ultrasound scan, diagnosis: atherosclerosis of the right subclavian artery (the intima-media complex is thickened to 1.5 mm at the mouth of the right subclavian artery). I'm very worried. Tell me, is this dangerous and what needs to be done to stop this process? I'm really looking forward to your response. Thank you in advance.

Answer:

Thickening of the intima is not a cause for concern. However, it is advisable to check your blood cholesterol levels.

SUBCLAVIA STEAL SYNDROME honey.

Subclavian steal syndrome is a cessation of blood flow through the branches of the proximal subclavian artery, supplying blood to the upper extremities, as a result of which blood enters this section from the arterial circle of the brain, which leads to ischemia of brain tissue; maximum manifestations occur during physical activity.

Etiology

Damage to the vascular wall itself - atherosclerosis (95% of cases), nonspecific arteritis, specific arteritis (in particular, syphilitic)

Pathological tortuosity of arteries, displacement of their mouths, anomalies in the development of the aortic arch

Extra-vasal factors that contribute to compression of the vessel from the outside (accessory cervical ribs, anterior scalene syndrome, etc.).

Clinical picture

Dizziness or lightheadedness (especially during physical exertion), possible blurred vision, hemianopsia and ataxia

Muscle weakness in the limb on the affected side

Absence or weakening of the pulse on the affected side.

Diagnostics

Noninvasive measurement of blood pressure in the upper extremities (the difference for unilateral lesions reaches more than 20 mm Hg)

Differential diagnosis

Subclavian artery occlusion

Subclavian artery occlusion

Occlusion of the subclavian artery is a complete closure of the lumen of the subclavian artery, accompanied by insufficient blood supply to the brain and upper extremities. In vascular surgery and cardiology, stenosis and occlusion of the carotid arteries are more common (54-57%). Occlusion of the first segment of the subclavian artery, according to various authors, is found in 3-20% of cases; Moreover, in 17% of cases there are concomitant lesions of the vertebral artery and/or the second segment of the subclavian artery. Bilateral occlusion of the subclavian artery occurs in 2% of cases; the second and third segments of the subclavian artery are affected much less frequently and do not have independent significance in the pathogenesis of cerebrovascular ischemia. Occlusion of the left subclavian artery occurs 3 times more often than the right one.

The subclavian artery is a paired branch of the aortic arch, consisting of the right and left subclavian arteries that supply blood to the upper limbs and neck. The right subclavian artery originates from the brachiocephalic trunk, the left one directly arises from the aortic arch. Topographically, 3 segments are distinguished in the subclavian artery. From the first segment depart the vertebral artery (supplies the spinal cord, muscles and dura mater of the occipital lobes of the brain), the internal thoracic artery (provides blood supply to the pericardium, main bronchi, trachea, diaphragm, sternum, anterior and superior mediastinum, pectoral muscles, rectus abdominis ) and the thyrocervical trunk (supplies blood to the thyroid gland, esophagus, pharynx and larynx, muscles of the scapula and neck).

The only branch of the second segment of the subclavian artery (costocervical trunk) supplies blood to the muscles of the neck, cervical and the beginning of the thoracic spine. The branch of the third segment (transverse cervical artery) mainly supplies blood to the back muscles.

Causes of occlusion of the subclavian artery

The main reasons causing occlusion of the subclavian artery are obliterating atherosclerosis. obliterating endarteritis. Takayasu's disease (nonspecific aortoarteritis), post-embolic and post-traumatic obliterations.

Atherosclerosis is the most common cause of occlusive lesions of the aorta and its branches. At the same time, atherosclerotic plaques protruding into the lumen of the vessel are formed in the intima of the arteries. As a result of subsequent sclerosis and calcification of the vascular wall in the area of ​​the affected area, deformation and stenosis of the lumen of the vessel gradually progress, which determine the ischemic stage of atherosclerosis. In some cases, atherosclerotic lesions may be complicated by thrombosis, leading to acute ischemia and necrosis of the blood supplying organ (thrombo-necrotic stage of atherosclerosis). Additional risk factors for atherosclerosis include smoking and arterial hypertension. hypercholesterolemia. diabetes. cardiovascular diseases.

Obliterating endarteritis, as the cause of occlusion of the subclavian artery, is characterized by inflammatory changes in the walls of the arteries, pronounced hyperplastic processes leading to thrombosis and obliteration of blood vessels.

Takayasu's disease, named after the Japanese ophthalmologist. who first described it, can occur with damage to the branches of the aortic arch and the development of aortic aneurysms. coarctation syndrome, aortic insufficiency. renovascular hypertension, abdominal ischemia, pulmonary artery damage, general inflammatory reaction. Nonspecific aortoarteritis most often leads to occlusion of the distal (second-third) segments of the subclavian arteries.

The development of occlusion of the subclavian artery can be facilitated by extravasal compression factors: scars and tumors of the mediastinum. curvature of the cervicothoracic spine, cervical osteochondrosis. neck injuries, fracture of the clavicle and first rib with the formation of excess callus, chest injuries. In some cases, occlusion of the subclavian artery is a consequence of congenital anomalies of the aortic arch and its branches.

In the pathogenesis of disorders arising from occlusion of the subclavian artery, the main role is played by ischemia of the tissues supplied by the affected branch. Thus, when the proximal segment of the subclavian artery is occluded, blood enters its distal segment and upper limb through the vertebral artery, which leads to depletion of the blood supply to the brain. This phenomenon, especially manifested during physical activity, is called steel syndrome or “subclavian steal syndrome.”

The rapid development of occlusion of the subclavian artery, associated with associated thrombosis, leads to cerebral ischemia - acute ischemic stroke.

Symptoms of subclavian artery occlusion

Occlusion of the first segment of the subclavian artery is manifested by one of the characteristic syndromes or a combination of them: vertebrobasilar insufficiency. upper limb ischemia, distal digital embolism or coronary-mammary-subclavian steal syndrome.

Vertebrobasilar insufficiency with occlusion of the subclavian artery it develops in approximately 66% of cases. The clinic of vertebrobasilar insufficiency is characterized by dizziness. headaches, cochleovestibular syndrome (hearing loss and vestibular ataxia), visual disturbances due to ischemic optic neuropathy.

Upper limb ischemia with occlusion of the subclavian artery, it is observed in approximately 55% of patients. During ischemia there are 4 stages:

I – stage of full compensation. Accompanied by increased sensitivity to cold, chilliness, a feeling of numbness, paresthesia, and vasomotor reactions. II – stage of partial compensation. Circulatory failure develops against the background of functional load on the upper limbs. It is characterized by transient symptoms of ischemia - weakness, pain, numbness, coldness in the fingers, hand, and forearm muscles. Transient signs of vertebrobasilar insufficiency may occur. III – stage of decompensation. Circulatory insufficiency of the upper extremities occurs at rest. It occurs with constant numbness and coldness of the hands, muscle wasting, decreased muscle strength, and the inability to perform fine movements with the fingers. IV – stage of development of ulcerative-necrotic changes in the upper extremities. Cyanosis, swelling of the phalanges, cracks, and trophic ulcers appear. necrosis and gangrene of the fingers.

Ischemia of stages III and IV with occlusion of the subclavian artery is rarely detected (6-8% of cases), which is associated with the good development of collateral circulation of the upper limb.

Distal digital embolism with occlusion of the subclavian artery of atherosclerotic origin, it occurs in no more than 3-5% of cases. In this case, ischemia of the fingers occurs, accompanied by severe pain, paleness, coldness and impaired sensitivity of the fingers, and occasionally gangrene.

In patients who have previously undergone mammary coronary bypass surgery. in 0.5% of cases it may develop coronary-mammary-subclavian steal syndrome. In this case, hemodynamically significant stenosis or occlusion of the first segment of the subclavian artery can aggravate cardiac ischemia and cause myocardial infarction.

Diagnosis of occlusion of the subclavian artery

Occlusion of the subclavian artery can be suspected already during a physical examination. If the difference in blood pressure in the upper extremities is >20 mm Hg. Art. one should think of a critical stenosis, and >40 mm Hg. Art. – about occlusion of the subclavian artery. The pulsation of the radial artery on the affected side is weakened or absent. With occlusion of the subclavian artery, a systolic murmur is heard in 60% of patients in the supraclavicular region.

Doppler ultrasound or duplex scanning of the vessels of the upper limb helps to detect occlusion of the subclavian artery in 95% of cases. The criteria for occlusion of the first segment of the subclavian artery are vertebral-subclavian steal syndrome, the presence of collateral blood flow in the distal subclavian artery, the presence of retrograde blood flow along the vertebral artery, and a positive reactive hyperemia test.

Peripheral arteriography allows you to finally determine the diagnosis of occlusion of the subclavian artery and treatment tactics. Using X-ray contrast angiography, the level of occlusion of the subclavian artery, retrograde blood flow through the vertebral arteries, the extent of obliteration, the presence of poststenotic aneurysms, etc. are revealed.

Treatment and prognosis of occlusion of the subclavian artery

Occlusion of the subclavian artery, accompanied by subclavian-vertebral steal syndrome, symptoms of vertebrobasilar insufficiency, and ischemia of the upper limb, is an indication for angiosurgical intervention.

Reconstructive interventions for occlusion of the subclavian artery are divided into:

plastic (endarterectomy, resection with prosthetics, implantation of the subclavian artery into the common carotid); shunting (aorto-subclavian bypass, carotid-subclavian bypass, carotid-axillary bypass, cross subclavian-subclavian bypass); endovascular (dilatation and stenting of the subclavian artery, laser or ultrasound recanalization of the subclavian artery).

Due to the high sensitivity of the brain to ischemia and the complexity of the anatomy of the neck, during surgical treatment of occlusion of the subclavian artery, specific complications are possible - intraoperative or postoperative stroke; damage to peripheral nerves with the development of Horner's syndrome, plexitis, paresis of the diaphragm dome, dysphagia; cerebral edema, pneumothorax. lymphorrhea, bleeding.

The prognosis of occlusion of the subclavian artery depends on the nature and extent of damage to the vessel, as well as the timeliness of surgical intervention. Early surgery and good condition of the vessel wall is the key to restoring blood flow in the limb and vertebrobasilar area in 96% of cases.

SUBCLAVIC ARTERY [arteria subclavia(PNA, JNA, BNA)] is a large vessel that supplies blood to the occipital lobes of the cerebral hemispheres, the medulla oblongata, the cerebellum, the cervical part of the spine and spinal cord, the deep muscles of the neck, partially the organs of the neck, the shoulder girdle and the upper limb.

Anatomy

Both P. a. begin in the upper mediastinum: right P. a. - from the brachiocephalic trunk (truncus brachiocephalicus), and the left - directly from the aortic arch; therefore, it is longer than the right one and its intrathoracic part lies behind the left brachiocephalic vein (Fig. 1). P. a. pass upward and laterally, forming a slightly convex arc, the edges go around the dome of the pleura and the apex of the lung. Having reached the first rib, P. a. penetrates into the interscalene space (spatium interscalenum), formed by the adjacent edges of the anterior and middle scalene muscles. In the interscalene space the artery lies on the first rib. Having turned around the first rib at the exit from the interscalene space, P. a. passes under the collarbone and enters the axillary fossa (see), where it passes into the axillary artery (a. axillaris).

For orientation in the localization of damage to P. a. and the choice of rational operational access to it, a conditional division of P. a is recommended. into three sections: 1) intrathoracic - from the beginning of the vessel to the inner edge of the anterior scalene muscle, 2) interscalene - from the inner to the outer edge of the anterior scalene muscle, 3) clavicular - from the outer edge of the anterior scalene muscle to the outer edge of the first rib. Trunks of P. a. differ in the constancy of their position. Variations in the variability of the position of the P. a., associated with the presence of an additional cervical rib, are of practical importance.

Trunks of P. a. in the second and third sections they have a symmetrical arrangement and are projected on both sides to the middle of the clavicle. The bifurcation of the brachiocephalic trunk is usually projected in the area of ​​the upper edge of the right sternoclavicular joint.

According to V.V. Kovanov and T.I. Anikina (1974), the angle of departure of the left P. a. in 90% of cases it does not exceed 90°, and the right one in 88% is 30-60°. It was noted that the diameter of the right P. a. larger than the left - in 72% of cases it is 10-12 mm, while in the left in 62% it is 7-9 mm.

In the first section on the right to the front wall of P. a. the right venous angle is adjacent, often intimately fused by fascia to the P. a.; here the artery is crossed by the vagus and phrenic nerves, passing in front of it. The recurrent laryngeal nerve lies behind in this area, and the common carotid artery (see) originates medially. This syntopy of vessels and nerves in this area creates significant difficulties during operations on P. a. On the left in front of P. a. the left brachiocephalic vein and the thoracic duct are located (see). The nerves on the left do not cross the P. a., but run parallel. In the first section from P. a. the following branches depart (Fig. 2): the vertebral artery (a. vertebralis), the internal thoracic artery (a. thoracica int.) and the thyrocervical trunk (truncus thyreocervicalis). The vertebral artery arises from the P. a. directly at the place where it exits the thoracic cavity and goes upward, located behind the common carotid artery, along the long muscle of the neck (m. longus colli), where it enters the transverse foramen of the VI cervical vertebra. The internal thoracic artery (a. thoracica int.) starts from the lower surface of the P. a. at the level of the origin of the vertebral artery. Heading down, the internal mammary artery passes behind the subclavian vein, enters the chest cavity and, being covered by the transverse muscle of the chest (m. transversus thoracis) and the parietal layer of the pleura, descends parallel to the edge of the sternum along the posterior surface of the cartilages of the I - VII ribs. The thyrocervical trunk extends from the anterosuperior surface of the P. a. before it enters the interstitial space; it has a length of 1.5 cm and is immediately divided into the following branches: the inferior thyroid artery (a. thyreoidea inf.); ascending cervical artery (a. cervicalis ascendens); superficial branch (g. superficialis) or superficial cervical artery (a. cervicalis superficialis); suprascapular artery (a. suprascapularis), passing along the anterior surface of the anterior scalene muscle.

In the second section, only one branch departs from the P. a., from its posterior surface - the costocervical trunk (truncus costocervicalis), which begins in the interscalene space of the P. a. and soon divides into two branches: the deep cervical artery (a. cervicalis profunda) and the highest intercostal artery (a. intercostalis suprema).

In the third section from P. a. after it leaves the interscalene space, only one branch also departs - the transverse artery of the neck (a. transversa colli), the edges are divided into two branches: ascending and descending.

Research methods

Research methods for various lesions of P. a. the same as other blood vessels (see Blood vessels, research methods). Wedge methods are widely used - determining the degree of ischemic disorders in the upper limb (changes in color and venous pattern of the skin, trophic disorders, etc.), as well as palpation and auscultation of the affected area of ​​the vessel (absence of pulse in peripheral vessels, the appearance of systolic or continuous noise, etc. .). Assessment of function and state of collateral circulation in cases of P. a. carried out on the basis of the Henle, Korotkov, etc. tests (see Vascular collaterals). Instrumental studies (thermoplethysmo-, oscillo-, rheovasography, flowmetry, ultrasound dopplerography, etc.) make it possible to objectively study hemodynamics in the P. a. Contrast rentgenol methods make it possible to detect the nature of patol, changes in the vessel (partial or complete occlusion, violation of integrity, the nature of the aneurysm, the size of the aneurysmal sac, the paths of inflow and outflow of blood in it, etc.), as well as to objectively study the existing paths of collateral circulation. Radioisotope angiography is used less frequently (see).

Pathology

Developmental defects. Along with angiodysplasias, which are characteristic of all blood vessels (see Blood vessels, malformations), a significant role in impaired blood supply to P. a. various anomalies play a role. So, some anomalies of P. a. cause compression of the esophagus, which is detected x-ray in the form of a triangular defect in its filling (Fig. 3). Clinically, this is manifested by constant difficulty in passing food through the esophagus. Occasionally, patol occurs, tortuosity of the right P. a., accompanied by ischemic disorders in the upper limb (weakening of the pulse in the radial artery, decreased sensitivity, periodic pain in the muscles of the arm, especially during physical activity). The same symptoms are observed in the presence of additional, or so-called. cervical, ribs, with syndromes of the pectoralis major and minor muscles, accompanied by compression of the lumen of the P. a. Treatment is usually surgical. The prognosis is favorable.

Damage P. a. are the most common type of its pathology. It is extremely rare that when the chest is compressed, separation of the P. a is observed. from the aorta (usually in combination with damage to the spine, main bronchus, lung, etc.). A complete break of the subclavian vessels and brachial plexus occurs when the entire upper limb is torn off along with the scapula. Such an injury, observed when: a hand gets into a rotating device, usually leads to the development of shock (see); due to the fall in ADH, the lumen of the ends of the artery and vein is closed by the crushed edges of their walls, severe bleeding may not be observed.

Injuries of P. a. during the Great Patriotic War of 1941 - 1945. accounted for 1.8% of the total number of injuries to the main arteries, and in 30.3% of cases simultaneous nerve injury was observed. According to B.V. Petrovsky, with injuries to P. a. damage to the lungs and pleura was observed in 77% of cases. More than Vg wounds of P. a. combined with gunshot fractures of bones - collarbone, ribs, humerus, scapula, etc. Approx. 75% of injuries to the subclavian vessels were injuries to the artery alone; simultaneous injury to the subclavian artery and vein was approx. 25%; external bleeding when wounded only by P. a. was observed in 41.7% of cases, with combined injury of an artery and vein in 25.8%. The resulting internal bleeding (into the pleural cavity) usually ended in death. Damage to various parts of P. a. have some features. Thus, injuries in the first section of the P. a., often together with a vein, are the most life-threatening. In case of damage to the left P. a. sometimes there is also injury to the thoracic duct (see); lesions in the second section are more often than lesions in other sections, accompanied by injury to the brachial plexus (see). Pulsating hematoma (see) after P.’s wounds. developed in 17.5% of cases.

In peacetime, according to statistics from specialized clinics of the Military Medical Academy, P. a. account for 4% of injuries of all arteries; in 50% of cases they are combined with damage to the brachial plexus. Variety of combined injuries of P. a. and other anatomical formations determines the following features of their wedge, manifestations. 1. Threatening massive primary bleeding (see), especially with wounds of the vessel in the first section. 2. Frequent arrosive bleeding, the cause of which is suppuration of the wound canal, damage to the walls of the vessel by projectile fragments, bone fragments, osteomyelitis, with pulsating hematomas of P. a. can lead to the rapid death of the victim. 3. The constant possibility of rupture of the arterial aneurysmal sac, requiring careful monitoring of all changes in its size (sudden enlargement of the sac is a reliable and objective sign of rupture) and hemodynamics. 4. Formed aneurysm P. a. manifests itself with classic signs (see Aneurysm): the appearance of systolic (with arterial) or continuous systolic-diastolic (with arteriovenous) noise, which disappears when the proximal end is compressed; change in pulse on the radial artery; the appearance of an expanded venous pattern in an arteriovenous aneurysm on the arm, shoulder girdle, chest wall, including in the subclavian region (see); progressive increase in autonomic disorders (impaired sweating, trophism of the skin, nails, hair growth, etc.), especially in the presence of paresis, paralysis and other phenomena of damage to the brachial plexus (see). With an arteriovenous aneurysm, the blood circulation that arose due to the constant discharge of arterial blood into the venous bed causes an increased load on the myocardium with the development of cardiac decompensation. Yu. Yu. Janelidze found that in the pathogenesis and dynamics of its development the so-called is important. fistulous circle, i.e. the distance between the aneurysmal sac and the cavities of the heart; the shorter it is (especially when the aneurysm is localized on the P. a., carotid arteries), the faster cardiac decompensation occurs.

For all types of damage to the aneurysm, if spontaneous stopping of bleeding or self-healing of the aneurysm is not observed, surgical intervention is indicated.

Diseases. The inflammatory process of P. a. - arteritis (see), aortoarteritis - clinically manifested by occlusive syndrome (see Obliterating lesions of the vessels of the extremities), occurs as a result of Ch. arr. atherosclerosis. Diffuse damage to the vessel is possible, but the most common option is occlusion of the first section of the P. a. At the same time, signs of ischemia of the arm develop, and with occlusion of the vertebral artery - symptoms of insufficiency of blood supply to the brain: headache, dizziness, staggering, nystagmus (see), etc. With contrast roentgenol. The study reveals the absence of a contrast agent in the lumen of the vessel, a break in its shadow at the level of the mouth or a pronounced stenosis with a distally located poststenotic expansion (Fig. 4). So-called scalene muscle syndrome is a consequence of scar-inflammatory processes in the tissue of the interscalene space of the neck. It leads to occlusion of P. a. in the second section with a typical wedge, a picture of arm ischemia (see Scalene muscle syndrome). Sclerotic and mycotic (infectious nature or embolic) aneurysms of P. a are relatively rare. Unlike ordinary atherosclerotic occlusions, with which morphol, changes occur mainly in the inner lining of the vessel; with sclerotic aneurysms, the elastic frame of the artery wall is destroyed, which contributes to its saccular expansion (Fig. 5).

Mycotic aneurysms of P. a. more often occur in various heart diseases (rheumatism, endocarditis, etc.), and are localized in the peripheral parts of the vessel. Their aneurysmal sac is filled with a thrombotic mass, from which the same microflora can be inoculated as from the cavities of the heart.

Acute thromboembolism of P. a. usually accompany mitral valve stenosis, complicated by thrombosis of the left atrium, atherosclerosis, and scalene muscle syndrome. They begin suddenly and are characterized by rapid development of arm ischemia: coldness and marble

pallor of the skin of the arm, muscle pain, inability to actively move, disappearance of the pulse in the brachial and radial arteries (see Thromboembolism).

Treatment of diseases of P. a. conservative (see Obliterating lesions of the vessels of the extremities, treatment) and surgical.

Operations

Indications for surgery are bleeding, rupture of a pulsating hematoma or aneurysmal sac, stenosis or occlusion of P. a. with progressive ischemic and neurological disorders of the arm, and with lesions of the vertebral artery - cerebral disorders (see Brain, operations). As a rule, various operations are simultaneously performed on the nerves of the brachial plexus and its trunks - neurolysis (see), reconstructive operations, primarily nerve suture (see).

A contraindication may be inflammatory processes on the skin in the area of ​​the surgical field (see).

Anesthesia: usually one of the types of inhalation anesthesia (see), Neuroleptanalgesia (see), while, according to indications, controlled hypotension is used at certain stages of the intervention (see Artificial hypotension); Local anesthesia is used less frequently (see Local anesthesia).

More than 20 operational approaches to P. a. have been described. The most common are the classic incision, incisions according to Lexer, Reich, Dobrovolskaya, Petrovsky, Akhutin, Dzhanelidze, etc. (Fig. 6). Since the mid-70s. for access to the first section of P. a. began to widely use thoracotomy (see) in combination with sternotomy (see Mediastinotomy), to access the second section - supra- and subclavian incisions (usually the clavicle does not intersect).

In the mid-70s. for limited stenoses of atherosclerotic origin, P. a dilation began to be used. special catheters (see X-ray endovascular surgery). Outcomes of operations on P. a. depend not only on the intervention on the vessel, but no less on the nature of the operation on the brachial plexus and its trunks.

Bibliography: Vishnevsky A. A. and Galankin N. K. Congenital heart defects and large vessels, M., 1962; Vishnevsky A. A., Krakovsky N. I. and Zolotorevsky V. Ya. Obliterating diseases of the arteries of the extremities, M., 1972; Knyazev M. D., Mirza-Avakyan L. G. and Belorusov O. S. Acute thrombosis and embolism of the main arteries of the extremities, Yerevan, 1978; Kovanov V.V. and Anikina T. I. Surgical anatomy of human arteries, M., 1974, bibliogr.; Lytkin M.I. and Kolomiets V.P. Acute injury of the main blood vessels, L., 1973; Multi-volume guide to surgery, ed. B.V. Petrovsky, vol. 10, p. 416, M., 1964; Experience of Soviet medicine in the Great Patriotic War of 1941-4945, vol. 19, M., 1955; Ostroverkhov G. E., Lubotsky D. N. and Bomash Yu. M. Operative surgery and topographic anatomy, p. 158, 375, M., 1972; Petrovsky B.V. Surgical treatment of vascular wounds, M., 1949; Petrovsky B.V. and Milonov O.B. Surgery of aneurysms of peripheral vessels, M., 1970; Pokrovsky A. V. Clinical angiology, M., 1979; Guide to angiography, ed. P.I. X. Rabkina, M., 1977; Savelyev V.S. et al. Angiographic diagnosis of diseases of the aorta and its branches, M., 1975; Sinelnikov R.D. Atlas of human anatomy, vol. 2, p. 286, 302, M., 1979; Emergency surgery of the heart and blood vessels, ed. M. E. De Beki and B. V. Petrovsky, M., 1980; Hardy J. D. Surgery of the aorta and its branches, Philadelphia, 1960; R i with h N. M. a. Spencer F. S. Vascular trauma, Philadelphia, 1978; The surgical management of vascular diseases, ed. by H. Haimovici, Philadelphia, 1970.

G. E. Ostroverkhov (an.), M. A. Korendyaeev (sir.).

The materials are published for informational purposes only and are not a prescription for treatment! We recommend that you consult a hematologist at your medical institution!

The subclavian artery and its branches is a paired organ, since it includes two parts that supply the organs of the upper body. Being part of the systemic circulation, it represents an important part of the system that must uninterruptedly deliver blood.

Structure

The right subclavian artery arises from the brachiocephalic trunk. The base of the left side is determined by the beginning of the aortic arch. Conventionally, this artery can be divided into several parts:

• scalenus ant. Its location is defined as the distance from the origin to the inner edge of the anterior scalene muscle.
• spatium interscalenum. Limited by the interstitial space.
• axillaris. It begins at the outer edge of the anterior scalene muscle and extends to the axillary artery in the middle of the clavicle.

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The length of the left subclavian artery is longer - its length differs by 2-2.5 cm.

Functions

The subclavian artery carries blood through its branches to the organs. Thus, it interacts with the following departments:

• First: Blood flows through the vertebral artery to the spinal cord—the spinal cord and the dura mater of the brain—as well as to the muscles. In the lower part, supply through the thoracic artery is carried out to the diaphragm, bronchi, mediastinal tissues, and the thyroid gland. Nutrition also goes to the sternum, rectus abdominis and chest.
• Second: blood flows along the costocervical trunk to the spinal cord and muscles.
• Third: Blood flows to the muscles of the shoulders and back through the transverse artery of the neck.

• Occlusion can be caused by obliterating atherosclerosis and endarteritis, post-embolic and post-traumatic obliterations, as well as Takayasu’s disease. Active development of the disease in combination with thrombosis can lead to cerebral ischemia.

The human circulatory system is a complex pattern of intricate veins, arteries and many capillaries. The subclavian artery is a paired and very large vessel; it belongs to the arteries of the great circle. It receives blood from the aortic arch and brachiocephalic trunk and supplies the occipital region, part of the spinal cord located in the cervical region, and the cerebellum with nutrients. Also, blood from this vessel supplies oxygen to the upper limbs, shoulder girdle and some parts of the peritoneum and chest.

Anatomy

This artery is a convex arch-shaped vessel located in the anterior mediastinum. Heading up the chest laterally, the vessel bends around the pleura and overlaps the upper part of the lung. The topography of the subclavian artery, relative to the neck area, contributes to the supply of oxygen to the neck muscles and the back of the head.

The vessel is located on the surface and is visible next to the brachial plexus of nerves. The anatomy of the subclavian artery makes it possible to use it to administer medications, and also, in case of heavy bleeding, there is an excellent chance to prevent unpleasant consequences.

Departing from the brachial plexus, the vessel bends over the rib. Here a groove of the subclavian artery is formed, which extends under the collarbone and rises into the armpit. In this area, the vessel passes into the axillary artery. After passing through the armpit, the artery enters the shoulder and becomes the brachial artery. In the area of ​​the elbow joint, the subclavian artery diverges into the ulnar and radial arteries.

Main branches

The left subclavian artery, like the right one, is very large and is part of the systemic circulation. On its way through the body, it gives off several branches through which blood passes to supply oxygen and nutrients to the internal organs, skin, and various parts of the body.

At certain points this vessel diverges into five branches.

Internal thoracic artery

This vessel departs from the main artery in the area of ​​the pleural dome. It passes between the intrathoracic fascia and the pleura, heading towards the lower part of the sternum.

In turn, the thoracic internal artery is divided into:

1. Mediastinal branch;
2. Tracheal;
3. Perforating;
4. Thymus;
5. Bronchial;
6. Anterior intercostal;
7. Pericardiodiaphragmatic;
8. Superior epigastric;
9. Muscular-diaphragmatic.

Vertebral artery

This vessel originates several millimeters medial to the anterior edge of the scalene muscle, in the interscalene space. The anterior part of the artery is covered by the inferior supraclavicular thyroid vessel and the carotid artery.

This branch from the subclavian artery is one of the largest and gives off the following branches:

1. Posterior inferior cerebellar;
2. Villous;
3. Posterior, anterior spinal;
4. Meningeal.

Thyroid trunk

This vessel has a length of about 0.5-1.5 cm. It branches from the subclavian artery in the area of ​​the anterior scalene muscle.

Just like other branches, it is divided into several arteries branching from it:

1. Ascending cervical;
2. Superficial cervical;
3. Inferior thyroid;
4. Suprascapular.

Costocervical trunk

This large vessel extends from the wall of the subclavian artery to the small axillary vessel in the interscalene space and is located at the first rib, at its head.

The trunk along its course is divided into the following branches of the great subclavian artery:

1. Cervical transverse;
2. Intercostal overhang;
3. Cervical deep;
4. Superficial.

Basilar artery

This vessel is formed as a result of the connection of two vertebral arteries in the area of ​​the posterior edge of the bridge.

The following branches of blood channels depart from it:

1. Posterior brain;
2. Artery of the labyrinth;
3. Superior cerebellar;
4. Pontine artery;
5. Inferior anterior cerebellar;
6. Midbrain.

Departments and functions

The surface location of this vessel is very convenient for puncture. Subclavian artery catheterization is also often performed in this area of ​​the neck. Experts give preference to this area because it is accessible, due to its anatomical features, the artery has a more than suitable lumen diameter and a stable position.

During catheterization, the placed catheter will not come into contact with the walls of the vessel, and the drug that will be administered through it will quickly reach its target, actively influencing hemodynamics.

The main sections of the subclavian artery are three sections:

• Interstitial space. The vertebral and paired arteries depart from it;
• Costocervical trunk;
• Branching of the transverse cervical artery.

The subclavian vessel, located in the 1st section, passes into the skull. Its function is to supply blood to the brain and neck muscles. The internal mammary artery supplies blood to the thyroid gland, diaphragm and bronchi. It is divided into the overhanging intercostal vessel and other adjacent arteries.

Palpation

Palpation and examination of the subclavian artery (palpation) is carried out according to the pattern of palpation of the apical impulse, that is, with three or two fingers. First, the arteries at the edge of the sternocleidomastoid muscles above the collarbones are examined. Then a transition is made to the area of ​​​​the depth of the subclavian fossae under the collarbones at the edges of its deltoid muscles. The examination is carried out very carefully, using the method of applying fingers and pressing on the soft tissue in the area of ​​the externally examined area.

In a healthy person who is at rest, the subclavian arteries will not be palpated, or their pulsation will be subtle. This is explained by their sufficient depth. You can feel a strong pulsation in people with poor development of the muscle tissue of the shoulder and neck, after physical exertion, emotional shock, as well as in asthenic patients.

With pathology of the subclavian artery, its pulsation is clearly manifested. This phenomenon can be observed with aortic insufficiency and hyperkinetic type of hemodynamics. With a vascular aneurysm, pulsation is usually felt in the supraclavicular area, slightly limited (2-3 cm). The weakening of the pulsation of these arteries can be accurately assessed by palpating them simultaneously using both hands. This may be due to a violation of their patency (thrombosis, compression, atheromatosis) or if there is an anomaly - an aberrant right subclavian artery.

Possible pathologies

The most common disease that affects the subclavian artery and its branches is stenosis. This pathology develops due to the presence of atherosclerosis or thrombosis. The disease can be either congenital or acquired. People who smoke, are overweight and suffer from diabetes are at risk of getting stenosis.

Also, quite often, stenosis develops against the background of impaired metabolism, due to neoplasms and a long-term inflammatory process. During the first course of the disease in acute form, a significant decrease in blood flow is possible, which can cause stroke or ischemia. With stenosis of the subclavian arteries, the majority of patients complain of severe pain, which intensifies with exercise.

Treatment method

A disease such as stenosis can be treated with medication, in its mild form, interventionally and surgically. But the main methods of therapy, according to experts, are bypass surgery and stenting. These treatments have been used for a very long time and have an excellent success rate during the procedure.

Bypass surgery

If stenosis is detected in the 2nd section of the artery, bypass surgery is indicated. If the ipsilateral common carotid artery is damaged, crossover shunting is preferred. This method of surgical intervention does not injure the patient’s tissues and organs, does not require the use of general anesthesia, takes little time and does not cause serious postoperative complications. Before performing it, it is necessary to perform an ultrasound.

If the great subclavian artery is damaged on the left or on both sides, then its reconstruction in the affected area will first be necessary. If the operation is unsuccessful, repeated intervention is difficult. Contralateral lesions of the subclavian vessels require preliminary elimination of the style syndrome, only then can bypass surgery be started. Reconstruction of the damaged section of the artery is possible only with non-regressive vertebrobasilar insufficiency. All surgical interventions, be it bypass surgery, stenting and others, are not carried out without a complete preliminary examination of the patient and an accurate diagnosis.

Stenting

This method is indicated for patients who have a hypersthenic physique and a special topography of their subclavian arteries. The first section of the artery in such people is difficult to feel. The stenting method is very convenient and significantly prevails over surgical abdominal intervention. During this gentle process, no changes occur in the arteries, and body tissues are not injured.

Using stenting, doctors increase the lumen of the affected vessel. For this purpose, a catheter and a balloon-shaped stent are used. All procedures are performed under local anesthesia. The movement of the stent through the artery occurs under the supervision of an experienced specialist who regulates its location. Having reached the narrowing area, the device opens. If the stent is not open enough, angioplasty is performed. The total operation time is no more than 2 hours.

Complications

Although such operations cannot be called complex, they still have a fairly long rehabilitation period. After stenting, it is recommended to take painkillers, since the puncture sites and incisions of the soft tissues and arteries may hurt. Postoperative complications are extremely rare, since before the procedure the patient undergoes a complete examination of the entire body (ultrasound, etc.). But still, the body’s reaction under certain circumstances can be unpredictable (for example, if there is a defect - an aberrant subclavian artery).

After stenting, the patient may experience:

• Allergy to drugs;
• Temperature increase;
• Headache;
• Wound infection;
• Air embolism;
• Stent migration;
• Bleeding at puncture sites;
• Arterial thrombosis;
• Neurological complications.

Interventional therapy of stenosis and other diseases of the subclavian arteries using stenting and agioplasty is a modern minimally invasive measure. Such effective procedures are carried out in a very short time and do not require long-term hospitalization. It is enough to first undergo an ultrasound and pass the necessary tests.