6.The great Vessel

• SUBCLAVIAN ARTERY

  Subclavian artery divided into 3 parts by SCALENOUS ANTERIOR muscle

  • First part

  o Vertebral

  o Thyrocervical – Inferior Thyroid Superficial Cervical

  Suprascapular o Internal Thoracic

  • Second part - Costocervical

  • Third part – NO BRANCH
• ASCENDING AORTA

  Right coronaries

  Left coronaries
• ARCH OF AORTA

  oBrachiocephalic/Innominate

  o Left common carotid

  o Left subclavian
• DESCENDING AORTA

  o Bronchial

  o Mediastinal

  o Esophageal

  o Posterior intercostal

  o Pericardial

  o Subcostal
• DIVISION OF AORTA

  • ASCENDING AORTA
  • ARCH OF AORTA
  • DESCENDING AORTA
  • ABDOMINAL AORTA
• DESCENDING THORACIC AORTA

  • It is the continuation of the aortic arch

  • At the level of the 12th thoracic vertebra, it passed through. The

  diaphragm and continues as the abdominal aorta
• DESCENDING THORACIC AORTA

  Branches

  o Pericardial

  o Esiohageal

  o Bronchial

  o Posterior intercostal
• ARCH OF THE AORTA


  Continuation of the Ascending aorta; lies behind the manubrium sterni and arches upward, backward and to the left in front of trachea; at the level of sternal angle becomes continues with the Descending aorta
• ARCH OF THE AORTA

  Branches:

  1. Brachiocephalic artery
  2. Left Common Carotid
  3. Left Subclavian
• ANEURYSM OF THE AORTIC ARCH

  Lies behind the manubrium sterni

  • PULSATILE SWELLING IN THE SUPRASTERNAL NOTCH

  • May compress the trachea, esophagus and left recurrent

  laryngeal nerve

  • Experience difficulty breathing, swallowing and hoarseness

  • 2.5 CM INFERIOR TO THE SUPERIOR BORDER OF THE

  MABUBRIUM
• COARCTATION OF THE AORTA

  • constriction of varying length of the aorta

  • Occurs twice as often in males than females
• Postductal coarctation

  constriction is just DISTAL to the

  ductus arteriosus; most common form; Adult form of coarctation
• Preductal coarctation

  constriction is PROXIMAL to the ductus arteriosus; prognosis is poor; Infantile form of coarctation
• An 18 y/o is diagnosed to have high blood pressure during PE and significantly higher in both upper limbs than in lower limbs. Imaging reveals bilateral erosion of the anterior and lateral parts of his ribs. Angiography reveals a narrowing of the aorta. Where is the most likely site of aortic constriction?

  Just distal to the ligamentum arteriosum
• COARCTATION OF THE AORTA

  Constriction of the Aorta that occurs just PROXIMAL (Infantile) or DISTAL (Adult) to the ligamentum arteriosum • Blood pressure is reduced in the lower limbs and elevated in

  the head, neck and upper limbs

  • Anastomoses in the Intercostal spaces between the anterior

  intercostal (from internal thoracic) and posterior intercostal (from descending aorta) ; DILATION OF THE INTERCOSTAL ARTERIES may result in RESORPTION OF RIBS and NOTCHING seen on X-rays
• INTERNAL JUGULAR VEIN

  • Continuation of Sigmoid sinus

  • Leaves the skull through Jugular foramen

  • Descends through the neck in the carotid sheath LATERAL to

  Vagus nerve and Internal and Common carotid arteries o Closely related to the Deep Cervical lymph nodes
• INTERNAL JUGULAR VEIN

  TRIBUTARIES:

  o Inferior petrosal sinus

  o Pharyngeal

  o Sup thyroid

  o Facial

  o Lingual

  o Middle thyroid
• A first-year emergency medicine resident inserts a subclavian venous catheter using an infraclavicular approach. Subsequently, the patient has difficulty breathing. What nervous structure may have been injured?

  Phrenic nerve
• Indications for Central Venous Catheter

  • Administration of drugs and parenteral nutrition • Hemodynamic monitoring

  • Rapid fluid administration

  • Long term venous access
• CENTRAL VENOUS CATHETERS

  Common Sites:

  • Internal jugular

  • Subclavian

  • Femoral
• Internal Jugular Vein (Central or Anterior approach)

  needle is inserted at the apex of triangle formed by the heads of SCM and clavicle on R side
• Subclavian vein (Infraclavicular approach)

  place index finger at sternal notch and thumb at intersection of clavicle and first rib; needle is inserted below the clavicle and lateral to thumb on R side
• Subclavian vein


  Lies close to the undersurface of the medial third of the clavicle
• Needle insertion of SUBCLAVIAN CATHETHERIZATION – INFRACLAVICULAR APPROACH

  1. Place index finger at sternal notch and thumb at intersection of clavicle and first rib

  2. Needle is inserted below the clavicle and lateral to thumb on R side (along the inferior edge of the clavicle 2 – 4 cm lateral to its midpoint; advanced towards the sternal notch)

  3. Gentle aspiration is applied until dark, nonpulsatile venous blood is evident
• Needle pierces following the procedure for SUBCLAVIAN CATHETHERIZATION – INFRACLAVICULAR APPROACH


  • Skin
  • Superficial fascia
  • Pectoralis major (clavicular head)
  • Clavipectoral fascia
  • Subclavius muscle
  • Wall of Subclavian vein
• Patient positioning for SUBCLAVIAN CATHETHERIZATION – INFRACLAVICULAR APPROACH

  TRENDELENBURG position (supine with head lower by 10 – 15 degrees) with the head turned to the opposite side
• Needle insertion for SUBCLAVIAN CATHETHERIZATION – INFRACLAVICULAR APPROACH

  1. Along the inferior edge of the clavicle 2 – 4 cm lateral to its midpoint; advanced towards the sternal notch

  2. Gentle aspiration is applied until dark, nonpulsatile venous blood is evident
• Anatomy of problems for SUBCLAVIAN CATHETHERIZATION – INFRACLAVICULAR APPROACH

  • Hitting the clavicle
  • Hitting the first rib
  • Hitting the subclavian artery
  • Hitting the phrenic nerve
• Complications (CENTRAL VENOUS CATHETERS)

  • Pneumothorax
  • Hemothorax
  • Subclavian artery puncture
  • Internal thoracic artery puncture
  • Diaphragmatic paralysis
• Advantages of using the right IJV

  • Larger than left
  • Its course to the SVC is straight
• Disadvantages and Risks of using the left IJV

  • Thoracic duct joins the left; misplaced catheter may result in CHYLOTHORAX
  • Cervical pleura extends further into the neck on the left; misplaced catheter may result in PNEUMOTHORAX
  • Longer; it turns and joins the subclavian Brachiocephalic vein and again to enter the SVC
• Internal Jugular Catheterization Procedure

  1. Patient is placed in a TRENDELENBURG position

  2. Head is turned to the LEFT

  3. After sterile preparation and draping of the patient, local anesthetic is infiltrated subcutaneously into the lesser supraclavicular fossa

  4. Needle is INSERTED at the APEX of the lesser supraclavicular fossa or heads of SCM and clavicle

  5. Gentle aspiration during needle insertion is applied until dark, nonpulsatile venous blood is evident
• Why head is turned to the LEFT for INTERNAL JUGULAR CATHETERIZATION

  • It flattens the IJV
  • It stretches the SCM and accentuates the Lesser to form supraclavicular fossa
  • The pulse of the CCA is more easily palpated in the apex of the fossa
• Key Anatomical Relationships for INTERNAL JUGULAR CATHETERIZATION


  • The POSITION of the CAROTID SHEATH in the LESSER SUPRACLAVICULAR FOSSA
  • The POSITION within the CAROTID SHEATH - IJV is LATERAL to the CCA
• BRACHIOCEPHALIC

  VEIN

  • union of Internal jugular and Subclavian vein

  • At the level of the inf border of the 1st R costal cartilage, R / L unite
• Tributaries of Brachiocephalic vein

  o Internal thoracic

  o Vertebral

  o Inferior thyroid

  o Superior intercostal
• 3rd, right chondrosternal junction

  The superior vena cava drains into the right atrium at the level of:
• SUPERIOR VENA CAVA

  • Union of Right / Left Brachiocephalic veins

  • Ends at the level of the 3rd Right costal cartilage to enter the R atrium
• AZYGOS SYSTEM

  • Connects SVC from IVC

  • Formed by the union of Right Ascending Lumbar and Right

  Subcostal veins

  • Arches over the root of the R lung and empties into SVC

  • Ascends through the Aortic opening in the diaphragm on the

  RIGHT side of the Aorta to the level of the 5th thoracic vertebra
• Tributaries of azygous system

  o Intercostal vein o Mediastinal

  o Esophageal

  o Bronchial

  o Hemiazygos (Left Subcostal and Ascending Lumbar) o Accessory Hemiazygos