·208·PARTIⅢ1ANGIOLOGYAscending aortSuperior vena cavePulmonary trunkRight pulmonary w.Left pulmonary vv.InferiorvenaFig.II-1-14 Pericardiumphragm. Anteriorly it is also attached to the stemum.of the left atrium and the posterior part of the pericar-The pericardium is securely anchored and maintainsdium.It contains the roots of the left pulmonary veinsthe general thoracic position of the heart.on the left, and the roots of the right pulmonary veinsand the inferior vena cava on the right. The anterioin-2. Serous pericardiumferior sinus of pericardium lies the anteroinferior partof the pericardial cavity and is formed by the reflex-ion of the anterior wall into the inferior wall of theThe serous pericardium is a closed sac within theparietal layer of serous pericardium.fibrous pericardium, having a visceral and a parietalPericardial puncture can be performed either inlayer.The visceral layer (epicardium) covers the heartthe left fifth intercostal space close the left margin ofand the roots of the great vessels and is reflected intosternum to avoid damaging the pleura and the intermalthe parietal layer, which lines the intermal surface ofthoracic artery, or at the left costoxiphoid angle, pass-thefibrouspericardium.The separationof thevisceraling up and backwards into the pericardial cavityand parietal layers createsanarrow space,thepericardial cavity.It contains serous fluid,which provides lu-WangHaijie（王海杰）brication to preventfrictionbetween thelayers oftheserous pericardium as they glide over each other withSection 3 Arterieseverybeat of the heart.The recesses of the pericardialcavity include the transverse, oblique, and anteroin-Arteries are the vessels that carry blood awayferior sinuses. The transverse sinus of pericardiumfrom the heart to the capillaries in all parts of theextends from the intervalbetweenthe ascending aortabody. In the majority parts of the human body, espe-and the superior vena cava on the right to that be-cially in the head, neck,pelvis and limbs,arteries aretween thepulmonary trunk and the left atrium on thebilaterally symmetrical.However, some of the largeleft.Onefingercanbepassedthrough it.The obliqueand deep arteries in the thoracic and abdominal cavi-sinus of pericardium lies between the posterior wallties are asymmetrical.口D扫描全能王创建口
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Chapter1 Cardiovascular System · 209 uasiyoftheseumItrunsupwardsforashodistanearsltand poterioyandthndsdsathe vertebral column tothe inferior partof the abdo-men.Fordescribepurpose,theaorta isdividedinothreesgments:theascendingara,theaorticarchyand the descending aorta that is then subdivided intoythe thoracic aorta and the abdominal aorta.(1) Ascending aorta1.Arteries of PulmonaryThe ascending aorta (Fig.I-1-12, 14, 15) origi-Circulationnates from the leff ventricle behind the pulmonarytrunk. It ascends obliquely to emerge from the peri-The pulmonaytkleaves therght ventrileocardium at the levelof the upper border of the rightthehearathelevelothethidsterocostaljsecond costal cartilage and then turns left to continueanawith the aortic arch.The only branches of the ascend-ssroandosterorlfsoding aorta are the right and left coronary arteries thatnedndsadrht pumSupply the heart (See Section 2).ysbahthrpumoareryentersthelungthroughthehilus and at which(2) Aortic archidividesintolobararterieswithontoachlobofthe lungThrightpulmonaryarterydivides intheThe aortic arch (Fig. II-1-15) is the continuationright superiomddeandinferrobarareries,andof the ascending aorta. It arcs left and posteriorly to-the let pulmonary artery, into the let superior andwards the left side of the vertebral column. At the lev-inferior lobar arteries. Within the lung, the lobar ar-el of the lower border of the fourth thoracic vertebrateries branch along with bronchi andfinally become(T),it turns inferiorly to continue into the thoracicarerioles that connect tothe capillaries surroundingaorta. From the convexity of the aortic arch, threethe lung alveoli.branches arise to supply the head, neck and upperAfibrous cord that interconnects the concavity oflimbs,namelythebrachiocephalic trunk,the left com-the aortic arch and the bifurcation of the pulmonarymon carotid artery and the left subclavian artery.Thetunk is called the arterial ligament. It is the remnantbrachiocephalic trunk ascends to the back of the rightofthe obliterated ductus arteriosus.The ductus arteri-sternoclavicular joint, where it divides into the rightosus isafetalvesselthatconductsblood directlyfromcommon carotid artery and the right subclavian artery.the pulmonary trunk to the aorta.It usually closesThewall of the aortic arch contains numerousafer birth and gradually changes into the arterial lig-sensory nerve endings called thepressure receptorsament.Ifthe duct is still unclosed afterbirth,blood inthat can dynamicallymonitor andreflectively regulatethe aorta will leak through it into the pulmonary cir-the blood pressure.Beneath the aortic arch, there arecuit, leading to a clinical syndrome called pulmonarya few of small and millet like structures called theaortic glomera, which are chemical receptors moni-hypertension.toring the levels ofco, in the aortic flow.II . Arteries of Systemic Cir-(3) Thoracic aortaculationThe thoracic aorta is the superior segment of thedescending aorta in the thoracic cavity. Continuingfrom the aortic arch, it descends along the anterior1.Aortasurfaceofthe vertebral columnfrom the level ofT,toTr2 (Fig. I-1-15) .As we will describe, the thoracicTheaortais the largest arterialtrunkinthe bodyaorta sends numerous branches to the thoracic wallaising fromthelventricleofthehearatthelevand organs.hiditasrtb口扫描全能王创建可
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ANGIOLOGY·210·PARTⅢRight common carotid aLeft common carotidaThyrocervical trunkLeftsubclavianaRight subelavian aBrachiocephalic trunkAortic archBronchial a.Ascending aortePosteriorintercostalaEsophagusThoracic aortaAbdominalaortaFig. II-1-15 The aorta and its branchescostocervical trunk.(4) Abdominal aorta(1)Common carotid arteriesPassing through the aortic hiatus in the diaphragm,The common carotid arteries (Fig.II-1-17) are thethe descending aorta enters the abdominal cavity and ismain contributors to the blood supply for the necknamed the abdominal aorta (Fig.II-1-16).The abdominalaorta sendsmanybranchestotheabdominal wall andand head.The right common carotid artery originatesfrom the brachiocephalic trunk and the left,from theorgans.And finally,it ends at thelevel of thefourthaortic arch.Both ascend along the lateral sides of thelumbar vertebra bybifurcating into the rightand lefttrachea and esophagus.At the level of the upper bor-common iliac arteriesder of the thyroid cartilage, the arteries divide into theexternal and internal carotid arteries.A slight dilation2. Arteries of the neck and headisformed at theend of thecommon carotid arteryandextends to the initial part of the intermal carotid arteryThe neck and head are supplied by four pairs ofThis dilated part is called the carotid sinus that con-arteries (Fig.IIl-1-17,18),the common carotid arter-tains numerous sensory nerve endings in its wall andies and three branches from each subclavian artery:acts as a pressure receptor to participate in regulationthe vertebral artery, the thyrocervical trunk and the-扫描全能王创建
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Chapter1 CardiovascularSystem·211.HepaticveinsRight phrenic a.Superior suprarenal aLeft suprarenal glandMiddle suprarenal aCeliac trunkInferior suprarenal aSplenic a.Left kedneyLeft renal a.LumbaraLeft testicular a.MediansacralaCommon iliaca.7IliolumbaraExtemal iliac a.Intemal iliacLateral sacral a.DeepiliaccircumflexRectumInferior epigastricUrinary bladderFig. II-1-16The abdominal aorta and its branchesThe superficial temporal artery ascends just an-of blood pressure.Asmall elliptic structure on theposterior surface of the carotid bifurcation is calledteriorto the ear,passes over the zygomatic archtoenter the superficialfascia of thetemporal region,andthe carotid body and it functions as a chemical recep-tortomonitorthe levels of CO,in the carotidflowbranches to supply the most part of the scalp.1) Extermal carotid arteries (Fig.lI-1-17) supply mostThe maxillary artery extends deep in the neck ofparts of the face and the anterior region of the neck.mandible to enter the infratemporal fossa, where itAlong its wayascending,each cxtemal carotid arterygives off branches to the upper and lower teeth,thecheek, the nasal cavity and the masticatory muscles.sends the superior thyroid artery to the upper part ofA clinicallyimportantbranch of the maxillary arterythe thyroid gland and larynx, the lingual artery to thetongue, the facial arteryto the skin and muscles in theis the middle meningeal artery which enters the skullthrough the spinal foramen in the temporal bone andanterior face, and the occipital artery to the scalp inruns along the internal surface of the sidewall of thethe occipital area. Near the temporomandibular joint,cranial vault. Thus a hit on the side of the head may tearthe external carotid artery splits into two terminalthis artery,leading to an intracranial hematoma that maybranches: the superficial temporal artery and the max-compress the cerebrum and disrupt its function.illary artery.口扫描全能王创建口
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·212.PARTⅢANGIOLOGYBasilaraMaxillaryaSaperficial temporala.Occipital a.Facial a.LingualaIntermal carotid aExtemal cartid aSuperior thyroid a.Vertebral a.CommoncarotidaInferior thyroid a.Thyrocervical trunkRight subclavian a.Costocervical aFig. I-1-17 The arteries of the head and neck2) Intermnal carotid arteries (Fig.II-1-17) ascendcupula of pleura, passes through the scalene fissurein the carotid sheath lateral to the larynx and passesand crosses over the outer edge of the first rib to con-through the carotid canal in the base of the cranium totinue into the axillary artery. The subclavian arteryenter the skull,where theybranch to supply thebraingives off three branches to the head and neck.and the eyes(Please refer to PARTIV).The intermal1) Vertebral arteries rise from the convex of thecarotid arteries have no branches in the neck.subclavian artery (Fig. I-1-17, 18) . On each side,itruns superiorly through the transverse foramina of(2) Subclavian arterythe cervical vertebrae C6 to CI, and enters the skllthrough the foramen magnum, where it branches toThe right subclavian artery arises from the bra-supply the brain and the spinal cord (also refer tochiocephalic trunk and the left, from the aortic archPART IV).(Fig. I-1-15, 17) . Both arteries emerge from the2) Thyrocervical trunk springs just lateral to theupper aperture of the thorax to enter the roots of thevertebral artery and immediately divides into severalneck,whereeach artery arches laterally in front of thebranches.One is the inferiorthyroid artery that runsO扫描全能王创建O
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Chapter1CardiovascularSystem·213.Exterralcarotidacrior thyroid aScalenus mediuVertebral aSuperficial cervical aInferior thyroid a.Thyrocervical trunkSubclavian a.Costocervical trunkSuprascapulara.Intemal thoracic a.Dorsal scapularThoracoacrominalaateral thoracic a.Anteriorhumeracircumflexa.Posteriorhumeral circumflexaFig. II -1-18 The subclavian artery and its branchesmedially behind the carotid sheath to the lower part2)Lateral thoracic artery follows the lateral bor-of the thyroid gland. The other branches run laterallyder of the pectoralis minor and branches to supply theor posteriorly overthe scapula to supplythe scapularpectoralmuscles,theserratusanteriorandthebreastmuscles.3)Subscapular arteryruns downwards along the3) Costocervical trunk arises just lateral to theposterioraxillary wall and divides into the circumflexthyrocervical trunk. It branches to supply the deepscapular artery which passes through the triangularmuscles of the neck and the first two intercostalspace in the posterior axillary wall to the dorsal scap-muscles.ular region and the thoracicodorsal artery that sup-plies the subscapularis and the latissimus dorsi (Fig.II-1-19, 20)3. Arteries of the upper limb4)Anterior and posterior circumflex humeral ar-teries wrap the surgical neck of the humerus to helpAfer passing through the scalenefissure,the sub-supply the shoulder joint and the adjacent muscles.clavian artery crosses over the outer edge of the firstrib and enters the axillary cavity as the axillary artery(2) Brachial arterythatserves the most parts the upper limb (Fig.II-I-19) .The brachial artery is the continuation of the ax-(1) Axillary arteryillary artery. It descends along the medial side of thehumerus deep to the biceps brachial muscle and endsThe axillary artery descends through the centralat the level of the neck of the radius by dividing intopant of axillary cavity and continues into the brachialthe radial and the ulnar arteries, It sends branches toartery at the lower border of the teres major. In itsthe flexor muscles of the arm and the elbow joint.Thecourse, it gives off several chief branches.largest branch of the brachial artery is the deep bra-I) Thoracoacromial artery is a short trunk arisingchial artery which runs inferiorly and laterally withfomtheaxillaryartery abovetheupperboarderofthethe radial nerve along the posterior surface of the hu-pectoralis major.It pierces the clavipectoral fascia andbranchestosupplythe pectoralanddeltoidmusclesmerus and supplies the triceps muscle. A fracture口3扫描全能王创建口
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.214·PARTIⅢIANGIOLOGYThoracoacrominal:Superior thoracic a.Axillary a.Pectoralis minorMusculocutaneousAnterior circumflexLateral thoracic a.humeral a.Median n.Axillaryn..Axillarya.Ulnar n.Subscapularaircumflexscapulara.Thoracodorsal a.Fig.Il-1-19 The axillaryarterySuprascapularDorsal scapular a.Levator scapulaePosterior circumflexhumeral aDeltoidLong head of tricepsbrachitSubscapularaCircumflex scapular aTeresmajoAThoracodorsal a.HumeTeresminorFig. II-1-20 The artery of scapular regiornof the humerus shaft may injure the artery and thethe radius it lies just lateral to the tendon of the fexornerve, leading to severe local hemorrhage and paraly-carpi radialis and is very near the surface, thus providingsis of related muscles (Fig. III-1-21)aconvenient siteto palpate its pulseAlong its way,thradial artery gives off nutrient branches to the lateral(3) Radial and Ulnar arteriespart of the elbow joint, theflexor muscles in theradialpart ofthe forearm and the lateral part of the wrist.The radial artery descends along the medial mar-The ulnar artery runs downwards in the medialgin of the brachioradialis.At the level of styloid ofside of the forearm between the superficial and deep可口扫描全能王创建口
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CardiovascularSystem·215.Chapter1SubclavianaItemalthoracicaThoracoacromialPosterior humeralAxillarya.circumflexa.AnteriorhumerialcircumflexaLaterl thoracic a.SubscapularaBrachial a.Deep brachil a.periorulnarcollateralaBiceps brachiRadialaUlnar a.Superficial palmararchDeeppalmar archCommonpalmardigital aPalmar metacarpal a.1Fig. II-1-21 The arteries of upper limb(Fig. III-1-22, 23)digital flexor muscles.The artery gives off branchesto the medial part of the elbow joint and the muscles(4) Palmar archesthat cover the ulna. A major branch called the com-mon interosseous artery springs from the proximalIn the palm, the branches of the radial and thepart of the ulnar artery and splits immediately into theulnar arteries anastomose into two arches. The super-anterior and posterior interosseous arteries. The an-ficial palmar arch is formed by the ulnar artery andterior interosseous artery descends along the anteriorthe superficial palmarbranch of the radial artery,andsurface of the interosseous membrane and supplieslies just beneath the palmar aponeurosis.It gives offthe deep flexor muscle ofthe forearm. The posteriorthrce common palmardigital arteries with each final-interosseous artery pierces the interosseous mem-ly splitting into two proper palmar digital arteries tobrane, descends along its posterior surface and sendssupply the fingers (Fig. II-1-24). The deep palmarbranches to all the extensor muscles of the forearm口扫描全能王创建口
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ANGIOLOGY.216PARTⅢIMidian nBrachial aInterosseous recurrenta.Short head of biceps brachiInferiorulnarcollateralaRadial recurrent aPosteriorinterosseous a.UinarrecurrentaCommonPosterior interosseous a.interosseousa.-Extensor carpi ulnarisAnteriorinterosscousaRadialaUlnan a.Radial a.Pronator quadratusPrincipal a.of thumtSuperior palmar archPalmar digital aa.Fig. II-1-23 The radial and ulnar arteriesFig.II-1-22 The arteries of forearmRadial aUlnara.MediannUlnarn-DeeppalmarbranchSuperficialpalmarbranchSuperficialpalmararchUlnarpalmara.ofminimiRadial palmar pollicisCommonpalmardigitalaaUlnarpalmarpollicisRadial a, of indexProper palmar digital aa.Fig.II-1-24 The superficial palmar archD扫描全能王创建
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CardiovascularSystem·217.Chapter 1Radial aUlnara.Deep palmar branchPrincipal a.of thumDeeppalmararchRadial palmar pollicisPalmar metacarpal aa.Ulnar palmar pollicisCommon palmardigitalaaUlnar palmar a.of lttle fingerRadial a. of indexProper palmar digital aa.Fig.I-1-25The deep palmar archarch is formed by the radial artery and the deepmuscles. It also sends branches superficially to thepalmar branch of the ulnar artery, and lies againstmammarygland.the metacarpal bones.The main branches of the archTheposterior thoracic wall receives its bloodfrominclude the principal thumb artery that supplies mainthe paired posterior intercostal arteries and subcos-ly thethumb and three palmar metacarpal arteries thattal arteries (Fig.I-1-15).The first two pairs of thejoin to the ends of the three common palmar digitalintercostal arteries are branches of the costocervicaltrunk,while the rest nine,plus onepair of subcostalarteries (Fig. II-1-25)arteries,issue in a segmental mannerfromtheback of4.Arteries of the thoraxthe thoracic aorta. All of these arteries run along thecostal grooves of the corresponding ribs and end byanastomosing with the anterior intercostal branches oftheinternal thoracic artery.In addition,a pair ofsmall(1) Arteries of the thoracic wallbranches, the superior phrenic arteries, arise from themost inferior part of the thoracic aorta and supply theThe anterior wall of the thorax is supplied mainlyposterior part of the diaphragm.by the internal thoracic artery that springs from eachsubclavian artery in the root of the neck (Fig. I-1-(2) Arteries of the thoracic viscera18).The artery descends behind the costal cartilages,about I cm lateral to the side of the sternum. It endsThe thoracic viscera receive their nutrient bloodat the level of the sixth intercostal space by dividingsupply from the visceral branches of the thoracic aor-intothemusculophrenicarterytothediaphragm andta (Fig. II-1-15). These include the bronchial arteriesthesuperiorpigastricarterytotheanteriorabdomto the bronchi and lung, the esophageal arteries to theawalngiwytayesophagus,and the pericardial arteries to the posteriorgives off six anterior intercostal branches that runmediastinum and pericardium. These arteries are usu-horizontaly and anastomose with the correspondingally very small and vary in their numbers and origins.posterior intercostal arteries to supply the intercostal口3扫描全能王创建口
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