Anatomic Exposures For Vascular Surgery 2013 PDF

Anatomic Exposures
in Vascular Surgery
THIRD EDITION
THIRD EDITION
Anatomic Exposures
in Vascular Surgery
Gary G. Wind, M.D., F.A.C.S.
Professor of Surgery
Department of Surgery
Uniformed Services University of the Health Sciences
Director of Art and Education, Vesalius.com
Bethesda, Maryland
R. James Valentine, M.D., F.A.C.S.

Professor and Chairman
Division of Vascular and Endovascular Surgery
Executive Vice Chairman, Department of Surgery
Alvin Baldwin, Jr. Chair in Surgery
University of Texas Southwestern Medical Center
Dallas, Texas
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© 2013 by Gary G. Wind and R. James Valentine

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Library of Congress Cataloging-in-Publication Data
Wind, Gary G.
Anatomic exposures in vascular surgery / Gary G. Wind, R. James Valentine; illustrated by Gary G.
Wind. — 3rd ed.
p. ; cm.
Rev. ed. of: Anatomic exposures in vascular surgery / R. James Valentine, Gary G. Wind.
Includes bibliographical references and index.
ISBN 978-1-4511-8472-3 (alk. paper) — ISBN 1-4511-8472-7 (alk. paper)
I. Valentine, R. James, 1954- II. Valentine, R. James, 1954- Anatomic exposures in vascular surgery.
III. Title.
[DNLM: 1. Blood Vessels—anatomy & histology—Atlases. 2. Vascular Surgical Procedures—Atlases.
WG 17]
611ʹ.13—dc23
2012036861
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the contents of the publication. Application of
the information in a particular situation remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and
dosage set forth in this text are in accordance with current recommendations and practice at the time of
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flow of information relating to drug therapy and drug reactions, the reader is urged to check the package
insert for each drug for any change in indications and dosage and for added warnings and precautions. This
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(FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care
provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.
This book was written by Drs. Gary G. Wind and R. James Valentine in their private capacity.
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10 9 8 7 6 5 4 3 2 1
To our wives
Marilyn Gail Wind and Tracy Williams Valentine
for their patience and support
CONTRIBUTORS
Forearm Fasciotomy:
Jeffrey A. Marchessault, MD
Adjunct Faculty, Lincoln Memorial University-DeBusk College
of Osteopathic Medicine, Harrogate TN
Associated Orthopaedics of Kingsport, TN
Vascular Exposure of the Lumbar Spine:
David Whittaker, MD, FACS

CDR, MC, USN
Chief, Vascular Surgery
Walter Reed National Military Medical Center
Bethesda, MD
Leo Daab, MD
Fellow, Vascular Surgery
Walter Reed National Military Medical Center
Bethesda, MD
vii
CONTENTS
Contributors vii
Foreword from the First Edition xi
Preface to the First Edition xiii
Preface to the Third Edition xv
INTRODUCTION Embryology of the Arteries and Veins 1
EXTRACRANIAL CIRCULATION OF THE HEAD AND NECK 21
CHAPTER 1 Carotid Arteries 23
CHAPTER 2 Vertebral Arteries 51
VESSELS OF THE CHEST 77
CHAPTER 3 Thoracic Aorta 79
CHAPTER 4 Superior Thoracic Aperture and Cervicothoracic Sympathetic Chain 113
VESSELS OF THE UPPER EXTREMITY 153
CHAPTER 5 Axillary Artery 155
CHAPTER 6 Brachial Artery 177
CHAPTER 7 Forearm Vessels 189
CHAPTER 8 Hand Vessels 217
VESSELS OF THE ABDOMEN 235
CHAPTER 9 Upper Abdominal Aorta, Including the Visceral and Supraceliac Segments 237
CHAPTER 10 Celiac and Mesenteric Arteries 273
CHAPTER 11 Renal Arteries 295
CHAPTER 12 Infrarenal Abdominal Aorta, Pelvic Arteries, and Lumbar

Sympathetic Chain 315
CHAPTER 13 Inferior Vena Cava 349
CHAPTER 14 Portal Venous System 365

ix
VESSELS OF THE LOWER EXTREMITY 389
CHAPTER 15 Common Femoral Artery 391
CHAPTER 16 Vessels of the Thigh 429
CHAPTER 17 Popliteal Artery 449
CHAPTER 18 Vessels of the Leg 483
VASCULAR VARIATION 539
CHAPTER 19 Anatomic Variation of the Blood Vessels 541
APPENDIX Selected Anatomic References 577
Subject Index 579
x | CONTENTS
FOREWORD FROM THE FIRST EDITION
The illustrations are the strong point of this excellent book. These have been drawn
from the perspective of a surgeon who clearly knows what is seen during a surgi-
cal operation. An anatomist illustrates the anatomy as seen in the dissecting room.
Drs. Gary Wind and R. James Valentine have given us outstanding drawings of
what a surgeon will see in the operating room.
Dr. Wind is experienced in the use of a microcomputer to create three-
dimensional reconstructions of anatomy. These unusual visual images and models
provide different concepts of conventional anatomic views. The knowledge gained
from this study of many regions of the body has been used to provide the unusual and
very informative illustrations that fill this book. In a standard illustration, it appears
that the vertebral artery travels only a short distance before it enters the foramen in
the transverse process of the sixth cervical vertebra. A surgeon who has operated on
this artery at this point knows that there is a length of several centimeters before it
enters the bony foramen. This book is filled with similar useful information, which
has been uncovered by Dr. Wind’s special anatomical reconstructions. The text is
clear and concise and there is a good bibliography after each chapter. This text has
obviously been written by those who know what is of importance to a clinician.
Of special interest are two sections, the introduction on embryology and the last
section on vascular variation. Such variations have always been a challenge for sur-
geons. Embryology demonstrates the possible explanations for these variations, and
the final chapter on anatomic variations will help the surgeon to expect and identify
the unexpected should he or she encounter them.
This is an anatomic book written by surgeons, but the objective has not been
to describe surgical procedures. It has been to describe and illustrate the anatomic
relationships of blood vessels. The result is a book of great value, not only to vascular
surgeons but also to anatomists, because it throws new light on an old subject—gross
anatomy.
Charles G. Rob, M.D., F.R.C.S., F.A.C.S†
Professor of Surgery
Uniformed Services University of
the Health Sciences
Bethesda, Maryland
†Dr. Charles Rob passed away in 2001. He was a preeminent pioneer of vascular surgery and one of the last
of the surgical giants. The force of his personality was always evident beneath his impeccable gentlemanly
persona. He will be missed by us and by the surgical world as a whole.
Gary G. Wind, M.D.
R. James Valentine, M.D.
xi
PREFACE TO THE FIRST EDITION
Dispel from your mind the thought that an understanding of the human body
in every aspect of its structure can be given in words; for the more thoroughly
you describe, the more you will confuse. . . I advise you not to trouble with
words unless you are speaking to blind men.
—Leonardo da Vinci
Understanding the anatomy of the blood vessels is a highly visual enterprise,

given the complex ramification of the vascular tree through all the tissue planes of
the body. This book is designed to convey the clinical anatomy of the blood ves-
sels through extensive new illustrations with a minimum of words. The focus is on
a concise, clear presentation of key anatomic relationships necessary to understand
the vascular pattern in all areas of the body. The chapters are divided into anatomic
overview and surgical approach sections.
As a monograph, this book has the advantage of a uniform concept and presen-
tation sometimes lacking in multiauthor works. At the same time, as the work pro-
gressed we were privileged to have the advice and criticism of the eminent surgeons
listed as consulting editors. The visualization of the anatomy was aided by original
fresh cadaver dissection for each body region. The clinical insights are based on both
experience and a thorough review of current and historical references.
The literature of a relatively young specialty such as vascular surgery natu-
rally grows by accretion as new procedures are devised and perfected. The surgical
anatomy associated with the procedures is described in variable detail in the original
papers and is then condensed in surgical texts and atlases. There comes a time in this
evolutionary process when a comprehensive treatment of the anatomic context of
vascular surgery is beneficial. It is the purpose of this book to provide a detailed and
practical guide for exposing and manipulating blood vessels with minimal trauma to
the surrounding structures and to the vessels themselves.
The format of the book is designed to provide a unified, integrated concept of
anatomic approaches to blood vessels. The anatomy is described in the context of the
latest techniques and is organized by body region. The same anatomic descriptions
should be equally applicable to new procedures as they arise. The text is intended to
describe clinically relevant anatomy as concisely as possible without getting bogged
down in trivial and esoteric points. The reader is credited with sufficient anatomic
knowledge to be comfortable with the level of presentation and with the intellectual
curiosity to look up details that pique his or her interest. Illustrations showing surgi-
cal approaches depict ideal exposure, and laparotomy pads, which would normally
be present to protect wound edges, are omitted for purposes of clarity and orientation.
Clinical references are listed at the end of each chapter, and anatomic references are
listed at the end of the book. We hope that in this way to bring crisp clarity and unity
to the anatomy of vascular surgery.
xiii
PREFACE TO THE THIRD EDITION
The last two decades have witnessed a surge of interest in catheter-based vascular in-
tervention, with a corresponding decrease in the number of open vascular procedures
currently being performed. As the clinical experience with open vascular exposure
declines, we believe that there is an enduring need for a comprehensive text that
features vascular anatomy from a surgical point of view. The original purpose of this
book has not changed—it is intended to be a detailed and practical guide for exposing
blood vessels with minimal trauma to surrounding structures. The volume of recent
literature regarding novel exposure techniques and refined indications for specific
approaches has provided the impetus for a third edition.
Based on favorable response to the previous editions, we have maintained an
emphasis on clinical anatomy, focusing on detailed illustrations rather than extensive
written descriptions. A key feature of this book is that all of the illustrations were
drawn by a single artist, who is also a surgeon and anatomist. This uniformity has
allowed inclusion of more detail in each illustration for maximal educational benefit.
A major enhancement in this third edition is the use of full color for the anatomic
illustrations, giving a greater appreciation of three-dimensional relationships. The
procedural text and clinical references have been updated to reflect current concepts.
New sections on forearm compartment syndrome/fasciotomy and vascular exposure
of the lumbar spine have been added. In addition, references to web-based three-
dimensional anatomy resources have been included.
As before, chapters are divided into anatomic overview and surgical exposure
sections. The text is written from a surgeon’s point of view, using practical descrip-
tions based on key anatomic relationships. Trivial and esoteric details have been
avoided. Related clinical discussion is based on a thorough review of the modern
literature.
Perhaps, the most important point to be made about this book is that it is in-
tended to have lasting applicability. Human anatomy will not change in the fore-
seeable future. Vascular procedures may wax and wane in popularity, but exposure
techniques remain a standard part of any present or future operation.
xv
INTRODUCTION
Embryology of the
Arteries and Veins
Development of the Blood Vessels remodeling that extends through the second and
final month of the embryonic period. Development
Overview at the cephalad end of the embryo proceeds more
rapidly than at the caudal end as the arteries and
Between the third and eighth week of embryonic veins change and interact with the growing thora-
gestation (measured in postovulatory days), the coabdominal organs, parietes, and extremities. The
blood vessels form and evolve into an approxima- incredibly complex bioarchitectural development
tion of the definitive human circulatory pattern. To- and reorganization take place while the embryo is
ward the end of the third week, primitive circulation between 3 mm and 3 cm in size (crown-to-rump
begins, propelled by the newly fused heart. Rapid length; Fig. 1). The next significant change in the
changes in the fourth week set the stage for extensive vascular pattern occurs at birth.
30 mm
20 mm 8 weeks
6 weeks
5 mm
4 weeks
1 cm.
Fig. 1 Rapid vascular development and reorganization

takes place in the embryonic period (the first 2 months
of gestation) when the embryo is between 3 and 30 mm
in crown-to-rump length. The basic pattern of definitive
vessels is established by the end of this period.
1
Understanding the changes that take place first somites appear at midbody (Fig. 3). The lining
in the evolution of the adult vascular system pro- cells of mesenchymal clefts that have developed in-
vides a logical framework in which to conceptual- dependently until this time begin to interconnect and
ize the many variations and anomalies that one will form two pairs of longitudinal channels, one medial
encounter in vascular surgery. and one lateral. The medial channels attach to the
ends of the paired heart tubes at the cephalad end
Primordial Vessels and the Inception of Circulation of the embryo, forming the primitive aortas, which
extend into distal vitelline arterial networks. The lat-
At the inception of circulation, the embryo appears eral set attaches to the caudal ends of the heart tubes
as a polypoid excrescence within the chorionic ves- and will become the vitelline and umbilical veins.
icle (Fig. 2). The pedicle constitutes the body stalk. Within a few days, the heart has fused and be-
The head of the polyp is subtly bilobed, with the gun peristaltic pulsations that propel blood through
groove separating the two lobes reflecting the mar- the vitelline circuits. The vitelline circulation pro-
gins of the embryonic disk within. The dome above vides nutrients from the rapidly regressing mam-
the 3-mm embryonic plate is the amnion, and the malian yolk sac for only a brief time before this
pendant bleb is the yolk sac. function is assumed by the precociously maturing
Between these mirror-image domes, the elon- chorion. The umbilical vessels, extending from the
gating 2-mm embryonic disk rolls its lateral edges vitelline complexes through the body stalk and then
up to begin the closure of the neural groove, and the to the chorion, become dominant.
Extra embryonic coelom

Chorionic villi
Chorion
Body stalk
Amnion
Amnionic cavity
Neural fold
Heart
Yolk sac
Allantois
Fig. 2 At the onset of angiogenesis, the embryonic plate lies in a polypoid excrescence
within the chorionic vesicle.
2 | INTRODUCTION
Amnionic cavity
Body stalk
Mesoderm
Hindgut
Ectoderm
Dorsal aorta
Foregut
Midgut
Neural fold
Allantois
Heart
Umbilical a.
Umbilical v.
Extraembryonic
coelom
Endoderm
Yolk sac
Vitelline v’s Vitelline a’s
Fig. 3 The first two sets of primitive vessels attach to the ends of the newly fused heart tube.
EMBRYOLOGY OF THE ARTERIES AND VEINS | 3

Aortic Arches the third arch to form the internal carotid arteries.
The external carotid arteries arise as new branches
Six sets of aortic arches have penetrated the cores of the aortic sac and by differential growth migrate
of successive branchial arches, and the first, second, distally onto the third arches (Fig. 6). The roots of
and rudimentary fifth have largely regressed by the the third arches, therefore, become the common ca-
beginning of the fifth week when the embryo is 6 mm rotid arteries. The external carotid arteries follow the
in length (Fig. 5). The dorsal aortas persist at the level muscles derived from the first two branchial arches
of the first two arches, retaining their connection to in their migration to the face and head.
1 2
Internal carotid a.
External
1 mm carotid a’s
Gut
Pulmonary a. Aortas
Lung buds
Fig. 5 The aortic arches evolve in a cephalad to caudad

progression.
Fig. 6 The internal carotid arteries are left as cephalad

dorsal aorta remnants after resorption of the first two
arches and are fed by the third arches.

The fourth arches both persist, the left as the The sixth (pulmonary) arches grow from the
adult aortic arch and the right as the root of the dorsal aortas to meet the developing pulmonary arter-
right subclavian artery (Fig. 7). The subclavian ar- ies that extend from the aortic sac to the lung buds. The
teries arise initially as outgrowths of the terminal right sixth arch disappears while the left becomes the
paired aortas just proximal to their union. The re- ductus arteriosus (later the ligamentum arteriosum).
sorption of the right aorta between the subclavian During weeks 5 through 7, when these arch changes
artery and the fused trunk isolates the right subcla- are taking place, the truncus and aortic sac of the heart
vian artery. are separating into aortic and pulmonary stems.
Internal carotid a.
External carotid a.
6 Ductus
arteriosus
Truncus Vagus n.
arteriosus Pulmonary a.
Subclavian a. Aorta
Fig. 7 Selective resorption of the remaining arches results in a definitive aortic and
pulmonary pattern.
6 | INTRODUCTION
The Dorsal Aorta of serial intersegmental branches to the body wall
and extremities, genitourinary branches in the
While the arches are reforming at the cephalad end nephrotome region, and ventral visceral branches.
of the embryo, the dorsal aorta is elaborating dorsal, The dorsal branches divide into dorsal and
lateral, and ventral branches (Fig. 8). These consist ventral rami. The dorsal rami in the cervical region
Dorsal intersegmental a
Fusions (ventral branch)
Aorta
Fig. 8 The fused dorsal aorta elaborates segmental dorsal and lateral branches and retains
single ventral visceral branches descended from the vitelline arteries.

Multiple lateral branches extend to the neph- single when the aortas fuse. As the yolk sac regresses,
rotome region supplying the mesonephros, gonads, the number of vessels decreases. Near the end of the
metanephros, and adrenal glands (Fig. 10). As the fifth week, when the embryo is 8 mm in length, the
mesonephros involutes, the number of branches also celiac, superior mesenteric, and inferior mesenteric
decreases, leaving the renal, adrenal, and internal arteries are left. In addition, the original continuity
gonadal vessels. The phrenic arteries are also defini- of the umbilical arteries with the vitelline system is
tive lateral branches. lost, and the umbilical arteries connect to an adja-
The ventral branches of the aorta are deriva- cent dorsal intersegmental branch that becomes the
tives of the paired vitelline arteries that become common iliac artery (see below and Fig. 14).
Adrenal
Gonad
Celiac a.
Mesonephros
Superior
mesenteric a.
Metanephros
(kidney)
Dorsal
intersegmental a’s
Inferior mesenteric a.
Fig. 10 Lateral branches in the nephrotome region supply the gonadal ridge, the meso-
nephros, and metanephros (definitive kidney).

form longitudinal fusions that persist when all but arteries. Two longitudinal precostal fusions similar
the most caudal segmental dorsal ramus resorb, to the dorsal branch fusions form the thyrocervical
leaving the vertebral arteries (Fig. 9). The vertebral trunks cephalad to the subclavian arteries and the
artery and subclavian artery have a common origin costocervical trunks caudal to the subclavian arter-
from the seventh cervical intersegmental artery. The ies. The axial vessels of the limb buds are also de-
ventral rami constitute the intercostal and lumbar rived from dorsal intersegmental branches.
Internal carotid a.
External carotid a.
Common carotid a.
Ductus arteriosus
Vertebral a.
Pulmonary a.
Aorta
Left pulmonary a.
Right
subclavian a.
Thyrocervical trunk
Left subclavian a.
Internal
thoracic a.
Costocervical
trunk
Fig. 9 Longitudinal fusion of the cervical and upper thoracic dorsal branches results in the
vertebral arteries and costocervical trunks.
8 | INTRODUCTION
Multiple lateral branches extend to the neph- single when the aortas fuse. As the yolk sac regresses,
rotome region supplying the mesonephros, gonads, the number of vessels decreases. Near the end of the
metanephros, and adrenal glands (Fig. 10). As the fifth week, when the embryo is 8 mm in length, the
mesonephros involutes, the number of branches also celiac, superior mesenteric, and inferior mesenteric
decreases, leaving the renal, adrenal, and internal arteries are left. In addition, the original continuity
gonadal vessels. The phrenic arteries are also defini- of the umbilical arteries with the vitelline system is
tive lateral branches. lost, and the umbilical arteries connect to an adja-
The ventral branches of the aorta are deriva- cent dorsal intersegmental branch that becomes the
tives of the paired vitelline arteries that become common iliac artery (see below and Fig. 14).
Adrenal
Gonad
Celiac a.
Mesonephros
Superior
mesenteric a.
Metanephros
(kidney)
Dorsal
Fig. 10 Lateral branches in the nephrotome region supply the gonadal ridge, the meso-
nephros, and metanephros (definitive kidney).

The Extremities bud is fed by several dorsal intersegmental arteries
(Fig. 12). One stem assumes a dominant position,
The limb buds arise in the 3- to 4-mm embryo, with and the others regress. The veins also form a domi-
the upper extremities developing more precociously nant channel, which takes the form of a marginal
(Fig. 11). The base of the buds spans several seg- vessel lying under the apical growth ridge of the
ments, and the diffuse initial capillary plexus of the primitive limb paddle.
7–9 mm
33 days
11–14 mm 16 mm
37 days 41 days
17–20 mm 25–27 mm
47–48 days 54 days
Fig. 11 The upper extremity leads the lower extremity in developmental maturity.
10 | INTRODUCTION
Aorta 6th Dorsal
intersegmental a.
Subclavian a.
Postcardinal v.
Axial a.
Subclavian v.
Dorsal aorta
R. subclavian a. Marginal v.
Apical growth
ridge
Postcardinal v.
Fig. 12 The primitive axial arteries of the limbs are connected by a fine vascular mesh to
a substantial marginal vein that drains initially into the postcardinal veins.

Brachial a.
Ulnar a.
Median a.
Radial a.
Ulnar a.
11–14 mm
41 days
25–27 mm
54 days
17–20 mm
48 days
Fig. 13 Radial and ulnar arteries branch from the axial vessel and replace an intermediary
median artery to supply the forearm and vascular arcade of the hand.
Umbilical a’s
Anastomotic a.
Dorsal Sciatic a.
Common iliac a.
Fig. 14 The umbilical arteries shift their bases to dorsal intersegmental roots in the fourth week.
12 | INTRODUCTION
The subclavian artery, which arose in con- common and internal iliac arteries. These root ves-
cert with the changes in the aortic arches, forms sels give rise to the primitive axial vessels of the
the axial artery of the upper extremity in the lower extremities, sciatic arteries, and external iliac
5-mm, 4-week embryo. This original axis per- arteries.
sists as the brachial and interosseous arteries of The sciatic arteries arise from the new dor-
the arm and forearm (Fig. 13). The brachial artery sal roots of the umbilical arteries in the 9-mm,
gives rise to three branches to the vessels of the 5-week embryo. The external iliac arteries arise
hand: the median, ulnar, and radial arteries. The from the same vessel segment as the sciatic, and
median artery regresses, leaving the other two. the two vessels interconnect, selectively resorb,
Because of the relatively caudal initial position and branch to form the definitive arteries of the
of the upper extremity buds, the venous arch first lower extremities (Fig. 15). The anterior and pos-
drains into the postcardinal vein. The cranial mar- terior tibial vessels are derived from the popliteal
gin of the venous arch regresses, and the caudal remnant of the sciatic artery and from the femoral
margin remains as the basilic, axillary, and sub- artery, respectively.
clavian veins. By this stage, differential growth The marginal vein in the lower extremity forms
has shifted the drainage of the subclavian into the later than in the upper extremity, commensurate
precardinal region. with the caudal developmental lag. As in the upper
In the fourth week, the umbilical arteries extremity, the cephalad or tibial connection of the
anastomose with adjacent dorsal intersegmental marginal vein regresses, leaving the fibular branch.
aortic branches (Fig. 14). This secondary connec- The latter interconnects with the great saphenous
tion quickly becomes dominant, and the original vein, which arises independently of the postcardinal
aortic connection is lost. The new dorsal roots of vein. The two vessels give rise to the definitive ve-
the umbilical arteries are destined to become the nous drainage of the leg.
Sciatic a. Inferior
gluteal a.
Femoral a.
External
iliac a.
Superficial
femoral a.
Popliteal a.
Anterior
tibial a. Posterior
tibial a.
Peroneal a.
17–20 mm
47–48 days
23 mm
52 days 9 weeks
Fig. 15 The axial sciatic artery of the leg and the external iliac trunk interact to form the
mature vascular pattern of the lower extremity.

The establishment of the final vascular pattern The vitelline veins pass from the yolk sac
of the lower extremity lags behind that of the up- through the septum transversarum to enter the
per extremity, being completed in the third month, sinus venosus alongside the foregut. In their course
whereas the upper extremity has a mature pattern by through the septum transversarum, they interweave
the end of the eighth week. The middle sacral artery with the ingrowth of liver buds and become hepatic
is the remnant of the dorsal aorta distal to the iliac sinusoids (Fig. 17). Part of the sinusoidal system
arteries. contributes to the ductus venosus (see below), and
the suprahepatic branches on the right become the
hepatic veins. The infrahepatic vitelline veins are
The Veins paired by 4 weeks (5 mm) and lie on each side of
the duodenum. Through cross-anastomosis and
In the third week, when the embryo is 3 mm long partial resorption of the vitelline veins, the por-
and the neural tube begins to close, three sets of tal vein is formed with a serpentine route around
paired veins become established (Fig. 16). The ear- the duodenum. The superior mesenteric vein is a
liest are the vitelline veins from the yolk sac, then replacement of the vitelline veins connecting to
the umbilical veins from the chorion, followed by the portal vein. Cephalad to the liver, the left vi-
the cardinal veins draining the body proper. Venous telline vein and the left horn of the sinus venosus
developmental changes are more complex than disappear.
arterial, involving additions, deletions, interconnection, The umbilical veins initially pass from the
position, and flow changes. body stalk through the lateral body walls on each
Precardinal v.
Common
cardinal v.
Sinus venosus
Septum transversarum
Vitelline v’s
Umbilical v.
Fig. 16 Three pairs of veins give rise to the definitive venous pattern of the body.
14 | INTRODUCTION
side of the liver mass to reach the sinus veno- toward the midline and lies in the free edge of the
sus. As the liver expands, vascular connections falciform ligament.
between the umbilical veins and the hepatic sinu- The paired pre and postcardinal veins estab-
soids are established. Flow is progressively chan- lished in the 5-mm embryo at 4 weeks of age un-
neled through more direct pathways to the heart dergo a series of changes leading to the mature
until the ductus venosus is established. By 4½ venous drainage pattern of the body. The precardi-
weeks, all the umbilical vein blood in the 6-mm nal veins mature into the veins of the superior vena
embryo flows through the liver. The entire right caval drainage basin, and the postcardinal veins,
umbilical vein and the proximal extrahepatic por- supplemented by two sets of parallel channels, be-
tion of the left umbilical vein regress, leaving only come the inferior vena caval system of the lower
the left umbilical vein. The remaining vein shifts body.
Gut
Sinus
venosus
Common
cardinal v.
Vitelline v. 5 mm
Umbilical v.
Communication
of left
umbilical v.
6 mm with hepatic
sinusoids
Ductus venosus
Portal v.
9 mm
Fig. 17 The vitelline veins interdigitate with the developing liver buds to become hepatic
sinusoids. The left umbilical vein connects secondarily to the intrahepatic plexus, and the
major ductus venosus channel is established.

During the eighth week, an oblique venous The postcardinal veins lie dorsal to the meso-
channel connects the precardinal veins lying ven- nephroi, which they drain along with the legs and
trolateral to the brain (Fig. 18). The root of the body wall (Fig. 19). The distal ends of the postcar-
left precardinal regresses, leaving the root of the dinals interconnect early, before the postcardinal
right as the superior vena cava and the cross- trunks regress along with the mesonephroi. This dis-
connection as the left brachiocephalic vein. The tal connection at the level of the leg vein entry will
cephalad portions of the precardinal veins become become the left common iliac vein (Fig. 20). The
the internal jugular veins. External jugular and root of the azygous vein is the only other remnant of
subclavian veins develop independently and at- the postcardinal veins.
tach to the precardinal veins. The segment of right The subcardinal veins arise after the postcar-
precardinal vein between the right subclavian dinal veins, but while the latter are still in place,
and left brachiocephalic vein becomes the right and lie ventromedial to the mesonephroi. Intercon-
brachiocephalic vein. nections through the mesonephroi occur between
The evolution of the caudal venous system the subcardinal and postcardinal veins. A central
is not quite as straightforward. During the second subcardinal anastomosis arises that is destined to
month of embryonic life, the postcardinal veins become the stem of the left renal vein. The subcar-
are supplemented by the subcardinal and supra- dinal veins quickly lose their cephalad connection
cardinal veins, successively. As the sets of veins with the postcardinals, and the right subcardinal
partially regress in the order that they appeared, connects with a caudal extension of the hepatic
multiple interconnections lead to the mature vas- veins, forming the future subhepatic, suprare-
cular pattern. nal portion of the inferior vena cava. The adrenal
56 days
Internal
jugular v’s
Subclavian v.
Precardinal v’s Superior

vena cava Brachiocephalic v’s
Common cardinal v’s
Postcardinal v’s
Azygous v.
Fig. 18 A diagonal branch connects the precardinal veins in the eighth week, forming the
left brachiocephalic vein.
16 | INTRODUCTION
and gonadal veins are remnants of the subcardinal
veins.
The supracardinal veins appear last and
lie dorsomedial to the postcardinal veins. As the
kidneys develop and assume their final position, the
supracardinal veins anastomose with the subcardinal
veins at the level of the developing renal veins, form-
ing a portion of the left renal vein. The connection
on the right becomes the continuation of the inferior
vena cava below the renal veins, leading into the
persistent caudal portion of the right supracardinal
Mesonephric folds vein. The latter connects to the persistent early
cross-connection of the postcardinal veins that will
Postcardinal v. constitute the iliac confluence. The disconnected
Aorta cephalad portions of the supracardinal veins cross-
Metanephros connect, forming the azygous and hemiazygous
veins. The intercostal and lumbar veins that initially
drain into the postcardinal veins ultimately drain into
the derivatives of the supracardinal veins. Thus, the
cephalad body wall branches drain into the azygous
Fig. 19 The postcardinal veins lie in the dorsal sub- system, and the lower lumbar veins drain into the
stance of the mesonephric ridges, shown here in a 4-week distal inferior vena cava.
embryo.
4 weeks 6 weeks 7 weeks 8 weeks

Postcardinal v’s
Supra-
cardinal v’s
Caudal
extension of
hepatic v’s
Azygous v.
Intersubcardinal IVC
Sub- Sub-
cardinal v. anastomosis
supra-
anastomosis
Renal v’s
Illiac v’s
Aorta Supracardinal v. Aorta

Postcardinal v.
Sub-
cardinal v.
Subcardinal v.
Fig. 20 Complex interactions between the postcardinal veins and their subcardinal
and supracardinal derivatives result in the definitive venous drainage of the lower part of
the body.

Fetal Circulation and Birth At birth, the pulmonary vascular circuit sud-
denly fills, returning larger volumes of blood to the
During the remaining 7 months of gestation, the left atrium at the same time as the umbilical circula-
fetal period, oxygen-rich blood from the um- tion ceases. The result is a reversal in right and left
bilical vein passes through the liver, mostly via atrial pressures, closing the foramen ovale and ending
the ductus venosus (Fig. 21). It is mixed in the the interatrial shunt. The ductus arteriosus is closed
heart with desaturated, waste-laden blood from by muscular contraction and ultimately fibroses along
the fetal body. Flow dynamics and preferential with the ductus venosus and umbilical vessels.
shunting through the foramen ovale and ductus The vestiges of the specialized fetal circula-
arteriosus favor oxygen delivery to the cephalad tory channels are the ligamentum arteriosum, liga-
end of the body. Contaminated blood returns to mentum venosum, and round ligament of the liver
the placenta from the descending aorta via the in the chest and upper abdomen and the medial um-
common iliac to internal iliac to umbilical artery bilical ligaments on the inner surface of the lower
route. abdominal wall.
Ductus arteriosus
Ductus Inferior
venosus vena cava
Umbilical v.
Umbilical a’s
Fig. 21 The fetal circulation is dominated by preferential flow of oxygenated umbilical

blood across the foramen ovale and to the head and body via the aorta. Caval and pulmonary
admixture occurs directly in the inferior vena cava and atria and secondarily via the ductus
arteriosus.
18 | INTRODUCTION
Bibliography 5. Sadler TW. Langman’s Medical Embryology.
Baltimore, MD: Lippincott Williams & Wilkins; 2009.
1. O’Rahilly R, Muller F. Developmental Stages in 6. Stewart JS, Kincaid OW, Edwards JE. An Atlas
Human Embryos. Washington, DC: Carnegie of Vascular Rings and Related Malformations of
Institution of Washington, DC;1987. Publication the Aortic Arch System. Springfield, IL: Charles
637. C Thomas; 1964.
2. Arey LB. Developmental Anatomy. Philadelphia, 7. Senior HD. Development of the arteries of the hu-
PA: WB Saunders; 1963. man lower extremity. Am J Anat. 1919;25:55–95.
3. Gray SW, Skandalakis JE. Embryology for Surgeons. 8. Seyfer AE, Wind G, Martin R. Study of upper extrem-
Philadelphia, PA: WB Saunders; 1991. ity growth and development using human embryos
4. Moore KL. The Developing Human. Philadelphia, and computer reconstructed models. J Hand Surg.
PA: WB Saunders; 2008. 1989;14A:927–932.

EXTRACRANIAL
CIRCULATION OF THE
HEAD AND NECK
21
Carotid Arteries
1
Surgical Anatomy of the Neck
In the neck, nature has ingeniously compacted an

intricate complex of vital structures and enfolded
them on three sides with muscle and bone. It is
possible to master this daunting array of anatomy
if one conceptualizes the neck in a systematic way.
There is a central visceral column containing the
digestive and respiratory passages and the thyroid
gland (Fig. 1-1). Posteriorly, the visceral compart-
ment is bounded by the main structural element of
the neck, the cervical spine, and its supporting struts
of muscle. On either side of the visceral cylinder,
the large, axial neurovascular structures of the neck
Carotid
pass between the head and the superior thoracic
sheath
aperture enclosed in the loose, areolar carotid sheath.
Wrapped around these central neck elements, like
the spiral sheath of an electrical cable, are the strong,
flat trapezius and sternocleidomastoid muscles. In
Trapezius m.
the context of these structural groupings, it is now
possible to make some sense of the fascial layers of
the neck.
Sternocleidomastoid m.
Visceral
compartment
Fig. 1-1 The three major components of the neck con-

sist of a structural column of muscle and bone, a central
visceral column, and paired fascicles containing major
neurovascular structures.
23
The Prevertebral Fascia the anterior longitudinal ligament of the thoracic
spine. Posteriorly, it attaches along a midline seam
The supple cervical spine is surrounded by a central to the ligamentum nuchae of the cervical spinous
group of muscles attached to the ribs, to the base processes. The prevertebral fascia covers the ori-
of the skull, and to adjacent vertebrae (Fig. 1-2). gins of the cervical nerves and the phrenic nerve
These include small intrinsic muscles and power- arising from them. At the base of the neck, the pre-
ful erector spinae muscles posteriorly, the small vertebral fascia takes a more complex form. Fan-
longus colli and longus capitis muscles anteriorly, ning out laterally, it covers the roots of the brachial
and the levator scapulae and scalene muscles lat- plexus and the subclavian artery and forms a neu-
erally. This paraspinal grouping is wrapped in a rovascular wrap called the axillary sheath. The vis-
discrete fibrous layer called the prevertebral fas- ceral components of the neck lie along the center
cia. Anteriorly, this fascia runs from the base of of this delta-shaped anterior sheet of prevertebral
the skull down the vertebral bodies to blend with fascia.
Semispinalis
capitis m.
Longus capitis m.
Longissimus
capitis m.
Splenius
capitis m.
Levator
scapulae m.
Longus colli m.
Scalene m’s
Axillary
Phrenic n. sheath
Prevertebral
Anterior longitudinal lig. fascia
Fig. 1-2 The musculoskeletal pillar of the neck is wrapped in the prevertebral fascia that
extends into the shoulder as the axillary sheath.
24 | EXTRACRANIAL CIRCULATION OF THE HEAD AND NECK

The Visceral Fascia the strap muscles has also been called the middle
cervical fascia. The plane between the bucco-
In the central neck, the roughly cylindrical vis- pharyngeal fascia and the prevertebral fascia is a
ceral compartment is surrounded by a thin layer highway for spread of air and GI contents between
of fascia called pretracheal fascia in front and buc- neck and mediastinum after esophageal injury. A
copharyngeal fascia behind (Fig. 1-3). The strap variable midline adhesion between the two fascial
muscles are also enclosed within the lamellae of layers may limit spread of abnormal contents to
this layer. The portion of visceral fascia around some extent.
Fig. 1-3 The visceral compartment is surrounded by its own fascial layer. The portion
immediately apposed to the trachea is called pretracheal fascia. The fascia around the strap
muscles is sometimes called the middle layer of deep cervical fascia.
CAROTID ARTERIES | 25
The Investing Fascia skirting the posterior base of the skull, the zygo-
matic arch, and the lower border of the mandible.
Wrapping the neck into a neat bundle is the best The lower margin attaches to sternum, clavicle, ac-
defined and most superficial layer of the deep fas- romion, and the spine of the scapula. The parotid
cia, the investing fascia (Fig. 1-4). It attaches to the and submaxillary glands are also enclosed within
ligamentum nuchae in the posterior midline and layers of this fascia.
splits to invest the trapezius and sternocleidomas- The flat sternocleidomastoid muscles form the
toid muscles within its laminae. The investing fas- final, lateral boundary of the space containing the
cia forms a complete sheath, with its upper margin carotid sheath.
Investing
fascia
Fig. 1-4 The broad sternocleidomastoid and trapezius muscles are enclosed in the most
superficial layer of the deep cervical fascia, which is also called the investing fascia.

The Carotid Sheath Because of the amorphous nature of this “sheath,”
a path to any of the enclosed structures can be dis-
The carotid sheath is best thought of as an aggre- sected with minimal disturbance to the adjacent
gation of connective tissue filling a long cleft with structures.
a triangular cross section. The boundaries of this Two additional neural structures are associ-
cleft consist of the visceral compartment medially, ated with the carotid sheath. The cervical sympa-
the prevertebral fascia posteriorly, and the sterno- thetic chain is superficially embedded in the most
cleidomastoid muscle anterolaterally (Fig. 1-5). posterior fibers of the carotid sheath. The ansa cer-
The sheath is not a discrete fascial sheet like the vicalis, providing motor innervation to the strap
investing fascia. It surrounds the carotid artery, muscles, is slung within the anterior fibers of the
the internal jugular vein, and the vagus nerve. sheath.
Superior cervical
sympathetic ganglion
Superior
Vagus n. thyroid a.
Internal jugular v.
Carotid a. Ansa
cervicalis
Carotic sheath
Middle thyroid v.
Fig. 1-5 The carotid sheath is a loose network of fascia containing the carotid arteries, the
internal jugular veins, and the vagus nerves.
The Superficial Fascia Cutaneous nerves and superficial veins lie in
the well-defined cleavage plane between the pla-
The superficial fascia of the neck contains two flat tysma and the investing fascia. A cross section of the
sheets of muscle, the platysma (Fig. 1-6). These neck at the level of the thyroid cartilage (Fig. 1-7)
muscles represent the remnant of the more exten- demonstrates the relationships of these and the other
sive panniculus carnosus of other mammals with fascia-bound anatomic groupings. With this back-
which they shake their coats. The muscles of fa- ground, the remainder of the chapter focuses on the
cial expression are specialized modifications of this carotid artery and its relationship to surrounding
layer. structures.
Platysma m.
External
jugular v.
Fig. 1-6 The platysma muscle lies in the superficial fascial layer and lends substance to
this plane for purposes of surgical dissection.

A normally positioned carotid bifurcation is mandibular ramus. This is especially true of the
readily accessible in the carotid triangle bounded anatomy surrounding the distal internal carotid
by the sternocleidomastoid muscle, the posterior artery. In order to ensure a safe surgical approach
belly of the digastric muscle, and the anterior to this artery, a thorough grasp of its relationships
belly of the omohyoid muscle. The area between is essential. The overall pattern of individual ves-
the carotid bifurcation and the base of the skull is sels and nerves in the neck will be considered
a dense intertwining tangle of vessels, nerves, and first, followed by an in-depth look at the carotid
muscles packed into a confined space behind the triangle.
Middle cervical fascia

Anterior Pretracheal Superior laryngeal n.
jugular v. fascia Superior thyroid a.
Platysma m.
Carotid sheath
Ansa cervicalis
Investing
fascia
Thyroid Vagus n.
Cervical Prevertebral
gland
sympathetic fascia
trunk External
jugular v.
Vertebral a.
Prevertebral
fascia
Cervical n.
Scalene m’s
Fig. 1-7 A cross section of the neck shows the discrete boundary between the musculo-
skeletal element of the neck and the other components.
The Carotid Artery structures of the head, gives off several branches
before its terminal bifurcation into the internal
The common carotid artery ascends in the neck maxillary and superficial temporal arteries. These
medial to the internal jugular vein and normally are the superior thyroid, ascending pharyngeal,
has no branches (Fig. 1-8). Occasionally, the su- lingual, facial, occipital, and posterior auricular
perior thyroid artery arises proximal to the bifur- arteries. The internal carotid artery proceeds pos-
cation into internal and external carotid arteries. teromedially to enter the carotid canal at the base
The bifurcation is usually located at the level of the of the skull without giving off any branches. On
superior border of the thyroid cartilage. Variations the medial side of the bifurcation lie the small,
in the levels at which the carotid bifurcates are oval carotid body, a chemoreceptor, and the ca-
more often above this position than below. The rotid sinus, a pressure receptor intrinsic to the
external carotid artery, supplying the extracranial wall of the common and internal carotid arteries.
Internal maxillary a.
Posterior auricular a. Internal
Facial a. carotid a.
Lingual a.
Ascending pharyngeal a. Occipital a.
Carotid body
Superior
thyroid a.
Vertebral a.
Common carotid a.
Fig. 1-8 The common carotid artery ascends two-thirds of the length of the neck without
branches until it bifurcates. The external carotid has multiple extracranial ramifications
while the internal carotid is branchless.

The Jugular Veins communicate distally through the retromandib-
ular veins. The external jugular lies deep to the
The internal and external jugular veins sandwich platysma for most of its course, and the internal
the sternocleidomastoid muscle between them, jugular vein lies deep to the sternocleidomastoid
following a somewhat diagonal course from the muscle. The common facial vein usually enters
distal anterior margin to the proximal posterior the internal jugular vein at the level of the carotid
margin of that muscle (Fig. 1-9). The two veins bifurcation.
Retromandibular v.
Facial v.
Superior thyroid v.
External
Internal jugular v.
jugular v.
Middle thyroid v. Anterior

jugular v.
Fig. 1-9 The internal jugular vein lies immediately beneath the sternocleidomastoid mus-
cle and is paralleled by the smaller external jugular vein crossing the superficial surface of
that muscle. The pattern of the smaller venous branches is more variable than that of the
corresponding arteries.
The Nerves of the Neck cervical plexus emerge from the prevertebral fascia
deep to the sternocleidomastoid muscle and then
There are three groups of nerves in the neck: the cra- pierce the investing fascia at the posterior border of
nial nerves, the nerves of the cervical plexus, and that muscle.
the nerves of the brachial plexus (Fig. 1-10). Only The nerve roots of the brachial plexus emerge
the first group is of major concern when considering between the anterior and middle scalene muscles
approaches to the distal carotid artery. Of the cra- and lie lateral to the course of the common carotid
nial nerves, the facial (VII), glossopharyngeal (IX), arteries. This relationship is examined in more detail
vagus (X), spinal accessory (XI), and hypoglossal in Chapter 4.
(XII) are intimately related to the distal internal ca- The final key to understanding the approach to
rotid artery and are discussed further below. In the the carotid bifurcation and internal carotid artery is
midneck, the vagus, cervical sympathetic chain, and knowing the relationships of the pharynx, the cra-
ansa cervicalis (also called ansa hypoglossi) share nial nerves mentioned above, the vessels, and the
the carotid sheath. The cutaneous branches of the ramus of the mandible.
Fig. 1-10 The cranial nerves generally

parallel the long axis of the neck and are in
the most critical location relative to carotid
artery surgery.
Facial n.
Hypoglossal n.
Lesser occipital n.
Great auricular n.
Glossopharyngeal n.
Transverse
cervical n. Superior laryngeal n.
Vagus n.
Supraclavicular n.
Ansa
cervicalis
Accessory n.
Phrenic n.
Middle
cervical Recurrent laryngeal n.
ganglion
Inferior
cervical
ganglion

The Pharynx originate on this bony spine and attach in a fan-
shaped pattern to the upper pharyngeal wall and hy-
The focal point of the posterior suspension of the oid bone. The digastric muscle provides additional
pharynx from the base of the skull is the styloid support. Interleaved among these structures are the
process (Fig. 1-11). The stylohyoid ligament, sty- carotid and jugular arborizations and the cranial
loglossus, stylopharyngeus, and stylohyoid muscles nerves.
Superior pharyngeal constrictor m.

Styloglossus m.
Styloid process
Stylohyoid lig.
Digastric m. (divided)
Stylopharyngeus m.
Stylohyoid m.
Mylohyoid m.
Middle constrictor m.
Hyoglossus m.
Thyrohyoid mbr.
Inferior constrictor m.
Fig. 1-11 The pharynx and its related muscles constitute the deep surface on which the
carotid vessels lie.
The Internal and External Carotid Arteries complex of the larynx by passing between the
digastric and stylohyoid muscles laterally and the
The internal carotid artery passes deep to the sty- styloglossus and stylopharyngeus muscles medi-
loid process and all associated structures to reach ally. Beneath the posterior belly of the digastric
the base of the skull (Fig. 1-12). The external muscle, the occipital artery crosses the distal inter-
carotid artery divides the posterior suspensory nal carotid artery.
Internal Superficial
maxillary a. temporal a.
Styloglossus m.
Digastric m. (posterior belly)

Occipital a.
Stylohyoid m.
Internal carotid a.
External carotid a.
Facial a. Lingual a.
Superior thyroid a.
Carotid sinus
Common carotid a.
Fig. 1-12 The internal carotid artery passes deep to the posterior suspensory muscles of
the pharynx to terminate medial to the styloid process, while the continuation of the exter-
nal carotid passes between these muscles.

The Distal Jugular Vein stylohyoid muscles. However, cephalad to the stylo-
hyoid muscle, the retromandibular vein and external
Just outside the jugular foramen, the internal jug- carotid artery pass between the parotid gland and
ular vein lies between the internal carotid artery the ramus of the mandible, a relationship usually de-
and the root of the styloid process (Fig. 1-13). The scribed as being within the substance of the parotid
retromandibular and facial branches of the com- gland. Both vessels lie deep to the branches of the
mon facial vein lie superficial to the digastric and facial nerve fanning out through the parotid.
External jugular v.
Retromandibular v.
Facial v.
Superior thyroid v.
Fig. 1-13 The internal jugular vein runs posterolateral to the internal carotid artery and
follows a similar course. The superficial veins of the face drain via the relatively constant
facial vein, which crosses the carotid bifurcation to reach the internal jugular.
The Cranial Nerves Revascularization vs. Stenting Trial,1 which was
lower than the 8.6% of 1,415 patients randomized
The immediate extracranial portions of the cranial to surgery in the North American Carotid Endarter-
nerves mentioned above intertwine with the muscu- ectomy Trial reported two decades prior.3 The fre-
lar and vascular structures we have been discussing, quency of cranial nerve injury is higher in patients
putting them at risk for injury during carotid sur- undergoing repeat carotid endartarectomy.4 The
gery (Fig. 1-14). Although most iatrogenic nerve in- frequency of individual nerve injuries remains con-
juries resulting from carotid surgery are temporary troversial, but most authors report that either the hy-
and subtle, careful examination will reveal such poglossal nerve2 or the recurrent laryngeal nerve3,4
injuries in 5% to 21% of patients.1-5 Detailed post- is most commonly injured. The glossopharyngeal
operative evaluations by neurologists documented nerve is among the least frequently injured, but per-
cranial nerve injuries in 4.7% of the 1,240 patients manent damage is associated with severe impair-
randomized to the surgical arm of the Carotid ment due to swallowing difficulties.
Lingual n. Facial n.
Accessory n.
Inferior
alveolar n. Glossopharyngeal n.
Hypoglossal n.
Ansa cervicalis
Superior
larygeal n.
Vagus n.
Fig. 1-14 The hypoglossal nerve swinging down superficial to the carotid vessels is often
visualized during carotid surgery. The limb of the ansa cervicalis running with the hypo-
glossal nerve is often sacrificed with no ill effect during carotid surgery.

The emergence of the cranial nerves from the glossopharyngeal nerves exit from the jugular fora-
base of the skull provides orientation for describ- men. The hypoglossal nerve emerges from the hy-
ing their subsequent paths (Fig. 1-15). The facial poglossal canal just medial to the jugular foramen.
nerve arises posterior to the base of the styloid The superior cervical sympathetic ganglion has a ce-
process and immediately passes anterolaterally to phalic connection via the small carotid nerve arising
enter the parotid gland. The accessory, vagus, and at its cephalad pole.
Facial n.
Digastric m.
Accessory n.
Hypoglossal n.
Styloid
process Internal jugular v.
Glossopharyngeal n.
Superior sympathetic
ganglion
Vagus n.
Medial
Internal carotid a.
pterygoid m.
Pharyngobasilar
fascia
Fig. 1-15 An understanding of the emergence of the cranial nerves at the base of the skull
helps prevent injury to these nerves during operations on the distal internal carotid artery.
The marginal mandibular branch of the facial The vagus nerve and sympathetic chain lie
nerve (ramus mandibularis) emerges from behind posteriorly in the groove between the internal jugu-
the parotid gland and runs below the angle of the lar vein and the internal and later common carotid
mandible before turning upwards to run parallel artery (Fig. 1-17). Occasionally, the vagus nerve is
with the mandibular ramus (Fig. 1-16). Although located in a more anterior position in relation to the
the nerve is usually within one finger’s breadth of carotid artery at the base of the neck. The superior
the inferior border of the mandible,6 variants can and inferior laryngeal branches of the vagus supply
course significantly below this level, making them the muscles of the larynx, and varying degrees of
prone to injury during carotid endarterectomy. The dysphonia result when they are injured. The supe-
nerve innervates the muscles of the lower lip; in- rior laryngeal nerve accompanies the artery of the
jury results in the inability to draw the angle of the same name from its origin high in the neck and is
mouth downward, with compensatory drooping of at direct risk from mobilization of the artery. The
the contralateral lip.6,7 The ramus mandibularis is recurrent laryngeal nerve, arising low in the neck, is
prone to injury from longitudinal incisions that are at indirect risk from injury to the main vagal trunk
placed too far anteriorly and from retractors that in the midneck. In rare cases, a nonrecurrent laryn-
are placed on the angle of the mandible.5 Position- geal nerve may branch directly from the vagus at
ing retractors superficial to the platysma and curv- the level of the carotid bifurcation and course medi-
ing the longitudinal incisions posteriorly toward the ally behind the carotid bulb to reach the larynx. This
mastoid process may help to reduce injuries to the anomaly is usually seen on the right side, associated
ramus mandibularis. with an aberrant right subclavian artery.
Marginal
mandibular n.
Fig. 1-16 The ramus mandibularis branch of the facial nerve runs below the edge of the
mandible and is prone to injury during carotid endarterectomy.

The spinal accessory nerve penetrates and sup- At the carotid bifurcation, there is a fine network
plies the sternocleidomastoid muscle before passing of nerves providing complex innervation to the carotid
across the posterior triangle of the neck to the trape- body and carotid sinus.8 The carotid body is a discrete
zius. Its high location puts it at low risk for injury. flat ovoid chemoreceptor located on the posterior as-
The hypoglossal nerve passes between the in- pect of the carotid bifurcation. It is one of several such
ternal carotid artery and internal jugular vein. It turns receptors in the body, probably of neural crest origin,
anteriorly, spiraling around the internal carotid artery, which are sensitive to hypoxia, hypercarbia, and aci-
and passes under the occipital artery along its course. dosis and cause reflex respiratory stimulation. Nerve
It loops across the lateral surface of the external carotid twigs to the carotid body from glossopharyngeal, va-
artery and passes deep to the stylohyoid insertion and gus, and superior cervical sympathetic ganglion lie
digastric sling before disappearing beneath the poste- between the internal and external carotid arteries.
rior edge of the mylohyoid muscle. Although usually The carotid sinus nerve arises from the glosso-
found about 2 cm cephalad to the carotid bifurcation, pharyngeal nerve and descends to the carotid sinus
its location may vary. The hypoglossal nerve is teth- receptors in the dilated bulb and proximal internal
ered by the descendens hypoglossi and by the sterno- carotid artery. In its course, it anastomoses with the
mastoid artery and vein; the nerve can be mobilized vagus, superior cervical sympathetic ganglion, and
during high carotid dissections by careful division of carotid body. Its distal segment is entwined with the
these structures. Nerve injury impairs motor function plexus of nerves associated with the carotid body.
of the tongue and may cause dysarthria and dysphagia. Besides the normal stimulus of elevated blood pres-
The glossopharyngeal nerve also passes su- sure, surgical manipulation of the carotids may also
perficial to the internal carotid artery to reach the cause reflex bradycardia and hypotension.
posterior edge of the stylopharyngeus muscle. It spi-
rals to the anterior surface of that muscle and disap-
pears beneath the posterior edge of the hyoglossus Facial n.
muscle. Loss of its sensory and motor fibers to the
tongue and pharynx may result in aspiration in the
rare instances when it is injured.
Sympathetic chain
Vagus n.
Accessory n.
Occipital a.
Glossopharyngeal n.
Digastric m.
(posterior belly)
Internal carotid a.
Hypoglossal n.
Carotid sinus n.
External
carotid a.
Superior laryngeal n.
Internal jugular v.
Fig. 1-17 All the major cranial nerves in the Ansa cervicalis

neck originate deep to the styloid process except
the facial nerve. They reach their destinations
through paths intimately related to the internal
carotid artery.
The Retromandibular Space
Access to a highly placed bifurcation and to the

distal common carotid is limited because of the
proximity of the mandibular ramus and the mastoid
process (Fig. 1-18). Strategies for dealing with this
special situation are discussed in the second half of
this chapter.
Fig. 1-18 The distal internal carotid artery is cramped in a narrow space behind and deep
to the ramus of the mandible, making access difficult.

Exposure of the Carotid Artery and Its Branches segment from 1 cm above the clavicle to the angle
of the mandible, and zone III extends from the angle
Optimal approaches to the extracranial carotid ar- of the mandible to the base of the skull. For carotid
tery depend on the segments that are to be exposed. exposure confined to zone II, a single anterior cer-
The major portion of the cervical carotid artery is vical incision is appropriate. Concomitant median
relatively superficial and is approached through a sternotomy should be considered to ensure adequate
single anterior cervical incision. However, exposure proximal circulatory control in patients who may re-
of the carotid segments located near the base of the quire carotid arterial exposure in zone I. Exposure
skull and at the base of the neck may require spe- of the carotid segment in zone III may require man-
cialized maneuvers9 to achieve adequate circulatory dibular subluxation and periauricular extension of
control. In planning approaches for carotid surgery, the cervical incision.
we have found it useful to divide the neck into three The following discussion considers exposure of
anatomic regions as recommended by Monson et the carotid artery in zones II and III. Performance of
al.10 (Fig. 1-19). Zone I extends from the base of median sternotomy for exposure of the proximal ca-
the neck to 1 cm above the clavicle, zone II is the rotid artery segment will be considered in Chapter 3.
Fig. 1-19 A conceptual division of the neck into three zones helps to determine appropri-
ate surgical approaches to different regions of the carotid arteries.
Exposure of the Carotid Bifurcation in the Neck extending from the clavicular head to the retro-
(Zone II) mandibular area (Fig. 1-20). The incision should
be curved slightly and extended just inferior to the
The neck is slightly extended, and the head is lobe of the ear at its distal end. This posterior dis-
turned opposite the side of the intended incision placement of the incision helps avoid injury to the
and placed upon a gel ring. Elevation of the shoul- marginal mandibular branch of the facial nerve.11
ders with a rolled sheet will enhance neck exten- Alternatively, a transverse cervical incision may
sion, especially in patients with short, broad necks. be used, but this oblique incision is associated with
The upper chest, lower face, and lower ear are limited carotid exposure and a higher risk of injury
prepped and draped. to the marginal mandibular nerve.11
A longitudinal incision is made along the an- The incision is deepened through the pla-
terior border of the sternocleidomastoid muscle, tysma muscle, and the investing layer of the deep
Fig. 1-20 Postauricular extension of the cephalad end of the longitudinal neck incision

avoids injury to the ramus mandibularis of the facial nerve.

cervical fascia is opened on the anterior border of accessory nerve, which crosses the superior aspect
the sternocleidomastoid muscle. The sternocleido- of the wound to pierce the sternocleidomastoid mus-
mastoid muscle is separated from the underlying cle.13 By retracting the freed sternocleidomastoid
vascular sheath by sharp dissection on its medial posteriorly, the vascular sheath is identified. The
border (Fig. 1-21). The small sternomastoid branch sheath is opened superior to the omohyoid muscle;
of the superior thyroid artery will require ligation more proximal exposure necessitates division of the
during this maneuver. More distal mobilization will muscle. The internal jugular vein is dissected free
require division of the sternocleidomastoid branch along its anterior border in the central part of the
of the occipital artery near the superior part of the wound and retracted posteriorly with the sternoclei-
incision.12 Care should be taken not to injure the domastoid muscle. This maneuver requires division
External
carotid a.
Internal
jaugular v.
Omohyoid m.
Fig. 1-21 Posterior retraction of the sternocleidomastoid muscle exposes the carotid sheath.
of the common facial vein (Fig. 1-22). The common to be dissected before manipulation of the athero-
facial vein is usually well-defined, and its division sclerosis-prone bifurcation. The common carotid
can be likened to the of a trap door, immediately artery is isolated first, using sharp dissection. The
exposing the carotid arteries. vagus nerve usually lies posterior to the common
Dissection of the common carotid artery and carotid artery, but it is occasionally found anterior
its branches is performed next. It is important to and lateral to the artery.11 The recurrent laryngeal
use exact and careful movements during arterial nerve is usually located in the tracheoesophageal
mobilization to prevent dislodgement of small em- groove, well removed from injury during carotid
boli from irregular luminal surfaces. We favor the dissection. However, a nonrecurrent laryngeal
isolation of the common carotid and its branches nerve anomaly may be present that renders it
away from the bifurcation, which is dissected last. more susceptible to injury. Although this anomaly
This allows vessels with relatively normal surfaces is usually associated with aortic arch anomalies,
Facial v.
Fig. 1-22 After division of the facial vein, the jugular vein can be mobilized posteriorly
to expose the carotid bifurcation cephalad to the anterior belly of the omohyoid muscle.

it has been reported in patients with normal arch wound will allow exposure of the internal carotid
anatomy.14 A nonrecurrent laryngeal nerve occurs away from the bifurcation. Lymphatic tissue over-
more frequently on the right side with an incidence lying the vein requires division. Small venous
of 0.3% to 0.8% and is usually associated with an branches draining into the anterior vein surface
aberrant right subclavian artery.14 The nonrecur- above the level of the facial vein should be identi-
rent laryngeal nerve leaves the vagus at the level fied and ligated to prevent troublesome bleeding.12
of the carotid bifurcation and is at risk of injury if Isolation of the artery requires careful sharp dis-
the dissection is extended either medial to or pos- section. The hypoglossal nerve trunk crosses the
terior to the bulb area. Once the common carotid internal carotid artery at a variable distance from
is completely freed from surrounding tissue, it is the bifurcation and must be avoided during dis-
encircled with an elastic vascular loop away from section. Identification of the hypoglossal nerve is
the bifurcation area (Fig. 1-23). Clearance of tis- facilitated by following the ansa hypoglossi nerve
sues from the anterior surface of the common ca- to its junction with the hypoglossal trunk.15 The
rotid may be facilitated by transection of the ansa hypoglossal nerve is tethered by the sternoclei-
hypoglossi nerve. domastoid branch of the occipital artery.11 If not
The internal carotid artery is isolated next. already ligated during the initial dissection, this
It is located posterior and medial to the external branch should be divided to mobilize the nerve at
carotid artery and found deep to the internal jugu- the time of distal internal carotid artery exposure.
lar vein (Fig. 1-23). Dissection along the medial Once the internal carotid artery is freed, it is en-
border of the internal jugular vein in the superior circled with an elastic vascular loop.
Occipital a.
Hypoglossal n.
Fig. 1-23 Proximal and distal control is obtained before the carotid bifurcation is mobilized.
The external carotid artery is isolated at the bi- reflex increase in vagal nerve function, resulting in
furcation and encircled with an elastic vessel loop hypotension and bradycardia.17,18 In order to inter-
(Fig. 1-24). The superior thyroid artery requires iso- rupt the reflex arc between the baroreceptors and
lation when it branches directly from the common the vagus nerve, some authors advocate inactivating
carotid artery. The superior laryngeal nerve courses the carotid sinus nerve by injecting local anesthesia
behind the external carotid artery16 and is avoided at the carotid bifurcation or by dividing the nerve
by encircling the artery at its most proximal point. plexus containing the carotid sinus nerve posterior
If not previously identified, the hypoglossal nerve to the bifurcation area.17,18 Citing a propensity to-
can be avoided by dissection in the periadventitial ward development of hypertension after these ma-
tissues. neuvers, other authors do not routinely inactivate
The carotid bifurcation area can now be dis- the nerve but do so only after the development of
sected from surrounding tissues. A great deal of vagal hyperactivity.19 Once the decision to anes-
attention has been paid to the carotid sinus nerve thetize the carotid sinus has been made, the carotid
(nerve of Herring). The carotid sinus is a collec- bifurcation should be mobilized completely to fa-
tion of pressure receptors located at the junction cilitate endarterectomy. Previous isolation of the
of the common and internal carotid arteries. It has common carotid artery and branches greatly facili-
been suggested that changes in these baroreceptors tates dissection and minimizes injury to surround-
induced by endarterectomy are associated with a ing nerves and veins.
Fig. 1-24 Periadventitial dissection minimizes risk to adjacent cranial nerve branches.

Exposure of the Internal Carotid Artery in the Upper Neck Many approaches have been described in the expo-
(Zone III) sure of the distal internal carotid artery, including
mandibular osteotomy,21 creation of pre- and post-
Arterial pathology may extend into the upper cervi- auricular flaps,22 removal of a portion of the mastoid
cal segments of the internal carotid artery, an area bone,23 and radical mastoidectomy with obliteration
considered to be relatively inaccessible. Common of the middle ear cavity.24 We have come to rely on
lesions in this segment include aneurysms from exposure through the standard vertical incision de-
trauma, intimal dissection, or atherosclerosis, and scribed above, using the technique of mandibular
luminal disease from atherosclerosis or fibromuscu- subluxation described by Fisher et al.25
lar hyperplasia. Exposure of the distal carotid artery General anesthesia with nasotracheal intuba-
near the skull may be required in the surgical repair tion is required for this approach. The mandibular
of these lesions, as simple carotid ligation may have condyle on the side to be operated is subluxed and
undesired consequences in noncomatose patients.20 transfixed with transnasal/oral wiring (Fig. 1-25).
1 cm.
Fig. 1-25 Unilateral subluxation of the mandibular condyle provides an additional 1 cm of

working space in the area of the distal internal carotid artery.
The optimal technique for temporary fixation de- the common and internal carotid arteries proceeds as
pends on the presence of adequate dental stability, above. The hypoglossal nerve should be identified
and a number of wiring options have been described and protected, sometimes necessitating division
by Simonian et al.26 Yoshino et al. have recently of the occipital artery and ansa hypoglossi to al-
described a less invasive method of subluxation us- low optimal mobilization. In isolating the internal
ing a mouthpiece made by a dentist to stabilize the carotid artery, care should be taken to identify and
mandible in the subluxated position.27 The patient ligate small crossing branches of the jugular vein.
is positioned and surgically prepared as above, and The lower edge of the parotid gland is retracted
the incision is made along the anterior border of the anteriorly during this maneuver.
sternocleidomastoid muscle. The incision should Division of the posterior belly of the digas-
be extended as high as possible and curved poste- tric muscle allows exposure of the internal carotid
riorly just behind the lobe of the ear. Exposure of artery within 2 cm of the skull base (Fig. 1-26).
Facial n.
Styloid process
Hypoglossal n.
Digastric m.
Glossopharyngeal n.
Occipital a.
Carotid Accessory n.
sinus n.
Superior
laryngeal n.
Vagus n.
Fig. 1-26 Division of the posterior belly of the digastric muscle and of the occipital artery
allows cephalad mobilization of the hypoglossal nerve. If the styloid process is divided,
dissection must adhere closely to the bone to avoid injury to the immediately subjacent
glossopharyngeal nerve.

The occipital artery and its accompanying vein 9. Perry MO. Basic considerations in the diagnosis and
course near the lower margin of the posterior belly management of carotid artery injuries. J Vasc Surg.
of the digastric muscle and should be ligated at the 1988;8(2):193–194.
time of muscle division. Higher exposure of the in- 10. Monson DO, Saletta JD, Freeark RJ. Carotidñverte-
ternal carotid artery is obtainable by dividing the bral trauma. J Trauma. 1969;9(12):987–999.
11. Schauber MD, Fontanelle LJ, Soloman JW, et al.
stylohyoid ligament and stylohyoid, stylopharyn-
Cranial/cervical nerve dysfunction after carotid end-
geus, and styloglossus muscles to permit removal of arterectomy. J Vasc Surg. 1997;25:481–487.
the styloid process.28 The glossopharyngeal nerve is 12. Fróes LB, Castro de Tolosa EM, Camarga RD, et
at risk for injury during these maneuvers. The nerve al. Blood supply of the human sternocleidomastoid
courses between the internal carotid artery and in- muscle by the sternocleidomastoid branch of the oc-
ternal jugular vein, lying deep to the styloid process cipital artery. Clin Anat. 1999;12(6):412–416.
and attached muscles. Although the nerve may not 13. Yagnik PM, Chang PS. Spinal accessory nerve in-
be adequately exposed, the risk of injury can be less- jury: a complication of carotid endarterectomy.
ened by confining dissection of the internal carotid Muscle & Nerve. 1996;19:907–909.
to its periadventitial tissues.29 14. Coady MA, Adler F, Davila JJ, et al. Nonrecur-
Should more superior isolation of the inter- rent laryngeal nerve during carotid artery surgery:
nal carotid artery be desired, exposure and gentle case report and literature review. J Vasc Surg.
2000;32:192–196.
retraction of the facial nerve are required. Excision
15. Demos NJ. The ansa hypoglossi as a guide to the
of the tail of the parotid will assist soft tissue expo- hypoglossi nerve during carotid endarterectomy and
sure behind the mandible.28 A preauricular extension related anatomy. Surg Rounds. 1984;7(12):50–52.
of the cervical incision may be required to expose 16. Hertzer NR, Feldman BJ, Beven EG, et al. A pro-
the facial nerve safely. The intrapetrosal internal spective study of the incidence of injury to the cranial
carotid artery can be exposed using an anterior in- nerves during carotid endarterectomy. Surg Gynecol
fratemporal approach described by Thomassin and Obstet. 1980;151:781–784.
Branchereau.30 17. Bove EL, Fry WJ, Gross WS, et al. Hypotension and
hypertension as consequence of baroreceptor dys-
function following carotid endarterectomy. Surgery.
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18. Tarlov E, Schmidek H, Scott RM, et al. Reflex hypo-
1. Brott TG, Hobson RW II, Howard G, et al. Stenting tension following carotid endarterectomy: mechanism
versus endarterectomy for treatment of carotid-artery and management. J Neurosurg. 1973;39:323–327.
stenosis. N Engl J Med. 2010;363(1):11–23. 19. Elliott BM, Collins GJ, Youkey JR, et al. Intraop-
2. Cunningham EJ, Bond R, Matberg MR, et al. Risk of erative local anesthetic injection of the carotid sinus
persistent cranial nerve injury after carotid endarter- nerve: a prospective, randomized study. Am J Surg.
ectomy. J Neurosurg. 2004;101:445–448. 1986;152(6):695–699.
3. Ferguson GG, Eliasziw M, Barr HWK, et al. The 20. Reva VA, Pronchenko AA, Samokhvalov IM. Opera-
North American symptomatic carotid endarterec- tive management of penetrating carotid artery inju-
tomy trial: surgical results in 1,415 patients. Stroke. ries. Eur J Vasc Endovasc Surg. 2011;42(1):16–20.
1999;30:1751–1758. 21. Nelson SR, Schow SR, Stein SM, et al. Enhanced
4. AbuRahma AF, Choueiri MA. Cranial and cervical surgical exposure for the high extracranial carotid
nerve injuries after repeat carotid endarterectomy. artery. Ann Vasc Surg. 1992;6:467–472.
J Vasc Surg. 2000;32(4):649–654. 22. Perdue GF, Pellegrini RV, Arena S. Aneurysms of
5. Basile RM, Sadighi PJ. Carotid endarterectomy: the high carotid artery: a new approach. Surgery.
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1989;2(3):147–155. 23. Pellegrini RV, Manzetti GW, DiMarco RF, et al.
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by a palsy of the marginal mandibular branch of the high internal carotid artery. J Cardiovasc Surg.
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2000;53(5):378–385. 1980;88(5):548–554.
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sinus nerve and intercarotid ganglion. Surg Gynecol subluxation for high carotid exposure. J Vasc Surg.
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26. Simonian GT, Pappas PJ, Padberg FT Jr, et al. posterolateral anatomic approach. J Vasc Surg.
Mandibular subluxation for distal internal carotid 1988;8(5):618–622.
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1999;30:1116–1120. Glossopharyngeal nerve injury complicating carotid
27. Yoshino M, Fukumoto H, Mizutani T, et al. Mandib- endarterectomy. J Vasc Surg. 1987;5:469–471.
ular subluxation stabilized by mouthpiece for distal 30. Thomassin JM, Branchereau A. Intrapetrosal inter-
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the internal carotid artery near the skull base: the

Vertebral Arteries
2
Surgical Anatomy of the Vertebral Arteries
Deep in the root of the neck, the vertebral arteries

run the first third of their course from the proximal
subclavian arteries to the transverse processes of the
sixth cervical vertebrae (Fig. 2-1). For the remaining
two-thirds of their course to the foramen magnum,
the arteries are encased in a ladder-like bony lattice
made up of the fenestrated transverse processes of
the upper cervical vertebrae. The foramina for the
artery occupy the anterior portion of the trough-like Vertebral a.
transverse processes, while the roots of the cervical

nerves occupy the posterior position. Carotid tubercle
After passing through the transverse processes (C6 transverse
process)
of the atlas, the arteries loop behind the articular
processes and follow an anterior conver ging course
upward through the foramen magnum. Within the Thyrocervical
cranium, the vertebral arteries unite at the lower trunk
border of the pons to form the basilar artery. Subclavian a.
Internal
thoracic a.
Fig. 2‑1 The proximal third of the vertebral

a rtery lies in the deepest plane at the root of the
neck. The remainder of the vessel lies within
the bony lattice of the cervical transverse pro-
cesses anterior to the cervical nerve trunks.
51
The deep centr al location of the vertebral ar- spine between them. Laterally, the scalene muscles
teries affords protection but makes surgical access fan out from the cervical transverse processes and
more difficult than access to the companion carotid insert on the first and second ribs. The lower cervi-
system. The following discussion focuses on the de- cal nerve roots emerge between anterior and middle
tails of important relationships at different levels of scalene muscles, while the upper roots appear be -
the arteries. tween the longus capitis and levator scapulae mus -
cles. This muscular delta is covered by prevertebral
Anterior Paravertebral Musculature fascia. The anterior scalene and longus colli mus -
cles converge at the prominent anterior tubercle of
The vertebral arteries lie within a plane defined by the transverse process of C6, sometimes called the
a delta-shaped array of muscles attaching to the ver- carotid tubercle (of Chassaignac). In the inverted
tebral bodies and transverse processes (Fig. 2-2). “V” formed by the muscles below this landmark,
The longus colli and longus capitis muscles pro - the first portion of the vertebral artery penetrates the
vide anterior support to the cervical vertebrae and prevertebral fascia to ascend through the C6 trans -
bracket the anterior longitudinal ligament of the verse foramen.
Longus capitis m.
Middle
scalene m.
Carotid tubercle
C6
Anterior
scalene m. Phrenic n.
Posterior
scalene m.
Vertebral a.
Longus
colli m.
Fig. 2-2 The vertebral artery penetrates and lies buried beneath the delta of preverteb ral
and scalene muscles.

The Root of the Neck vessels (Fig. 2-3). These origins are arrayed
radially around the subclavian with the verte -
The vertebral arteries originate from the first bral arising superiorly and posteriorly. The first
part of the subclavian arteries close to the ori - portion of the vertebral arteries passes over the
gins of the internal thoracic (formerly internal cupola of the lung to reach the scalenovertebral
mammary), thyrocervical, and costocervical angle.
Longus
capitis m.
Longus
colli m.
L. carotid a.
Vertebral a. Internal
jugular v.
Thyrocervical
trunk Subclavian a.
R. carotid a.
Subclavian v.
Fig. 2-3 The great vessels at the root of the neck overlie the vertebral arteries and must be
mobilized during surgical approaches to the vertebral arteries.
Vertebral Arteries | 53
The venous tributaries that accompany the transverse processes housing the vertebral arteries.
distal vertebral artery converge to form a single The middle cervical sympathetic ganglion lies at
vertebral vein on emer ging from the sixth trans - about the level of the carotid tubercle, and the infe-
verse process (Fig. 2-4). The vein enters the prox- rior ganglion lies posteromedial to the origin of the
imal subclavian vein just distal to the internal vertebral artery. The inferior ganglion gives off fi-
jugular vein. On the left side, the thoracic duct bers that wrap around and ascend with the vertebral
emerges from the posterior thorax, arches over artery.
the subclavian artery , and enters the subclavian The costocervical trunk arises posteriorly
vein between the internal jugular and vertebral from the subclavian. Its cervical division as -
veins. cends in the deep posterior cervical muscles
The cervical sympathetic chain lies on the and communicates with the vertebral along its
prevertebral fascia anterior to the longus colli and course and with descending branches of the
capitis muscles, which in turn lie anterior to the o ccipital artery.
Middle Vertebral a.
cervical
ganglion 6th Cervical n.
Sympathetic
trunk
VI
Middle
cervical
cardiac n.
Vertebral v.
Thoracic duct
Inferior
cervical
Vagus n. ganglion
Costocervical
trunk
Internal Subclavian a.
jugular v.
Subclavian v.
Fig. 2-4 In this lateral view of the proximal left vertebral artery, the scalene fat pad has
been removed to show relationships to the thoracic duct, venous, and neural structures.

Anterior Relations of the Proximal and pad directly overlies the first portion of the vertebral
Midvertebral Artery artery.
In and around the fat pad are critical structures
Beneath skin and platysma, the sternocleidomas - that must be respected when approaching the verte-
toid muscle and investing fascia constitute the first bral artery. Medially on the left side is the previously
layer to unroof on the way to the vertebral arteries described thoracic duct. Deep to the fat pad laterally,
(Fig. 2-5). The omohyoid muscle runs diagonally the phrenic nerves descend diagonally across the an-
between the sternocleidomastoid and the underlying terior scalene muscles, pass lateral to the thyrocervi-
carotid sheath. The carotid sheath lies between the cal trunks, and dip between subclavian artery and
sternocleidomastoid muscle and prevertebral fascia vein to enter the chest. The inferior thyroid artery
medially, and lateral to the sheath, the scalene fat crosses anterior to the proximal vertebral artery.
Internal
jugular v.
Carotid a.
Vagus n. Middle cervical
ganglion
Inferior
thyroid a. Phrenic n.
Inferior
cervical Vertebral a.
ganglion Brachial
plexus
Trapezius m.
Thoracic
duct
Thyrocervical
trunk Omohyoid m.
Fig. 2-5 This cut-away view shows the major anatomic landmarks that must be negotiated
to reach the vertebral artery.
The Distal Vertebral Artery At the level of the posterior groove, the arter -
ies give off branches to the deep muscles of the neck
Between the transverse processes of the atlas and that anastomose with ascending cervical, occipital,
axis vertebrae, there is more space for access to and deep cervical arteries. Medial to the articular
the vertebral arteries than in other interspaces due facets, the arte ries give of f branches that descend
to the decreased bulk of the bony arches poste- within the vertebral canal, supplying vertebral bod -
riorly (Fig. 2-6). After emerging through the fo - ies and meninges. Prior to converging at the level of
ramina of the atlas, the arteries take a sharp bend the pons, small descending branches fuse to form
backward and lie in grooves encircling the pos - a midline vessel along the ventral surface of the
terior rims of the bony articular plateaus. They medulla.
then course anteriorly , medial to the atlantooc - The tortuous terminal extracranial vertebral
cipital articulation, and pass through the foramen arteries lie deep within the suboccipital muscu-
magnum. lar triangles and are difficult to expose (Fig. 2-7).
Basilar a.
Fig. 2-6 The space between the transverse processes of the atla s and axis vertebrae af fords
the best exposure of the distal vertebral artery. The arterial segment above the atlas is the site
of collateral arterial connections and is surrounded by a prohibitively dense venous plexus.

Semispinalis capitis m. Rectus capitis posterior minor m.
Obliquus capitis
superior m.
Rectus
capitis
posterior
major m.
Obliquus
capitis
inferior m. 2nd cervical n.
Vertebral a.
Fig. 2-7 The depth of the vessel in the posterior cervical triangle is shown in this view.
An anterolateral approach to the C1 to C2 segment
is possible by detaching the levator scapulae origins
from the tips of the transverse processes (Fig. 2-8).
After passing around the posterior part of the
articular process, the vertebral artery penetrates first
the atlantooccipital ligament and then the dura on its
way to the foramen magnum (Fig. 2-9).
Trapezius m.
Longissimus
capitis m.
Semispinalis
capitis m.
Splenius
capitis m.
Levator
scapulae m.
Splenius
cervicis m.
Fig. 2-8 The insertions of muscle slips from the leva-
tor scapulae and splenius cervicis onto the first transverse
process must be divided to gain access to the C1/C2 seg-
ment of the vertebral artery.
Vertebral a.
Dura
mater
Posterior
atlantooccipital
membrane
Fig. 2-9 The cervical portion of the vertebral artery ter-

minates by penetrating the atlantooccipital membrane and
dura mater to enter the spinal canal and ascend through
the foramen magnum.

Exposure of the Vertebral Artery origin of the vertebral artery to the level at which
in the Neck the artery enters the transverse process of C6. The
interosseous segment (V2) courses within the trans-
A number of approaches are available to expose verse processes of the cervic al vertebrae from C6
the extracranial vertebral artery, depending on the to C2. The third segment (V3) begins at the top of
segment. A useful classification for describing the the C2 transverse process and terminates at the base
regional anatomy of the vertebral artery has been of the skull. The intracranial portion (V4) begins at
highlighted by Morasch1 (Fig. 2-10). The most the atlantooccipital membrane and terminates at the
proximal segment (V1) extends from the subclavian basilar artery.
V4
V3
V2
V1
Fig. 2-10 The surgical segments of the vertebral arteries are shown.
Exposure of the Extraosseous Vertebral Artery (V1 Segment) supraclavicular approach is employed for elective
operations involving vertebral artery reimplantation
There are two main options for exposure of the into the adjacent common carotid artery , and the
most proximal portion of the vertebral artery: the anterior cervical approach is favored during emer-
transverse supraclavicular approach and the verti - gency explorations for suspected vertebral artery
cal anterior cervical approach. Although the su - injury.1–4
praclavicular approach af fords excellent exposure
of the vertebral artery at its origin, the exposure is
relatively limited and requires transection of the Supraclavicular Approach
sternocleidomastoid muscle. The anterior cervical
approach does not require muscular transection, and The patient is supine, and the head is turned away
it permits rapid extension of the incision for vascu - from the side of sur gery. The incision is made ap -
lar control of more distal vertebral artery segments. proximately 1 cm above the clavicle, beginning at
However, exposure of the vertebral artery is more the clavicular head and extending laterally for a
difficult through a cervical incision. In general, the distance of 7 or 8 cm (Fig. 2-11). The incision is
Internal
jugular v.
Omohyoid m.
Platysma m.
External jugular v.
(clavicular head)
Fig. 2-11 The transverse supraclavicular incision is carried down through the cla -

vicular head of the sternocleidomastoid muscle.

deepened through the platysma muscle and super - of the junction of the left internal jugular and subcla-
ficial fascia. The external jugular vein is divided vian veins. If the common carotid artery is needed
at the lateral border of the sternocleidomastoid for subsequent vertebral artery reimplantation,1,2,5,6
muscle. it is carefully isolated at this time and encircled with
Division of the clavicular head of the sterno- a silastic loop. Caution should be exercised during
cleidomastoid muscle and retraction of the sternal these dissections to avoid injury to the vagus nerve
head exposes the underlying carotid sheath. The and to the sympathetic chain, which usually course
sheath is mobilized by vertical dissection along in the posterolateral aspect of the carotid sheath. Af-
the lateral border of the internal jugular vein, and ter dissection is complete, the carotid sheath con-
the omohyoid muscle is divided (Fig. 2-12). When tents are gentl y retracted into the medial incision
operating on the left side, the thoracic duct should be with the sternal head of the s ternocleidomastoid
ligated and divided near its termination at the angle muscle.
Carotid
Internal sheath
jugular v.
Sympathetic
trunk
Vagus n.
Omohyoid m.
Carotid a.
Scalene fat
pad
Thoracic
duct
(divided) Subclavian v.
Fig. 2-12 Omohyoid muscle, external jugular vein, and thoracic duct (on the left) are di-
vided, and the carotid sheath is mobilized medially.
The medial margin of the scalene fat pad is and is usually found coursing near the muscle’ s
next mobilized, and the fat pad is retracted later - medial border (Fig. 2-13). Edwards and Edwards2
ally. Careful sharp dissection is required in order note that visualization of the phrenic nerve and
to identify superficial vascular structures cours - anterior scalene muscle should alert the sur geon
ing within the fat pad, which must be individually that the dissection has proceeded too far later -
ligated to ensure good hemostasis. Mobilization ally. However, identification of these structures
of the fat pad exposes the underlying anterior helps to insure that the phrenic nerve will not be
scalene muscle. The phrenic nerve is located on inadvertently injured from a poorly positioned
the ventral surface of the anterior scalene muscle retractor.
Vertebral v.
Vertebral a.
Longus colli m.
Inferior Anterior scalene m.

thyroid a.
Phrenic n.
Inferior cervical Thyrocervical

sympathetic ganglion trunk
Subclavian a.
Fig. 2-13 Careful medial to lateral dissection of the scalene fat pad reveals the sympathetic
chain, anterior scalene muscle, and phrenic nerve. The inferior thyroid artery and vertebralvein
overlie the proximal vertebral artery.

The vertebral artery is located in the center multiple branches. The latter has no branches at
of the angle formed by the anterior scalene and this level. The inferior thyroid branch of the thy -
longus colli muscles. The artery is most easily rocervical trunk crosses anterior to the vertebral
identified and isolated by retracting the anterior artery and should be ligated. The accompanying
scalene laterally (Fig. 2-14). Some authors advo - vertebral vein should also be ligated. By continu -
cate division of the anterior scalene muscle, 7 but ing the dissection craniad, the entire extraosseous
this is rarely necessary. The vertebral artery should vertebral artery can be exposed to the level of the
be exposed proximally to its origin at the subcla- sixth cervical vertebrae, where the artery dips un -
vian artery. The nearby thyrocervical trunk can der the longus colli muscle to enter the transverse
be differentiated from the vertebral artery by its process of C6.
Fig. 2-14 Division of the inferior thyroid artery and vertebral vein exposes the artery.
Anterior Cervical Approach fascia to reach the anterior fibers of the sternoclei -
domastoid muscle. This muscle is dissected away
The patient is placed in the supine position with the from the underlying carotid sheath and retracted
neck extended and head turned away from the side laterally (Fig. 2-15). The superior belly of the
of the intended incision. A vertical incision is made omohyoid muscle may be divided at this point to
along the anterior border of the sternocleidomas- achieve adequate exposure in the inferior aspect of
toid muscle, extending from the retromandibular the wound. The carotid sheath and its contents are
area to the clavicular head. The incision is deep - carefully freed by vertical dissection along the lat -
ened through the platysma muscle and investing eral border of the internal jugular vein. Great care
External jugular v.
Platysma m.
Investing
fascia
Carotid
sheath
Omohyoid m.
Fig. 2-15 An anterior longitudinal neck incision can be used to expose all three cervical
segments of the vertebral artery.

should be taken to avoid injury to the vagus nerve phrenic nerve should be identified on the ventral
and sympathetic chain, which course in the pos - border of the anterior scalene and protected from
terolateral aspect of the carotid sheath. Once freed injury. The inferior thyroid artery should be ligated
from surrounding tissue, the carotid sheath and its and divided as it crosses the medial border of the
contents are retracted medially 3 (Fig. 2-16). The anterior scalene muscle. The vertebral artery is
scalene fat pad is mobilized along its medial bor - identified by retracting the anterior scalene muscle
der and retracted laterally, exposing the underlying fibers laterally. The remainder of the dissection
anterior scalene muscle in the lateral wound. The proceeds as above.
Phrenic n.
Vertebral a.
Thyrocervical trunk
Fig. 2-16 Medial mobilization of the carotid sheath and proximal neck dissection as previ-
ously described exposes the proximal vertebral artery.
Exposure of the Interosseous Vertebral Artery performed in the extraosseous (V1) segment (see
(V2 Segment) above).
The patient is placed in the supine position with
Control of hemorrhage is the most common indica- the neck slightly extended and turned away from the
tion for exposure of the vertebral artery segment side of operation. The same anterior cervical ap-
lying within the foramina of the cervical transverse proach is used as shown in Figures 2-15 and 2-16.
processes. Although the majority of vertebral in - A vertical incision is made along the anterior border
juries are now treated using endovascular means, of the sternocleidomastoid muscle from the clavicu-
there are still situations such as severe hemorrhage lar head to the mastoid process. The superior incision
or endovascular failure when sur gical control is should be curved posteriorly at its uppermost mar-
necessary.8 Ligation of vertebral arteries injured in gin, such that it passes just inferior to the lobe of the
this segment is appropriate and has not been as - ear. The incision is deepened through the platysma
sociated with worsening neurologic sequellae. 3,9,10 muscle and investing fascia. The sternocleidomas-
Distal ligation is performed one transverse process toid muscle is freed from medial attachments and
above the injured interosseous vertebral artery , or retracted laterally to expose the underlying carotid
higher if necessary. Direct exposure of the verte - sheath. The carotid sheath, pharynx, and larynx are
bral artery is best performed within the bony canal next freed from the prevertebral fascia by clearing
by unroofing the transverse process, as originally attachments between the visceral and prevertebral
described by Shumacker .11 Proximal ligation is fasciae in the retropharynge al space. The carotid
Anterior
longitudinal lig.
Phrenic n.
Carotid
tubercle
Fig. 2-17 Medial retraction of the carotid sheath and cervical viscera exposes the cervical
vertebrae covered by the anterior longitudinal ligament.

sheath and visceral contents are retracted as far me- (Fig. 2-18). A periosteal elevator is used to sepa -
dially as possible, leaving the sympathetic ganglia rate the prevertebral fascia, longus colli, and longus
lying on the prevertebral muscles just medial to capitis muscles away from the vertebral bodies and
the bulge of the transverse processes. The anterior transverse processes.3 It is extremely important to
longitudinal ligament is exposed deep in the me - avoid extending the dissection beyond the lateral
dial wound (Fig. 2-17). It is incised vertically over border of the transverse processes to prevent injury
the vertebral column for the length of the incision to the cervical nerve roots.3
Anterior longitudinal lig.
Fig. 2-18 Lateral retraction of anterior longitudinal ligament and anterior paraspinous mus-

cles unroofs the transverse processes encasing the vertebral artery and veins.
The vertebral artery lies directly behind the segments.3 The increased exposure afforded by en-
bone forming the anterior border of the canal in the tering the bony canal provides safer control of the
transverse process. The artery is most conveniently artery. The bony canal is opened by removing the
controlled within the bony canal rather than between bone forming its anterior border. This can be accom-
the transverse processes because of the multiple ve- plished with a small rongeur, working from cepha -
nous tributaries that surround the artery in the latter lad to caudad3 (Fig. 2-19).
Fig. 2-19 Optimal access to the vertebral artery is obtained by removing the anterior arch
of the transverse process.

Exposure of the Distal Extracranial Vertebral is difficult to expose and has been associated with
Artery (V3 Segment) dangerous bleeding from the surrounding venous
plexus.3 Injuries to this arterial segment that require
Berguer12 has stated that the distal vertebral artery surgical control should be treated with proximal liga-
is surgically accessible within the space between tion of the artery in the space between the transverse
the transverse processes of C1 and C2, the widest processes of C1 and C2. As noted above, these in -
gap between the transverse processes of the cervi - juries are more frequently treated with transcatheter
cal spine. Berguer’s surgical approach was first de - techniques, which appear to be simpler , safer, and
scribed for use in constructing bypasses to the V3 more rapid compared with operation. However, when
artery segment.12 In a 23-year experience with over endovascular techniques are not appropriate, 8 rapid
320 patients, Kief fer13 has reported excellent long- proximal and distal ligation may be necessary. Proxi-
term outcome after distal vertebral artery recon - mal ligation is easily accomplished in the V1 seg-
struction. However, outside of specialized centers, ment, as described above. The following discussion
the need to perform anastomoses in this area of the concerns surgical exposure of the V3 segment at the
vertebral artery is very rare in clinical practice. The space between the C1 and C2 transverse processes.
approach is more practical in the control of traumatic The patient is positioned as before. A vertical
injuries to the distal vertebral artery. It may be a use- incision is made along the anterior border of the ster -
ful site for proximal control of the vertebral artery nocleidomastoid muscle, extending from the level
segment between C1 and the base of the skull, which of the cricoid to the mastoid process (Fig. 2-20).
Fig. 2-20 The longitudinal incision is used for exposure of the distal vertebral artery.
The distal incision should be curved posteriorly just have found this to be unnecessary . Our dissec -
beneath the lobe of the ear to cross over the mas - tions would strongly suggest that partial or com -
toid. The incision is deepened through the platysma plete detachment of the sternocleidomastoid origin
muscle and investing fascia, and the sternoclei - greatly enhances exposure (Fig. 2-21). With either
domastoid is dissected free and retracted later- technique, it is important to identify the spinal ac-
ally. The carotid sheath and contents are retracted cessory nerve, which usually enters the sternoclei-
medially as before. Some authors 3,14 prefer to de- domastoid 2 to 3 cm below the mastoid tip.4,11 The
tach the sternocleidomastoid and splenius capitis nerve should be mobilized and gently retracted
muscles from the mastoid process, but others 12 anteriorly.
Mastoid process
Digastric m.
C1 transverse
process
Accessory n.
2nd cervical n.
Fig. 2-21 Access to the upper two transverse processes is greatly facilitated by detaching

the insertion of the sternocleidomastoid muscle, especially in a thick, short neck.

The tip of the transverse process of the atlas the safe division of the covering muscles. A small
(C1) should be palpated in the superior wound deep retractor should be inserted between the C2 nerve
to the digastric muscle. It should be noted that the ramus and the muscles. 12 The retractor serves as a
tip of the transverse process of the atlas is anterior guide as the levator scapulae and splenius cervicis
to the transverse process of the axis (C2) due to head muscles are divided as close to the transverse pro-
rotation.3 The prevertebral fascia is next incised pos- cess of C1 as possible. Excision of these muscles
teriorly from the transverse process of C1 along a over the C1 and C2 interspace will expose the verte-
line parallel to the spinal accessory nerve. Once bral artery. A 2-cm segment of vertebral artery is ac-
the spinal accessory nerve is retracted anteriorly, cessible in this interspace. The C2 nerve ramus will
the levator scapulae and underlying splenius cer- be noted to emerge behind the artery and will require
vicis muscles are readily identified in the posterior protection during arterial manipulation. Many small
wound (Fig. 2-22). These muscles cover the C1 and venous tributaries enter the vertebral vein posterior
C2 interspace in which the vertebral artery is most to the artery. These tributaries are most dense near
accessible. The anterior ramus of the C2 nerve root the transverse processes of C1 and C2; manipulation
emerges from under the anterior border of the leva- of the artery between these structures is least likely
tor scapulae and serves as an important landmark in to cause troublesome bleeding.12
Levator
scapulae m.
Splenius
cervicis m.
Fig: 2-22 With the acce ssory nerve retracted anteriorly, the highest slips of the levator
scapulae and splenius cervicis are detached from the C1 transverse process to expose the
vertebral artery between C1 and C2.
Posterior Exposure of the Suboccipital Vertebral downward and extended for 2 to 3 cm parallel to
Artery (V4) Segment the posterior border of the sternocleidomastoid
muscle (Fig. 2-23).
Berguer has described a now-classic approach to The incision is deepened by cutting the fibers
the portion of the V4 segment between the trans - of the trapeziu s, splenius capitis, semispinalis ca -
verse process of C1 and the base of the skull. 15 pitis, and longissimus capitis muscles. The greater
This technique is applicable to treat rare patho - occipital nerve (dorsal ramus of C2) courses up -
logic lesions such as dissections or aneurysms in - ward over the semispinalis capitis muscle and may
volving the most distal portions of the extracranial require division as it is encountered approximately
vertebral artery. The posterior approach also al - 2 cm lateral to the posterior midline (Fig. 2-24). The
lows exposure of the distal internal carotid artery, sternocleidomastoid muscle should be divided at
which can be used as a source of inflow in these its mastoid insertion and reflected inferiorly. This
cases. will expose the internal jugular vein and the acces -
The patient is placed in the prone position sory nerve in the lateral wound. Palpation of the
with the head turned toward the operative side. Ber- transverse process of C1 will aid in identifying the
guer has recommended placing the patient in the obliquus capitis superior muscle, which attaches to
“park bench” position, with the temple contralat - the superior margin of the bony prominence. The
eral to the operative side resting on the forearm. 15 large condyloid emissary vein should be ligated and
A curved transverse incision is made beginning divided near the muscle’s medial border (Fig. 2-25).
at the occipital protuberance in the midline of the Partial division of the rectus capitis posterior major
posterior neck and extended horizontally to the tip muscle lying in the medial wound will expose the
of the mastoid process. From there, it is curved vertebral artery.
Fig. 2-23 The incision for posterior exposure of the suboccipital vertebral artery is shown.

Fig. 2-24 Deep exposure requires division of four
muscle layers. The greater occipital nerve can be
sacrificed to improve exposure in the lateral wound.
Splenius
capitis
Trapezius
Longissimus
capitis
Semispinalis
capitis
Greater
occipital n.
Obliquus capitis superior

Condyloid emmisary v.
Srernocleido-
mastoid
Rectus
capitis
posterior
major
Spinal
accessory n.
Fig. 2-25 The mastoid insertion of the sternoclei-
domastoid muscle is divided to expose the internal
jugular vein. The obliquus capitis superior muscle
can be identified by its attachment to the transverse
process of C1.
A large venous plexus overlies the artery at Care should be taken to avoid injury to the ventral
this level (Fig. 2-26). Meticulous ligation and di - ramus of the C1 root, which courses below the ver-
vision of bridging vein segments will allow the tebral artery in this location. The distal internal ca-
plexus to be dissected away from the arterial ad - rotid artery can be isolated in the lateral wound for
ventitia. Branches of the suboccipital nerve should use as inflow.15 The artery can be exposed in the
be divided as they cross the vessels at this level. plane medial to the sternocleidomastoid muscle and
The vertebral artery can then be mobilized to the isolated between the hypoglossal and vagus nerves
level of the atlantooccipital membrane (Fig. 2-27). (Fig. 2-28).
Fig. 2-26 A large venous plexus over -

lies the suboccipital vertebral artery.
Gr. occipital n.
(cut) Vertebral a.
Fig. 2-27 The vertebral artery can be Atlanto-occipital

mobilized to the level of the atlantooc- membrane
cipital membrane.

Hypoglossal n.
Vertebral a.
Internal
carotid a.
Vagus n.
Fig. 2-28 The distal internal carotid artery can be isolated in the lateral wound and used as
inflow for bypass to the suboccipital vertebral artery.
References 8. Kesser BW, Chance E, Kleiner D, et al. Contem-

porary management of penetrating neck injury. Am
1. Morasch MD. Vertebral artery disease. In: Cronen - Surg. 2009;75:1–10.
wett JL, Johnston KW, eds. Rutherford’s Vascular 9. Reid JDS, Weigelt JA. Forty-three cases of vertebral
Surgery. 7th ed. Philadelphia, PA: Saunders Elsevier; artery trauma. J Trauma. 1988;28:1007–1012.
2010:1557–1574. 10. Pearce WH, Whitehill TA. Carotid and vertebral in-
2. Edwards WH, Edwards WH Jr. Vertebral-carotid juries. Surg Clin N Am. 1988;68:705–723.
transpositions. Semin Vasc Surg. 2000;13(1):70–73. 11. Shumacker HB. Arteriovenous fistulas of the cervi -
3. Meier DE, Brink BE, Fry WJ. Vertebral artery cal portion of the vertebral vessels. Surg Gynecol
trauma: acute recognition and treatment. Arch Surg. Obstet. 1946;83:625–630.
1981;116(2):236–239. 12. Berguer R. Distal vertebral artery bypass: technique,
4. Roberts LH, Demetriades D. Vertebral artery inju - the “occipital connection,” and potential uses. J Vasc
ries. Surg Clin North Am. 2001;81:1345–1356. Surg. 1985;2:621–626.
5. Kline RA, Ber guer R. Vertebral artery reconstruc- 13. Kieffer E, Praquin B, Chickle L, et al. Distal verte-
tion. Ann Vasc Surg. 1993;7:497–501. bral artery reconstruction: long-term outcome. J Vasc
6. Berguer R, Flynn LM, Kline RA, et al. Sur gi- Surg. 2002;36:549–554.
cal reconstruction of the extracranial vertebral 14. Henry AK. Sternomastoid eversion giving an ex-
artery: management and outcome. J Vasc Surg. posure extensile to the vertebral artery. In: Henry
2000;31:9–18. AK, ed. Extensile Exposure. Edinburgh, England:
7. Imparato AM. Vertebral artery reconstruc- Churchill Livingstone; 1973:58–74.
tion: a nineteen-year experience. J Vasc Surg. 15. Berguer R. Suboccipital approach to the distal verte-
1985;2:626–634. bral artery. J Vasc Surg. 1999;30:344–349.
VESSELS OF THE CHEST
77
Fig. 3-1 The short span of the mediastinum is packed with vital structures connected via
major conduits traversing the superior thoracic aperture.
78 | VESSELS OF THE CHEST

Thoracic Aorta
3
Surgical Anatomy of the Great Vessels of the Chest superior thoracic aperture, the major branches blos-
som out to the arms and head. Understanding the
Overview relationships at these two key sites leads to an appre-
ciation of the surgical approaches to these vessels.
To understand the anatomic disposition of the
great vessels of the chest, one must view them The Mediastinum
in the context of the mediastinum and the supe-
rior thoracic aperture. The mediastinum is a short At the level of the superior mediastinum, half the
handspan in height from its base at the subcardiac A-P diameter of the chest is occupied by the ver-
portion of the diaphragm to the superior thoracic tebrae (Fig. 3-2). In the small anterior component
aperture (Fig. 3-1). The origin of the great vessels of this cross-section lie the great vessels, tracheo-
from the base of the heart lies at the midpoint of bronchial tree, and esophagus. The lateral surfaces
this length. The aortic arch, superior vena cava, and of this space are covered by closely applied parietal
their branches lie closely packed with the trachea pleura, giving the underlying structures the appear-
and esophagus in the superior mediastinum. At the ance of having been shrink-wrapped.
Brachiocephalic veins
Phrenic n. (bifurcation)
Internal thoracic a. and v.

Axillary a. and v.
Aortic arch
Azygous v.
L. vagus n.
Trachea
Esophagus
T4
Fig. 3-2 At the level of the superior mediastinum, the anterior half of the A–P chest
diameter is occupied by the great vessels, trachea, and esophagus.
79
The parietal pleura surrounds the pulmonary descending segments of the aorta are approached by
hilum, forming a short, broad-based bundle, and is reflecting the lung away in the appropriate direction.
reflected onto the medial lung surfaces (Fig. 3-3). Between the pleura and pericardium, the phrenic
The leaves of pleura surrounding the lung hila extend nerves descend to the diaphragm accompanied by
caudally between the lung and mediastinum to form thin pericardiophrenic vessels (Fig. 3-4). The latter
the inferior pulmonary ligaments. The aorta frames arise from the brachiocephalic vessels and/or from
the left lung root, and the ascending, transverse, and the internal thoracic (internal mammary) vessels.
L. pulmonary a.
L. superior pulmonary v.
L. mainstem bronchus
L. inferior
pulmonary v.
Phrenic n.
Inferior
pulmonary
ligament
Fig. 3-3 The closely applied parietal pleura encloses the mediastinum laterally and
surrounds the hilar stalks of the lungs.

Internal
thoracic a. and v.
Phrenic n.
L. vagus n.
L. recurrent
laryngeal n.
Fig. 3-4 The phrenic and vagus nerves lie beneath the parietal mediastinal pleura. The
distal part of the phrenic nerve lies between pleura and pericardium.
THORACIC AORTA | 81
The second set of major nerves traversing the aortic arch. Here the left recurrent laryngeal nerve
mediastinum is the right and left vagus (Fig. 3-5). diverges to pass beneath the aortic arch behind
These are worth considering separately. The right the ligamentum arteriosum. The vagus descends
vagus passes in front of the subclavian artery just to reach the left side of the esophagus. At their
lateral to its origin from the brachiocephalic artery. junction with the esophagus, the vagi shift posi-
The right recurrent laryngeal nerve turns posteri- tion, with the left moving anteriorly and the right
orly beneath the subclavian artery and ascends in moving posteriorly. Both trunks break up into mul-
the tracheoesophageal groove, while the vagus tiple branches, which freely anastomose around the
descends behind the right main stem bronchus to esophagus. This plexus coalesces into two major
reach the esophagus. The left vagus nerve passes and several minor nerves at the distal esophagus.
between the left subclavian artery and left bra- The major trunks lie anterior and posterior to the
chiocephalic vein to reach the lateral side of the esophagus.
Middle
cervical
ganglia Recurrent
laryngeal
Ansa nerves
subclavia Inferior
cervical
ganglion
Stellate
ganglion
Esophageal
plexus
Fig. 3-5 The vagus nerves pass posterior to the lung roots to reach the midesophagus
where they form an interconnecting plexus.

Two additional anatomic features should be noted
for completeness. At the posterior limit of the medias-
tinum, the thoracic duct ascends between the esopha-
gus and the vertebral bodies (Fig. 3-6). An extensive
plexus of autonomic nerves surrounds the vascular and
bronchial structures of the superior mediastinum.
L. brachiocephalic v.
Pulmonary a.
Azygous v.
Esophagus
Sympathetic
ganglion
Thoracic
duct
Hemiazygous v.
Fig. 3-6 The most posterior part of the mediastinum is occupied by the thoracic duct and
the vessels supplying the chest wall.
THORACIC AORTA | 83
The Aorta remnant of the thymus gland. Flanking the sternum
on either side are the internal thoracic vessels, which
The ascending aorta lies beneath the sternomanu- are tethered at their origins proximally. The medial
brial joint and is accessible directly through the ster- pleural reflections closely approach the midline over
num (Fig. 3-7). The only intervening tissue is the the ascending aorta. The apex of the aortic arch lies
Vagus n.
Phrenic n.
Thymus
Internal
thoracic a. and v.
Fig. 3-7 The relationships of the vessels and lungs beneath the sternum are depicted.

in a diagonal direction relative to the sagittal plane is more posteriorly placed. The confined space at
of the chest (Fig. 3-8). As a result, the origins of the the tapering lung apices restricts anterior access to
brachiocephalic and left common carotid arteries the proximal left subclavian artery and mandates a
arise relatively anteriorly, while the left subclavian left transthoracic approach for adequate exposure.
L. subclavian a.
Brachiocephalic a.
L. common
carotid a.
Fig. 3-8 The oblique axis of the aortic arch relative to the transverse plane of the chest
places the origin of the left subclavian artery posteriorly.
THORACIC AORTA | 85
As these vessels ascend and diverge, they right. The left brachiocephalic vein, on the other
surround the trachea and esophagus on three sides hand, arches anteriorly over the origins of the left
(Fig. 3-9). The arteries in turn are covered by an common carotid and brachiocephalic arteries in its
outer layer of major venous trunks. The superior descent from left to right (Fig. 3-11). On the right
vena cava lies lateral and parallel to the ascending side, the azygous vein drains into the superior vena
aorta (Fig. 3-10). At the bifurcation of brachioce- cava just above the upper limit of the pericardium.
phalic veins, the right branch lies in the same coro- On the left, the accessory hemiazygous vein drains
nal plane as the vena cava, inclined slightly to the into the brachiocephalic vein.
Fig. 3-9 The ascending and descending great vessels surround the trachea.

◄ Fig. 3-10 The superior vena cava parallels
the ascending aorta, and both are covered with
pericardium to their midpoints.
▼ Fig. 3-11 The left brachiocephalic vein wraps

around the left common carotid and brachiocephalic
arteries in its diagonal descent.
R. common carotid a.
L. internal L. common carotid a.
Vertebral a. and v. jugular v.
R. subclavian L. subclavian a.
a. and v.
R. brachiocephalic v. Brachiocephalic a.
L. brachiocephalic
v.
Azygous v.
Right lateral view Left lateral view

The Superior Thoracic Aperture brachial plexus descend over the posterior margin
of the domes to converge with the subclavian ar-
The central viscera at the thoracic aperture are con- teries over the first ribs. Proximal branches of the
fined anteriorly by the manubrium of the sternum subclavian vessels arise and ramify above these
and posteriorly by the vertebral column. A strong domes.
dome of fascia (Sibson’s), continuous with the en- The clavicle articulates with the manubrium
dothoracic fascia, covers the apex of each lung. The medially and acts as a protective barrier over the
anterior halves of these domes support the arching subclavian vessels. The costoclavicular ligament be-
subclavian vessels (Fig. 3-12). The cords of the tween the clavicle and the first rib forms the anterior
Vertebral a.
Vagus n.
Thyrocervical trunk
Phrenic n.
Anterior
scalene m.
Subclavius m.
Internal thoracic
a. and v.
Fig. 3-12 The domes of the lung apices rise above the rim of the superior thoracic aperture
and support the arching vessels and descending brachial plexus nerves. Sibson’s fascia and
pleura are removed in this illustration.

boundary of the aperture where the axillary vein the first rib, and the posterior scalene to the sec-
passes over the first rib to become the subclavian. ond rib, the strap muscles attach to the manubrium,
This structure marks the highest limit of an axillary and the sternocleidomastoid muscles attach to the
dissection and is an important landmark for subcla- medial part of the clavicle and to the manubrium.
vian puncture. With all this protective architecture, it takes consid-
An inverted cone of muscles attaches around erable force to fracture the first rib. When such a
the rim of the superior thoracic aperture (Fig. 3-13). fracture occurs, associated major vessel injury must
The anterior and middle scalene muscles attach to be suspected.
Trapezius m.
Scalene mm.
Posterior
Middle
Anterior
Subclavius m.
Clavicular head
Sternal head
Sternothyroid m.
Sternohyoid m.
Fig. 3-13 The viscera of the superior thoracic aperture are covered by an inverted cone of
muscles.
THORACIC AORTA | 89
Beyond the arch, the proximal descending exploration is indicated in unstable patients.1 Standard
aorta lies to the left of the thoracic vertebral bodies open surgical approaches remain the standard of care
(Fig. 3-14). It becomes progressively more midline to treat blunt and penetrating injuries of the aortic arch
as it approaches the aortic hiatus at the level of the branches because the long-term stent graft durability
twelfth thoracic vertebra. These relationships deter- is unknown in the trauma population.1,2
mine the optimal surgical approaches to the great The aortic arch branches include the left sub-
vessels of the chest for control of hemorrhage in clavian, left common carotid, and brachiocephalic
trauma and for elective surgical procedures. arteries. Adequate exposure of these arteries without
a thoracic incision is virtually impossible. Injuries to
vascular structures at the base of the neck (zone I, see
Exposure of the Aortic Arch Branches Chapter 1) are also difficult to manage without ex-
posure of more proximal arteries in the chest. Early
The importance of obtaining vascular control proximal thoracotomy or sternotomy and rapid proximal arte-
and distal to an arterial injury is nowhere more evident rial control in the chest can significantly reduce the
than in the mediastinum. Rapid exsanguination, airway mortality associated with injuries to the vessels of
compromise, and cardiac tamponade threaten patients the mediastinum and base of the neck.3–5 Although
who have sustained injuries to the major branches of repair of aortic arch injuries almost always requires
the aortic arch. Although endovascular management hypothermic cardiac arrest and or/cardiopulmonary
may have a place in the treatment of highly selected bypass, arch vessels can usually be repaired without
patients with contained hematomas, immediate open extracorporeal circulatory support or arterial shunts.6
Fig. 3-14 The descending aorta initially lies

anterolateral to the vertebral column and as-
sumes a midline position at the aortic hiatus of
the diaphragm in front of the twelfth thoracic
vertebra.

Exposure of the brachiocephalic artery, proxi- treated with direct arterial repair or bypass through
mal right subclavian and carotid arteries, and the a median sternotomy.10,11
proximal left common carotid artery requires median
sternotomy.4,5 Because of the relatively posterior lo- Exposure of the Anterior Branches: Brachiocephalic, Proximal
cation of the left subclavian artery in the mediasti- Carotid (Zone I), and Proximal Right Subclavian Arteries
num (see Fig. 3-9), a left thoracotomy is required for
adequate proximal exposure of the proximal left sub- The most direct approach to the brachiocephalic
clavian artery, usually in combination with a separate and left carotid arteries at their respective origins
supraclavicular incision or “trap door” extension.4,7 is through a median sternotomy. This incision also
Patients with chronic occlusions of aortic arch provides rapid and complete access to the distal
branches rarely require thoracic incisions. Extratho- brachiocephalic artery and its branches in patients
racic arterial revascularizations such as the carotid- with right-sided zone I cervical injuries, particularly
subclavian bypass have been shown to be simple and when combined with cervical or supraclavicular ex-
durable approaches with low morbidity.8 Likewise, tensions.4 The low morbidity of a median sternot-
preoperative revascularization of the left subclavian omy has been well-established.12
artery before thoracic endovascular aortic repair can
be performed through an extrathoracic incision.9 Median Sternotomy
One notable exception is the repair of symptom- The patient is placed in the supine position with the
atic brachiocephalic artery lesions, which are best arms drawn inward. The head should be turned to-
ward the right in cases involving exposure of the left
common carotid artery and toward the left for expo-
sure of the brachiocephalic artery and its branches
(Fig. 3-15). The anterior chest, abdomen, and neck
are prepped and draped in the usual sterile fashion.
Fig. 3-15 The sternotomy incision

extends from the suprasternal notch
to the linea alba below the xiphoid
process.
THORACIC AORTA | 91
A vertical incision is made over the sternum to the periosteum of the sternum. The linea alba
from the suprasternal notch to a level 5 cm caudal in the inferior wound is divided to the tip of the
to the xiphoid process. The incision is extended xiphoid process, allowing development of a plane
superiorly along the anterior border of the left ster- between the peritoneum and the posterior rectus
nocleidomastoid muscle when exposing the left sheath. Using blunt finger dissection, this plane
carotid artery, or along the right sternocleidomas- is extended behind the xiphoid and lower sternum
toid muscle when exposing the brachiocephalic (Fig. 3-16). A similar plane is developed behind
artery and its branches. The cervical incision is the upper sternum at the suprasternal notch. It
deepened through the platysma, and the sternal is not necessary to connect the two retrosternal
incision is deepened through subcutaneous tissue planes.
Fig. 3-16 The retrosternal plane is developed by blunt finger dissection.

In preparation for division of the sternum, the midline is crucial to achieve an optimal closure and
anesthesiologist should be directed to deflate the prevent dehiscence.13 Bleeding from the edges of
lungs temporarily. This may help avoid inadvertent the sternal incision is best controlled with electro-
entry into the pleural spaces. The sternum is next cautery. The use of bone wax on the sternal edges
divided in the midline using either an electric sternal is contraindicated except in unusual circumstances
saw with a vertical oscillating blade or a Lebsche because of the risks of impaired wound healing,
knife (Fig. 3-17). Maintaining the sternotomy in the increased infection, and embolization of wax to
Fig. 3-17 The sternum is divided.
THORACIC AORTA | 93
the lungs.14 After hemostasis is obtained, a sternal on its medial surface. The underlying sternothyroid
retractor is carefully positioned and opened a few and sternohyoid muscles are divided. Lateral retrac-
turns at a time to avoid sternal fractures (Fig. 3-18). tion of the sternocleidomastoid muscle will expose
The carotid sheath is exposed through the cer- the internal jugular vein. After mobilizing the inter-
vical extension of the sternotomy (Fig. 3-19). The nal jugular vein and retracting it laterally, the com-
investing fascia is incised along the anterior border mon carotid artery can be identified and isolated
of the sternocleidomastoid muscle, which is freed (see Chapter 1).
L.brachiocephalic v.
Thymus
Fig. 3-18 The sternal retractor is opened slowly to allow strain to dissipate and avoid
fracture. For clarity, all exposures are shown without laparotomy pads beneath retractors.

Omohyoid m.
Strap mm.
Platysma m.
Investing fasia
Internal jugilar v.
L. common carotid a.
Fig. 3-19 A cervical extension of the sternotomy incision allows exposure of the carotid sheath.
THORACIC AORTA | 95
Exposure of the aortic arch and its branches be identified by retracting the left brachiocephalic
proceeds through the sternotomy incision vein superiorly. During mobilization of the brachio-
(Fig. 3-20). The thymus gland is divided vertically cephalic artery, care should be taken to identify the
in the midline and ligated. The left brachiocephalic right vagus and recurrent laryngeal nerves. The right
vein is identified, mobilized, and encircled with a vagus nerve courses along the lateral aspect of the
silastic loop. Although there are numerous venous right carotid artery, crosses anterior to the right sub-
tributaries that serve as collateral channels if the left clavian artery near its origin, and descends into the
brachiocephalic vein is occluded, intentional divi- mediastinum posterior to the right brachiocephalic
sion of this vein is usually not required. Instead, the vein (Fig. 3-21). The recurrent laryngeal branch of
inferior thyroid vein and other tributaries of the left the right vagus nerve loops around the inferior bor-
brachiocephalic vein should be divided to permit der of the proximal subclavian artery and courses
wide mobilization of the brachiocephalic vein. The medially to ascend in the neck between the trachea
brachiocephalic artery is identified superior to the and esophagus. These nerves are best preserved in
left brachiocephalic vein; its origin at the aorta can the periadventitial tissues. Lateral retraction of these
L. brachiocephalic v.
L. common carotid a.
L. vagus n.
Brachiocephalic a.
Fig. 3-20 Complete mobilization of the left brachiocephalic vein exposes the proximal

brachiocephalic artery and left common carotid artery.

tissues during dissection of the distal brachioce- resection of the medial half of the clavicle or a sepa-
phalic and proximal right subclavian arteries should rate right supraclavicular incision (see Chapter 5).
prevent neural injury. Identification of the proximal left common
Isolation of the proximal right subclavian and carotid artery proceeds in the left half of the ster-
common carotid arteries is performed just distal to notomy incision by retracting the brachiocephalic
the brachiocephalic bifurcation. Transection of the vein superiorly. Care should be taken to preserve
right-sided strap muscles is necessary to fully ex- the left vagus nerve, which descends into the me-
pose these vessels. More distal exposure of the right diastinum between the left common carotid and left
carotid artery may require superior extension of the subclavian arteries to cross the left side of the aortic
cervical incision, with division of the omohyoid mus- arch. The left recurrent laryngeal branch passes un-
cle (see Chapter 1). More distal exposure of the right der the aortic arch and ligamentum arteriosum, and
subclavian artery may require a lateral extension of then inclines medially to reach the tracheoesopha-
the midline wound across the right clavicle, with geal groove.
R. common carotid a.
R. vagus n.
R. subclavian a.
R. recurrent
laryngeal n.
Brachiocephalic a.
R. internal
thoracic v.
R. brachiocephalic v.
L. internal
thoraic v.
Superior
vena cava L. brachiocephalic v.
Fig. 3-21 On the right side, exposure of the bifurcation of the brachiocephalic artery and
the proximal right subclavian and common carotid arteries requires mobilization of the
vagus nerve.
THORACIC AORTA | 97
Limited Upper Sternotomy abdomen are prepped and draped completely in the
Full median sternotomy is recommended for most event a full sternotomy should become necessary. A
operations involving exposure of the aortic arch vertical skin incision is made from the sternal notch
branches, especially in emergency situations when to a level 2 cm below the angle of Louis. The ster-
the exact location of injury has not been identified. num is divided in the midline from the manubrium
In extremely limited circumstances, a complete to the third intercostal space using an oscillating
sternotomy may not be necessary to expose the bra- saw (Fig. 3-22). The sternum is then transected
chiocephalic and left common carotid arteries in horizontally in the third intercostal space to form
the chest. Sakopoulos15 has described a “minister- an inverted “T” incision, taking care to avoid in-
notomy” exposure for direct treatment of brachio- jury to the nearby internal mammary vessels. Af-
cephalic and left common carotid lesions in elective ter hemostasis is obtained, the upper sternum is
circumstances. This less invasive approach is useful gently opened using a pediatric sternal retractor.15
for amenable aortic arch branch lesions but should (Fig. 3-23) The underlying thymus is divided and
be avoided in patients with more extensive disease ligated to expose the left brachiocephalic vein.
and in emergency circumstances. Identification and exposure of the brachiocephalic
The patient is placed supine with the arms and left common carotid arteries proceeds as above
drawn into the sides. The neck, chest, and upper (Fig. 3-24). This approach is particularly suited for
Fig. 3-22 The upper sternum is divided, then transected horizontally at the level of the
third intercostal space to form an inverted “T.”

Fig. 3-23 The aortic arch and its proximal branches are readily exposed through the
limited sternotomy.
Fig. 3-24 Elevation of the left brachiocephalic vein

exposes the origins of the brachiocephalic and left com-
mon carotid arteries.
THORACIC AORTA | 99
Fig. 3-25 Proximal brachiocephalic lesions are readily
repaired using this approach.

direct repair of proximal brachiocephalic artery thoracotomy and the “trap door” thoracotomy. The
lesions (Fig. 3-25). former approach is optimal for emergency proxi-
mal control of the left subclavian artery and can
Exposure of the Proximal Left Subclavian Artery be combined with a separate supraclavicular inci-
sion for definitive repair (see Chapter 5). The latter
Mediastinal exposure of the left subclavian artery approach is a radical extension of the anterolateral
is indicated in control of proximal injuries, which thoracotomy and is ideal for control and repair of
often result from penetrating trauma to the left me- left subclavian artery injuries near the sternocla-
diastinum or base of the neck. Mediastinal control vicular joint. The “trap door” incision is limited in
may also be urgently indicated in more distal sub- exposure, however, and should be reserved for inju-
clavian artery injuries heralded by expanding su- ries in the left side of the superior thoracic aperture.
praclavicular hematomas. The need to expose this
segment of the artery in cases of chronic occlusion Anterolateral Thoracotomy
has been superseded by the advent of extrathoracic The patient is placed in the supine position. A rolled
bypass procedures, which are both durable and sheet or pad should be placed behind the left scapula
safe.8 and hip to bring the left chest approximately 20° up-
The posterior location of the left subclavian ar- ward. The entire anterior and lateral chest, shoulder,
tery relative to the other aortic arch branches renders axilla, and neck are prepped and draped.
it extremely difficult to expose through a median A left transverse curvilinear incision is made
sternotomy (see Fig. 3-9). There are two surgical over the fifth rib, just below the nipple. The incision
approaches that permit optimal exposure of the may be made along the lower contour of the pecto-
left subclavian artery at its origin: the anterolateral ralis major muscle to enhance cosmesis (Fig. 3-26).
Fig. 3-26 Landmarks for a left anterolateral thoracotomy incision are demonstrated.
THORACIC AORTA | 101
In females, it may be made just below the muscles along the top of the fifth rib (Fig. 3-27),
breast. Some authors advocate a third interspace in- which prevents injury to the neurovascular bundle
cision above the nipple,16–18 but we have found this lying just deep to the inferior border of the fourth rib.
to be somewhat limited by the bulk of the pectoralis After incising the parietal pleura, the lung is allowed
major muscle and cosmetically inferior to the lower to collapse away from the chest wall, and the remain-
incision. The incision should extend from the lateral der of the wound is opened for the entire length of the
sternal border to the anterior axillary line. The fourth skin incision. The internal thoracic artery and vein
interspace is reached by dividing the tough pectoralis should be ligated and divided near the lateral ster-
fascia and lower fibers of the pectoralis major mus- nal border. A rib spreader is placed in the wound and
cle. The interspace is entered by dividing intercostal opened slowly to lessen the chance of rib fracture.
Pectoralis major m.
5th rib
Fig. 3-27 The fourth interspace is entered over the top of the fifth rib.

By retracting the superior lobe of the left lung
downward, the aortic arch can be readily seen un-
der the glistening sheen of the mediastinal pleura
(Fig. 3-28). The mediastinal pleura should be incised
over the aortic arch at a point posterior to the left
vagus nerve. The incision is then carried vertically
L. subclavian a.
L. vagus n.
Aortic arch
Fig. 3-28 The aortic arch is exposed by retracting the lung caudally.
over the left subclavian artery, which is most easily as it courses anterolateral to the left subclavian ar-
isolated just above its origin (Fig. 3-29). Care should tery and crosses the aortic arch. The thoracic duct
be taken to avoid injuring the left vagus nerve and is posteromedial to the left subclavian artery and
the thoracic duct during these maneuvers. The nerve is prone to injury during attempts at isolating the
should be recognizable under the mediastinal pleura artery distal to its origin.
Fig. 3-29 The mediastinal pleura is opened over the arch and left subclavian artery poste-
rior to the vagus nerve.

“Trap Door” Thoracotomy aperture, particularly when the surgeon has already
This approach combines the left anterior thoracot- performed a left anterior thoracotomy in an unstable
omy with a left supraclavicular incision and an in- patient.
terconnecting upper median sternotomy (Fig. 3-30). The patient is placed in the supine position.
The chest wall is not folded back as suggested by the The entire chest, neck, and left shoulder are prepped
nomenclature; rather, it is spread at the sternal divi- and draped.
sion using a standard retractor.18 Despite the criti- The anterolateral thoracotomy is performed
cisms19,20 concerning the prolonged time involved in first, as described above. We favor entry into the
making the incision, pleural entry, excess bleeding, pleural space through the fourth interspace and per-
and a propensity for rib fractures, the “trap door” form an infra-areolar incision accordingly. Initial
thoracotomy remains an important option for ex- performance of this part of the incision permits early
posure of left-sided injuries at the superior thoracic and rapid control of the left subclavian artery while
Fig. 3-30 The incisions for the “trap door” thoracotomy are outlined.
the incision is completed. The internal thoracic ligated near the junction of the internal jugular and
(mammary) vessels should be ligated and divided in subclavian veins.
the medial portion of the incision, near the sternum. The carotid sheath is located on the medial
Exposure of the extrathoracic subclavian ar- edge of the fat pad. The lateral border of the internal
tery is performed next, allowing distal control of jugular vein is freed, permitting medial retraction of
the arterial injury. The supraclavicular approach is the carotid sheath contents. This exposes the anterior
preferred over resection of the medial half of the scalene muscle in the medial wound (Fig. 3-32). The
clavicle, since claviculectomy is time consuming left phrenic nerve courses on the anterior surface of
and does not significantly improve exposure.18,21 this muscle, and great care should be taken to isolate
A transverse incision is made 2 cm above and par- the nerve away from the anterior scalene muscle.
allel to the left clavicle, beginning at the sternal Once nerve protection is ensured, the anterior
notch and extending laterally for 8 cm. The incision scalene muscle is divided near its attachment to the
is deepened through subcutaneous tissues and the first rib. Division should be performed under direct
platysma muscle, exposing the sternocleidomastoid vision, cutting a few fibers at a time to prevent injury
and omohyoid muscles. Both muscles are divided to the left subclavian vein, which lies anterior to the
near their inferior attachments (Fig. 3-31). The ex- muscle. The subclavian artery is isolated deep to the
ternal jugular vein is ligated and divided. The thin anterior scalene muscle (Fig. 3-33). The thyrocervi-
fascia overlying the supraclavicular fat pad is in- cal trunk and vertebral artery should be identified.
cised transversely, and the fat pad is swept laterally A vertical incision is made over the up-
using sharp dissection. The thoracic duct should be per sternum to connect the medial borders of the
Subclavian v.
Thoracic
duct
Internal
jugular v.
External jugular v. Omohyoid m. (cut)
L. subclavian a.
Fig. 3-31 The supraclavicular incision is developed after the anterolateral thoracotomy is

complete.

Omohyoid m.
Vertebral a.
Inferior thyroid a.
Internal jugular v.
Phrenic n.
Superficial cervical a.
Suprascapular a.
Anterior scalene m.
Subclavian a.
Subclavian v.
Fig. 3-32 Retraction of the carotid sheath and scalene fat pad exposes the subclavian
vessels and anterior scalene muscle.
Fig. 3-33 The anterior scalene muscle is divided close to the scalene tubercle of the first rib.
supraclavicular and anterior thoracotomy incisions Exposure of the Descending Thoracic Aorta
(Fig. 3-34). After deepening the sternal inci-
sion to the periosteum, a retrosternal plane is created The most common site of blunt injury to the thoracic
at the suprasternal notch. The sternum is divided in aorta is just distal to the origin of the left subclavian
the midline using a sternal saw or Lebsche knife artery, with the tear beginning at the ligamentum
(see above), beginning at the suprasternal notch and arteriosum.22 Although a majority of victims who
extending to the level of the fourth interspace. The sustain such injuries are dead prior to arrival at treat-
sternotomy is extended laterally into the fourth in- ment facilities, up to 20% may be alive.23,24 Urgent
terspace incision with the bone-cutting instrument. diagnosis of this injury is crucial to survival, as the
The sternal retractor is placed in the sternot- mortality rate rises with increasing time to definitive
omy incision and opened slowly. The internal tho- repair. Endovascular treatment has become a popu-
racic vessels should be ligated and divided as they lar alternative to open repair, but the superiority of
are exposed during the sternal retraction. The entire one technique over the other remains controversial.
length of the subclavian artery and vein are visible Although the endovascular approach appears to be
through this incision.
Fig. 3-34 A partial median sternotomy completes this incision.

associated with reduced morbidity and duration of Posterolateral Thoracotomy
hospitalization,24,25 the durability of thoracic stent
grafts in trauma patients who tend to be younger and The patient is placed in a true lateral position, with
resistant to follow-up remains unknown. Further- the right side down. A roll is placed beneath the right
more, a recent analysis suggests that survival in pa- axilla. The right arm is placed on an armboard per-
tients with blunt aortic injuries is determined by the pendicular to the patient, and the left arm is sup-
extent of associated injuries and not influenced by ported with pillows or on a Mayo stand. The right
the type or timing of surgical repair.26 The follow- leg is flexed to 90°, and the left leg is extended and
ing discussion describes exposure of the descending supported by pillows placed between the patient’s
thoracic aorta for open repair, which is best obtained knees (Fig. 3-35). Stabilization of the pelvis is en-
through a posterolateral thoracotomy. sured with wide tape that is brought from one side
Fig. 3-35 Patient position for a left posterolateral thoracotomy incision is shown.
of the operating table to the other across the left be entered is determined by the level of aorta to be
hip. The exposed chest, flank, and left shoulder are exposed. The proximal segment of the descending
prepped and draped. thoracic aorta is best exposed through the fourth
The skin incision begins just below the left interspace, and the distal segment is best exposed
nipple and extends posteriorly to 1 inch below the through the sixth interspace. The chosen interspace
tip of the scapula, then curves upward between the should be verified by counting the ribs from above
scapula and the spine (Fig. 3-36). The wound is downward. The surgeon’s hand is placed beneath
deepened through the subcutaneous tissue and in- the scapula and pushed upward through loose areo-
vesting fascia. The latissimus dorsi, serratus anterior, lar tissue toward the apex of the chest. The ribs are
and trapezius muscles are divided. Division of these counted downward from the first. The fourth inter-
muscles allows the shoulder girdle to move upward space is identified and entered by incising the inter-
and the scapula to retract away from the incision. costal muscles along the superior border of the fifth
The optimal interspace through which the chest will rib. After entering the pleural cavity, the left lung is
Trapezius m.
Serratus Latissimus
anterior m. dorsi m.
Fig. 3-36 Trapezius, latissimus, and serratus muscles are divided in turn.

allowed to collapse. Rib spreaders are placed in the artery (Fig. 3-37). Control of the aorta at this level
wound and opened slowly to prevent rib fracture. requires identification and protection of the vagus
The descending thoracic aorta will be seen an- and phrenic nerves as they cross the aortic arch.
terior to the vertebrae beneath the glistening surface This may be accomplished with vertical incision of
of the mediastinal pleura. Control of the distal tho- the mediastinal pleura posterior to the vagus nerve.
racic aorta is easily obtained by incising the medi- The left vagus nerve and surrounding periaortic
astinal pleura directly over the vessel. The aorta is tissues are bluntly swept forward until the aorta is
encircled with heavy tapes, taking care to preserve sufficiently cleared to be clamped. The left phrenic
intercostal arteries. nerve should be carefully dissected from the aor-
Aortic tears at the level of the ligamentum ar- tic arch and gently retracted away from the area of
teriosum require control of the aorta between the injury. The left subclavian artery can be controlled
left common carotid and left subclavian arteries, near its origin by extending the pleural incision
as well as control of the proximal left subclavian superiorly (see above).
Fig. 3-37 Proximal and distal control is demonstrated for lesions of the proximal descend-
ing aorta.
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Superior Thoracic
Aperture and
Cervicothoracic
Sympathetic Chain
4
Anatomy of the “Thoracic Outlet” The Cephalad Passages
The superior opening of the bony thorax has come The superior thoracic aperture is bounded by the
to be called the thoracic outlet. The anatomic term first ribs, which connect the spinal column poste-
superior thoracic aperture and the term thoracic out- riorly with the sternum anteriorly (Fig. 4-1). The
let will be used interchangeably in this chapter to vertebral bodies indent the oval shape of this open-
designate the regional anatomy. ing. The manubrium of the sternum rises above the
Compression of upper extremity neurovascular plane of the first ribs to articulate with the heads of
structures, collectively called the thoracic out- the clavicles. The mobile sternoclavicular joint is
let syndrome, encompasses considerably more the only osseous connection between the axillary
anatomy than the cephalad aperture of the bony skeleton and the bones of the upper extremity. The
thorax. The vessels exiting the chest and the nerves mobility of the clavicle is important in determining
emerging from the spinal column pass between the amount of space available for passage of the sub-
the scalene muscles above the rim of the superior clavian vessels and brachial plexus draped over the
thoracic aperture. They then pass through the tri- first rib. The costoclavicular ligament as well as the
angle formed by the first rib, clavicle, and scapula sternoclavicular joint attach the clavicle medially.
and run beneath the coracoid process on their way The transverse processes of the cervical vertebrae
to the brachium. are trough-shaped and contain central apertures. The
The following discussion considers all of the vertebral arteries normally enter the sixth transverse fo-
structures that can compress and compromise the ramen and traverse the upper five foramina to reach the
nerves and blood vessels of the upper extremity. base of the skull. The transverse process of the seventh
The basic surgical approaches to correcting such cervical vertebra is often quite large. Rarely, a cervical
compression are addressed in the second part of the rib may be present, which attaches to this transverse
chapter. process and lies in the path of the brachial plexus.
113
Intervertebral
foramen
Transverse
process
First rib
Head
Neck
Angle
Body
C7
Scalene
tubercle
T1
Manubrium
Costoclavicular
ligament
Fig. 4-1 The bony landmarks associated with the thoracic outlet include the obliquely
angled face of the superior thoracic aperture between the spinal column posteriorly and the
manubrium anteriorly. The clavicle and scapula constitute the pectoral girdle.

The fifth through the eighth cervical nerves tubercles of transverse processes three through six
and the first thoracic nerve give origin to the bra- and insert on the scalene tubercle of the first rib be-
chial plexus (Fig. 4-2). The nerves emerge through tween the subclavian artery and vein. The middle
the intervertebral foramina and lie in the troughs of scalene muscles arise from the posterior tubercles
the transverse processes posterior to the vertebral of the lower six cervical transverse processes and
vessels. The anterior and middle scalene muscles attach more broadly to the posterior parts of the first
sandwich the roots of the brachial plexus. The an- ribs. The posterior scalene muscle rarely contributes
terior scalene muscles originate from the anterior to the thoracic outlet syndrome.
Scalene muscles
Anterior
Middle
Posterior
Fig. 4-2 The scalene muscles form struts between the cervical spine and the first ribs. The
nerves to the upper extremity pass between the anterior and middle scalene muscles.
SUPERIOR THORACIC APERTURE AND CERVICOTHORACIC SYMPATHETIC CHAIN | 115

The Neurovascular Core rise to the ulnar nerve. A branch of the medial cord
unites with the lateral cord to form the median nerve
The roots of the brachial plexus are the ventral rami anterior to the artery.
of the fifth through eighth cervical and first thoracic There are three important branches which
nerves, which lie between the anterior and middle deviate from the central location of the brachial
scalene muscles (Fig. 4-3). Topographically these plexus. Twigs from the roots of the fifth, sixth,
lie in the posterior triangle of the neck. As they and seventh nerves unite to form the long thoracic
emerge between the scalene muscles, the roots of nerve and pass through the substance of the mid-
the brachial plexus unite to form three trunks. At the dle scalene muscle to reach the serratus anterior
level of the first rib, the trunks divide into anterior muscle on the chest wall. This relationship is im-
and posterior divisions which lie posterior to the portant during the posterior dissection for first rib
first part of the axillary artery. The posterior divi- resection.
sions unite to form the posterior cord which contin- The phrenic nerve arises from the third, fourth,
ues behind the axillary artery to become the radial and fifth ventral nerve roots. It descends on the sur-
nerve. The anterior divisions form lateral and me- face of the anterior scalene muscle, running from
dial cords around the artery. The medial cord gives a lateral to a medial position. It enters the chest
C3
C4
C5
Roots
C 6
Phrenic n.
C7 Trunks
C8 Divisions
Cords
T1 Lateral
Posterior
Medial
Long
Supreme thoracic n.
thoracic a.
Lateral
Subscapular a.
thoracic a.
Thoracodorsal n.
Median n.
Ulnar n.
Intercostobrachial n. Radial n.
Fig. 4-3 The relationship between the brachial plexus and subclavian/axillary arteries is

depicted in this illustration.

between the subclavian artery and vein at the inner The axillary artery gives off the small supreme
margin of the first rib, just medial to the anterior sca- thoracic artery at the lateral margin of the first rib,
lene attachment to the scalene tubercle. the lateral thoracic artery in the midaxilla, and the
Another branch of the brachial plexus that is subscapular artery in the distal axilla. The supreme
notable by its proximity during surgical correction and lateral thoracic vessels lie directly on the chest
of thoracic outlet compression syndromes is the tho- wall. The subscapular vessels arise more laterally
racodorsal nerve. It arises from the posterior cord in and are not directly on the chest wall.
the midaxilla and joins the thoracodorsal vessels to
the latissimus dorsi muscle. Its lateral origin puts it The Axillary Passages
at the periphery of the operative field when the arm
is elevated. The mobile pectoral girdle frames the upper border of
The intercostobrachial nerve is a branch of the the axilla (Fig. 4-4). The muscles attaching the clavi-
second intercostal nerve which crosses the center of cle and scapula to the chest wall form the boundaries
the axillary space and usually joins the medial bra- of the axilla and create the neurovascular bundle’s
chial cutaneous nerve. Some numbness on the inner passageway to the upper extremity. Elevation of the
aspect of the brachium may result from division of pectoral girdle widens the passage, while depression
this nerve. and posterior displacement narrow the space.
Fig. 4-4 The great mobility of the pectoral girdle affects the amount of space available for
the nerve and vascular trunks to the upper extremity.

The serratus anterior muscle forms the ma- The axillary space and neurovascular bundle
jority of the medial axillary wall (Fig. 4-5). The are enclosed by several well-defined fascial lay-
subclavius muscle forms a bridge from the under- ers. The prevertebral fascia surrounding the scalene
surface of the distal clavicle to the costochondral muscles continues onto the surface of the vessels
junction of the first rib. A second bridge is formed and nerves lying over the first rib, forming an axil-
by the arching coracoid process and the origin of lary sheath. The clavipectoral fascia extends from
the pectoralis minor muscle. Subscapularis, teres the subclavius muscle across the pectoralis minor
major, and latissimus dorsi muscles form the pos- muscle, which it enfolds, and joins the axillary fas-
terolateral boundary of the axilla. The neurovascu- cia. The latter spans from the lateral edge of the
lar bundle passes under these bridges to reach the pectoralis major muscle to the anterior edge of the
axillary space. latissimus dorsi.
Prevertebral fascia
Serratus
anterior m.
Axillary sheath
fascia
Subclavius m.
Latissimus
Clavipectoral dorsi m.
fascia
Pectoralis minor m.
Pectoralis
major m. Brachial
sheath
Axillary fascia
Fig. 4-5 The clavipectoral and axillary fasciae form anterior and lateral walls of the
axillary space.

Looking from below the clavicle, one can see them. The insertion of the subclavius muscle forms
the geometry which causes compression of the cos- the medial margin of the foramen through which
toclavicular passage with depression and posterior the subclavian vein enters the chest. It is an impor-
movement of the clavicle (Fig. 4-6). The angle be- tant landmark toward which the needle is directed
tween the clavicle and first rib is acute and subject when cannulating the subclavian vein, and it is the
to scissors-like closure, with the most pronounced highest point of a complete axillary lymph node
effect being on the subclavian vein lying between dissection.
Costoclavicular Clavipectoral
ligament Subclavius m. fascia
Fig. 4-6 Oblique fibers of the pectoralis minor and major and the latissimus dorsi make
the distal clavicle a lever that closes the costoclavicular angle.

The surgical view of the axilla shows the rela- first rib and must be divided for access. The long
tionships of the neurovascular bundle, its branches, thoracic and lateral thoracic nerves posterolaterally
and the surrounding structures (Fig. 4-7). The su- are important to preserve. The intercostobrachial
preme thoracic and lateral thoracic vessels and tho- nerve may be preserved or divided, depending on
racoepigastric vein cross the critical portion of the whether it interferes with exposure.
Triceps m. Deltoid m.
Biceps m.
Subscapular v.
Coracoid process
Axillary a.
Axillary v.
Intercostobrachial n.
Teres
major m.
Latissimus
Supreme dorsi m.
thoracic a.
Thoracodorsal
a. and v.
Lateral
thoracic a. and v.
Thoracodorsal n.
Long thoracic n.
Thoracoepigastric v.
Fig. 4-7 Several nerves and vessels cross the axillary space and lie in the way of access to
the first rib from below.

Vasomotor Sympathetics (Fig. 4-8). Within the sympathetic trunk, the pregan-
glionic fibers synapse with multiple postganglionic
Autonomic control of vascular tone in the upper ex- neurons at various levels. Postganglionic axons from
tremity is regulated by sympathetic nerves whose the middle cervical, stellate, and second thoracic
preganglionic fibers originate in the lateral grey ganglia join the roots of the brachial plexus or run di-
column of the second to eighth thoracic spinal cord rectly in the adventitia of blood vessels. The major-
segments. The axons pass from the cord through the ity of upper extremity vascular sympathetic nerves
ventral nerve root to the ventral rami where they reach their destination through the lower trunk of the
exit via the white rami to the sympathetic trunk brachial plexus and the median and ulnar nerves.
Nasociliary
branch Trigeminal n.
Carotid plexus
Pupillary
dilator
Superior cervical
ganglion
Brachial plexus
Grey rami
(unmyelinated
postganglionic
fibers) Cutaneous n.
Lateral grey
column
Stellate
ganglion
White ramus
(myelinated preganglionic
fibers)
Fig. 4-8 Each sympathetic ganglion may have one to four communicating rami that con-
nect to both contiguous spinal nerves and adjacent nerves. Interruption of the sympathetic
trunk at the lower part of the stellate ganglion’s thoracic component blocks the majority of
sympathetic efferents to the upper extremity while preserving enough sympathetic innerva-
tion to prevent Horner’s syndrome.

Anatomically, there are fewer thoracolumbar Complete interruption of the sympathetic in-
sympathetic ganglia than there are cord segments. nervation of the upper extremity also interrupts
The stellate ganglion found in most individuals rep- the innervation of the pupillary dilator, local facial
resents the fusion of the inferior cervical and the first sweat glands, and blood vessels, resulting in Horn-
thoracic ganglia. The cervical sympathetic chain on er’s syndrome. Section of the sympathetic chain at
each side lies between the carotid sheath and the pre- the lowermost part of the stellate ganglion preserves
vertebral fascia anterior to the transverse processes enough TI sympathetic outflow in most cases to
of the cervical vertebrae (Fig. 4-9). The middle cer- avoid a Horner’s syndrome. The amount of sympa-
vical ganglion lies at the level of the C6 transverse thetic innervation left in the upper extremity is not
process (carotid tubercle) medial to the vertebral felt to be clinically significant by advocates of this
artery as it enters the vertebral foramen. The trunk procedure.
then turns posterolateral to assume a paravertebral An older controversy involved the denerva-
position. The thin ansa subclavia loops around the tion hypersensitivity to circulating catecholamines,
subclavian artery between the middle cervical gan- which results from interruption of postganglionic
glion and the stellate ganglion. In the chest, the sym- sympathetic fibers. Older procedures to selectively
pathetic trunks and ganglia lie beneath the parietal divide white rami only have been abandoned, since
pleura on the necks of the ribs. this syndrome is rarely observed clinically.
Longus capitis m.
Longus colli m. Middle scalene m.
Anterior scalene m.
Carotid tubercle
Cardiac n’s (C6 transverse
process)
Middle cervical ganglion
Stellate ganglion
Vertebral a.
Vagus n.
Ansa
subclavia
Fig. 4-9 The stellate ganglion lies dorsal to the vertebral artery.

Exposure of the Thoracic Outlet The presence of first rib anomalies, fibromuscular
bands, or abnormal muscular insertions can result in
Compression syndromes involving neurovascu- a fibromuscular vise that compresses the subclavian
lar structures in the thoracic outlet have been rec- vessels and brachial plexus in this area.2–4 The costo-
ognized for many years. The anatomic situation clavicular passage is a second triangle made up of the
underlying compression in this area is the normal subclavius muscle and clavicle anteriorly, the first
existence of four narrow spaces through which the rib posteromedially, and the scapula and subscapu-
neurovascular bundle must pass in coursing from laris muscle posterolaterally. This area is a common
the neck to the axilla: the superior thoracic aperture, site of subclavian vein compression in patients with
interscalene triangle, costoclavicular passage, and effort thrombosis.5,6 A third anatomic triangle exists
subcoracoid space. Thyromegaly, thymic lesions, or in the subcoracoid space, where the neurovascular
adenopathy may reduce space availability within the bundle passes between the coracoid process and
superior thoracic aperture1 (Fig. 4-10A). The inter- the pectoralis minor tendon. A tight band of supe-
scalene triangle is a narrow confine bordered by the rior clavipectoral fascia, the costocoracoid ligament,
anterior scalene muscle anteriorly, the middle sca- may narrow the subcoracoid space during shoul-
lene muscle posteriorly, and the first rib inferiorly. der abduction. Hypertrophy of the pectoralis minor
muscle in athletes may also cause subcoracoid space
narrowing.7 More laterally, an accessory muscle
that crosses the axilla from the latissimus dorsi to
the pectoralis major muscle, Langer’s axillary arch
(Fig. 4-10B), has been reported to cause upper limb
deep vein thrombosis from compression.8
Anterior scalene m.
Middle
scalene m.
Interscalene
triangle
Superior
thoracic
aperture Costoclavicular
passage
Subcoracoid
space
A
Fig. 4-10 A: Important components of the passage between

the chest and upper extremity are schematically represented.
B: A rare accessory muscle slip (Langer’s arch) can compress B
the distal axillary structures.

Space availability within the confines of these common in the general population,4,9,12 others have
narrow apertures may be further reduced by a com- suggested that local trauma may be an important
bination of physiologic, anthropometric, and patho- causative influence in patients who are predisposed to
logic factors (Fig. 4-11). Hypertrophy of the anterior compression syndromes by congenital anomalies.2,9
scalene or the pectoral muscles, scoliosis, abnormal There are three discrete types of thoracic outlet
shoulder posture, existence of cervical ribs, and compression syndromes: brachial plexus compres-
clavicular fracture malunions, and other shoulder sion, subclavian artery compression, and subcla-
injuries have all been implicated in compression vian vein compression. Neural compression is by
syndromes.2,3,9 In addition, the existence of abnor- far the most common type, accounting for nearly
mal myofascial bands or anomalous scalene muscle 97% of thoracic outlet compression symptoms.2,3,13
insertions may underlie compression symptoms. Diagnosis and evaluation of patients with all three
Roos11 feels that congenital fibrous bands or abnor- types of suspected thoracic outlet compression are
mal muscle insertions are the most common causes well-described elsewhere.2,3,14 It should be stressed
of this disorder. However, since these anomalies are that a majority of patients will experience relief of
Middle
scalene
band
Cervical
rib
Anterior
scalene m.
Fig. 4-11 Several different pathologic conditions are associated with the thoracic outlet
syndrome. These include cervical ribs (usually embedded within the middle scalene
muscle) and middle scalene bands (A); anomalous muscle insertions, fascial bands, and
clavicular compression (B); and osseous anomalies and traumatic malformations (C).

Fig. 4-11 (Continued)
Outlet band Middle scalene

band
Anterior
insertion of
middle scalene m.
Costoclavicular
compression
Incomplete first rib
Clavicular
malunion

neurologic symptoms with nonoperative therapy.2,3 because it is the anatomic structure common to all
In a recent review, Brooke and Freischlag13 noted three of the narrow thoracic apertures described
that injecting lidocaine or botulinum toxin A (bo- above (Fig. 4-12). Clagett17 was the first to recom-
tox) into the anterior scalene muscle at its insertion mend routine resection of the first rib as a way to
onto the first rib may provide durable symptom alleviate symptoms regardless of the site of com-
relief of neurogenic thoracic outlet syndrome for pression. Most modern surgeons have adopted
up to 3 months. Moreover, the degree of symptom this view and remove the first rib through one of
relief appears to correlate with successful response two approaches, transaxillary and supraclavicular.
to physical therapy and surgical intervention. The transaxillary approach has been favored
Several surgical procedures have been de- for many years. It is cosmetically superior but diffi-
scribed for the treatment of thoracic outlet com- cult to perform in muscular individuals. The anterior
pression syndromes. Early reports suggested that supraclavicular approach has undergone rejuvena-
simple scalenectomy was effective in alleviating tion and is currently favored by some.18–20 This ap-
symptoms.15 Although some authors suggest that proach should be used in cases involving agenesis
anterior scalene muscle excision may be appropri- of the first rib and when arterial reconstruction is
ate in highly selected patients,2,16 the consensus planned. The posterior approach originally de-
of opinion is that the first rib should be removed scribed by Clagett17 has been abandoned because it
Fig. 4-12 The compression from a variety of causes responds to removal of the body of

the first rib.

is technically demanding. The anterior infraclavicu- Anterior Supraclavicular Approach
lar approach21 offers only limited first rib resection,
and the view of the neurovascular structures is ob- The principal advantage of this approach is that it
structed by the clavicle. It is most useful to ensure provides wide exposure of all anatomic structures
sternal disarticulation of the first rib and complete of the thoracic outlet. It can also be combined easily
resection of the subclavius muscle in patients with with other incisions to correct arterial pathology at
venous thoracic outlet compression (see below). the time of outlet decompression. Although the su-
The transclavicular approach requires resection of praclavicular approach has been used since 1910, it
the clavicle and is most useful in cases involving has become a popular method of thoracic outlet de-
clavicular pathology. Because of the high reported compression within the last three decades.23 Long-
risk of postoperative shoulder pain, claviculectomy term results attest to its efficacy in correcting neural
is not recommended for thoracic outlet decom- compression symptoms.19,20
pression in most cases.22 The following discussion The patient is placed supine with the head
concerns the three currently popular approaches to turned away from the operative side (Fig. 4-13).
thoracic outlet decompression. The head of the table should be elevated slightly
Fig. 4-13 The incision for the supraclavicular approach to the first rib is shown. The ideal
exposures shown in the following illustrations for clarity are seldom achieved in reality due
to the funnel-like depth of the operative field.

to reduce venous pressure in the operative field. A clavicular head of the sternocleidomastoid muscle
rolled towel placed vertically between the scapu- should be divided to enhance medial exposure at
lae may help extend the shoulder and flatten the the time of first rib resection. Just deep to the di-
supraclavicular fossa. The neck, shoulder, and up- vided sternocleidomastoid fibers is the internal
per chest are prepped and draped in sterile fashion. jugular vein, which should be dissected on its lat-
An incision is made 1 to 2 cm above and parallel eral border and carefully retracted medially. The
to the clavicle, beginning at the clavicular head and underlying scalene fat pad is mobilized along its
extending approximately 8 cm laterally (Fig. 4-14). medial, superior, and inferior borders and then re-
The incision is deepened through subcutaneous tis- flected on a pedicle in the lateral wound.24 On the
sue and the platysma. Subplatysmal flaps are devel- left side, the thoracic duct should be identified and
oped in the superior wound to the level of the cricoid carefully ligated as it arches through the inferome-
cartilage and in the inferior wound to the clavicle.23,24 dial corner of the scalene fat pad toward its termi-
The external jugular vein and the omohy- nation near the junction of the left internal jugular
oid muscle are divided in the midwound. The and subclavian veins.
Platysma m.
External jugular v.
Sternocleidomastoid
m. (clavicular
head)
Scalene
fat pad
Internal
jugular v.
Thoracic
duct Anterior
scalene m.
Subclavian v. Phrenic n.
Fig. 4-14 The clavicular head of the sternocleidomastoid muscle and the omohyoid
muscle are divided, and the scalene fat pad is separated from the internal jugular vein. The
fat pad and vein are retracted in opposite directions, and the thoracic duct is ligated and
divided on the left side.

The anterior scalene muscle lies directly be- muscle is next divided at its insertion on the first
neath the fat pad. Coursing on the anterior surface rib (Fig. 4-15). The muscle should be divided a few
of this muscle, usually near the medial border, is the millimeters at a time under direct vision to avoid in-
phrenic nerve. The nerve should be freed from the jury to the overlying subclavian vein. The muscle
adjacent fascia of the anterior scalene muscle and can then be divided as close to its transverse process
carefully protected during the ensuing dissection. origins as possible to complete the resection. The
The nerve should not be forcibly retracted because subclavian artery lies in the inferior wound and is
even minimal compression can result in a tempo- easily isolated should associated arterial pathology
rary diaphragmatic palsy.23 The anterior scalene warrant surgical correction.
Anterior scalene m.
Suprascapular a.
Phrenic n.
Subclavian a.
Internal
jugular v.
First rib
Subclavian v.
Fig. 4-15 The phrenic nerve is protected as the anterior scalene muscle insertion is divided.

Because of its possible contribution to and protected on the muscle’s anterolateral sur-
compression problems at the thoracic outlet, the face, the middle scalene fibers are divided a few
middle scalene muscle is resected next. It is lo- short segments at a time along the first rib at-
cated posterior and lateral to the roots of the bra- tachments (Fig. 4-16). The long thoracic nerve
chial plexus. To facilitate exposure of the middle marks the lateral boundary of muscle division.
scalene, the C5 and C6 nerve trunk is mobilized The most anterior portion of the middle scalene
along its lateral border and gently retracted down- muscle may not be identified without undue trac-
ward. After the long thoracic nerve is identified tion on the brachial plexus. These fibers can be
Middle
scalene m.
Brachial
plexus
Long
thoracic n.
First rib
Fig. 4-16 The middle scalene muscle posterior to the brachial plexus is cautiously
separated from the first rib (A), keeping in mind the location of the long thoracic nerve.
The most anterior fibers of the middle scalene muscle may be approached between the
subclavian artery and the lower nerve trunk as shown or may be approached between the
seventh and eighth nerve roots to avoid undue traction on the brachial plexus (B).

divided in the space between the subclavian ar- of the brachial plexus, including those associated
tery and the lower nerve trunk. Although most with C7 vertebrae and Sibson’s fascia. Likewise,
compressing bands will be removed with resec- certain muscle anomalies, such as split middle
tion of the anterior and middle scalene muscles, scalene insertions and posterior scalene hyper-
the operative field should be palpated to detect trophy,1 should be recognized. Cervical ribs are
the presence of any other fibrous constrictions. usually embedded within the fibers of the middle
It is particularly important to remove any fibro- scalene muscle and are easily resected at the time
muscular bands associated with the exposed areas of middle scalenectomy.23
Fig. 4-16 (Continued)

The first rib is now ready for resection. while the body of the first rib is divided cleanly just
Extraperiosteal resection is preferred over the sub- distal to the tubercle using a sagittal air-drive saw24
periosteal approach because the former is simpler, or piecemeal with a narrow rongeur23 (Fig. 4-17).
and removal of the periosteum may prevent reossi- The posterior rib remnant is removed as close to
fication of the periosteal bed and associated recur- the transverse process as possible with a rongeur.
rent symptoms.25 The rib is freed by blunt finger This maneuver should be performed under direct
dissection along the inferior rib surface to detach vision to minimize the possibility of damage to the
intercostal muscle fibers. In the lateral wound, the C8 and TI nerve roots, which pass near the neck
brachial plexus is gently displaced anteromedially of the first rib. If the jaws of the rongeur cannot
Thyrocervical
trunk
Fig. 4-17 In the extraperiosteal approach shown here, the intercostal and scalene muscles
and endothoracic fascia are separated from the rib before it is divided anterior to the costal
angle.

be seen, it is better to leave the posterior rib rem- anterior scalene tubercle. This portion of the rib is
nant in place.24 The subclavian artery is carefully exposed by elevation and retraction of the clavicle
separated from flimsy periadventitial attachments and subclavian vein, with posterior retraction of the
to the top of the first rib, and the intercostal muscle subclavian artery (Fig. 4-18). If exposure is too dif-
and pleura are separated from the rib’s underside ficult or if the saw or rongeur cannot be visualized,
using the extraperiosteal technique. The rib is now an infraclavicular counterincision can be made to
completely free of all attachments and ready for an- allow rib division at the costochondral junction
terior division, which is performed in front of the (see below).
Fig. 4-18 The posterior rib is held as a lever while the subclavian artery and vein are
separated for a clear view of the anterior division site.

Transaxillary Approach incomplete exposure of the elements comprising
the scalene triangle: most of the congenital fibro-
Since its original description by Roos26 in 1966, this muscular bands are medial to the first rib and thus
approach has become a “gold standard” among sur- hidden by the neurovascular trunks in this approach.
geons performing thoracic outlet decompression. It Complete excision of the anterior and middle sca-
offers a rapid approach to the first rib, and the in- lene muscles is also difficult. Finally, correction of
cision is cosmetically appealing. However, several associated arterial pathology requires a second op-
drawbacks of the transaxillary approach have been eration. Despite these shortcomings, a large amount
recognized. The most important is that visualiza- of literature has been accumulated, attesting to the
tion of the anatomic structures is limited within a success of this approach.2,27–29
relatively deep hole, making them prone to injury, The patient is placed in a true lateral position
especially the TI nerve root and the subclavian with a soft pad placed under the opposite axilla to
vein. In addition, the transaxillary approach affords prevent neurovascular compression (Fig. 4-19).
Fig. 4-19 A true lateral position with the affected extremity left free is used for the
transaxillary approach to the first rib.

The ipsilateral arm remains free and is held and posi- released on an intermittent basis during the opera-
tioned by an assistant throughout the operation. The tion to prevent arm ischemia and brachial plexus in-
axilla, back, chest, shoulder, and arm are prepped jury. As an alternative, Illig30 has recently described
and draped. A stockinette covers the distal arm. a method of passive arm elevation using a shoul-
The second assistant elevates the arm and der suspension kit in which the arm is elevated by
shoulder using the double wristlock described a weighted nylon cord suspended over a “shower
by Roos25 (Fig. 4-20). Arm retraction should be curtain” assembly.
Fig. 4-20 The assistant holding the arm uses a wrist lock position for security and to
minimize fatigue.

A transverse incision is made at the lower mar- on the surface of the serratus anterior. The inter-
gin of the axillary hairline between the pectoralis costobrachial nerve will be encountered at the level
major and latissimus dorsi muscles. The incision is of the second intercostal space in the middle of the
deepened through subcutaneous tissue and the axil- operative field. Roos26 has recommended preserva-
lary fascia to reach the fascia of the serratus an- tion of the nerve to avoid axillary and medial arm
terior at the level of the third rib (Fig. 4-21). The anesthesia, but Dale31 has recommended nerve di-
thoracoepigastric vein and lateral thoracic artery vision to prevent postoperative neuritic pain. The
cross the incision just deep to the subcutaneous tis- dissection plane is continued to the level of the first
sue; these vessels should be ligated and divided. rib. The supreme thoracic artery and vein cross the
A tissue plane is begun deep to the axillary fascia first rib in the anterior wound and will also require
and developed superiorly in the loose areolar tissue division.25
Pectoralis major m.
Lateral thoracic a. and v. Latissimus

dorsi m.
Serratus
anterior m.
Thoracoepigastric v.
Fig. 4-21 Superficial axillary vessels are divided. The intercostobrachial nerve is

mobilized or divided as necessary.

Roos25 has noted that there is a cul-de-sac of thoracic outlet. From anterior to posterior, one
fascia at the lateral border of the first rib that sepa- should identify the axillary vein, anterior sca-
rates the axilla from the thoracic outlet. This tis- lene muscle, axillary artery, brachial plexus, and
sue should be opened bluntly along the top of the middle scalene muscle. The long thoracic nerve
first rib to expose the outlet structures (Fig. 4-22). emerges dorsal to the brachial plexus and should
Gentle elevation of the shoulder by the second as- be avoided as it passes along the lateral surface
sistant and retraction of the pectoralis major will of the serratus anterior muscle in the posterior
greatly enhance exposure of the structures at the wound.
Axillary v.
Axillary a.
Subclavius m. Brachial
plexus
Anterior
scalene m.
First rib Middle

scalene m.
Pectoralis
major m.
Supreme thoracic Thoracodorsal

a. and v. n., a., and v.
Intercostobrachial n. Long
Thoracoepigastric v. thoracic n.
Fig. 4-22 The axillary fascia is opened, and the pectoralis major muscle is retracted to
visualize the vessels and brachial plexus at the apex of the axilla.

In the anterior wound, the subclavius muscle is overemphasized that to prevent vein injury, the sub-
identified as a taut band under the clavicle. It is di- clavian vein requires careful and complete isolation
vided under direct vision and resected as medially as from the subclavius before the muscle is divided. If
possible (Fig. 4-23). This provides increased expo- the vein is adherent to the subclavius muscle, mus-
sure for rib resection and prevents subclavian vein cle resection should be abandoned to avoid tearing
compression by the subclavius muscle.25 It cannot be the thin-walled vessel.
Anterior scalene m.
Axillary v.
Axillary a.
Brachial
plexus
Phrenic n.
Middle
Subclavius m. scalene m.
Thoracodorsal n.
Long
thoracic n.
Fig. 4-23 Division of the subclavius muscle insertion allows elevation of the clavicle for
improved visibility.

The anterior and middle scalene muscles hemostat can be used to retract the anterior sca-
are next separated from their attachments to the lene away from its surrounding vessels, and its
first rib. During division of the anterior scalene division is best performed a few fibers at a time.
muscle, care should be taken to avoid injuring the The phrenic nerve passes medial to the muscle
subclavian artery that passes posterior and deep to insertion. The middle scalene muscle is easily
the muscle at this level (Fig. 4-24). A right-angled pushed off the first rib with a blunt-tipped elevator
Subclavian a.
Subclavian v.
Brachial
plexus
Phrenic n. Long thoracic n.

Anterior
scalene m.
Fig. 4-24 When the anterior scalene insertion is isolated and divided, care must be taken
not to injure the phrenic nerve.

(Fig. 4-25). After muscle separation is complete, rib from Sibson’s fascia.25 Once the rib is completely
the subclavian artery and brachial plexus should freed circumferentially from the TI transverse process
be freed by sharply dividing their delicate attach- posteriorly to the costal cartilage anteriorly, it is ready
ments to the first rib. In cases involving arterial for resection. The TI nerve is carefully retracted later-
compression, the artery may be adherent to the ally to protect it during posterior rib division. Angled
rib, and its wall may be thinned from poststenotic rib shears are placed as far posteriorly as possible
dilatation. Development of a subperiosteal plane without injuring the long thoracic nerve, and the rib
underneath the artery may allow its safe dissec- is cleanly divided (Fig. 4-26). The anterior division
tion away from the rib in these cases. takes place at the costochondral junction, with the
The rib can now be resected. Although a sub- subclavian vein carefully pushed away (Fig. 4-27).
periosteal resection may help avoid injuring the inter- Sharp bony remnants are smoothed with rongeurs.
costal vessels and avoid entry into the nearby pleural Cervical ribs are separated from the sur-
space, most authors23,24 prefer an extraperiosteal rounding middle scalene muscle and resected with
resection (see above). The intercostal muscles are rongeurs as close to the spine as possible. Careful
stripped from the undersurface of the first rib with digital palpation of the wound is necessary to detect
a blunt-tipped elevator, then an Overholt #1 raspa- anomalous fibromuscular bands, especially in the
tory is used to separate the inside curve of the first area of the TI nerve.
Fig. 4-25 Division of the middle scalene muscle insertion and separation of loose
attachments between the first rib and the vessels completes the cephalad mobilization. The
long thoracic nerve is again protected.

Fig. 4-26 After separation of the remaining
muscular and fascial attachments to the cau-
dad and deep rib surfaces, the rib is divided
posteriorly.
Fig. 4-27 Anterior rib division completes

the resection.

Infraclavicular Approach the costoclavicular space, where excessive narrow-
ing due to first rib anomalies or hypertrophy of the
Extrinsic compression of the subclavian vein at subclavius muscle can lead to compressive occlu-
the level of the first rib can lead to spontaneous sion3,6,35 (Fig. 4-28). Successful treatment usually
thrombosis in healthy patients. If recognized dur- requires removal of the first rib and complete ve-
ing the acute phase, this so-called effort thrombosis nolysis.33 In many cases, this can be successfully
(Paget–Schroetter syndrome) can be treated us- accomplished using a transaxillary or supraclavicu-
ing catheter-directed clot lysis followed by selec- lar approach,32–35 but complete resection to the cos-
tive relief of thoracic outlet compression.32–35 The tosternal junction is not always possible. In these
most common site of compression occurs within circumstances, direct vision of the proximal first
Anterior scalene m.
Middle scalene m.
Phrenic n.
External jugular v.
Subclavian v.
Vertebral v.
Subclavius m.
Cephalic v.
Axillary v.
Costoclavicular lig.
Fig. 4-28 The subclavian vein can be compressed within the costoclavicular space by

bony or ligamentous abnormalities.

rib may be indicated; the infraclavicular approach subclavian vein, preserves shoulder function, and is
affords direct exposure of this segment.36 This ap- cosmetically superior to claviculectomy.
proach may also be required for visualization of the The patient is placed supine with the arms
proximal subclavian vein to allow complete venoly- drawn inward. A transverse skin incision is made
sis, as recommended by Thompson et al.37 Medial 2 cm below the clavicle, extending approximately
claviculectomy is another option that provides di- 5 cm from the lateral border of the sternum
rect exposure of the subclavian vein, but clavicu- (Fig. 4-29). The incision is deepened through the
lar resection has been associated with bothersome pectoral fascia, and the pectoralis major muscle is
symptoms in up to half of patients.22 The infracla- split in the direction of its fibers to expose the junc-
vicular approach allows excellent exposure of the tion between the first rib and the sternum.36
Fig. 4-29 The incision for infraclavicular approach to the first rib is made 2 cm below the
clavicle.

The subclavius muscle tendon is divided at because its medial fibers may impinge on the sub-
its insertion onto the superior surface of the first clavian vein along with the subclavius. Complete
rib and excised (Fig. 4-30). The underlying sub- division will also simplify removal of the first rib
clavian vein can be freed using circumferential at the sternoclavicular junction. Once all areas
dissection. The costoclavicular (Halsted’s) liga- of extrinsic venous compression have been re-
ment lies just behind the insertion of the subcla- leased, the subclavian vein will be soft and easily
vius muscle. This ligament should be divided compressible37 (Fig 4-31).
Costoclavicular Subclavius
lig. insertion
Fig. 4-30 The subclavius muscle is divided and excised. The nearby costoclavicular
ligament should also be divided, since medial fibers may contribute to vein compression.

Subclavius m.
(divided)
Costoclavicular
lig.
Cephalic v.
Subclavian v.
Fig. 4-31 The subclavian vein is freed using circumferential dissection.

In situations when most of the first rib has as above (Fig. 4-32). Downward traction on the an-
been resected using the supraclavicular or transaxil- terior end of the divided rib will help expose the an-
lary approach (see above), the first rib remnant and terior scalene muscle insertion. The subclavian vein
its short costal cartilage are easily removed using should be retracted superiorly with a Langenbeck re-
downward tension and detachment at the costoster- tractor as the anterior scalene is divided (Fig. 4-33).
nal junction. If the first rib is intact, the intercostal The phrenic nerve should be identified and carefully
muscles along the rib’s inferior border are divided. protected during this maneuver. The middle scalene
The pleura is carefully displaced from the inner bor- muscle can be visualized by retracting the vein and
der of the rib using blunt dissection, starting in the artery together into the superior wound. Molina36
lateral wound and proceeding medially.36 The ante- has recommended that the rib be divided at least
rior end of the first rib should be divided under di- 1 cm behind the subclavian artery after the middle
rect vision, and any medial remnant can be removed scalene has been transected (Fig. 4-34).
Fig. 4-32 The anterior end of the first rib is divided under direct vision.

Phrenic n.
Anterior scalene m.
Fig. 4-33 Downward traction on the anterior end of first rib helps expose the anterior sca-
lene muscle. The phrenic nerve should be identified and carefully protected during muscle
division.
Fig. 4-34 The rib is divided at least 1 cm behind the subclavian artery.

Exposure of the Cervicothoracic Sympathetic Chain endoscopic technology may have diminished the
value of these exposures to little more than historical
The role of open cervicothoracic sympathectomy interest, they are included in this chapter for the sake
has become increasingly limited for two reasons. of completeness.
First, recent experience suggests that the procedure
is best performed with endoscopic technology.38–41 Anterior Supraclavicular Approach to Dorsal
Second, few of the indications for the procedure Sympathectomy
have withstood the test of time. Most modern sur-
geons agree that cervicothoracic sympathectomy is This approach is direct, and it offers the advan-
indicated for treatment of upper extremity causal- tage of reduced postoperative incisional pain.45,48
gia,38,42 reflex sympathetic dystrophy,38,43 and palmar A singular disadvantage is the limited exposure of
hyperhidrosis.38–41 The role of sympathectomy in the lower sympathetic chain, leading to potential
the treatment of primary Raynaud’s symptoms and problems of inadequate sympathectomy and un-
thromboangiitis obliterans is somewhat more con- controlled hemorrhage in the deep wound. Despite
troversial. Sympathectomy is no longer indicated this limitation, the procedure is considered simple
for treatment of disorders such as angina pectoris, and effective, with operative results similar to other
epilepsy, thoracic outlet syndrome, migraine head- techniques.45,49
aches, and systemic hypertension. The patient is placed in the supine position
The proper extent of sympathectomy is also with the head turned toward the opposite side. The
somewhat unsettled. To ensure a complete and per- supraclavicular incision and deep dissection pro-
manent sympathetic denervation, some authors be- ceed as described in detail above. The fat pad is
lieve that the sympathetic chain should be resected dissected away from underlying structures, and the
from the inferior cervical ganglion to the third dorsal sternocleidomastoid muscle and carotid sheath are
ganglion.44 This will result in a permanent Horner’s mobilized and retracted medially. After the phrenic
syndrome. To prevent this, most experienced sur- nerve is identified and protected, the anterior sca-
geons prefer to spare at least the upper half of the lene muscle is divided near its first rib attachment,
stellate ganglion.38–41,43 The second through third exposing the subclavian artery directly beneath
and possibly fourth dorsal thoracic ganglia and (Fig. 4-35). The subclavian artery should be mobi-
their interconnecting rami should be removed in lized extensively and encircled with a vessel loop.
all cases. Sympathectomies extending from T2 to The vertebral artery is similarly mobilized in the
T4 appear to be adequate for patients with palmar medial wound, beginning at its origin at the subcla-
hyperhidrosis.38–41 vian and extending as far cephalad as possible. This
There are four traditional approaches for expos- may require ligation of the vertebral vein. The stel-
ing the cervicothoracic sympathetic chain: anterior late ganglion lies posterior to the vertebral artery, on
transthoracic, posterior paravertebral, anterior supra- the anteromedial surface of the brachial plexus. The
clavicular, and transaxillary. The anterior transtho- ganglion is most easily exposed by retracting the
racic approach provides wide and direct exposure of subclavian artery downward and dissecting in the
the sympathetic chain,45,46 but it has lost favor because deep tissues behind the vertebral artery (Fig. 4-36).
of the large anterior thoracotomy that is required. The thoracic sympathetic chain is exposed by free-
The posterior paravertebral approach requires third ing Sibson’s fascia from the inferior border of the
rib resection and is limited in exposure, especially first rib and bluntly entering the retropleural space.
of the stellate ganglion.45,47 The following discus- The pleura is further dissected away from the chest
sion concerns the two remaining popular techniques wall until the first four ribs and associated ganglia
for sympathetic chain exposure. Although modern are exposed.

Ascending
cervical a.
clavicular head Superficial
cervical a.
Omohyoid m. Phrenic n.
Vertebral a. and v.
(vein ligated) Anterior
scalene m.
Inferior thyroid a.
Middle scalene m.
Suprascapular a.
Stellate
ganglion
Subclavian a.
Vertebral v.
Thoracic duct
(ligated)
Subclavian v.
Fig. 4-35 Subclavian and vertebral First rib Scalene

arteries are exposed and mobilized to External Platysma m. fat pad
jugular v.
allow access to the underlying stellate
ganglion.
Stellate
ganglion
Sibson’s fascia
Lung
Vertebral a.
Subclavian a.
Parietal pleura
Fig. 4-36 The lower part of the stellate

ganglion is divided, and the upper tho-
racic ganglia are exposed by retracting
the apex of the lung and opening parietal
pleura.

Transaxillary Approach to Dorsal Sympathectomy wall. The long thoracic and thoracodorsal nerves lie
near the border of the latissimus dorsi in the poste-
This approach offers complete exposure of the rior wound and should be carefully protected during
sympathetic chain and a superior cosmetic muscle retraction. The wound is further deepened
result.45,50,51 The principal disadvantage is the rela- through the serratus anterior and intercostal muscle
tively narrow wound, through which dissection may fibers, which should be divided on the superior bor-
be cumbersome in muscular individuals. Although der of the second rib. After the pleural space is en-
the transpleural approach is preferred, an extrapleu- tered, the second and third ribs are slowly spread
ral approach may be used in individuals with pleural apart with a small rib retractor (Fig. 4-37). The apex
adhesions.53 of the lung is retracted caudally, and the sympathetic
The patient is placed in a lateral position, with chain is readily identified beneath the posterior pa-
the ipsilateral arm placed on an overhanging sup- rietal pleura. The pleura is opened directly over
port (see Fig. 4-19). Although Haimovici45 prefers the sympathetic chain, which is lifted with a nerve
entering the pleural space through the bed of the hook. The sympathectomy is performed by dividing
third rib, others have described entrance through the the branching rami of the fourth thoracic ganglion
second intercostal space.44,51,52 Accordingly, a trans- and progressing cephalad. The stellate ganglion is
verse incision is made parallel to the second inter- identified near the border of the first rib; at least half
costal space, extending from the pectoralis major of this structure should be left intact to prevent a
muscle anteriorly to the latissimus dorsi posteriorly. Horner’s syndrome. On the left side, care should be
The wound is deepened through subcutaneous tis- taken to identify the thoracic duct, which courses
sue and the axillary fascia to reach the lateral chest near the stellate ganglion in the superior chest.
Stellate
ganglion
L. subclavian a.
Aorta
Lung
Fig. 4-37 Idealized exposure of the left

thoracic sympathetic chain through a
transaxillary thoracotomy is shown.

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VESSELS OF THE
UPPER EXTREMITY
153
Coracoid
prominence
Cephalic v.
Coracoid
process
Clavicle
Humeral
head
Cephalic v.
Fig. 5-1 Between the deltohumeral promi-

nence laterally and the pectoral muscle mass
medially there is a groove that overlies the
axillary neurovascular bundle.
154 | VESSELS OF THE UPPER EXTREMITY

Axillary Artery
5
Anatomy of the Axillary Artery coracoid process of the scapula pushing the me-
dial part of the deltoid anteriorly. It is not gener-
When the arm is in its relaxed, adducted position, ally appreciated that the corticoid is so clearly
the axillary artery is enfolded on all sides by mus- visible on surface inspection and requires no eso-
cles of the chest wall, pectoral girdle, and proxi- teric palpation to locate. The cephalic vein lies in
mal brachium. Surface landmarks help locate the the deltopectoral groove and may be visible in a
position of the vessel in relation to the underlying thin or muscular individual. A depression is formed
musculoskeletal structures when the arm is at rest beneath the clavicle between the coracoid promi-
(Fig. 5-1). The recurved clavicle defines the upper nence of the shoulder and the lateral clavicular
frame of the axilla. The pectoral muscle mass fol- origin of the pectoralis major muscle. The axillary
lows the tapering contour of the upper chest wall artery is most superficial within this depression and
beneath the clavicle medially. Laterally, the hu- can be easily palpated. To follow the courses of the
meral head with its overlying deltoid and subscap- remainder of the vessel, it is necessary to unfold
ular muscles forms a prominent bulge. The most the muscular envelope and view the artery in its
medial component of this bulge is created by the anatomic context.
155
The Muscular Boundaries its origin on the medial border of the deep scapu-
lar surface. The coracoid process arches over the
The axillary artery is anatomically defined by the axillary neurovascular bundle and gives origin to
lateral margin of the first rib proximally and the lat- muscles that lie anterior to the vessels. One of these,
eral edge of the teres major muscle distally. Along the pectoralis minor muscle, is used as a landmark
this span, the artery lies within a cleft formed by to divide the axillary artery into three parts which
muscles originating on the scapula (Fig. 5-2). The are medial to, behind, and lateral to the muscle.
broad subscapularis, converging toward the head of The coracobrachialis, a small muscle analogous to
the humerus, forms the majority of the posterior bed the adductors of the thigh, and the short head of the
on which the vessel lies. The lowest segment of the biceps brachii also originate from the tip of the cora-
artery crosses the teres major and latissimus dorsi coid process. The neurovascular bundle parallels the
insertions. course of these muscles. The pectoralis major adds
The medial wall of the cleft consists of the ser- the final anterior blanket of muscle over the axillary
ratus anterior, wrapping around the upper ribs from space.
Trapezoid lig. Subclavius m.

Coracoacromial lig.
Conoid lig. Pectoralis major m.

Coracoid
(clavicular origin)
process
Deltoid m.
Supraspinatus m.
Costo-
clavicular
lig.
Biceps brachii m.
(short head)
Coraco-
brachialis m.
Biceps Serratus
(long head) anterior m.
Pectoralis
major m.
insertion
Teres major m.
Latissimus dorsi m.
Pectoralis
Subscapularis m. minor m.
Fig. 5-2 The axillary contents are enclosed by pectoral girdle muscles.

Branches of the Axillary Artery descends from the second part of the axillary artery
to the lateral chest wall, pectoralis major muscle,
The first segment of the axillary artery has one and breast.
branch, the second has two, and the third segment The largest branch of the axillary artery is
has three branches (Fig. 5-3). Immediately after the subscapular artery, which arises from the third
passing over the outer rim of the first rib, the axil- part lateral to the pectoralis minor muscle. It is sur-
lary artery gives origin to the small supreme tho- rounded by the fat and lymph nodes of the central
racic artery. axilla. It divides into the circumflex scapular artery
Behind the medial margin of the pectoralis and thoracodorsal artery. The latter is joined by the
minor muscle, the second part of the axillary artery thoracodorsal nerve to form the principal neurovas-
gives rise to the thoracoacromial artery from its an- cular pedicle of the latissimus dorsi muscle. The re-
terior surface and the lateral thoracic artery from its maining two branches of the distal axillary artery
inferior surface. After penetrating the clavipectoral are the medial and lateral humeral circumflex arter-
fascia, the thoracoacromial artery divides into lat- ies. The medial branch runs between the subscapu-
eral acromial and deltoid branches, and medial cla- laris tendon and deltoid muscle. The lateral branch,
vicular and pectoral branches. The pectoral branch, accompanied by the axillary nerve, passes between
with its accompanying vein and lateral pectoral the teres major, teres minor, long head of the triceps,
nerve, forms the major neurovascular pedicle to the and the humerus to reach the posterior aspect of the
pectoralis major muscle. The lateral thoracic artery shoulder.
Lateral thoracic a.
Thoracoacromial a.
Supreme thoracic a.
Subscapular a.
Medial
humeral
circumflex a.
Deep
brachial
Lateral
a.
humeral
circumflex a. Thoracodorsal a.
Circumflex scapular a.
Fig. 5-3 The axillary artery branches are shown.
AXILLARY ARTERY | 157
The Nerves of the Axilla usually divides into two to four branches and sup-
plies the cephalad portion of the pectoralis major
The divisions and cords of the brachial plexus in- muscle. The branches that join the pectoral branch
terchange fibers in the proximal axilla and assume of the thoracoacromial artery form a neurovascular
the final configuration of nerves to the arm around pedicle on which the pectoralis muscle can be trans-
the third part of the axillary artery (Fig. 5-4). Sev- planted. The medial pectoral nerve passes between
eral important branches arise from the roots, trunks, the axillary artery and vein, penetrates and supplies
divisions, and cords of the brachial plexus and tra- the pectoralis minor muscle, and continues through
verse the axillary space. that muscle as one or more branches to supply the
The nerve of the axilla with the most proxi- caudal part of the pectoralis major muscle.
mal origin is the long thoracic arising from the ven- The musculocutaneous nerve arises from the
tral primary rami of cervical nerves three, four, and lateral cord and supplies the coracobrachialis, biceps
five. The long thoracic nerve emerges through the brachii, and the medial part of the brachialis mus-
body of the middle scalene muscle dorsal to the bra- cles. The medial antebrachial and brachial cutaneous
chial plexus and lies on the serratus anterior muscle, nerves arise from the medial cord in the midaxilla.
which it innervates. It lies relatively far posterior in The latter is usually joined by the intercostobrachial
the serratus/subscapularis cleft described above. nerve spanning the distal axillary space from the sec-
The lateral and medial pectoral nerves are ond intercostal nerve. The thoracodorsal nerve arises
named for the cords of the brachial plexus from from the posterior cord and joins the thoracodorsal
which they arise. Anatomically, they occupy rela- artery to the latissimus dorsi muscle. The subscapular
tive positions opposite to what their names imply nerves to the subscapularis and teres major muscles
and have been described in clinical literature by also arise from the posterior cord. The last branch of
positional designations.1,2 The following discussion the posterior cord is the axillary nerve to the teres
uses the descriptors based on origin. The pectoral minor and deltoid muscles and posterior shoulder.
nerves are important because they innervate the The three major nerves to the upper extrem-
large pectoralis muscle. The lateral pectoral nerve ity, the median, ulnar, and radial, surround the distal
Lateral pectoral n.
Lateral cord
Musculocutaneous n.
Axillary n.
Medial cord
Radial n.
Medial pectoral n.
Median n.
Medial brachial and
Deep antebrachial
brachial a. cutaneous n’s
Thoracodorsal n.
Long thoracic n.
Ulnar n.
Fig. 5-4 The brachial plexus nerves surround the axillary artery within the axillary sheath.

axillary artery. The median and ulnar nerves accom- identify the neurovascular branches when beginning
pany the brachial artery in the arm. The radial nerve an axillary dissection. A second clear plane is found
deviates from the neurovascular bundle at the distal between the fat and the deep fascia over the serratus
border of the latissimus tendon and passes posteriorly anterior muscle. The intercostobrachial nerve pen-
around the humerus with the deep brachial artery. etrates the axillary fat in the distal axilla and often
must be divided to obtain a clean axillary dissection.
The Fasciae of the Axilla The next fascial layer anterior to the axillary
contents is the clavipectoral fascia, which encloses
The central compartment of the axilla is occupied the subclavius and pectoralis minor muscles. This
by the neurovascular bundle and loose, fatty, areo- layer is penetrated by the thoracoacromial vessels,
lar tissue containing lymphatics and lymph nodes pectoral nerves, and cephalic vein. Lateral to the
(Fig. 5-5). The neurovascular bundle is surrounded pectoralis minor muscle, the clavipectoral fascia at-
by a fascial wrapping called the axillary sheath. Vas- taches to the axillary fascia and is thought to tether
cular and nerve branches exit the sheath and traverse the latter, giving the axillary skin its concave shape.
the fatty axillary contents to reach their destinations. The outermost layer of fascia is the deep, investing
The bulk of the fatty axillary content is anterior, pectoral fascia, which encloses the pectoralis major
caudal, and posterior to the sheath. There is a clear and deltoid muscles. The continuation of this fascia
plane between the sheath and fat along the anterior between the lateral edge of the pectoralis major and
surface of the axillary vein. This plane is used to latissimus dorsi muscles is called the axillary fascia.
Cephalic v.
Clavipectoral
fascia
Pectoral fascia Subclavius m.
Pectoralis
Axillary major m.
sheath
Deltoid
m.
Brachial
fascia
Pectoralis
minor m.
Axillary
fascia
Medial
intermuscular
septum
Fig. 5-5 The clavipectoral fascia is the outer envelope of the axillary contents.
Exposure of the Axillary Artery tough axillary sheath prevents exsanguination from
these injuries but permits rapid compression of its
The axillary artery is an ideal donor artery in extraana- contents as blood accumulates. Symptoms of bra-
tomic bypasses to the opposite arm or to the lower ex- chial plexus compression are reversible only with
tremities. It is a direct extension of major aortic arch rapid evacuation of blood within the sheath.
branches and is usually free of flow-limiting arterial Covered stents have become a popular alterna-
stenoses. Its location outside of the thorax and below tive to open repair of axillary artery injuries in mul-
the clavicle affords easy accessibility and allows con- tiply injured patients and in selected patients with
struction of superficial bypasses. The physiologic ad- penetrating trauma.10,11 However, the long-term re-
vantage of these bypasses has been well-documented in sults are not well established, due in large part to the
elderly, poor-risk patients who would not tolerate more notoriously poor follow-up of trauma patients. Lim-
direct intraabdominal or intrathoracic bypasses.3–5 Su- ited data suggest that stent grafts may not be durable
perficial bypasses are also indicated for lower extrem- in large upper extremity arteries: one recent study of
ity revascularization in cases of aortic sepsis.6 stented subclavian artery injuries reported that one-
The superficial location of the axillary artery third of patients experienced stenosis or occlusion of
and its proximity to the brachial plexus also carry the stent graft after a mean of 4 years.12 Regardless
disadvantages, as the neurovascular bundle is prone of outcome, most surgeons agree that endovascular
to injury. The long-term consequences are deter- repair of an axillary artery injury is contraindicated
mined by the degree of neurologic trauma.7–9 Long- in a hemodynamically unstable patient and in any
term functional deficits are rare after isolated axillary injury resulting in vessel transection or an inade-
artery injuries, but patients with combined neuro- quate proximal fixation site.13 Rapid open exposure
vascular trauma may experience severe disability of the axillary artery remains an important part of
and even require late arm amputation. In addition the modern vascular surgeon’s armamentarium.
to injuries resulting from accidents or violence, the For purposes of exposure, the axillary ar-
axillary artery is subject to iatrogenic trauma from tery can be considered in three anatomic sections
invasive diagnostic tests, such as arteriograms. The (Fig. 5-6). The first part, extending from the edge
Fig. 5-6 The three parts of the axillary artery are marked by the borders of the pectoralis
minor muscle.

of the first rib to the medial border of the pectora- Infraclavicular Approach to the First Part of the Axillary
lis minor muscle, is relatively fixed and anterior to Artery
the brachial plexus. The second part courses beneath
the pectoralis minor muscle and requires deep dis- The patient is placed supine with the ipsilateral arm
section for exposure. The third part extends from abducted approximately 90° (Fig. 5-7). Arm abduc-
the lateral border of the pectoralis minor to the lat- tion is important to ensure a proper amount of laxity
eral border of the teres major; it is best approached in a graft that is anastomosed to the axillary artery,14–16
through a lateral incision. but hyperabduction may be associated with traction
Fig. 5-7 The arm is abducted 90° for the infraclavicular approach to the axillary artery.
injury to the brachial plexus.17 The shoulder, ante- A horizontal skin incision is made 2 cm below
rior chest, and axilla should be prepped and draped. the middle third of the clavicle, extending for ap-
In operations utilizing bypasses to groin arteries, the proximately 8 cm (Fig. 5-8). The incision is deepened
surgical prep should also include the anterior trunk through subcutaneous tissue and the pectoral fascia.
and both legs, which are prepped and draped to the The underlying pectoralis major muscle is split by
level of the midthigh. bluntly separating its fibers for the length of the
Axillary a. Coracoid
Cephalic v. Clavipectoral
process
fascia
Pectoralis
major m.
Brachial a.
Fig. 5-8 The pectoralis fibers over the first portion of the axillary artery are separated.

wound, exposing the tough clavipectoral fascia. minor muscle can be freed and laterally retracted to
The neurovascular bundle and its enveloping axil- enhance exposure of the first part of axillary artery
lary sheath are located in the adipose tissue deep to (Fig. 5-9). Care should be taken to avoid injury to
the clavipectoral fascia, which should be sharply the lateral pectoral nerves during division of the
incised. At the lateral wound margin, the pectoralis pectoralis minor muscle.1,2
Lateral pectoral n.
Cephalic v.
Clavipectoral fascia
Thoracoacromial
a. and v.
Pectoralis major m.
(split)
Pectoralis
minor m.
Fig. 5-9 Clavipectoral fascia is opened to expose the axillary sheath. Pectoral nerves and
vessels as well as cephalic vein are seen in the operative field.
The axillary vein is the first structure to be branch of the thoracoacromial artery should be pre-
encountered in the axillary sheath. The artery lies served when ligating the arterial trunk. The nerves
just superior and deep to the vein and is most con- of the brachial plexus lie deep to the first part of the
veniently exposed by mobilizing and retracting the axillary artery and are at risk for injury during blind
vein caudally (Fig. 5-10). Several vein tributaries placement of occluding arterial clamps. The artery
may require ligation during this maneuver. Most should be mobilized as proximally as possible, tak-
anastomoses will be created proximal to the thora- ing care to identify the nearby pectoral nerves and
coacromial artery. This large branch is usually left their interconnecting loop1 (Fig. 5-11). Once mobi-
intact but may be ligated at its origin to permit more lized, the artery can be encircled with a vessel loop
adequate exposure of the axillary artery in small pa- and elevated above the vein and brachial plexus to
tients. The lateral pectoral nerve joining the pectoral protect these structures prior to clamp placement.
Axillary a.
Lateral
cord
Lateral
pectoral n.
Axillary v.
Connecting
loop
Medial
pectoral n.
Fig. 5-10 The axillary vein is gently retracted to clearly expose the axillary artery.
Fig. 5-11 The axillary artery is mobilized.

Proximal anastomoses of axillary artery by- in up to 5% of patients after axillofemoral by-
passes should be constructed in the first portion, pass.14 This catastrophe is usually associated with
the area least likely to be stressed by shoulder mo- forceful arm abduction or shoulder trauma14–16
tion. Proximal graft disruption has been reported (Fig. 5-12).
Fig. 5-12 Attention to the configuration of an axillofemoral bypass graft is important.

Without sufficient laxity in the axillary portion, forceful arm abduction may lead to disrup-
tion of the anastomosis or fracture of the graft itself.
In order to decrease the risk of graft disruption, in a subcutaneous position against the chest wall for
Taylor et al.14 have recommended anastomosing the tunneling to the groin (Fig. 5-13). In addition to al-
graft to the first portion of the axillary artery and rout- lowing for unrestricted graft positioning, placing the
ing it parallel to the artery beneath the pectoralis mi- graft on the first portion of the axillary artery permits
nor muscle for 8 to 10 cm. The graft is then directed an anterior approach to the artery without the need to
inferiorly in a gentle curve in the axilla and placed mobilize nerves of the brachial plexus.
Fig. 5-13 The graft should be routed parallel to the axillary artery for a short distance
before it is directed inferiorly to reach the chest wall.

Axillary Approach to the Second and Third Parts of the The patient is placed in the supine position
Axillary Artery with the ipsilateral arm abducted 90°. The entire
axilla, shoulder, anterior chest, and upper arm are
This approach is cosmetically appealing and ideal prepped and draped so that the arm can be moved
for control of distal axillary artery injuries. It is during the procedure.
particularly useful for rapid evacuation of axil- An incision is made along the lateral border
lary sheath hematomas. However, the axillary of the pectoralis major muscle, extending from the
artery medial to the pectoralis minor cannot be chest wall to the intersection of the pectoralis major
adequately exposed through an axillary incision. and biceps muscles (Fig. 5-14). After the incision
This approach should therefore not be used alone is deepened through the subcutaneous tissue, the
for injuries to the first or second parts of the axil- pectoralis major is mobilized along its posterolat-
lary artery, when control of the most medial ax- eral border and retracted medially. The coracobra-
illary artery may be important. Proximal control chialis muscle is identified in the lateral wound. The
in these cases should be obtained through sepa- pectoralis minor muscle can be seen in the medial
rate supra- and infraclavicular incisions.18 Alter- wound at a right angle to the coracobrachialis. The
natively, the axillary incision can be abandoned neurovascular structures contained within the axil-
altogether in favor of a deltopectoral approach lary sheath are located in the connective tissue at the
(see below). posterior border of the coracobrachialis.
Axillary sheath
Biceps brachii m.
Long Short Pectoralis
head head major m.
Coracobrachialis m.
Fig. 5-14 The deep fascia at the lateral border of the pectoralis major muscle is opened,
and the muscle is retracted medially.
The median nerve is the most superficial The second portion of the axillary artery can
structure encountered in the distal axillary sheath. be exposed by dividing the pectoralis minor muscle
The axillary artery is located just deep to the nerve, near its coracoid insertion. Elevation of the bra-
which should be gently mobilized to ensure ad- chium relaxes the pectoralis major and enhances
equate arterial exposure. The axillary vein courses exposure. The pectoral nerves should be identified
on the medial side of the artery and is separated and protected prior to muscle division.1,2 The muscle
from the artery by the ulnar nerve (Fig. 5-15). More is then retracted caudally to expose the neurovas-
proximally, the median nerve contributions of the cular bundle, and the artery is exposed by opening
medial and lateral cords cross anterior to the ar- the axillary sheath. The brachial plexus surrounds
tery near the lateral border of the pectoralis minor the artery on three sides but leaves the most anterior
muscle. The third part of the axillary artery should aspect uncovered (Fig. 5-16). The thoracoacromial
be dissected free and elevated from its surrounding artery should be ligated and divided at its origin to
structures with vascular tapes prior to clamping. enhance exposure. The axillary artery can be en-
Arterial exposure near the lateral border of the pec- circled between the divided arterial branch and the
toralis minor is hampered by cord branches; injuries junction of the medial and lateral cords. Care should
in this area require exposure of the more proximal be taken not to injure the lateral thoracic artery dur-
axillary artery. ing this maneuver (Fig. 5-17).
Median n.
Coracobrachialis m. Pectoralis
major m.
Axillary sheath
Axillary a. Axillary v. Ulnar n.
Fig. 5-15 The axillary sheath is opened, and the median nerve is carefully mobilized away
from its position in front of the artery.

Fig. 5-16 To reach the second part of the axillary artery, the pectoralis minor insertion is
divided close to the coracoid process, preserving the medial pectoral nerve.
Thoracoacromial a.
Fig. 5-17 The artery is mobilized.
Deltopectoral Approach to All Parts of the Axillary Artery rotated. An incision is made from the midpoint of
the clavicle 5 to 7 cm along the anterior border of
This approach is somewhat difficult. The second the deltoid muscle (Fig. 5-18). The incision is deep-
and third parts of the axillary artery are located deep ened through the subcutaneous tissue to reach the
in a relatively narrow incision, and the precise deter- intermuscular groove between the pectoralis major
mination of tissue planes necessary in this approach and deltoid muscles, marked by the cephalic vein.
may be impeded by blood staining. Nevertheless, The intermuscular groove is separated along the
the deltopectoral incision is a very popular approach full extent of the wound, and the pectoralis major
in cases of axillary vascular trauma, as it is a direct is retracted medially (Fig. 5-19). If increased lateral
approach to all three parts of the axillary artery. It is exposure is required, the pectoralis major tendon
particularly useful as an extension of the infracla- can be divided near its insertion. The cephalic vein,
vicular incision described above. dissected along its medial border, is retracted later-
The patient is placed in the supine position with ally with the deltoid muscle. The underlying clavi-
the arm abducted approximately 30° and externally pectoral fascia and pectoralis minor muscle are now
Axillary a.
Cephalic v.
Deltoid m.
Pectoralis
major m.
insertion
Biceps
brachii
Fig. 5-18 The deltopectoral groove landmarks are shown.

Pectoralis
minor m.
Clavipectoral
fascia
Fig. 5-19 Deep fascia is opened along the deltopectoral groove, and the pectoralis major
muscle is retracted medially.
visible. The third part of the axillary artery is ex- axillary sheath. The third part of the axillary artery
posed by incising the clavipectoral fascia along the can be exposed by widely mobilizing the median
inferior border of the coracobrachialis muscle in the nerve and retracting it cephalad. It is important not
distal wound up to the coracoid process (Fig. 5-20). to mobilize more than a few centimeters of the cord
The neurovascular bundle is located in the areolar junction to avoid undue nerve tension. The artery
tissue beneath the clavipectoral fascia. The junction can be encircled with vascular tapes after careful
of the medial and lateral cords forming the median isolation from the ulnar nerve and axillary vein near
nerve is the most superficial structure within the its medial border (Fig. 5-21).
Coracoid Cephalic v. Deltoid m.

process
Musculocutaneous n. Pectoralis
minor m.
Biceps (short head)

Axillary a.
Pectoralis
major m.
Coracobrachialis m.
Clavipectoral
fascia
Median n. Axillary v.
Fig. 5-20 To expose the third part of the axillary artery, the clavipectoral fascia is opened
lateral to the pectoralis minor.
Medial Lateral
cord cord
Median n.
Ulnar n. Posterior
cord
Fig. 5-21 The medial cord of the brachial plexus is reflected laterally, and the artery is
mobilized.

The second part of the axillary artery is ex- artery just distal to the lateral border of the pec-
posed by transecting the pectoralis minor muscle toralis minor. The nerve loop connecting the pec-
near the coracoid process (Fig. 5-22). Ligation toral nerves also crosses anterior to the axillary
and division of the thoracoacromial artery near artery in this area and is prone to injury during
its origin will help expose the boundaries of the dissection. The second part of the axillary artery
pectoralis minor before muscle transection. The is best isolated between the nerve loop and the
pectoral nerves should be identified and protected cord junction. The lateral thoracic artery should
while the muscle is divided near the coracoid be identified on the inferior surface of the axillary
process.1 The junction of the medial and lateral artery and ligated only if necessary to enhance
cords lies on the anterior surface of the axillary exposure.
Pectoralis
minor insertion
(cut)
Fig. 5-22 The second part of the artery is exposed by dividing the pectoralis minor
insertion.
The first part of the axillary artery is exposed the clavipectoral fascia. The axillary artery lies
in the wound proximal to the pectoralis minor mus- just deep and slightly cephalad to the axillary vein.
cle. Again, division of the thoracoacromial vessels Mobilization and caudal retraction of the vein is
allows increased exposure of the axillary artery in required during dissection of the artery. As noted
this segment. The clavipectoral fascia should be above, the artery is best encircled with vascular
divided as proximally as possible, up to the level tapes and lifted into the wound above surrounding
of the subclavius muscle (Fig. 5-23). The axillary neurovascular structures before vascular clamps are
sheath is found in the fatty areolar tissue beneath applied.
Clavipectoral
fascia
Lateral pectoral n.
Subclavius m.
Thoracoacromial a.
(ligated)
Medial
pectoral n.
Fig. 5-23 The first part of the axillary artery is approached medial to the pectoralis minor.

References 10. Aksoy M, Tunca F, Yanar H, et al. Traumatic inju-
ries to the subclavian and axillary arteries: a 13-year
1. Moosman DA. Anatomy of the pectoral nerves and review. Surg Today. 2005;35:561–565.
their preservation in modified mastectomy. Am 11. Shalhub S, Starnes BW, Hatsukami TS, et al. Repair
J Surg. 1980;139:883–886. of blunt thoracic outlet arterial injuries: an evolu-
2. Porzionato A, Macchi V, Stecco C, et al. Surgi- tion from open to endovascular approach. J Trauma.
cal anatomy of the pectoral nerves and the pectoral 2011;71:E114–E121.
musculature. Clin Anat. 2012; 25:559–575. 12. Du Toit DF, Lambrechts AV, Stark H, et al. Long-
3. Martin D, Katz SG. Axillofemoral bypass for aortoil- term results of stent graft treatment of subclavian
iac occlusive disease. Am J Surg. 2000;180:100–103. artery injuries: management of choice for stable pa-
4. Liedenbaum MH, Verdam FJ, Spelt D, et al. The tients? J Vasc Surg. 2008;47:739–743.
outcome of the axillofemoral bypass: a retro- 13. Danetz JS, Cassano AD, Stoner MC, et al. Feasibil-
spective analysis of 45 patients. World J Surg. ity of endovascular repair in penetrating axillosub-
2009;33:2490–2496. clavian injuries: a retrospective review. J Vasc Surg.
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Comparison of axillofemoral and aortofemoral by- 14. Taylor LM Jr, Park TC, Edwards JM, et al. Acute
pass for aortoiliac occlusive disease. J Vasc Surg. disruption of polytetrafluoroethylene grafts ad-
1996;23:263–271. jacent to axillary artery anastomoses: a compli-
6. Seeger JM, Pretus HA, Welborn MB, et al. Long- cation of axillofemoral grafting. J Vasc Surg.
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Brachial plexus cords
Lateral
Posterior
Medial
Biceps brachii m.
Short head
Long head
Pectoralis major m.
insertion
Subscapularis
m.
Deltoid m.
Teres
Musculocutaneous n. major m.
Median n.
Extensor compartment
Flexor compartment Latissimus

dorsi m.
Deep fascia
Lateral Medial intermuscular

intermuscular septum
septum
Brachial a.
Radial n.
Biceps m. Medial epicondyle

insertion
Ulnar n.
Brachialis m. insertion
Fig. 6-1 The deep fascia and supracondylar septa of the arm contain the flexor muscles
anteriorly and the triceps complex posteriorly. The brachial artery and median nerve
are ensheathed in the anterior compartment, while the radial and ulnar nerves switch
compartments through the intermuscular septa in the distal arm.

Brachial Artery
6
Surgical Anatomy of the Brachium and is easily entered just anterior to the medial
intermuscular septum.
Unlike the leg, the brachium receives its major nerve
and vessel trunks in a dominant single bundle. The Nerves of the Arm
muscles of the brachium are grouped into clearly
defined flexor and extensor groups like the homolo- At the lateral edge of the latissimus tendon, three
gous structures of the leg, but the septae and fascial major nerve trunks surround the brachial artery. The
coverings are less robust. The neurovascular trunks median nerve lies anterior, the ulnar nerve medial,
should be considered in the context of the surround- and the radial nerve posterior to the vessel. The mus-
ing muscles and fasciae. culocutaneous nerve branches from the lateral cord
of the brachial plexus in the midaxilla and follows
Brachial Fascia an independent course through the coracobrachialis
to the other brachial flexors.
The anterior flexor compartment and posterior The median nerve continues with the brachial
extensor compartment of the arm are enclosed by artery through the length of the brachium and crosses
a thin, firm sheath of deep fascia (Fig. 6-1). The the artery diagonally from a relatively lateral to a me-
compartments are separated by medial and lateral dial position. The ulnar nerve penetrates the medial
intermuscular septae originating from the supra- intermuscular septum in midbrachium and continues
condylar ridges of the distal humerus. The encir- posterior to that septum to reach the groove behind
cling fascia attaches to these partitions and to the the medial epicondyle of the humerus. The radial
olecranon and humeral epicondyles distally. The nerve turns posteriorly at the caudal border of the
neurovascular bundle contained within the axillary latissimus tendon and follows a spiral course behind
sheath continues into the arm deep to the brachial the humerus between the origins of the lateral and me-
fascia. The radial nerve and profunda brachii ar- dial heads of the triceps muscle. In the midbrachium,
tery diverge posteriorly at the distal border of the the radial nerve penetrates the lateral intermuscular
latissimus tendon while the median, ulnar, and two septum to reach the forearm extensor compartment.
medial cutaneous nerves accompany the brachial The cutaneous branches emanating from these major
artery into the confined space of the well-defined trunks will not be described here but should be re-
neurovascular sheath of the brachium. This bra- viewed in terms of incision placement and the poten-
chial sheath is subcutaneous in the midbrachium tial for confusion with major nerves.
177
Brachial Vessels sends a major nutrient vessel to the middle of the
humeral shaft.
Each major nerve of the arm is accompanied by The brachial artery is usually accompanied
an artery. As noted above, the brachial artery runs by two veins. The basilic vein runs in a subcuta-
with the median nerve through the medial side of neous position from the antecubital fossa to the
the anterior compartment (Fig. 6-2). Proximally, medial aspect of the midbrachium where it pen-
the profunda branch of the brachial artery joins the etrates the deep fascia to join one of the brachial
radial nerve and follows it through the lateral in- veins. The brachial veins make numerous deep
termuscular septum, at which point it is called the and superficial anastomoses before uniting at the
radial collateral artery. The superior ulnar collateral level of the teres major to form the axillary vein.
artery arises from the midpoint of the brachial ar- The cephalic vein is superficial along its entire
tery and accompanies the ulnar nerve through the course to the deltopectoral groove. The vein ac-
medial intermuscular septum. A second ulnar col- companying the deep brachial artery empties
lateral branch penetrates the septum more distally. into the transition between brachial veins and the
In addition to muscular branches, the brachial artery axillary vein.
Supreme
thoracic a.
Anterior humeral
circumflex a.
Lateral
Posterior humeral thoracic a. Circumflex
circumflex a. and scapular a.
axillary n.
Subscapular a.
Deep brachial a. and
radial n. Thoracodorsal a.
Nutrient a.
Lateral
intermuscular Superior ulnar
septum collateral a.
Medial intermuscular
Radial collateral a. septum
Inferior ulnar
collateral a.
Radial
recurrent a.
Ulnar n.
Ulnar recurrent a.
Fig. 6-2 The branches of the brachial artery accompany the nerve trunks and make
collateral connections around the shoulder and elbow.

Anterior Brachial Muscles is penetrated by the musculocutaneous nerve. The
nerve then lies between the brachialis and biceps,
Proximally, the humerus is attached to the pectoral supplying both.
girdle and chest wall by several powerful muscles The proximal brachial artery and its associ-
that act around the shoulder joint (Fig. 6-3). Dis- ated nerves first lie posterior to the coracobrachialis
tally, the broad brachialis is the dominant ante- muscle close to the humeral shaft and then diago-
rior brachial muscle attached to the humerus. The nally cross the medial part of the brachialis belly.
small coracobrachialis muscle originates in com- The radial nerve emerges lateral to the distal belly
mon with the short head of the biceps brachii and of the brachialis.
Coracobrachialis m.
Brachialis m.
Musculocutaneous n.
Median n.
Brachioradialis m.
Brachial a.
Pronator teres m.
Radial n.
Ulnar n.
Fig. 6-3 The coracobrachialis and brachialis muscles, the deep muscles of the brachium,
are supplied by the musculocutaneous nerve, which penetrates the former and then runs
between the brachialis and biceps.
BRACHIAL ARTERY | 179
The biceps brachii muscle covers the length strong tendon inserting on the bicipital tuberos-
of the humerus anteriorly (Fig. 6-4). Proximally, ity of the radius. From the distal muscle, a broad
the heads of the biceps are restrained by the ten- secondary tendinous expansion runs medially to
don of the pectoralis major muscle crossing to attach to the deep fascia of the forearm flexors.
insert into the lateral lip of the bicipital groove This band bridges over the brachial artery and
of the humerus. Distally, the biceps tapers to a median nerve.
Pectoralis major
m. insertion
Coracobrachialis m.
Biceps
brachii m.
Triceps m.,
Brachial a. long head
Triceps, medial (deep)

head
Ulnar n.
Median n.
Biceps
tendon
septum
Bicipital aponeurosis
Fig. 6-4 The biceps brachii crosses both the shoulder and elbow joints and is bordered
medially by the brachial artery and median nerve.

Posterior Brachium nerve. The deep brachial artery anastomoses with
the posterior humeral circumflex artery. Before the
The back of the arm is dominated by the mass of artery and nerve penetrate the lateral intermuscular
the triceps muscle (Fig. 6-5). The long head origi- septum at the distal end of the spiral groove, the
nates from the infraglenoid tuberosity of the scap- artery gives off a posterior descending branch that
ula. The lateral and medial heads originate broadly anastomoses with ascending collateral vessels at
from the posterior humerus. Running diagonally the elbow.
between these two heads in the spiral groove of the After penetrating the medial intermuscular
humerus are the deep brachial artery and the radial septum, the ulnar nerve runs medial to the medial
Axillary n. and posterior

Teres minor m.
humeral circumflex a.
Triceps m., long head
Deep brachial a.
Teres major m.
Triceps m., lateral

Latissimus dorsi m. head
Radial n.
Triceps m., Posterior descending br.

medial (deep)
head
Superior ulnar
collateral a.
Brachioradialis m.
Ulnar n.
Fig. 6-5 The lateral and medial (or deep) heads of the triceps muscle originate from the
humerus, leaving a spiral cleft between them which accommodates the deep brachial artery
and radial nerve.
head of the triceps accompanied by the superior Topography
and inferior ulnar collateral branches of the brachial
artery. When the arm is abducted and extended, the neu-
The three heads of the triceps muscle merge rovascular bundle is visible as a cord-like struc-
over the distal humerus and insert on the olec- ture between the flexor and extensor compartments
ranon of the ulna by a broad, strong tendon (Fig. 6-7). Note the mass of muscles forming a hood
(Fig. 6-6). over the proximal humerus.
Deep brachial a. and

radial n.
Triceps m., long

head
Triceps m.,
lateral head
Brachioradialis m.
Triceps m.,
medial (deep)
head
Olecranon
Fig. 6-6 The triceps muscle covers the posterior brachium.

Deltopectoral groove,
cephalic v.
Deltoid m.
Coracobrachialis m.
Neurovascular
bundle
Biceps
brachii m.
Pectoralis
major m.
Medial Medial Triceps, Triceps, Teres major m.

Latissimus
epicondyle intermuscular medial long head
dorsi m.
septum head
Fig. 6-7 The coracobrachialis muscle and adjacent neurovascular bundle form a cord-like

ridge between biceps and triceps. The cephalic vein marks the deltopectoral groove.
Laterally, the course of the radial nerve is course of the radial nerve and deep brachial artery.
covered by the lateral head of the triceps (Fig. 6-8). The distal insertion of the deltoid and the proximal
The lateral intermuscular septum is evidenced by a origin of the brachioradialis divide the humeral
ridge running proximally from the lateral epicon- shaft into thirds. The penetration of the radial nerve
dyle. The depression between the deltoid and the through the lateral intermuscular septum occurs just
long head of triceps marks the beginning of the distal to the start of the brachioradialis.
Brachioradialis m.
Biceps m.
Deltoid m. Brachialis m.
Lateral
epicondyle
Triceps m., Triceps m., Lateral

long head lateral head intermuscular
septum
Fig. 6-8 The dimple between the deltoid and long head of the triceps marks the location of
the deep brachial artery and radial nerve proximally.

Exposure of the Brachial Artery The patient is placed supine near the edge of
the operating table with the arm abducted 90° and
The superficial location of the brachial artery and supported on an armboard. Shoulder hyperextension
its proximity to the humerus makes it vulnerable should be avoided to prevent stretch injury to the
to injury. Brachial artery trauma accounts for most brachial plexus. The axilla, brachium, and hand are
vascular injuries of the upper extremity.1–3 The vast prepped and draped. The hand and forearm are cov-
majority of brachial injuries are associated with ered with a stockinette to allow repositioning dur-
penetrating trauma,1 but blunt injuries have been re- ing the operation and to allow palpation of the radial
ported after posterior elbow dislocation and supra- pulse (Fig. 6-9).
condylar fractures in children.4,5 In supracondylar A 5- to 8-cm longitudinal incision is made
fractures, the direction of displacement determines in the groove between the biceps and triceps
the structures at risk: medial displacement of the dis- muscles on the medial aspect of the arm. The
tal fragment can result in injury to the radial nerve, incision can be extended as needed to increase
while lateral displacement risks injury to the median proximal or distal exposure. In the lower half of
nerve and brachial artery4 (Fig. 6-2). Regardless of the arm, care should be taken to prevent injury
the mechanism of injury, the close proximity of ma- to the basilic vein as the incision is deepened
jor nerve structures commonly leads to permanent through subcutaneous tissue. The vein perforates
dysfunction due to associated trauma.2,3 the deep fascia just distal to the middle of the
The brachial artery is quite simple to expose. arm and courses near the brachial vessels in the
The following discussion concerns isolation of the deep tissues proximal to this point. It is most
brachial artery proximal to the antecubital fossa; ex- convenient to retract the basilic vein into the pos-
posure of the brachial artery at its bifurcation will be terior wound, ligating crossing vein branches as
discussed in Chapter 7. needed.
Basilic v.
Fig. 6-9 To approach the brachial artery, the arm is abducted 90°.
The neurovascular bundle is exposed by incis- retracting the vein into the posterior wound, the
ing the deep fascia at the medial border of the biceps brachial sheath is opened. The median nerve is the
muscle, which is retracted anteriorly (Fig. 6-10). most superficial structure encountered upon enter-
The basilic vein should be identified coursing the brachial sheath. The nerve should be widely
ing medial to the brachial sheath. After carefully mobilized and gently retracted into the anterior
Biceps m.
Brachial sheath
Basilic v.
Deep fascia
Fig. 6-10 The deep fascia at the medial border of the biceps muscle is incised, exposing
the neurovascular bundle enclosed in its fascial sheath. The basilic vein penetrating the
deep fascia is preserved.

wound (Fig. 6-11). The artery lies just deep to the arteries, may require control during brachial artery
median nerve, surrounded by two brachial veins and isolation in the mid- and distal arm, respectively.
flanked posteriorly by the ulnar nerve. Isolation of In some patients, two arteries may be seen run-
the artery requires ligation of interconnecting vein ning in parallel from the upper arm to the antecubi-
branches that cross the artery’s medial surface. In tal space. This variation is due to high bifurcation
the proximal arm, the deep brachial artery should of the brachial artery, which occurs most commonly
be identified and protected on the posteromedial in the upper third of the arm.6 The two arteries oc-
surface of the brachial artery just distal to the lat- cupy the usual position of the brachial artery within
eral border of the teres major muscle. Two other the neurovascular bundle and continue in the fore-
branches, the superior and inferior ulnar collateral arm as the radial and ulnar arteries (see Fig. 19-7).
Brachial a.
Median n.
Ulnar n.
Basilic v.
Fig. 6-11 The vessels and nerves are exposed, the median nerve is retracted gently, and
vein branches are divided, allowing the artery to be mobilized.
References 4. Brahmamdam P, Plummer M, Modrall JG, et al.
Hand ischemia associated with elbow trauma in chil-
1. Franz RW, Goodwin RB, Hartman JF, et al. Manage- dren. J Vasc Surg. 2011;54:773–778.
ment of upper extremity arterial injuries at an urban 5. Korompilias AV, Lykissas MG, Mitsionis GI, et al.
level I trauma center. Ann Vasc Surg. 2009;23:8–16. Treatment of pink pulseless hand following supra-
2. Stone WM, Fowl RJ, Money SR. Upper extremity condylar fracture of the humerus in children. Int
trauma: current trends in management. J Cardiovasc Orthop. 2009;33:237–241.
Surg. 2007;48:551–555. 6. Bergman RA, Thompson SA, Afifi AK. Catalogue of
3. Topel I, Pfister K, Moser A, et al. Clinical outcome Human Variation. Baltimore, MD: Urban & Schwar-
and quality of life after upper extremity arterial zenberg;1984:108–114.
trauma. Ann Vasc Surg. 2009;23:317–323.

Forearm Vessels
7
Surgical Anatomy of the Forearm of the flexor/pronator muscle group and exten-
sor/supinator muscle group from medial to volar
The major nerves and arteries of the forearm run and from lateral to dorsal, respectively. Safe sur-
parallel with the two major muscle groups and lie gical approaches to the arteries require a good
between their layers as they converge toward the three-dimensional appreciation of the relationships
wrist. The axial rotation that uniquely characterizes between vessels, nerves, and muscles, particularly
the forearm is associated with a spiral disposition in the area of the cubital fossa.
189
Superficial Veins and Nerves veins draining the medial forearm and penetrates
the deep fascia on the medial side of the brachium.
The superficial veins of the distal forearm are The basilic vein is separated from the underlying
highly variable, but as they converge toward the brachial artery and median nerve by the biceps ten-
antecubital space they assume a more predictable don in the antecubital fossa and by the deep fascia
pattern (Fig. 7-1). The most constant vein in the in the distal brachium.
distal forearm is the cephalic, which starts along Two superficial nerves run the length of the
the lateral prominence of the radius. Before con- volar forearm and provide cutaneous sensation
tinuing up the arm along the lateral side of the for two-thirds of its circumference. The medial
biceps, it divides in front of the biceps tendon. antebrachial cutaneous nerve originates from the
There it sends a major tributary, the median cubi- medial cord of the brachial plexus and accompa-
tal vein, diagonally across the biceps tendon to join nies the brachial artery to the midbrachium. There
the basilic vein. The basilic vein is formed from the it exits the deep fascia through the same opening
Median cubital v.
Lateral antebrachial
cutaneous n.
Cephalic v.
Medial antebrachial
cutaneous n.
Fig. 7-1 The superficial veins and nerves of the volar forearm are depicted. The axially
oriented medial and lateral antebrachial cutaneous nerves provide sensation for two-thirds
of the forearm circumference.

traversed by the basilic vein and travels down the nerves are subject to injury during venipuncture of
forearm toward the ulnar side. The lateral ante- the antecubital veins.
brachial cutaneous nerve is a continuation of the The remaining strip of extensor forearm is inner-
musculocutaneous nerve which innervated the vated by the posterior antebrachial cutaneous nerve
biceps. This nerve emerges lateral to the biceps (Fig. 7-2). This nerve arises from the radial nerve in
tendon, divides into two branches, and runs over the spiral groove and becomes subcutaneous at the
the brachioradialis down the radial side of the lateral border of the triceps tendon. It passes behind
forearm in the subcutaneous plane. Both of these the lateral epicondyle to reach the dorsal forearm.
Lateral
antebrachial
cutaneous n.
Posterior
antebrachial
cutaneous n.
Fig. 7-2 The posterior antebrachial cutaneous branch of the radial nerve supplies the
remaining extensor surface of the forearm.
FOREARM VESSELS | 191
Bony Anatomy and Muscle Overview the forearm. The flexor/pronator group arises from
the medial epicondyle of the humerus and fans out
By virtue of its proximal and distal articulations, the across the volar forearm. Beneath this group, a
radius is capable of virtually 180° rotation at its dis- deep layer of flexor muscles arises from the radius,
tal end (Fig. 7-3). Both the intrinsic supinator and ulna, and interosseous membrane. The extensor/
pronators between radius and ulna and the major supinator muscle complex arises from the lateral
muscle groups effect this dramatic motion. The two- epicondyle of the humerus and extends toward
headed pronator teres acts proximally, and the flat the dorsum of the wrist. It, too, overlies a deeper
pronator quadratus acts distally between the radius layer. Two additional muscles, the brachioradialis
and ulna. The supinator wraps around the proximal and extensor carpi radialis longus, are anatomi-
radius from its origin on the posterior ulna. cally transitional between these two groups but are
Two large muscle groups, each arising from properly associated with the extensor group by vir-
an epicondyle-based common tendon, dominate tue of their radial nerve innervation. Between the
Common flexor
origin
Flexor digitorum
superficialis
Brachialis
Supinator
Pronator teres
Biceps brachii
(ulnar head)
Flexor digitorum
superficialis
(radial origin)
Flexor
Pronator teres
digitorum
(insertion)
profundus
Flexor pollicis
longus
Brachioradialis
Pronator quadratus
Fig. 7-3 Forearm muscle attachments to radius and ulna

are shown.

brachioradialis and flexor muscles proximally is The Flexors
the deep cubital fossa.
The forearm is wrapped in a firm layer of deep In the floor of the cubital fossa, the broad brachialis
fascia continuous with the fascia of the brachium. muscle converges to insert onto the proximal ulna
This is thickened around the biceps tendon, at the (Fig. 7-4). The biceps tendon passes over the bra-
epicondyles, and at the wrist where it forms the dor- chialis to reach the radial tuberosity which is virtu-
sal and volar retinacula. In addition, there are septa ally in the midline. A fascial expansion of the biceps
from the deep fascia to the radius and ulna. This tendon, the bicipital aponeurosis, extends down the
compartmentalization is completed by the dense medial forearm to spread over the proximal flexor
interosseous membrane. muscles.
Origins
Common Supinator
flexor
tendon
Ulnar
Radial
Pronator teres
(humeral head)
Flexor Brachialis m.
digitorum Pronator teres
superficialis m. (ulnar head)
Biceps
brachii tendon
Pronator
teres m.
Flexor
digitorum
Flexor profundus m.
pollicis
longus m.
Pronator
quadratus m.
Fig. 7-4 The deep and intermediate forearm flexor muscles

are shown.
The proximal flexor muscles lie on the consists of the muscles with a common origin
medial side of the brachialis and biceps inser- at the medial epicondyle, including the pronator
tions. The deepest layer consists of flexor digi- teres (Fig. 7-5).
torum profundus and flexor pollicis longus. The All the flexors except the flexor carpi ulnaris
flexor digitorum superficialis (FDS) which has (FCU) and the ulnar half of the flexor profundus are
humeral, ulnar, and radial origins is interposed as innervated by the median nerve. The exceptions are
an intermediate layer. The most superficial layer innervated by the ulnar nerve.
Flexor
digitorum
superficialis
m.
Brachioradialis
m.
Extensor
carpi
radialis
longus m.
Flexor
pollicis Pronator
longus m. teres m.
Flexor carpi Flexor carpi

radialis m. ulnaris m.
Palmaris
longus m.
Fig. 7-5 The superficial forearm flexors fan out from a common tendon of origin at the
medial epicondyle of the humerus.

Intermediate and Extensor Groups The dorsum of the forearm is also covered
by a superficial group with a common epicondy-
The brachioradialis and extensor carpi radialis longus lar origin and a deep layer beneath (Fig. 7-6). An
originate from the lateral supracondylar line of the interesting feature of the dorsal forearm muscles
humerus and the lateral intermuscular septum. They is the interdigitation of the specialized thumb
run in a direct line down the lateral side of the arm and muscles with the other muscles of the extensor
are innervated at their proximal end by the radial nerve. group.
Brachioradialis m.
Extensor carpi radialis longus m.
Extensor digitorum communis m.

Anconeus m.
Extensor carpi radialis brevis m.
Supinator m.
Flexor carpi ulnaris m. Abductor pollicis longus m.
Extensor pollicis brevis m.

Extensor carpi ulnaris m.
Extensor pollicis longus
Extensor digiti minimi m.
Extensor indicis m.
Fig. 7-6 The extensor muscle complex also consists of superficial and deep layers.
The Arteries and Nerves branches run on either side of the membrane to sup-
ply the deep muscles of each compartment.
Like the popliteal artery at the knee, the brachial The proximal radial and ulnar arteries give rise
artery is the single major trunk supplying the dis- to recurrent collateral branches which anastomose
tal extremity (Fig. 7-7). The artery bifurcates at the with brachial tributaries around the elbow. The radial
level of the radial tuberosity into radial and ulnar recurrent artery joins the radial collateral branch of the
branches. The radial branch is the more direct con- profunda brachii along the course of the radial nerve.
tinuation of the brachial artery, while the larger ulnar The anterior and posterior ulnar recurrent vessels join
artery takes off at almost a right angle to the parent the inferior and superior ulnar collateral branches of
vessel. Immediately after its origin the ulnar artery the brachial artery anterior and posterior to the medial
gives off a short common interosseous branch which epicondyle. An additional collateral artery, the inter-
bifurcates at the hiatus in the proximal interosse- osseous recurrent, arises from the common interosse-
ous membrane. The dorsal and volar interosseous ous artery and passes dorsal to the radius to join the
Posterior branch,
profunda brachii a.
Superior
ulnar
Radial collateral br. collateral a.
of profunda brachii a.
Inferior
ulnar
Radial n.
collateral a.
Radial recurrent a.
Anterior
ulnar
Deep br. radial n. recurrent a.
Superficial br. Posterior

radial n. ulnar
recurrent a.
Interosseous
recurrent a. Common
interosseous a.
Volar interosseous a.
Dorsal interosseous a.
Median n.
Anterior interosseous n.
Radial a. Ulnar n.
Ulnar a.
Fig. 7-7 The pattern of major nerve and vessel distribution in

the forearm is relatively straightforward. Note the collateral
channels around the elbow.

posterior branch of the profunda brachii as well as a understanding the disposition of the forearm vessels.
branch of the inferior ulnar collateral artery. One is the structure of the pronator teres muscle, and
The distal radial artery lies close to the super- the other is the structure of the FDS.
ficial branch of the radial nerve, and the distal ulnar The pronator teres muscle arises from two
artery is joined by the ulnar nerve. The median nerve heads. The humeral head is the most cephalad of the
follows a central route down the forearm. A deep muscles originating from the common flexor tendon
branch of the median nerve accompanies the anterior at the medial epicondyle. The ulnar head originates
interosseous artery (AIA), and the posterior interos- from the ulna lateral to the insertion of the brachia-
seous branch of the radial nerve passes through the lis muscle. This deep head rises between the median
supinator around the neck of the radius to reach the nerve and the ulnar artery to join the humeral head and
posterior interosseous artery and extensor muscles. separates the two structures. At the same time, it cre-
ates an isolated cleft through which the median nerve
The Cubital Fossa passes. The muscle is thus united as it passes over the
ulnar artery. It then passes under the radial artery on its
The relationship of the arteries to the surrounding way to inserting on the lateral border of the midradius.
muscles and nerves becomes somewhat complex The FDS forms an intermediate muscle layer
in the depths of the cubital fossa (Fig. 7-8). Two in the forearm. It has two origins medially, one from
elements of the regional anatomy are the keys to
Biceps brachii m.
Brachialis m.
Musculocutaneous n.
Brachioradialis m.
Pronator teres, humeral head
Radial n.
Radial recurrent a.
Brachial a.
Superficial br.
radial n. Median n.
Supinator m.
Common
Pronator flexor
teres m. origin
Pronator teres
(ulnar head)
Ulnar recurrent a.
Radial a.
Flexor digitorum
profundus m.
Flexor digitorum
superficialis m.
Ulnar a. Fig. 7-8 The interdigitation of nerves, vessels,

Ulnar n. and muscles in the cubital fossa is shown.
the common tendon at the medial humeral epicon- The courses of the superficial radial nerve,
dyle and the second from the ulna lateral to the bra- radial artery, and ulnar nerve are relatively straight-
chialis insertion just cephalad to the origin of the forward as the following description demonstrates.
deep pronator head. The broad lateral origin runs
along the anterior radius between the insertion of the The Distal Forearm
supinator and the origin of the flexor pollicis longus.
The inverted arc formed by the junction of the heads The radial artery in the midforearm lies beneath
is the gateway through which the ulnar artery and the medial border of the brachioradialis muscle
median nerve pass to reach the plane between the (Fig. 7-9). The ulnar artery becomes superficial in
flexors digitorum superficialis and profundus. Near
this arch, the artery and nerve reverse positions from
medial to lateral. Also beneath this arch, the interos-
seous vessels and anterior interosseous nerve pass
toward the interosseous membrane. Radial n.
Brachial a.
Brachioradialis m.
Median n.
Ulnar n.
Deep br. radial n.
Superficial br.
radial n.
Pronator
teres m., deep head
Pronator teres m.
Fibrous arc
Radial a.
Flexor
Median n. digitorum
superficialis
Flexor carpi
ulnaris m.
Ulnar a. and n.
Fig. 7-9 The radial artery and superficial branch

of the radial nerve are relatively superficial in the
midforearm, while the ulnar artery and median and
ulnar nerves lie between the superficial and deep
flexors of the digits.

the distal forearm at the lateral border of the FDS. The radial artery is a common site of catheterization
The ulnar nerve is covered along most of its course for indwelling arterial lines and for insertion of cath-
by the FCU. The median nerve traverses the forearm eters during interventional radiologic procedures.1–3
between the FDS and flexor digitorum profundus. Radial artery occlusion occurs in 5% to 25% of
Near the wrist the radial artery becomes superfi- patients undergoing these procedures,4,5 but radial
cial, lying anterior to the radius and pronator quadra- artery thrombosis does not usually lead to hand gan-
tus, between the tendons of brachioradialis and flexor grene. Radial artery catheterization has a reported
carpi radialis (Fig. 7-10). The ulnar artery and nerve incidence of permanent hand ischemia of 0.09%;1 in
are accessible on the radial side of the tendon of the most cases, digital gangrene is thought to occur as a
FCU. The median nerve is found ulnar to the tendon result of embolization from the site of initial arterial
of flexor carpi radialis between the tendons of the thrombosis.6
flexor pollicis longus and flexor digitorum profundus. The arterial circulation of the hand is variable.
In the vast majority of cases, the forearm arteries
terminate in the superficial and deep palmar arches
Exposure of Arteries in the Forearm that interconnect the radial and ulnar circulations.
Incomplete superficial and deep palmar arches are
The superficial location of the radial and brachial common, but one of the arches will be patent in most
arteries makes them ideal sites for arterial catheter- individuals (see Fig. 18-8). Because the ulnar artery
ization and for establishment of hemodialysis access. is usually the dominant artery to the hand, many
Brachialis m.
Biceps brachii m.
Brachioradialis m.
Pronator teres m.
Flexor carpi
radialis m.
Radial a.
Bicipital
aponeurosis
Palmaris longus m.
Flexor digitorum
superficialis m.
Flexor carpi ulnaris m.
Ulnar a. and n.
Fig. 7-10 The radial and ulnar arteries become superficial between the tendons of the wrist.
cardiovascular surgeons routinely harvest the radial synthetic conduits have inferior patency rates, favor-
artery for use as a coronary artery bypass conduit with able results have been obtained with prosthetic grafts
minimal hand sequela.7,8 However, it is important to in a variety of configurations, as long as the venous
keep in mind that some patients have disconnected anastomosis is kept below the elbow.12,15,16
ulnar and radial circulations. Radial artery harvest
may result in mild to moderate hand ischemia in up Exposure of the Distal Brachial Artery and Its Bifurcation
to 10% of individuals;8 it is critically important to
identify patients with radial artery-dependent hand The patient is placed in the supine position with the
circulations prior to performing radial artery har- arm abducted 90° and supported on a board attached
vest. Physical examination using the Allen test has to the operating table. The hand, forearm, and arm
been favored by many as a simple and inexpensive should be prepped circumferentially and draped
method of assessing the collateral circulation of the away from the trunk.
hand, but there is a high rate of false-positive and To expose the brachial artery in the antecu-
false-negative results.8 Complementary noninvasive bital fossa, a transverse skin incision is made 1 cm
tests such as the Allen test with Doppler insonation distal to the midpoint of the antecubital crease
of the palmar arch,9 finger pressure determinations,10 and extended medially for a distance of 3 to 4 cm
or full-length scanning of the ulnar artery with ultra- (Fig. 7-11). Longitudinal incisions across the ante-
sonography8 have been recommended for screening. cubital crease should be avoided to prevent flexion
The brachial and radial arteries are commonly
used to establish high-flow arteriovenous conduits
for hemodialysis access. The size of the vessels
appears to be ideal for balancing long-term conduit
patency with avoidance of high-output congestive
heart failure.11 The most favorable patency rates are
obtained with autogenous arteriovenous fistulas,12
and published guidelines from the National Kidney
Foundation indicate a strong preference for autog-
enous fistulas over prosthetic graft.13 The first choice
of arteriovenous fistula is the radiocephalic fistula
originally described by Brescia,14 followed by bra-
chiocephalic and brachiobasilic fistulas.12,13 Whereas
Fig. 7-11 Transverse or S-shaped antecubital

incisions can be used.

contractures from hypertrophic scarring. Wider On deepening the incision, one should take
proximal exposure of the brachial artery and distal care to avoid injuring subcutaneous veins, which
exposure of its branches can be gained by creating may be used as outflow vessels in arteriovenous
an S-shaped incision. The superior longitudinal por- shunt procedures (Fig. 7-12). It is often necessary
tion is made along the medial border of the biceps to mobilize the basilic vein and retract it medially.
muscle, and the horizontal portion is brought across The medial antebrachial cutaneous nerve should be
the flexion crease. The inferior portion is made lat- protected as well. When creating an S-shaped inci-
eral to the midpoint of the volar forearm for a dis- sion, it may be necessary to divide the median cubi-
tance of 4 to 6 cm. tal vein if its course interferes with exposure.
Bicipital
aponeurosis
Medial antebrachial Basilic v.

cutaneous n.
Fig. 7-12 The basilic vein and medial antebrachial cutaneous nerve are retracted, expos-
ing the deep fascia and bicipital aponeurosis over the brachial artery and median nerve. An
S-shaped incision has been depicted for clarity.
The bicipital aponeurosis is recognized in the the brachial artery requires ligation and division of
center of the wound at the fascial level. Division of these crossing vein branches.
this aponeurosis exposes the brachial artery, which The radial and ulnar arteries are exposed by
is flanked by two deep veins and crossed by their retracting the distal skin edge of the transverse skin inci-
communicating branches (Fig. 7-13). Isolation of sion or by deepening the distal portion of the S-shaped
Biceps Bicipital
tendon aponeurosis
(opened)
Pronator Brachial a. Median n.

teres m.
Fig. 7-13 The fascia is opened, revealing the artery and nerve medial to the biceps tendon.
The artery is accompanied by two veins that intercommunicate.

incision. The brachial bifurcation is usually located in forearm. It can be isolated at the brachial bifurcation
the antecubital fossa near the intersection of the bra- or at any point along the medial border of the brachio-
chioradialis and pronator teres muscles (Fig. 7-14). It radialis muscle. The ulnar branch dives beneath the
is most easily identified by tracing the brachial artery pronator teres a short distance from its origin. Isola-
distally. The radial branch courses in the same direction of the ulnar artery distal to this small segment will
tion as the brachial artery toward the radial side of the require separate incisions (see below).
Brachioradialis m. Brachialis m. Biceps

brachii m.
Pronator Median n. Brachial a.

teres m.
Fig. 7-14 The bifurcation of the brachial artery can be exposed by retracting the pronator
teres and flexor muscle mass. The radial artery can be followed the length of the incision,
but the larger ulnar artery dives between the heads of the FDS.
Exposure of the Radial Artery in the Midforearm muscle and can be exposed by retracting the bra-
chioradialis and pronator teres muscles apart. In
The patient is placed supine with the arm abducted the distal forearm, the artery lies just beneath the
at 90° on a supporting board. A 5-cm longitudinal antebrachial fascia between the tendons of the bra-
incision is made over the portion of the artery to be chioradialis and flexor carpi radialis muscles. In the
exposed. Alternatively, a long incision across the middle third of the forearm, the superficial radial
volar forearm should be used when the entire radial nerve is closely associated with the lateral aspect
artery is to be harvested for use in coronary bypass of the radial artery and must be carefully preserved.
procedures.17 The landmark for the incision follows The radial artery is accompanied by paired veins
a line from the midpoint of the antecubital crease to throughout its course, and care should be taken to
the styloid process of the radius, corresponding to separate these during arterial isolation.
the groove on the medial edge of the brachioradialis
muscle (Fig. 7-15). Subcutaneous veins are ligated Exposure of the Radial Artery at the Wrist
and divided as the wound is deepened, and the ante-
brachial fascia is incised along the medial border The patient is placed as described above, with the
of the brachioradialis muscle. In the proximal and entire forearm and hand circumferentially prepped
middle thirds of the forearm, the radial artery lies and draped. Proper placement of the incision will
beneath the medial fibers of the brachioradialis be determined by the indication for radial artery
Superficial
radial n.
Radial a.
Brachioradialis m.
Fig. 7-15 The radial artery in the midforearm can be easily exposed beneath the
brachioradialis.

exposure. In cases involving open arterial line place- should be made approximately halfway between
ment or simple arterial ligation, a longitudinal inci- the radial artery and the cephalic vein, near the lat-
sion should be made directly over the radial pulse, eral border of the radius. Longitudinal incisions per-
beginning just proximal to the level of the styloid pro- mit increased mobilization of the vein and artery;
cess (Fig. 7-16). For creation of radiocephalic arte- some authors prefer transverse, oblique, or sigmoid
riovenous fistulas, a 2- to 3-cm longitudinal incision modifications.
Flexor carpi
radialis tendon
Radial a.
Ulnar a.
Flexor carpi
ulnaris m.
Fig. 7-16 The incision for exposing the radial artery is shown. A more lateral incision also
gives access to the cephalic vein for creation of arteriovenous fistulas.
The cephalic vein is exposed in the subcuta- The superficial radial nerve and its medial and lat-
neous tissues of the lateral skin flap (Fig. 7-17). eral branches course between the cephalic vein and
The radial artery is exposed by incising the ante- radial artery in this area. These nerves lie superfi-
brachial fascia just medial to the radius. Two deep cial to the antebrachial fascia and should be care-
veins accompany the artery at this level and should fully preserved during creation of arteriovenous
be carefully dissected away during arterial isolation. fistulas.
Radial a.
Cephalic v.
Flexor carpi
radialis tendon
Brachioradialis
tendon
Deep fascia
Fig. 7-17 The radial artery at the wrist lies just deep to the deep fascia between the flexor
carpi radialis tendon and the insertion of the brachioradialis.

Exposure of the Ulnar Artery in the Forearm a line from the medial epicondyle to the pisiform
(Fig. 7-18). Superficial veins are ligated as neces-
The ulnar artery courses beneath the superficial sary, and the antebrachial fascia is incised for the
flexor muscles in the proximal forearm, emerging length of the incision. The ulnar artery is located
near the ulnar border at a point midway between the by developing a plane between the FCU and FDS
elbow and the wrist. Because of its deep placement muscles. In the proximal third of the forearm, the
in the proximal third of the forearm, exposure is artery and its accompanying veins can be identified
somewhat difficult. by laterally retracting the FDS muscle. In the mid-
The patient is placed in the supine position, dle third of the forearm, the vessels lie just deep to
with the arm supinated and the hand slightly flexed the FCU, which should be retracted medially. The
to relax the flexor muscles. In the proximal forearm, ulnar nerve joins the artery near the border of the
the ulnar artery is exposed between muscles of the upper and middle thirds of the forearm; the nerve
superficial flexor group. An 8- to 10-cm incision is should be identified on the artery’s medial border
begun approximately four fingerbreadths below the in the distal wound and protected during arterial
medial epicondyle of the humerus, extending along isolation.
Flexor digitorum
superficialis m.
Ulnar a.
Flexor Ulnar n.
digitorum Flexor carpi
profundus m. ulnaris m.
Fig. 7-18 The ulnar artery in the midforearm is reached between the FCU and FDS.
In the distal forearm, the ulnar artery courses of the ulnar nerve courses superficial to the ante-
just beneath the antebrachial fascia and is eas- brachial fascia and should be preserved during arte-
ily exposed through a longitudinal incision placed rial exposure.
radial to the FCU (Fig. 7-19). The palmar branch
Flexor carpi
radialis tendon
Radial a.
Ulnar a.
Flexor carpi
ulnaris m.
Fig. 7-19 The incision over the ulnar artery at the wrist is shown.

Forearm Fasciotomy ultimately resulting in ischemia and cell death
(myonecrosis). The deep fascia of the forearm, like
Compartment syndrome occurs whenever the that of the leg, firmly encloses the underlying mus-
interstitial tissue pressure within an enclosed ana- cles (Fig. 7-20A, B). The diagnosis of acute com-
tomic rises sufficiently to impair tissue perfusion, partment syndrome is based on history and physical
Flexor digitorum superficialis
Flexor pollicis longus
Flexor carpi radialis Palmaris longus
Brachioradialis Flexor carpi

ulnaris
Radius Flexor
digitorum
profundus
Extensor
carpi radialis
Ulna
longus
Extensor
carpi radialis Extensor carpi
brevis ulnaris
Abductor pollicis longus Extensor pollicis longus

A
Extensor digitorum
DORSAL
Fig. 7-20 A: There is a firm sleeve of deep fascia around the

forearm muscles. B: The relationships of the muscles are shown
B at three levels of the right forearm.
examination and confirmed with interstitial pressure 21%.20 Particular attention should be given to the skin
measurements.18 In particular, the combination of incision and to ensuring complete release of the deep
certain types of injury (i.e., crush, fracture, electrical muscles of the volar compartment.
burn) and physical findings (i.e., pain with passive The forearm consists of three primary com-
motion of the fingers, tense forearm, and neurologic partments (Fig. 7-21): volar, dorsal, and lateral or
findings referable to the compartment) should alert mobile wad (brachioradialis, extensor carpi radia-
the surgeon that an acute compartment syndrome is lis longus, and brevis). The volar compartment
developing. includes three deep muscles supplied by the AIA:
The threshold interstitial pressure at which flexor digitorum profundus, flexor pollicis longus,
fasciotomy is warranted remains controversial. The and pronator quadratus. The long, small diameter
most commonly quoted criteria for compartment syn- AIA is especially prone to occlusion from com-
drome is based on interstitial pressure related to either partment hypertension,21 and the three deeper volar
the mean arterial pressure or the diastolic pressure. compartment muscles are subsequently the most
Based on data from the classic paper of Whitesides et commonly affected in forearm compartment syn-
al.,19 fasciotomy is indicated when the dynamic inter- dromes. Hence, complete release of the “deep volar”
stitial pressure rises to within 30 mm Hg of the mean compartment is paramount.
arterial pressure or 20 mm Hg of the diastolic blood The use of a tourniquet is advocated by some.
pressure. Regardless of the specific criteria used, It is the author’s preference to have one in place, but
prompt fasciotomy is indicated to relieve compart- not elevated, to avoid further ischemic insult to the
ment ischemia and limit cell death. A properly exe- tissue. Multiple incisions have been described for
cuted forearm fasciotomy is crucial to minimize the volar forearm fasciotomy. Regardless of the specific
morbidity of this procedure. A retrospective review of configuration, the goal is to adequately decompress
84 forearm compartment syndromes found an overall all compartments, minimize injury to the major
complication rate of 42%, with neurologic deficits in nerves, and at the completion of the fasciotomy, be
Superficial
volar
Radial neurovascular compartment Ulnar neurovascular
bundle bundle
Lateral Deep volar

compartment compartment
Radius
Ulna
Dorsal compartment
Fig. 7-21 The three main compartments of the right forearm are shown at midforearm level.

able to safely cover the distal 3 to 4 cm of the median from Kaplan’s cardinal line to the wrist flexor crease
nerve which becomes superficial and only partially will allow adequate access to the median nerve
covered by the palmaris longus tendon. Figure 7-22 through the palmar fascia and transverse carpal liga-
shows our preferred incision.22 ment. The surgeon must not be unnecessarily rushed
The incision begins on the palm with a classic by the emergency of the situation when releasing
carpal tunnel incision lying in line with the radial the median nerve. Iatrogenic injury to this structure
border of the ringer finger and extending 2 to 3mm is the most debilitating complication related to the
ulnar to the thenar crease (Fig. 7-23). An incision procedure.
Fig. 7-22 The recommended incision is shown.
Fig. 7-23 The initial palmar portion of the incision is shown.

Kaplan’s cardinal line is shown in red.
The carpal tunnel incision is then carried if possible. Sharp and blunt dissection will allow
ulnarly along the distal wrist flexor crease to the elevation of the fascia with the ulnarly based full
FCU tendon. At the ulnar side of the FCU tendon, thickness skin flap. Once the plane between fascia
the incision is brought proximally 4 to 5 cm before and muscle is defined, the flap is elevated along its
gently curving to the midline. This incision protects entire length (Fig. 7-24). The flap is raised off of the
the ulnar nerve and artery, located radial to the ten- FCU tendon with the paratenon left intact, thereby
don, and forms an adequate flap to cover the distal protecting the deeper ulnar nerve and vessels.
median nerve. The ulnar neurovascular bundle is commonly
The skin incision is extended proximally and adherent to the deep and ulnar aspect of the FDS
toward the midline for simultaneous decompression muscle belly before becoming relatively superficial
of the mobile wad muscles. The large veins crossing between the FCU and FDS tendons (see Fig. 7-9).
the incision path often require suture ligation. Super- Branches from the ulnar artery to the deep muscles
ficial nerves crossing the forearm will be sacrificed can be sacrificed and the FDS elevated from the
and the patient should be counseled preoperatively FCU to gain access to the flexor pollicis longus and
Fig. 7-24 The elevation of the fasciocutaneous flap is shown.

flexor digitorum profundus (Fig. 7-25). The mus- incision lies adjacent to the mobile wad muscles
cle fascia overlying the deep compartment muscles (Fig. 7-26). Blunt subfascial dissection in a radial
will not be as thick as that overlying the FDS. fashion (arrow) will allow entry into the lateral
Upon completion of the release of the deep compartment. Proximal dissection will place radial
volar compartment, the midforearm portion of the nerve and artery at risk and is not necessary.
Fig. 7-25 The separation of the FCU and

FDS is shown. Note the inclusion of the ulnar
neuromuscular bundle with the FDS.
Fig. 7-26 Subfascial extension of
the lateral fasciocutaneous flap
decompresses the lateral
compartment.
In most situations, the dorsal compartment require dorsal compartment fasciotomy. A dorsal 6 to
muscles will be adequately decompressed by the full 8 cm incision in line from the lateral epicondyle to
length volar decompression. However, some inju- the radial styloid, ulnar to the mobile wad (Fig. 7-27),
ries, such as prolonged crush or electrical burn, will will allow release of the compartment fascia.
Fig. 7-27 Rarely, a dorsal counterincision will be necessary.

References arteriovenous hemodialysis fistula: two cases. Am
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tomic and physiologic investigations. Anesth Analg. surgical placement and maintenance of arteriovenous
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2. Nohara AM, Kallmes DF. Transradial cerebral angi- 13. The Vascular Access Work Group. NKF-DOQI clini-
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3. Brueck M, Bandorski D, Kramer W, et al. A random- 14. Brescia MJ, Cimino JE, Appel K, et al. Chronic
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and outcome of radial artery occlusion following tudinal comparison of dialysis access methods: risk
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6. Valentine RJ, Modrall JG, Clagett GP. Hand isch- versus tunneling radial artery harvest for coronary
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9. Ruengsakulrach P, Brooks M, Hare DL, et al. Pre- ment syndrome of the forearm: a systematic review.
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Hand Vessels
8
Vascular Anatomy of the Hand Cutaneous Nerves of the Hand
The anatomy of the hand is complex, and the ramifi- The superficial innervation of the hand is relevant
cation of the blood vessels within the tightly packed to the vascular surgeon in choosing an approach to
musculoskeletal structures is difficult to visualize. the underlying vessels. Sensation is more critical to
The following discussion presents hand anatomy the function of the hand than to any other area of the
as a framework for understanding the paths of the body. All three major nerves of the arm provide sen-
blood vessels. sation to areas of the hand, and the nerve branches
in adjacent territories interconnect.
217
On the volar surface of the hand (Fig. 8-1), two branching from the main trunks of the median and
major areas are supplied by the median and ulnar ulnar nerves beneath the palmar fascia. The super-
nerves. The division lies along the middle of the ficial palmaris brevis muscle at the base of the hy-
ring finger. A palmar cutaneous branch arises from pothenar eminence is innervated by the ulnar nerve.
the median nerve in the midforearm. This branch The radial side of the thenar eminence and dorsal
penetrates the deep fascia at the wrist and supplies thumb is served by the lateral branch of the superfi-
the skin over the thenar eminence. The remainder cial radial nerve.
of the palm and the volar surface of the fingers are The dorsum of the hand is supplied by the ul-
innervated by the common and proper digital nerves nar and radial nerves. The dorsal branch of the ulnar
Digital
palmar
crease
Thenar
crease
Digital n’s
Hypothenar Lateral branch

crease of superficial
radial n.
Palmar cutaneous
branch of median n.
Palmar cutaneous Lateral

branch of ulnar n. antebrachial
cutaneous n.
Fig. 8-1 The distribution of cutaneous nerves to the hand is shown. A: volar; B: dorsal.

nerve arises in the distal forearm 5 cm from the compartment into the lateral branch described previ-
wrist flexion crease and passes between the flexor ously and a larger medial division that supplies the
carpi ulnaris and the distal ulna to reach the ulnar remainder of the dorsum. A peculiarity of this distri-
side of the dorsum of the hand. Its territory is again bution is that the distal phalanges of the index and
marked by the midline of the ring finger. The su- middle fingers and the radial half of the ring finger
perficial branch of the radial nerve passes under the are supplied by the median nerve. The superficial
tendon of the brachioradialis muscle and crosses the radial nerve is at risk of injury when surgically ap-
anatomic snuffbox. It divides over the first extensor proaching the radial artery in the anatomic snuffbox.
Median n.
Superficial branch
of radial n. Dorsal branch
of ulnar n.
Lateral antebrachial
cutaneous n. Posterior antebrachial
cutaneous n.
Fig. 8-1 (continued)
HAND VESSELS | 219
Bones of the Hand tunnel for the flexor tendons is closed by a dense
transverse ligament extending from the trapezium
The key to understanding the bony framework of and scaphoid tubercle radially to the pisiform bone
the hand is the carpal arch (Fig. 8-2). The deep vo- and hook of the hamate bone on the ulnar end of
lar concavity of the carpal bones forms the channel the arch. Note that the pisiform bone and hook of
through which the major tendons pass from fore- the hamate bone are not aligned axially relative
arm to hand and establishes the foundation for op- to the ulna but angle toward the base of the third
position between the thumb and little finger. The metacarpal.
Capitate
Trapezoid
Transverse
carpal
lig.
Trapezium
Hamate
Pisiform Scaphoid
Triquetrum
Lunate
Fig. 8-2 The carpal bones form a deep arch that cradles the long flexor tendons. A: volar;
B: proximal view.

Hook of Transverse Trapezium
hamate carpal lig.
Pisiform
B Scaphoid
HAND VESSELS | 221
Fascia transverse carpal ligament is derived from carpal
ligaments with a contribution from the tendon of
The deep fascia of the forearm is thickened around flexor carpi ulnaris muscle, whereas the volar car-
the wrist, forming the extensor retinaculum on the pal ligament is a thickened band of deep fascia. The
dorsum and the volar carpal ligament on the volar only complexity in this relationship is the midline
side (Fig. 8-3). The palmaris longus tendon fuses adherence between the palmar aponeurosis and the
with the volar carpal ligament at the wrist and fans transverse carpal ligament. This adherence creates a
out over the central palm, reinforcing the deep fas- canal on the ulnar side of the wrist, with the ulnar ar-
cia there and forming the palmar aponeurosis. This tery and nerve sandwiched between the two fascial
layer of investing fascia is distinct from the under- layers (the canal of Guyon). The radial attachment
lying transverse carpal ligament, which bridges of the transverse carpal ligament divides to accom-
the carpal arch from end to end and forms the re- modate the passage of the flexor carpi radialis ten-
straining retinaculum for the flexor tendons. The don through a separate tunnel.
Fibrous digital
flexor sheath
Superficial
transverse
metacarpal lig.
Palmaris longus
tendon (reflected)
Palmar
cutaneous br.
of median n.
Motor br. of
Tunnel median n.
of Guyon
Palmaris Transverse
brevis m. capal lig.
Ulnar a. and n. Superficial

radial a.
Volar
carpal Flexor carpi
lig. radialis tendon
Radial a.
Flexor carpi
ulnaris
Median n.
Fig. 8-3 The volar carpal ligament is a thickening of the deep fascia and is superficial to
the transverse carpal ligament, which closes the carpal arch.

Beyond the wrist, the palm is divided into radial side. These potential spaces are the sites of
three compartments by two fascial septa that span deep hand infections.
between the palmar aponeurosis and the first and The palmar aponeurosis coalesces into four
fifth metacarpals, respectively (Fig. 8-4). These bands in the distal palm. These overlie and contrib-
septa separate the thenar and hypothenar spaces ute to the fibrous flexor tendon sheaths at the dis-
from the central palmar compartment. The eight tal end of the metacarpals. The interdigital space
digital flexors are enclosed in a common bursa and between the bands encloses the underlying digital
fill the central compartment. The lumbrical muscles, nerves, arteries, and lumbrical muscles. Between the
digital nerves, and vessels also occupy this space. flexor sheaths, superficial and deep transverse meta-
A deep oblique connective tissue septum runs carpal ligaments create three closed passages for
between the undersurface of the common bursa these structures. The lumbrical muscles pass above
and the shaft of the middle metacarpal. This sep- the deep transverse metacarpal ligaments, and the
tum divides the plane between flexor tendons and tendons of the interosseous muscles pass below.
the metacarpal/interossei layer into the midpalmar The radial bursa, the second palmar bursa,
space on the ulnar side and the thenar space on the encloses the single tendon of the flexor pollicis
Deep
Superficial
transverse
transverse
metacarpal lig.
metacarpal lig. Fibrous
digital
sheath
Interdigital
space
Volar
plate Flexor
pollicis
longus
Palmar tendon
aponeurosis
Thenar
Hypothenar fascia
fascia
Thenar
septum
Midpalmar space
Ulnar
bursa
Thenar space
Transverse
carpal lig.
Oblique septum
Fig. 8-4 The fascial compartments of the palm are shown.
HAND VESSELS | 223
longus muscle and passes between the heads of their base by the deep branches of the ulnar artery
the flexor pollicis brevis muscle. This bursa and and nerve. The artery forms one side of the deep pal-
tendon are thus contained within the thenar mar arch, which lies in the potential space between
compartment. the ulnar bursa and the metacarpal plane.
The recurrent motor branch of the median nerve
Intrinsic Hand Muscles arises just beyond the distal edge of the transverse
carpal ligament and supplies the thenar muscles.
Three muscles, an abductor, flexor, and opponens, The most volar of the thenar muscles, the abductor
constitute both the thenar and hypothenar groups pollicis brevis muscle, is usually penetrated by the
(Fig. 8-5). These muscles arise from both the end superficial thenar branch of the radial artery on its
bones of the carpal arch and from the transverse car- way to complete the superficial palmar arch. The
pal ligament. The hypothenar muscles are pierced at thumb is moved by one additional intrinsic muscle,
Volar
interossei
Radial a.
to deep arch
Adductor
pollicis m.
Flexor
Abductor
pollicis
digiti minimi m.
brevis m.
Flexor digiti
minimi brevis m. Opponens
pollicis m.
Opponens digiti
minimi m. Superficial br.
of radial a.
Deep branch of
Abductor
ulnar a. and n.
pollicis
brevis m.
Flexor carpi
radialis tendon
Radial a.
Flexor carpi
ulnaris
Median n.
Fig. 8-5 The intrinsic muscles of the hand form a cup to contain the central tendons,
nerves, and vessels.

the adductor pollicis. The radial artery reaches the Path of the Radial Artery
deep palm between the transverse and oblique heads
of the adductor. The ulnar nerve supplies the hy- The radial artery passes around the radial side of
pothenar muscles, all the interossei, the adductor the carpal bones under the tendons of abductor pol-
pollicis muscle, the deep head of the flexor pollicis licis longus and extensor pollicis brevis muscles
brevis muscle, and the two ulnar lumbrical muscles. (Fig. 8-6). The vessel then lies over the scaphoid in
The radial lumbrical muscles are supplied by the the depression between the extensor pollicis brevis
median nerve. and extensor pollicis longus tendons known as the
Extensor pollicis
longus
First dorsal
interosseous m.
Extensor pollicis
brevis
Radial a.
Abductor
pollicis
longus
Radial n. Dorsal carpal branch

of radial a.
Extensor retinaculum
Fig. 8-6 The radial artery turns around the lateral border of the carpal bones and passes
between the first two metacarpals to reach the palm.
HAND VESSELS | 225
anatomic snuffbox. There it gives off a dorsal car- After passing between the metacarpals, the
pal branch that runs beneath the extensor tendons. radial artery gives off two branches deep to the ad-
The superficial branch of the radial nerve overlies ductor pollicis muscle, the princeps pollicis and
the artery outside the deep fascia. The artery then radialis indicis arteries. These branches may have
crosses beneath the tendon of extensor pollicis lon- a common origin (Fig. 8-7). The continuation of
gus muscle and dives between the two heads of the the radial artery passes between the heads of the
first dorsal interosseous muscle and through the adductor muscle to become one end of the deep
first two metacarpals toward the deep palmar space. palmar arch.
Princeps
Lumbrical m’s pollicis a.
Deep palmar
arch
Radial a.
Flexor digitorum profundus
Fig. 8-7 The radial artery gives off two digital branches (shown with a common trunk)
deep to the adductor pollicis muscle.

Palmar Arches The deep arch has a dominant radial supply
and is slightly more proximal, lying just beyond the
The superficial palmar arch has a dominant ulnar bases of the metacarpals. The eight digital flexor
supply and a small radial end that may be absent tendons and the median nerve branches pass be-
in some cases1 (Fig. 8-8). The apex of the super- tween the two arches.
ficial arch is at the level of the proximal palmar Unroofing the palmar fascia reveals the su-
crease. perficial palmar arch lying on the digital nerves
Deep palmar
arch
Superficial
palmar arch
Radialis
indicis a.
Princeps
pollicis a.
Hook of
hamate
Transverse
carpal lig.
Pisiform
Abductor pollicis
longus tendon
Ulnar bursa
Flexor digitorum
Flexor carpi radialis
superficialis
Flexor digitorum Median n.

profundus
Radial bursa
Ulnar n. and a. Flexor pollicis longus
Flexor carpi
ulnaris m.
Fig. 8-8 The long digital flexors, lumbrical muscles, and digital nerves lie between the
two palmar arches.
HAND VESSELS | 227
and flexor tendons (Fig. 8-9). The ulnar end of the branch of the radial artery. Remember that the arch
arch starts in the cleft between the volar carpal liga- is penetrating both the hypothenar and thenar septa
ment and transverse carpal ligament, crosses the connecting the palmar fascia to the first and fifth
base of the hypothenar muscles, and turns across metacarpals in its course across the palm. The digi-
the central palmar structures to meet the superficial tal vessels lie superficial to the nerves near the arch
Median n.
Ulnar n.
Fig. 8-9 The superficial arch lies just beneath the palmar aponeurosis.

but assume a dorsal position relative to the digital branches of the deep and superficial arches in the
nerves in the fingers. palm (Fig. 8-10). In addition, there are anastomo-
There is a rich communication at the base ses between the metacarpals from the deep arch
of the metacarpophalangeal joints between the branches to the dorsal arterial network.
Fig. 8-10 There is a rich intercommunication among the vessels of the hand.
HAND VESSELS | 229
Exposure of Hand Arteries abnormalities,4 some cases can arise from recre-
ational activities or after a single traumatic episode.5
There are two situations in which the vascular
surgeon may become involved with exposure of ar- Exposure of the Radial Artery in the Anatomic Snuffbox
teries in the hand: creation of arteriovenous fistulae
and resection of aneurysms or irregular arterial seg- The patient is placed in the supine position with the
ments associated with finger embolization. Creation arm abducted and placed on a supporting board. The
of a radiocephalic arteriovenous fistula within the arm should be pronated to allow the hand to rest on
anatomic snuffbox has been recommended because its ulnar surface, and the entire hand and forearm are
it results in a long segment of arterialized vein for prepped and draped.
access and because it spares more proximal vessels A 3-cm longitudinal incision is made over
for secondary operations.2 Repetitive blunt trauma the anatomic snuffbox, extending from the radial
on the ulnar aspect of the hand can result in forma- styloid to the base of the first metacarpal (Fig. 8-11).
tion of aneurysms or intimal irregularities in the
ulnar artery at the level of the hamate bone.3 The le-
sions associated with this so-called hypothenar
hammer syndrome may thrombose or cause digital
embolization, leading to finger gangrene.4 Although
this syndrome has been attributed to repetitive occu-
pational trauma in patients with underlying arterial
Cephalic v.
Extensor pollicis
brevis
Radial n.
Fig. 8-11 The superficial branch of the radial nerve lies

on the deep fascia over the anatomic snuffbox. A zigzag
incision over this area helps to avoid keloid formation.

The cephalic vein of the thumb is located in the retraction toward the palmar or dorsal surface, de-
subcutaneous tissues and fully mobilized in cases pending on their location. The deep fascia is incised
involving arteriovenous fistula creation. Digital between the extensor pollicis longus and extensor
branches of the superficial radial nerve are identi- pollicis brevis muscles to expose the radial artery
fied on the surface of the deep fascia and protected. (Fig. 8-12). Mobilization of the radial artery requires
The nerves may require mobilization and gentle ligation of the dorsal carpal branch.
Extensor
pollicis
brevis
Radial a.
Extensor
Radial n. pollicis
longus
Dorsal carpal
branch
Fig. 8-12 The fascia is opened to expose the radial artery, and the dorsal carpal branch is
divided.
HAND VESSELS | 231
Exposure of the Radial Artery in the Distal Hand pollicis longus muscle and extend approximately
3 cm. Superficial veins should be preserved and
The patient is positioned and prepped as previously retracted in the subcutaneous tissue to expose the
described. A longitudinal incision is made paral- deep fascia. The fascia is incised between the two
lel to the second metacarpal on the dorsal surface heads of the first dorsal interosseous muscle, which
of the first interosseous space (Fig. 8-13). The are carefully separated and retracted to expose the
incision should begin at the level of the extensor radial artery.
First dorsal
interosseous m.
Radial a.
Fig. 8-13 The segment of radial artery beyond the extensor pollicis longus tendon is
exposed.

Exposure of the Ulnar Artery and Superficial Palmar Arch The incision is deepened to the level of the pal-
maris brevis muscle. The ulnar artery can be identi-
After the hand and forearm are prepped and draped, fied at the proximal edge of the muscle and traced
the hand is placed with the palmar surface up. An distally as the muscle is incised. It is important to
oblique incision is made in the hypothenar crease, confine the dissection close to the palmar surface
extending from the radial border of the pisiform of the ulnar artery to avoid injuring its several
bone to the distal transverse palmar crease, cross- branches. Palmar digital nerves of the superficial
ing the proximal transverse crease obliquely to ulnar nerve course on the ulnar side of the ulnar ar-
avoid scar contracture complications (Fig. 8-14). tery and should be carefully preserved. By dividing
Palmaris
brevis m.
Ulnar n. and a.
Fig. 8-14 The ulnar artery and nerve beyond the canal of Guyon are exposed beneath the
palmaris brevis muscle and hypothenar fascia.
HAND VESSELS | 233
fibers of the palmar aponeurosis, the artery can be Digital branches of the median nerve course be-
traced beyond the fifth digital artery branch, where neath the superficial palmar arch in this area and
it becomes the superficial palmar arch (Fig. 8-15). should be preserved.
Digital a.
Superficial
palmar arch
Ulnar a.
Fig. 8-15 The continuation of the ulnar artery toward the superficial palmar arch is exposed
by opening through the hypothenar compartment septum into the palmar aponeurosis.
References 3. Cooke RA. Hypothenar hammer syndrome: a dis-

crete syndrome to be distinguished from hand-arm
1. Gellman H, Botte MJ, Shankwiler J, et al. Arterial vibration syndrome. Occup Med. 2003;53:320–324.
patterns of the deep and superficial palmar arches. 4. Marie I, Herve F, Primard E, et al. Long-term fol-
Clin Orthop. 2001;383:41–46. low-up of hypothenar hammer syndrome: a series of
2. Wolowczyk L, Williams AJ, Donovan KL, et al. 47 patients. Medicine. 2007; 86:334–343.
The snuffbox arteriovenous fistula for vascular 5. Custer T, Channer LT, Hartranft T. Hypothenar ham-
access. Eur J Endovasc Surg. 2000;19:70–76. mer syndrome. Case report and literature review.
Vase Surg. 1999;33:567–577.

VESSELS OF THE
ABDOMEN
235
Lateral recess of
lesser sac
Visceral peritoneum
Parietal peritoneum
Transversalis fascia
Anterior renal fascia
Posterior renal fascia

Inferior Aorta
vena cava
Fig. 9-1 The upper abdominal organs are arrayed around the central core of the great
vessels. Note the relationship of the anterior renal fascia to the vessels in the retroperitoneum.
236 | VESSELS OF THE ABDOMEN

Upper Abdominal
Aorta, Including
the Visceral and
Supraceliac Segments
9
Surgical Anatomy of the Abdominal Aorta Overview
In its short span, the abdominal aorta is the center of The aorta occupies a central position in the abdomi-
some of the most complex anatomic relationships in nal cavity. In the upper abdomen, the major organs
the body. The unique problems of access to the vari- are arranged in a semicircle around the great vessels
ous segments are dealt with separately in the follow- and fill the domes of the diaphragm beneath the rib
ing chapters. Before focusing on regional details, it cage (Fig. 9-1). The vessels lie within the continua-
is useful to review the disposition of the abdominal tions of anterior and posterior renal fascia (Gerota’s
aorta in the context of the whole abdomen. fascia) across the midline.1 The viscera on the left
237
side can be mobilized in the plane between the pan- central location overlying the first to fourth lumbar
creas and anterior renal fascia. To mobilize the kid- vertebrae, the aorta sends branches to the whole
ney along with the other viscera, the anterior renal abdomen.
fascia must be opened. The abdomen consists of bony and muscular
The profile of the midabdomen is flattened walls capped by diaphragms at each end and lined by
and relatively shallow from front to back (Fig. 9-2). transversalis fascia. Contained within the abdominal
The prominent vertebral bodies of the lumbar spine cavity is the envelope of parietal peritoneum sur-
further impinge on the anterior-posterior diameter. rounding most of the abdominal organs (Fig. 9-3).
Thus, the abdominal aorta, which caps the ridge of The posterior wall of parietal peritoneum is in-
the lumbar spine, lies remarkably close to the an- vaginated in a complex pattern by the roots of the
terior abdominal wall in thin individuals. From its small bowel and the transverse and sigmoid colon
Lumbar
venous plexus
Aorta
Inferior
vena cava
Right colon
Quadratus
Ureter lumborum m.
Psoas m.
Fig. 9-2 The vessels cap the crest of the lumbar spine in the central abdomen.

Fig. 9-3 The anterolateral surfaces of the parietal peritoneal envelope are smoothly continuous.
UPPER ABDOMINAL AORTA, INCLUDING THE VISCERAL AND SUPRACELIAC SEGMENTS | 239

mesenteries as well as the broad attachments of the posterior peritoneal envelope and the posterior ab-
liver, spleen, and ascending and descending colon dominal wall (Fig. 9-5). The stomach, colon, and
(Fig. 9-4). The great vessels and the urologic and small bowel fill the parietal peritoneum and blanket
pancreaticoduodenal complexes lie between the the great vessels (Fig. 9-6).
Splenorenal lig.
Right colon
reflection
Transverse
Left colon mesocolon
reflection
Iliopsoas
indentation
True
pelvis
Esophagophrenic
Root of lig.
small bowel
mesentery
Falciform
Rectal lig.
peritoneal
reflection
Right triangular
lig.
Quadratus
lumborum m.
Iliacus m.
Psoas m.
Diaphragm
Fig. 9-4 The posterior parietal peritoneum is interrupted by numerous invaginations for

colonic and mesenteric attachments.

Fig. 9-5 The relationships of the major retroperitoneal structures
are shown.
Inferior
Superior
mesenteric a.
mesenteric a.
Celiac
trunk
Fig. 9-6 The hollow viscera blanket the great

vessels.
Diaphragm and the Supraceliac Abdominal Aorta central tendon (Fig. 9-7). The anterior two-thirds of
the circumferential origin attach to the free margin
To understand the relationships and approaches to of the costal cartilages and lower ribs. These slips
the proximal abdominal aorta, one must understand of origin interdigitate perpendicularly with the ori-
the anatomy of the diaphragm. The diaphragm gins of the transversus abdominis muscles. In the
consists of a crown of axial muscle fibers originat- deepest angle of the anterior sulcus thus formed,
ing from the rim of the inferior thoracic aperture the musculophrenic branches of the internal tho-
and inserting into a strong, aponeurotic, three-lobe racic arteries course along the costal margin on
Inferior phrenic v’s
Right phrenic n. Internal thoracic a. Musculophrenic a.
Left phrenic n.
Inferior
phrenic a.
Right
crus
Medial Lateral
lumbocostal lumbocostal
arch arch
Fig. 9-7 The origins and neurovascular supply of the diaphragm are shown.

each side. These vessels are transected when the The esophageal hiatus is muscular and consists
costal margin is divided. The internal thoracic ar- primarily of fibers from the right crus. Note the as-
teries penetrate the diaphragm between the sternal cending arrangement of aortic, esophageal, and in-
and costal slips. ferior vena cava openings.
Posteriorly, the diaphragm originates from the The topography of the diaphragm is best
lateral and medial lumbocostal arches spanning the appreciated when viewed from above (Fig. 9-8).
quadratus lumborum and psoas muscles, respec- The rim of the diaphragm reflects the inverted V
tively. The final components of the origins are the of the costal margin anteriorly, runs transversely
crura, which originate from the anterior surfaces around the posterior flanks, and appears to sprout
and anterior longitudinal ligament of the first three from the roots of the crura. The domes present a
lumbar vertebrae on the right and the first two on bilobed mammillation depressed centrally at the
the left. seat of the heart and indented posteriorly by the
The main blood supply on the undersurface of vertebral column and aorta. In this view, the ap-
the diaphragm consists of paired inferior phrenic ar- plication of the crura to several centimeters of ter-
teries that have a variable origin from the aorta or minal thoracic aorta above the aortic hiatus can be
its first major branches. These vessels have anterior appreciated.
and posterior divisions on each side. The veins fol- The inferior vena caval aperture is the most
low the arterial pattern and drain into the vena cava. cephalad and lies at the junction of the middle and
Right phrenic n. and

pericardiophrenic
vessels
Left phrenic n. and

pericardiophrenic
Pericardium vessels
Fig. 9-8 The undulating diaphragmatic contours wrap around the aorta and vertebral
bodies.

right lobes of the central tendon, directly beneath divides into anterior and posterior branches on the
the right atrium. The esophageal hiatus lies at an in- undersurface. The left phrenic follows a similar pat-
termediate level between the vena caval orifice and tern at the apex of the heart on the left.
the aortic hiatus, slightly to the left of midline. It is Viewed from behind, the enfolding of the
surrounded by muscular fibers of the right diaphrag- aorta by the diaphragmatic crura is evident, as
matic crus. is its anterior-posterior proximity to the lower
The motor innervation to the diaphragm is via esophagus (Fig. 9-9). The surest way to identify
the phrenic nerves, which also carry sensory fibers. the esophageal hiatus on abdominal exploration
Additional sensory fibers from the lower intercostal is to locate the pulsations of the aorta transmitted
nerves serve the periphery. The right phrenic nerve through the esophageal walls. The aortic passage
sends a branch to the cephalad surface of the dia- posterior to the diaphragm lies between the me-
phragm and then penetrates the right leaf of the cen- dian arcuate ligament connecting the crura anteri-
tral tendon just lateral to the vena caval orifice. It orly and the body of the T12 vertebra posteriorly.
Right phrenic n. and

pericardiophrenic
vessels
Right (posterior)
vagus n. Inferior
vena cava
Thoracic duct
Aorta
Azygous v.
Fig. 9-9 The diaphragmatic crura separate the intraabdominal esophagus from the lower
thoracic aorta.

Note the paraaortic structures and keep them in Exposure of the Upper Abdominal Aorta
mind when considering the anterior approach to
this segment of aorta. For purposes of discussion, the upper abdominal aorta
The supraceliac abdominal aorta is only 1 to can be anatomically divided into three segments by
2 cm in length (Fig. 9-10). Only the variable inferior the large visceral and renal branches that originate in
phrenic and T12 lumbar vessels arise from this short this area. The supraceliac aorta includes the portion
segment. The origin of the thoracic duct from the between the celiac artery and the mediastinum. The
cisterna chyli lies to the right of the aorta and passes visceral segment spans between the renal arteries and
beneath the right crus. the celiac axis and includes the origin of the superior
mesenteric artery. The juxtarenal area is the portion
within 1 cm above and below the renal arteries that
frequently overlaps with the visceral segment.
Exposure of the supraceliac aorta may be ac-
complished using transabdominal or retroperitoneal
approaches. Because the transabdominal approach
provides relatively limited exposure of the aorta
above the celiac axis, its use should be restricted to
situations in which more extensive exposure of the
upper abdominal aorta is not required. The trans-
abdominal approach is ideal for vascular control of
Thoracic duct the aorta above the celiac artery when control be-
low the level of the renal arteries is technically dif-
ficult, such as pararenal aneurysms, inflammatory
Cysterna aneurysms, ruptured aneurysms with disruption of
chyli local tissue planes, and aneurysms with hostile in-
frarenal aortic necks or prior endovascular repair.2–5
Clamp occlusion of the aorta above the celiac artery
has been associated with fewer complications com-
pared with occlusion between the renal and superior
mesenteric arteries in these circumstances.6,7 Lim-
ited exposure of the supraceliac aorta may also be
indicated in the construction of prograde bypasses
to the mesenteric and renal arteries.8 The segment of
aorta proximal to the celiac artery is often devoid of
plaque and may be an ideal site for placement of a
partial occlusion clamp during bypass construction.
The retroperitoneal approach allows more
extensive exposure of the juxtarenal and visceral
aorta. This approach has been used in the elective
treatment of aortic diseases of all types and appears
to confer important physiologic benefits compared
with transperitoneal exposures.9,10 We have found
it especially useful to treat juxtarenal aneurysms,
inflammatory aneurysms, and embolizing lesions
of the visceral aorta (“coral reef” syndrome). How-
ever, because access to the right renal and right iliac
arteries is limited, it should be avoided in patients
with extensive atherosclerosis in these locations.11
Operations that require full exposure of the
Fig. 9-10 The celiac trunk arises from the abdominal visceral, supraceliac, and lower thoracic segments
aorta within centimeters of the aortic hiatus. of the aorta cannot safely be performed through a

simple abdominal incision.12,13 Such exposure is Transabdominal Exposure of the Supraceliac Aorta
most commonly gained by simultaneously enter-
ing the abdominal and left thoracic cavities, the so- The patient is placed in the supine position, and the
called left thoracoabdominal approach. The unique chest, abdomen, groin, and thighs are prepped and
characteristics of vascular disease in this area and the draped. A longitudinal incision is made in the ab-
detrimental physiologic effects of thoracoabdomi- dominal midline from the xiphoid process to the um-
nal incisions have been chronicled elsewhere.14–16 bilicus. The peritoneal cavity is entered through the
The following discussions concern the limited linea alba, and the abdominal viscera is packed into
transabdominal exposure of the supraceliac aorta, the the lower half of the abdomen. The left lobe of the
more extensive retroperitoneal exposure of the visceral liver is retracted superiorly and to the patient’s right.
aorta, and the complete thoracoabdominal approach to Increased exposure may be gained by dividing the left
the lower thoracic and visceral aortic segments. Expo- triangular ligament of the liver (Fig. 9-11) and folding
sure of the infrarenal aorta is discussed in Chapter 12. the left lobe of the liver under a large Deaver retractor.
Left triangular
lig.
Diaphragm
Esophagophrenic
lig.
Left lobe
Esophagus
of liver
Fig. 9-11 When dividing the left triangular ligament to mobilize the lateral segment of the left lobe,
keep in mind the proximity of the hepatic veins and vena cava at the dome of the liver.

The lesser sac is entered through a longitu- curvature of the stomach (Fig. 9-12). Care should
dinal incision in the gastrohepatic ligament made be taken to avoid injuring a replaced or accessory
approximately 1 cm to the right of the esophagus (50:50) left hepatic artery, arising from the left gas-
and extended along the upper margin of the lesser tric in 10% to 15% of individuals. When present,
Right crus of Esophagophrenic

diaphragm lig.
Posterior Left vagus n.

peritoneum
of lesser
sac
Gastrohepatic
omentum
Fig. 9-12 Opening the gastrohepatic omentum exposes the right crus of the diaphragm.

this vessel runs in the cephalad portion of the gas- posterior peritoneum of the lesser sac. The aorta is
trohepatic ligament (Fig. 9-13). Retraction of the exposed by incising the posterior peritoneum and
esophagus and stomach to the left exposes the separating the two limbs of the right crus to cre-
right crus of the diaphragm, which lies beneath the ate a 5-cm opening over the anterior aortic wall
Gastrohepatic
(lesser) omentum
Replaced
L. hepatic a.
Left
gastric a.
Fig. 9-13 In 10% to 15% of individuals, a replaced or accessory left hepatic artery arises
from the left gastric artery and runs in the cephalad portion of the gastrohepatic ligament.

(Fig. 9-14). The medial and lateral walls of the circumferentially because of the limited exposure
aorta are cleared for a distance of 2 to 3 cm using and access with this approach. The index and mid-
blind finger dissection, which is not difficult be- dle fingers of the left hand are placed astride the
cause the aorta is devoid of periadventitial attach- cleared aorta as a guide for placement of an occlud-
ments in this area. The aorta should not be isolated ing clamp. A large, slightly curved clamp can be
Thoracic
aorta
Left gastric a.
Coronary v.
Fig. 9-14 The lower thoracic aorta can be exposed between the limbs of the right crus.

placed above and parallel to the fingers and pushed and arterial branches that cross this area, but care
posteriorly toward the vertebral column for aortic should be taken to avoid transecting a replaced left
occlusion (Fig. 9-15). hepatic artery (see above).7 Once divided, the muscle
Complete exposure of the supraceliac aorta is tissue is dissected laterally to expose a 5- to 7-cm
performed by vertically incising the median arcuate segment of aorta. The segment above the median
ligament and the right crus over the anterior aorta arcuate ligament is actually the descending thoracic
(Fig. 9-16). The incision is continued superiorly into aorta in the posterior mediastinum. The inferior
the posterior mediastinum until the entire crus has phrenic arteries arise from the aorta at variable levels
been divided. It is often necessary to divide venous in this area and should be identified to prevent injury.
Fig. 9-15 Proximal control for operations on the supraceliac abdominal aorta is obtained

by clamping the exposed thoracic aorta.

Median
arcuate lig. (cut)
Celiac
trunk
Fig. 9-16 Division of the aortic hiatus through the crura provides wider exposure of the
aorta.

Retroperitoneal Exposure of the Visceral Abdominal Aorta should be positioned so that the midpoint between the
left costal margin and the left iliac crest is centered
The patient is placed on a beanbag apparatus and the over the break in the table, then the table is jackknifed
left chest is rolled upward so that the scapula is el- to widen the space between the costal margin and
evated approximately 90° from the table. The pelvis is pelvic brim17 (Fig. 9-17). After air is evacuated from
twisted posteriorly to lie as flat as possible, and the left the beanbag to make it firm, the left chest and pelvis
arm is placed on an overhanging support. The patient should be further secured with wide adhesive tape.
Fig. 9-17 Patient positioning for retroperitoneal exposure of the visceral aorta. A: The

torso is twisted such that the pelvis lies horizontally and the left shoulder is rotated 90°
from the operating table. B: The table is jackknifed to widen the space between the costal
margin and pelvic brim.

To expose the most proximal portion of the interspace.17 The incision is deepened through sub-
abdominal aorta below the diaphragm, the incision cutaneous tissues, the external abdominal oblique
should begin in the 10th interspace, extending from aponeurosis, and the anterior rectus sheath. The ex-
the posterior axillary line to the abdominal midline ternal abdominal oblique muscle is split in the di-
approximately 1 cm below the umbilicus. Lower aor- rection of its fibers, and the internal oblique and the
tic exposure can be accomplished through the 11th left rectus muscles are divided using electrocautery

(Fig. 9-18). Branches of the epigastric vessels cours- The retroperitoneal plane is most easily entered
ing posterior to the rectus abdominis should be care- in the lateral wound by stripping the peritoneum
fully ligated. away from the abdominal wall using blunt finger dis-
The transversalis fascia is incised next, but the section. To enhance exposure, the peritoneum should
medial portion of the incision should stop 2 to 3 cm be dissected from the abdominal wall as far superi-
lateral to the midline because the underlying perito- orly and inferiorly as possible. Several small veins
neal surface may be adherent to the posterior rectus will be seen crossing the extraperitoneal space in the
sheath in this area. To facilitate exposure in the lateral lateral wound and should be cauterized during this
wound, we have found it advantageous to remove the maneuver. Dissection of the peritoneum proceeds
11th (or 12th) rib as far posteriorly as possible. The posteriorly, over the psoas muscle. To expose the
rib should be divided cleanly with a rib cutter, taking visceral aorta on its anterolateral surface, the kidney
care to avoid injuring the neurovascular bundle that should be mobilized anteriorly, allowing the ureter
courses just underneath the inferior rib margin. to be swept into the medial wound along with the
11th rib
External oblique
Internal oblique
Transversus
Fig. 9-18 The incision is begun in the 10th interspace and curved inferomedially to the
abdominal midline below the umbilicus.

peritoneal contents (Fig. 9-19). This is accomplished The left renal artery should be carefully iden-
by opening the anterior renal fascia and developing a tified in the areolar tissues overlying the left ante-
plane posterior to the kidney. A large lumbar branch rior surface of the aorta; Williams18 noted this to be
tethering the left renal vein on the lateral surface of the first important step in aortic exposure because
the aorta should be carefully ligated and divided dur- it is the only major structure that can be injured.
ing this maneuver. Exposure is improved by insert- After the left renal artery has been carefully ex-
ing deep blades of a self-retaining retractor to hold posed at its origin, dissection of the visceral aorta
the kidney and peritoneum anteriorly. proceeds by incising tissue surrounding the anterior,
Left renal v.
Lumbar v.
Fig. 9-19 Anterior mobilization of the left kidney requires careful ligation of a large
lumbar vein.

left lateral, and posterior surfaces. Proximal expo- accomplished by confining dissection to the ante-
sure to the level of the supraceliac segment is read- rior and posterior surfaces; circumferential control
ily obtained by dividing the diaphragmatic crus risks injury to the vena cava or other large venous
(Fig. 9-20). Vascular control of the aorta should be structures.18
Fig. 9-20 By incising the crus anterior to the supraceliac aorta (A), direct exposure
can be obtained to the level of the lowest thoracic segment (B).


Thoracoabdominal Incision for Extensive Exposure of the anesthesiologists routinely advocate cerebrospinal
Aorta, Including the Upper Abdominal and Lower Thoracic fluid drainage,16,19,20 epidural cooling,21,22 distal aor-
Portions tic perfusion,23 or a combination of techniques. Un-
fortunately, none of these adjunctive procedures is
Preoperative planning is extremely important to universally protective against paraplegia.24
minimize the morbidity of this approach. In addition After intubation, the patient is placed in the
to restoration of intravascular volume, all patients supine position on a beanbag apparatus. The left
should undergo optimization of cardiac and pulmo- scapula is elevated approximately 60° away from
nary parameters. A central venous catheter should the operating table so that the trunk is twisted.
be placed to monitor cardiovascular dynamics; de- The left arm is placed on an overhanging support,
pending on the experience of the anesthesiologist, and the beanbag is deflated. The left chest is fur-
monitoring with a pulmonary artery catheter or ther secured with wide adhesive tape (Fig. 9-21).
transesophageal echocardiography may be desirable. This unusual position has two advantages over the
Use of a double-lumen endotracheal tube enhances more traditional lateral thoracic position: it allows
exposure of the thoracic aorta during the procedure access to the femoral arteries should exposure at
by allowing the left lung to collapse while maintain- this level become necessary, and the trunk torsion
ing adequate right lung ventilation. To lessen the tends to widen the incision and lessen retraction
risk of spinal cord ischemia, many surgeons and requirements.

6th interspace
8th interspace
Fig. 9-21 Thoracoabdominal incisions in the sixth or eighth interspace can be extended down the
midline of the abdomen.

The precise location and extent of the tho- renal arteries. A type II aneurysm, the most exten-
racoabdominal incision should be dictated by the sive, descends from the left subclavian artery to the
specific area of aorta to be exposed. In most cases, infrarenal aorta. A type III aneurysm extends from
this is determined by the extent of aneurysmal dis- the middescending thoracic aorta to below the renal
ease. The most widely used classification of thora- arteries, and a type IV aneurysm extends from the
coabdominal aneurysms was originally proposed diaphragmatic aorta to the iliac bifurcation. In the
by Crawford et al.25 (Fig. 9-22). A Crawford type modified classification proposed by Safi et al.,26 a
I aneurysm begins just distal to the left subclavian type V aneurysm extends from the middescending
artery and extends to the visceral aorta above the thoracic aorta to above the renal arteries.
I II III IV V
Fig. 9-22 Classification of thoracoabdominal aneurysms.

The appropriate interspace level for the tho- fifth interspace. The descending thoracic aorta (an-
racic portion of the incision is determined by the eurysm types III and V) is best exposed through the
proximal extent of the aneurysm. Optimal exposure sixth interspace, whereas the eighth interspace is the
of the aorta at the level of the distal arch or subcla- optimal level for exposure of the aorta at the level
vian artery (aneurysm types I and II) is through the of the diaphragm (type IV aneurysm)26 (Fig. 9-23).
Fig. 9-23 The optimal level for the thoracic portion of the incision is determined by the
proximal extent of the aneurysm.

The length and location of the abdominal inci- extended to the abdominal midline to expose thora-
sion are determined by the distal extent of the an- coabdominal aneurysms involving the visceral aorta
eurysm. If limited exposure of the abdominal aorta (Fig. 9-24B). Type II, III, and IV aneurysms require
below the celiac artery is required (e.g., aneurysm more extensive exposure of the infrarenal abdomi-
types I and V), then the upper abdominal aorta can nal aorta; a more formal thoracoabdominal incision
be exposed through a modified thoracoabdomi- should be extended down the abdominal midline
nal incision26 (Fig. 9-24A). The incision should be (Fig. 9-24C).
Fig. 9-24 The abdominal portion of the incision is determined by the distal extent of the
aneurysm. A: The abdominal incision may terminate in the upper abdomen for aneurysms
that do not extend distal to the celiac artery. B: The incision should be extended to the
abdominal midline for aneurysms involving the visceral aortic segment. C: An extended
abdominal incision is required for aneurysms extending to the infrarenal aorta.

The incision is begun in the appropriate in- the anterior rectus sheath. The external abdominal
terspace, continued across the costal margin, and oblique muscle is split in the direction of its fibers,
extended obliquely to the abdominal midline and the underlying internal oblique and transversus
(Fig. 9-25). More distal exposure can be gained by abdominus muscles are divided between the costal
continuing the abdominal incision in the midline to margin and lateral edge of the rectus sheath. The
the level of the symphysis pubis. The abdominal left rectus muscle is divided, taking care to ligate
incision is deepened through subcutaneous tissue, branches of the epigastric vessels that course poste-
the external abdominal oblique aponeurosis, and rior to the muscle within the rectus sheath.
External
oblique m.
Serratus
anterior m.
Internal Costal
oblique m. margin
Rectus
abdominus m.
Stomach
Peritoneum
Omentum
Fig. 9-25 The layers of abdominal and chest walls are divided.

The thoracic portion of the incision should usu- abdominal aorta. The transperitoneal approach may
ally extend posteriorly as far as the erector spinae be preferred in cases in which visceral artery revas-
fascia. The incision is deepened through subcutane- cularization is planned, especially bypasses to the
ous tissue and the external oblique fascia to reach the right renal artery.
intercostal muscles over the appropriate interspace. The extraperitoneal approach proceeds by de-
Before entry into the left pleural cavity is attempted, veloping the plane between transversalis fascia and
the abdominal portion of the incision is developed. parietal peritoneum. The peritoneum is separated
The aorta may be reached by an extraperitoneal or from the lateral and posterior abdominal walls and
transperitoneal approach. The extraperitoneal tech- then from the diaphragm superiorly (Fig. 9-26).
nique may be ideal for repairing thoracoabdominal To assist in the development of the retroperitoneal
aneurysms, especially those involving the upper plane, wider exposure should next be gained by
Diaphragm
Peritoneum
Fig. 9-26 For the extraperitoneal approach to the abdominal aorta, the peritoneum is
separated from the undersurface of the diaphragm, and the chest is entered across the costal
margin.

opening the left thorax and dividing the diaphragm. complications; however, additional exposure of the
The intercostal muscles are divided, and the pleural aorta at the hiatus will be required. Complete divi-
cavity is entered on the superior border of the ninth sion proceeds from the divided costal margin to the
(or sixth or seventh) rib. Resection of the lower rib aortic hiatus. Some surgeons perform the incision ra-
aids in exposure and reduces pain associated with dially,28 while others29 prefer partial or complete di-
rib fracture from forceful retraction. It is important vision of the diaphragm in a circumferential fashion
to locate the intercostal vessels to prevent injury approximately 3 cm from the internal costal margin
during rib resection. A rib retractor is used to widen to avoid cutting major branches of the phrenic nerve.
the interspace, and the costal margin separating the The circumferential incision avoids transecting the
thoracic and abdominal wounds is divided. phrenic nerve branches, theoretically leading to ear-
The wound is further widened by incising the lier return of diaphragm function. This advantage
diaphragm, either partially or completely (Fig. 9-27). may prove extremely important because ventilatory
Partial incision through the muscular portion of the failure is one of the most common complications of
diaphragm with preservation of the central tendi- thoracoabdominal incisions. However, advocates of
nous portion has been recommended to minimize the radial incision technique have noted that circum-
respiratory complications.27 Preservation of the dia- ferential division is cumbersome, difficult to close,
phragm has been associated with reduced pulmonary and associated with equivalent results.28
Fig. 9-27 The diaphragm can be divided partially (A) or completely using radial (B) or
circumferential (C) incisions.

The retroperitoneal tissue plane in the poste- undersurface of the diaphragm, the pancreas is re-
rior abdomen can now be easily developed to the flected anteromedially along with the peritoneal
aorta. The anterior renal fascia is opened, and the contents. During exposure of the juxtarenal aortic
plane posterior to the left kidney is developed. segment, it is important to identify the left renal ar-
The left kidney is mobilized anteriorly along with tery in the areolar tissues overlying the anterome-
the adrenal gland, spleen, and pancreas (Fig. 9-28). dial surface of the aorta. The left renal artery will
The large lumbar branch of the left renal vein be in an unusual location when the left kidney is
should be ligated and divided during this maneu- retracted anteriorly, making it prone to accidental
ver (Fig. 9-19). The left ureter should be identified transection as the periaortic tissues are incised. The
and reflected with the mobilized retroperitoneal distal abdominal aorta and proximal left common
tissue. As the peritoneum is removed from the iliac artery are exposed by reflecting the peritoneal
Peritoneum
Diaphragm
Renal
fascia
Fig. 9-28 The anterior renal fascia is opened, and the kidney is mobilized along with the
upper abdominal organs on the left.

sac in the distal wound and ligating the inferior vessels can be exposed through a separate right
mesenteric artery at its origin (Fig. 9-29). Exposure flank incision (see Chapter 12).
of the more distal left iliac artery or any portion If the transperitoneal approach to the retro-
of the right iliac artery is technically difficult us- peritoneal tissue plane is chosen, the peritoneum
ing the extraperitoneal approach; revascularization should be opened for the full length of the abdominal
of these vessels should be performed at the level wound, up to the costal margin. A relatively avas-
of the femoral arteries. Alternatively, the right iliac cular plane is developed posterior to the left colon
Inferior
mesenteric a.
(ligated)
Diaphragm
Fig. 9-29 Further mobilization in the extraperitoneal plane along the left gutter exposes
the lower abdominal aorta.

mesentery by dividing the lateral peritoneal attach- of the left renal vein. The left kidney, adrenal gland,
ments along the left gutter and mobilizing the left spleen, pancreas, stomach, colon, and intestines are
colon medially (Fig. 9-30). Medial reflection of the all reflected to the midline, exposing the abdominal
colon and its mesentery is carried cranially to the aorta from the bifurcation to the diaphragm. Expo-
level of the spleen. The spleen is mobilized from the sure of the left iliac arteries and right common iliac
posterior peritoneum by dividing the splenorenal and artery is accomplished by reflection of the sigmoid
splenophrenic ligaments. Wider exposure is obtained colon and its mesentery in the distal wound.
at this juncture by opening the left pleural cavity and To expose the descending thoracic aorta through
incising the diaphragm as described above. The left the thoracoabdominal incision, the inferior pulmo-
kidney and adrenal gland are mobilized and reflected nary ligament and any adhesions between the left
anteriorly after dividing lumbar and gonadal branches lung and aorta are incised, allowing the left lung to
Fig. 9-30 The intraperitoneal approach to organ mobilization is shown.

deflate and be retracted superomedially (Fig. 9-31). The segment of the aorta immediately proxi-
The parietal pleura is incised directly over the seg- mal to the celiac artery is exposed by dividing the
ment of thoracic aorta to be exposed, gaining access left crus of the diaphragm. By extending the incision
to the lateral periadventitial plane. Using blunt dis- from the lateral side of the aortic hiatus through the
section, the aorta is carefully encircled at a level de- left crus to the posterior margin of the circumferen-
sired for proximal control. This is performed most tial incision, the entire thoracoabdominal aorta can
easily between intercostal arterial branches. be exposed.
Inferior
pulmonary v.
Inferior
pulmonary lig.
Fig. 9-31 The lower thoracic aorta is exposed by dividing the inferior pulmonary ligament
up to the inferior pulmonary vein.

References 15. Martin GH, O’Hara PJ, Hertzer NR, et al. Surgical re-
pair of aneurysms involving the suprarenal, visceral,
1. Lei QF, Marks SC, Touliopoulos P, et al. Fascial and lower thoracic aortic segments: early results and
planes of the posterior abdomen: the perirenal and late outcome. J Vase Surg. 2000;31:851–862.
pararenal pathways. Clin Anat. 1990;3:115. 16. Coselli JS, Bozinovski J, LeMaire SA. Open surgical
2. Back MR, Bandyk M, Bradner M, et al. Critical anal- repair of 2,286 thoracoabdominal aortic aneurysms.
ysis of outcome determinants affecting repair of in- Ann Thorac Surg. 2007;83:S862–S864.
tact aneurysms involving the visceral aorta. Ann Vasc 17. Shepard AD, Tollefson DFJ, Reddy DJ, et al. Left
Surg. 2005;19:648–656. flank retroperitoneal approach: a technical aid
3. Tang T, Boyle JR, Dixon AK, et al. Inflammatory to complex aortic reconstruction. J Vasc Surg.
abdominal aortic aneurysms. Eur J Endovasc Surg. 1991;14:283–291.
2005;29:353–362. 18. Williams GM. Extraperitoneal exposure of the aorta.
4. Wahlgren CM, Piano G, Desai T, et al. Transperitoneal Semin Vase Surg. 1989;2:217–222.
versus retroperitoneal suprarenal cross-clamping for 19. Estrera AL, Sheinbaum R, Miller CC, et al. Cerebro-
repair of abdominal aortic aneurysm with a hostile in- spinal fluid drainage during thoracic aortic repair:
frarenal aortic neck. Ann Vasc Surg. 2007;21:687–694. safety and current management. Ann Thorac Surg.
5. Mehta M, Paty PSK, Roddy SP, et al. Treatment op- 2009;88:9–15.
tions for delayed AAA rupture following endovascu- 20. Fedorow CA, Moon MC, Mutch WA, et al. Lumbar
lar repair. J Vasc Surg. 2011;53:14–20. cerebrospinal fluid drainage for thoracoabdominal
6. Darling RC III, Cordero JA Jr, Chang BB, et al. aortic surgery: rationale and practical considerations
Advances in the surgical repair of ruptured ab- for management. Anesth Analg. 2010;111:46–58.
dominal aortic aneurysms. Cardiovasc Surg. 21. Tabayashi K, Saiki Y, Kokubo H, et al. Protection from
1996;4:720–723. postischemic spinal cord injury by perfusion cooling
7. Schneider JR, Gottner RJ, Golan JF. Supraceliac of the epidural space during most or all of a descend-
versus infrarenal aortic cross-clamp for repair of ing thoracic or thoracoabdominal aneurysm repair.
non-ruptured infrarenal abdominal aortic aneurysm. Gen Thorac Cardiovasc Surg. 2010;58:228–234.
Cardiovasc Surg. 1997;5:279–285. 22. Black JH, Davidson JK, Cambria RP. Regional hy-
8. Oderich GS, Gloviczki P, Bower TC. Open sur- pothermia with epidural cooling for prevention of
gical treatment for chronic mesenteric ischemia spinal cord ischemic complications after thoracoab-
in the endovascular era: when is it necessary and dominal aortic surgery. Semin Thorac Cardiovasc
what is the preferred technique? Semin Vasc Surg. Surg. 2003;15:345–352.
2010;23:36–46. 23. Hsu CC, Kwan GN, van Driel ML, et al. Distal aortic
9. Borkon MJ, Zaydfudim V, Carey CD, et al. Retro- perfusion during thoracoabdominal aneurysm repair
peritoneal repair of abdominal aortic aneurysms of- for prevention of paraplegia. Cochrane Database
fers postoperative benefits to male patients in the Syst Rev. 2012;3:CD008179.
Veterans Affairs Health System. Ann Vasc Surg. 24. Shimizu H, Yozu R. Current strategies for spinal
2010;24:728–732. cord protection during thoracic and thoracoabdomi-
10. Arko FR, Bohannon WT, Mettauer M, et al. Retro- nal aortic aneurysm repair. Gen Thorac Cardiovasc
peritoneal approach for aortic surgery: is it worth it? Surg. 2011;59:155–163.
Cardiovasc Surg. 2001;9:20–26. 25. Crawford ES, Crawford JL, Safi HJ, et al. Thoracoab-
11. Cambria RP, Brewster DC, Abbott WM, et al. Trans- dominal aortic aneurysm: preoperative and intraop-
peritoneal versus retroperitoneal approach for aor- erative factors determining immediate and long-term
tic reconstruction: a randomized prospective study. results of operations in 605 patients. J Vase Surg.
J Vase Surg. 1990;11:314–325. 1986;3:389–409.
12. LeMaire SA, Green SY, Kim JH, et al. Thoracic or 26. Safi HJ, Miller CC III, Huynh TTT, et al. Thoracoab-
thoracoabdominal approaches to endovascular de- dominal aortic aneurysm graft repair. Contemp Surg.
vice removal and open aortic repair. Ann Thorac 2000;56:666–675.
Surg. 2012;93:726–732. 27. Engle J, Safi HJ, Miller CC III, et al. The impact of
13. Wong DR, Parenti JL, Green SY, et al. Open repair diaphragm management on prolonged ventilator sup-
of thoracoabdominal aortic aneurysms in the modern port after thoracoabdominal aneurysm repair. J Vase
surgical era: contemporary outcomes in 509 patients. Surg. 1999;29:150–156.
J Mm Coll Surg. 2011;212:569–579. 28. Acher CW, Wynn MM. Technique of thoracoabdomi-
14. Safi HJ, Estrera AL, Azizzadeh A, et al. Prog- nal aneurysm repair. Ann Vase Surg 1995;9:585–595.
ress and future challenges in thoracoabdomi- 29. Gilling-Smith GL, Wolfe JHN. Thoracoabdominal
nal aortic aneurysm management. World J Surg. aneurysms: which patients should we operate on?
2008;32:355–360. Perspect Vase Surg. 1995;8:29–53.

Liver
Left gastric a.
Stomach
Median
T-12 arcuate lig.
Hepatic a.
Celiac trunk
Pancreas Splenic a.
L-1
Splenic v. Superior
mesenteric a.
Right renal a.
Transverse L-2
colon Left renal v.
Duodenum
Right colic a. L-3
Inferior
Iliocolic a. mesenteric a.
L-4
Omentum Aortic
bifurcation
Left common
iliac a.
Superior
rectal a.
Fig. 10-1 The origins of the major mesenteric vessels are shown in relation to the adjacent
vertebral bodies.

Celiac and
Mesenteric Arteries
10
Surgical Anatomy of the Mesenteric Vessels superior mesenteric arteries, arise within centime -
ters of each other at the level of the first lumbar ver-
Three large, unpaired midline vessels supply the tebra (Fig. 10-1). The third, the inferior mesenteric
majority of organs enclosed by the outer envelope artery, arises from the anteri or wall of the aorta at
of parietal peritoneum. Two of these, the celiac and the level of the third lumbar vertebra.
273
Celiac Trunk the celiac trunk. Inside the omental bursa lies a final
covering membrane, the posterior parietal perito-
The celiac trunk is closely flanked by the median neum. Beneath the peritoneum, the celiac trunk is
arcuate ligament of the aortic hiatus above and the surrounded by lymphatic and nerve plexuses.
superior border of the pancreas below (Fig. 10-2). The celiac trunk is almost perpendicular to the
Viewed from an anterior perspective, the celiac aorta. The three branches of the celiac trunk most of-
trunk lies beneath the overlapping edges of the liver ten form a trifurcation (see variations, Chapter 19).
and stomach. On separating these two or gans, the One significant vein, the left gastric (or coronary)
connecting gastrohepatic ligament, which forms the vein, crosses over the celiac trunk in its course from
anterior wall of the omental bursa, is seen overlying the lesser curve of the stomach to the portal vein.
Median arcuate ligament
Anterior vagus n.
Left gastric
(coronary) v.
Posterior vagus n.
Hepatic a.
Celiac branch of
posterior vagus n.
Left gastric a.
Celiac trunk
Splenic a.
Superior
Inferior mesnteric a.
vena cava Left renal v.
Splenic v.
Common
Portal v.
bile duct
Gastroduodenal a.
Right gastric a.
Fig. 10-2 The gastrohepatic omentum and posterior peritoneum of the omental bursa have
been removed to expose the celiac trunk.

The hepatic artery passes to the right beneath of the spleen, it gives off short gastric branches and
the posterior peritoneum of the omental bursa, enters the left gastroepiploic artery that run in the gastro -
the hepatoduodenal ligament just cephalad to the py- splenic ligament and the gastrocolic ligament, re-
lorus, and ascends to the hilum of the liver on the left spectively (Fig. 10-3).
side of the common bile duct.The terminal branching The left gastric artery ascends a short distance
of the hepatic artery is highly variable, and alternate beneath the peritoneum to reach the lesser curve of
origins of hepatic artery branches are not uncommon. the stomach at the gastroesophageal junction. It is
The splenic artery descends beneath the peri- accompanied by the left gastric (coronary) vein and
toneum to undulate along the cephalad border of the celiac branch of the posterior vagus nerve. When
the pancreas where it gives of f a significant dorsal the esophagus is mobilized, the left gastric artery
pancreatic branch and a few smaller branches. After limits the surgeon from sliding a finger further down
dividing into four to five branches near the hilum the posterior wall of the stomach.
L. gastric a. Splenic a.
Common hepatic a.
Short gastric a’s
Gastroduodenal a.
R. gastroepiploic a. L. gastroepiploic a.
Fig. 10-3 Anastomoses of celiac branches around the stomach are shown.
Celiac and Mesenteric Arteries | 275

Superior Mesenteric Artery colic artery into the overlying root of transverse
mesocolon. At the level of the uncinate process,
The origin of the superior mesenteric artery from the superior mesenteric artery also gives rise to the
the aorta forms a sharp caudal angle. The left renal inferior pancreaticoduodenal artery, which makes
vein is wedged into the acute angle. The first part a potentially important connection with the celiac
of the superior mesenteric is crossed by the neck of circulation through the pancreaticoduodenal arcade.
the pancreas and the splenic vein. Behind the neck The continuation of the superior mesenteric
of the pancreas, the artery conver ges with the supe- artery gives rise to two named branches and numer-
rior mesenteric vein so that the two structures are ous vessels supplying the small bowel. Shortly af -
side by side at the lower mar gin of the pancreatic ter crossing the duodenum, the superior mesenteric
neck (Fig. 10-4). The vessels then pass over the un - gives off the right colic artery, which lies within the
cinate process of the pancreas and the third portion fused mesentery of the right colon. The ileocolic
of the duodenum to enter the root of the small bowel branch arises in common with or distal to the right
mesentery. colic and descends toward the cecum. The root of
As soon as the superior mesenteric artery the small bowel mesentery passes from midline to
emerges below the pancreas, it sends the middle the right lower quadrant, allo wing mobilization of
Gastroduodenal a.
R gastroepiploic a.
Anterior
superior
pancreatico-
duodenal a.
Superior
Anterior mesenteric a.
inferior
pancreatico-
duodenal a.
Superior
mesenteric v.
Middle colic a.
R. colic v.
Fig. 10-4 The superior mesenteric artery and vein lie together over the third portion of the
duodenum and uncinate process of the pancreas.

this mesentery to the right for exposure of the aorta 5 cm of its origin, the artery first gives of f a left
(Fig. 10-5). colic branch and then several sigmoidal branches
into the mobile sigmoid mesentery and finally ter-
Inferior Mesenteric Artery minates as the superior rectal branch. The latter
crosses over the left iliac vessels to reach the pos -
The inferior mesenteric artery emerges near the terior wall of the upper rectum (Fig. 10-1). In some
lower border of the third portion of the duodenum cases of superior mesenteric occlusive disease,
where the latter crosses the aorta (Fig. 10-1). It is mesenteric channels between the left colic and mid-
closely applied to the aorta as it passes to the left dle colic arteries hypertrophy to form a meandering
into the fused mesentery of the left colon. Within mesenteric artery (described by Riolan, see below),
Hepatic v’s
Esophagus
Hepatoduodenal
lig.
Root of
transverse
mesocolon
Duodenum
Root of
small
bowel
mesentery
Inferior
mesenteric a.
Sigmoid
mesentery
Fig. 10-5 The superior mesenteric artery can be located where the roots of the transverse
mesocolon and small bowel mesentery meet.

which supplements the deficient superior mesen - enlarged accessory collateral between the inferior
teric system. and superior mesenteric circulations. This so-called
meandering mesenteric artery (of Riolan) is named
Collateral Visceral Circulation for its tortuous appearance within the transverse me-
socolon owing to extensive hypertrophy in patients
Major communications among the three levels of with occlusive disease of the superior or inferior
visceral vessels provide collateral circulation in mesenteric branches. The inferior mesenteric circu-
case of segmental occlusion (Fig. 10-6). The pan- lation is also supported by collaterals between the
creaticoduodenal arcade connects the celiac and su- superior rectal artery and the inferior rectal branches
perior mesenteric circulations. The marginal artery of the internal iliac artery.
(of Drummond) is composed of the left branch of
the middle colic artery and the ascending branch of
the left colic artery. If complete across the splenic Exposure of the Mesenteric Arteries
flexure, the marginal artery may be adequate to
maintain visceral perfusion between the superior The collateral network between the three main
and inferior mesenteric circulations when one or arteries of the mesenteric circulation provides a
the other is occluded. Some individuals develop an margin of safety for bowel viability when flow to
Pancreaticoduodenal
arcade
Marginal a.
(of Drummond)
Meandering
mesenteric a.
(arc of Riolan)
Fig. 10-6 The celiac, superior mesenteric, and

inferior mesenteric circulations are connected by
collateral vessels.

one or more of the mesenteric arteries is slowly In contrast to chronic mesenteric arterial insuf-
reduced by atherosclerotic occlusive disease. In ficiency, acute occlusion of a single mesenteric ar -
general, flow in at least two of the three arteries tery usually produces sudden abdominal symptoms
must be reduced to produce symptoms of chronic because adequate collateral circulation does not have
intestinal ischemia.1 There appear to be many ex- time to develop. The superior mesenteric artery is
ceptions to this rule, however . Occlusion of two the most common site for acute occlusive mesenteric
or even all three of the vessels has been observed arterial insufficiency,9,10 and rapid restoration of flow
in asymptomatic individuals. 2,3 Conversely, the in this artery is necessary if intestinal necrosis is to
compression of a single mesenteric artery (the be avoided. The nonocclusive variety of mesenteric
celiac axis) by the median arcuate ligament or ischemia is adequately summarized elsewhere.10,11
by abnormal celiac ganglion fibers is believed The two common causes of acute flow interrup-
by many authors to be responsible for symptoms tion in the proximal superior mesenteric artery are of-
of mesenteric ischemia in the so-called celiac ten distinguishable at laparotomy. Thrombosis usually
axis compression syndrome.4,5 This syndrome re- occurs near the superior mesenteric artery origin, lead-
mains controversial because several authors have ing to gangrene of the entire small bowel and proxi -
shown that release of celiac axis compression mal half of the colon. In contrast, emboli usually lodge
may not permanently relieve symptoms in some near the point where the middle colic artery branches
patients.6,7 Furthermore, up to 5% of healthy, from the superior mesenteric artery , maintaining via-
asymptomatic individuals have evidence of ce - bility of a small segment of proximal jejunum through
liac compression on CT.8 the first few jejunal branches9 (Fig. 10-7).
Fig. 10-7 Superior mesenteric emboli

usually lodge at a point that spares a
Thrombosis
small segment of proximal jejunum.
Thrombosis, in contrast, affects the
entire midgut circulation.
Embolus

Endovascular techniques are a useful alterna - an alternative to bypass, retrograde stenting of the oc-
tive in some patients with chronic mesenteric isch- cluded superior mesenteric artery can be performed at
emia, but surgical treatment is still considered the the time of operative exploration and may shorten the
gold standard: surgical revascularization has been time of ischemia in an ill patient.18
associated with a lower incidenceof recurrent symp- The following discussions concern the expo -
toms compared with percutaneous angioplasty and sure of mesenteric arteries using a transperitoneal
stenting.12,13 Open surgical treatment with embolec- approach through abdominal incisions. The retro-
tomy or bypass is also indicated in acute mesenteric peritoneal approach using thoracoabdominal inci-
ischemia. Although direct infusion of thrombolytic sions favored for use in transaortic endarterectomy
agents through a percutaneou s catheter can restore is discussed in detail in Chapter 9.
superior mesenteric artery flow,14 operative inter-
vention for acute mesenteric ischemia affords the Transperitoneal Exposure of the Celiac and Superior
opportunity to inspect the intestine for viability. Mesenteric Arteries at Their Origins
Superior mesenteric artery embolectomy is a
simple and durable operation for the correction of The patient is placed in the supine position, and
acute embolic occlusions.9 The best method for restor- the entire abdomen and lower chest are prepped
ing mesenteric flow in patients with thrombotic occlu- and draped. A longitudinal incision is made in the
sion is controversial and dependent on the underlying midline, extending from the xiphoid process to the
disorder. Excellent long-term results have been re - umbilicus. The wound is deepened through subcuta-
ported for antegrade bypasses,15 retrograde bypasses16 neous tissue, the linea alba is incised, and the peri-
(see Fig. 10-16), and transaortic endarterectomy.17 As toneum is entered under direct vision. After routine
Fig. 10-8 The left triangular ligament

is incised to allow the lateral segment of
the left lobe of the liver to be retracted to
the right, and the gastrohepatic omentum
is opened to approach the cel iac trunk
directly.

examination of the peritoneal contents, the wound of the lower esophagus and lesser curvature to the
edges are retracted with a self-retaining device. patient’s left exposes the celiac artery trunk and its
The left triangular ligament is incised, allow- major branches lying deep to the posterior parietal
ing mobilization and retraction to the right of the lat- peritoneum. The distal thoracic aorta is exposed by
eral segment of the left hepatic lobe (Fig. 10-8). The opening the posterior peritoneum and vertically di-
underlying gastrohepatic ligament is opened from viding the median arcuate ligament and interdigitat-
the gastroesophageal junction to the pylorus, tak - ing fibers of the left and right crura over the anterior
ing care to preserve the vagus nerve fibers near the aortic surface (Fig. 10-9). Exposure of the celiac ar-
lesser curvature of the stomach. Gentle retraction tery is accomplished by dividing the celiac ganglion
Celiac branch of
Median arcuate posterior vagus n.
lig.
Left gastric a.
Celiac
ganglion
Thoracic duct
Cysterna chyli
Splenic a.
Left gastric
(coronary) v.
divided
Hepatic a.
Splenic v.
Pancreas
Fig. 10-9 The posterior parietal peritoneum and median arcuate ligament are opened to
gain access to the celiac trunk.

(Fig. 10-10), which surrounds the celiac artery 3 to cases19 and should be controlled during celiac trunk
5 mm from its origin and may be associated with isolation.
a thick layer of fibrous tissue. The inferior phrenic The superior mesenteric artery origin is exposed
arteries originate from the celiac artery in 47% of by mobilizing the superior border of the pancreas
Celiac ganglion
Cysterna chyli
Lymph node
Fig. 10-10 The celiac ganglion must be cleared to fully expose the celiac trunk.

(Fig. 10-11) and continuing the dissection on the an- origin of the superior mesenteric artery is exposed
terior surface of the aorta caudal to the celiac trunk.20 posterior to the neck of the pancreas, which is mobi-
The dissection proceeds between the superior border lized and retracted anteriorly along with the splenic
of the pancreas and the hepatic and splenic artery vein. Care should be taken to avoid inadvertent in -
branches. To prevent avulsing pancreatic branches of jury to the inferior pancreaticoduodenal arteries dur-
the splenic artery, lateral dissection or forceful retrac- ing mobilization of the superior mesenteric artery. If
tion of the superior pancreatic border to the left of the peripancreatic inflammation or other local pathology
aorta should be avoided. Fibers of the celiac ganglion renders exposure of the superior mesenteric artery
caudal to the celiac artery trunk should be cleared origin difficult or dangerous, the artery can be iso -
to expose the small intervening aortic segment. The lated in the intestinal mesentery (see below).
Left renal v.
Splenic v.
Fig. 10-11 The superior mesenteric artery origin can be exposed by retracting the superior
border of the pancreas caudally.

Exposure of the Superior Mesenteric Artery in the Intestinal After the peritoneal cavity is entered under
Mesentery direct vision, the peritoneal contents are rapidly
evaluated, noting especially the location and ex-
There are two popular approaches for exposure of tent of bowel necrosis. To approach the superior
the superior mesenteric artery distal to the inferior mesenteric artery anteriorly, the transverse colon
border of the pancreas. The anterior approach at the and omentum are elevated, and the intestines are
base of the transverse mesocolon is rapid and quite wrapped in moist laparotomy packs and retracted
adequate for simple embolectomy in cases of acute to the right. A horizontal incision is made in the
occlusion. However, retrograde bypasses from the peritoneum at the base of the transverse mesoco -
infrarenal aorta cannot be routed to the anteriorly lon, extending from the duodenal–jejunal junc-
exposed superior mesenteric artery without cross - tion toward the patient’ s right. The middle colic
ing the duodenum. In these cases, a lateral approach artery should be identified in the transverse me-
craniad to the fourth portion of the duodenum is socolon and traced proximal ly to locate its origin
necessary. from the superior mesenteri c artery (Fig. 10-12).
Fig. 10-12 An anterior approach to

the superior mesenteric artery at the
base of the transverse mesocolon is
preferred in cases of acute embolic
occlusion.
Superior mesenteric a.
Middle colic a. and v.
Right colic a.

The segment of superior mesenteric artery
between the middle and right colic artery branches
is readily isolated from surrounding lymphatics and
autonomic nerve fibers. It is important to p reserve
any jejunal branches seen before proceeding
with the embolectomy (Fig. 10-13). Extreme care
should be taken not to injure the fragile superior
mesenteric artery or its branches during isolation.
Exposure of more proximal segments is possible
by judicious cephalad retraction of the inferior
pancreatic border.
Fig. 10-13 Isolation, arteriotomy, and embolectomy

of the superior mesenteric artery are shown.

To expose the superior mesenteric artery from mesenteric artery can be isolated in the tissues ceph-
a lateral approach, the fourth portion of the duode- alad to the duodenum (Fig. 10-14). Proximal expo-
num should be mobilized by dividing Treitz’s liga- sure is enhanced by retracting the inferior border of
ment and other peritoneal attachments. The superior the pancreas to the level of the left renal vein.
Superior mesenteric a.
Middle
colic a. and v.
Left renal v.
Fig. 10-14 For bypassing a chronic superior mesenteric artery stenosis, the fourth portion
of the duodenum is mobilized to expose both the subpancreatic portion of the mesenteric
artery and subjacent aorta.

Several alternatives are available for mesenteric and with minimal dissection (Fig. 10-15). However,
reconstruction. Short bypasses to the superior mes - because of the frequent coexistence of atheroscle-
enteric artery routed in retrograde fashion directly rotic plaque in the infrarenal aorta, other inflow sites
from the infrarenal aorta can be completed rapidly are generally preferred. Superior patency rates have
Left renal v.
Fig. 10-15 A short, wide synthetic graft from the aorta to the superior mesenteric artery
creates a retrograde bypass.

been reported using either long, retrograde C-loop or antegrade bypasses routed posterior to the pan-
configurations from the right iliac artery (Fig. 10-16) creas from the supraceliac aorta15,16 (Fig. 10-17).
Fig. 10-16 A retrograde C-loop bypass

from the right iliac artery to the superior
mesenteric artery is shown.
Fig. 10-17 An antegrade supraceliac aorta

to superior mesenteric artery bypass is
shown.

Exposure of the Inferior Mesenteric Artery the duodenum is mobilized to the right with the rest
of the small intestine (Fig. 10-18). The abdominal
Isolated revascularization of the inferior mesenteric aorta is exposed by incising the posterior parietal
artery may be necessary in rare cases when revas - peritoneum. It is important to confine the dissection
cularization of the other maj or mesenteric arteries to the right of the aortic midline to avoid inadver -
is not possible owing to inadequate outflow or ex - tent injury to the inferior mesenteric artery or its
tensive intraabdominal adhesions.21 Evidence of a branches. Fibrous tissue overlying the anterior wall
large, intact collateral circulation with the inferior of the aorta should be ligated and divided to prevent
mesenteric artery must be present.21 lymphatic leak. The glistening surface of the aortic
Patient positioning and surgical preparation adventitia is recognized by incising a thin, fibrous
are as previously described. Most authors prefer sheath, allowing entry into the periadventitial plane.
vertical midline incisions, but transverse infraum- The aorta should be cleared of overlying tissue from
bilical incisions yield excellent exposure and su- the area just proximal to the bifurcation to the level
perior wound healing. 22 After the peritoneal cavity of the left renal vein. The inferior mesenteric artery
has been entered, the transverse colon is elevated, is recognized arising from the anterior surface of
wrapped in moist laparotomy pads, and placed on the aorta just to the left of the aortic midline, ap-
the superior abdominal wall. The small intestine is proximately 3 to 4 cm above the aortic bifurcation.
wrapped in moist laparotomy pads or in a bowel Isolation of the inferior mesenteric artery should be
bag and gently retracted to the right. After Treitz’s performed as close to its origin as possible to avoid
ligament and other duodenal adhesions are incised, injuring its nearby branches.
Left renal v.
Fig. 10-18 The inferior mesenteric artery is exposed by incising the posterior peritoneum

below the mobilized duodenum, staying to the right of midline.

Exposure of the Hepatic Artery the hepatic circulation, it is imperative to obtain pre-
operative imaging with CT, MR, or catheter angiog-
The hepatic artery has been used to revascularize raphy. To rule out the existence of occlusive disease
the right renal artery in cases in which aortic pathol- at the origin of the celiac axis, lateral views should
ogy or previous retroperitoneal surgery renders aor- be included in the preoperative studies.2
tic exposure difficult or dangerous (see Chapter 11, The patient is placed in the supine position
Fig. 11-14). Although aortorenal bypass is generally with the right flank elevated on a rolled sheet
preferred, the hepatorenal bypass is considered a (Fig. 10-19). The lower chest, abdomen, groin, and
safe and durable alternative for revascularization of thighs are prepped and draped. A right subcostal
the right kidney in patients with renovascular hy - incision is made 4 to 5 cm below and parallel to the
pertension or ischemic nephropathy .23,24 The hepa- inferior costal margin, extending from the midline
torenal bypass is also an excellent option to allow to a point opposite the tip of the right 1 1th rib.27
more proximal placement of aortic endografts in pa- When necessary in lar ge or obese individuals, the
tients with unsuitable infrarenal neck anatomy.25,26 incision may be carried across the midline as a
Because of the extreme variability in the anatomy of chevron.28
Fig. 10-19 The hepatic artery is approached through a right subcostal incision.

The area of the hepatoduodenal ligament is left side of the common duct. The artery should be
exposed by retracting the right lobe of the liver su- carefully mobilized and encircled with elastic ves-
periorly and packing the intestines and right colon sel loops on both sides of the gastroduodenal artery.
into the inferior wound with moist laparotomy Bypasses may be anastomosed to the side of the
packs (Fig. 10-20). The hepatoduodenal ligament hepatic artery either proximal or distal to the gastro-
is incised transversely near the superior wall of the duodenal artery,27 or the gastroduodenal artery can
duodenum, and the hepatic artery is located on the be sacrificed and used as a direct source of inflow.29
Celiac trunk
Right gastric a.
Hepatic a.
Gastroduodenal a.
Pylorus
Fig. 10-20 The hepatic artery is exposed by incising the gastroduodenal ligament above

the pylorus.

Exposure of the Splenic Artery attachments and developing a relatively bloodless
plane between the left colon mesentery and the an -
The splenic artery has been used as an alternative terior surface of Gerota’s fascia. After the left colon
source of inflow for left renal artery revasculariza- has been reflected to the level of the splenic flexure,
tion in cases in which the aorta cannot be used be - the spleen is mobilized by incising the splenophrenic
cause of previous surgery, local pathology, or severe and splenorenal ligaments. A plane between the pan-
atherosclerosis23,24 (see Chapter 11, Fig. 11-14). creas and Gerota’s fascia is developed bluntly, al-
The splenorenal bypass has also been used to allow lowing the spleen and distal pancreas to be reflected
more proximal placement of an aortic endograft in anteriorly and medially (Fig.10-21). The splenic
patients with unsuitable infrarenal neck anatomy.26 artery is easily identified near the superior border
To document the adequacy of flow, preoperative of the pancreas. To avoid kinking associated with
imaging studies should be obtained to document redundancy, only the central portion of the splenic
splenic artery patency and to rule out the existence artery should be dissected and mobilized. The distal
of occlusive disease at the origin of the celiacartery.2 portion is often smaller in caliber and should be left
The patient is placed in the supine position undisturbed. Pancreatic branches should be ligated
with the left flank elevated on a rolled sheet. The with fine silk sutures before being divided to pre -
lower chest, abdomen, groins, and anterior thighs are vent troublesome bleeding that occurs when hemo-
prepped and draped. Although Moncure et al.27 and clips are dislodged. Sufficient length of the splenic
Brewster and Darling30 advocate a thoracoabdominal artery should be obtained by proximal mobilization
incision for exposure of the splenic artery, Novick to allow a tension-free anastomosis with the left re -
et al.31,32 have achieved excellent visualization and nal artery. After the splenic artery is clam ped and
exposure through a bilateral subcostal incision. It is divided, the distal end should be ligated , and the
extremely helpful to use self-retaining retractors for proximal end gently dilated with a balloon embo -
cranial elevation of the superior wound. lectomy catheter or graduate d probes to overcome
After routine exploration of the peritoneal cav- spasm.30,31 The spleen receives sufficient blood sup-
ity has been performed, the transverse colon is el - ply from the short gastric and gastroepiploic collat-
evated and the small intestines are wrapped in warm erals and should not require removal. 30–32 However,
laparotomy packs and retracted to the right. The left splenic infarction has been reported after a spleno -
colon is mobilized by incising its lateral peritoneal renal arterial bypass.33

Pancreas
Splenic Splenic v.
flexure
Splenic a.
Superior
mesenteric a.
Left renal v.
Left renal a.
Fig. 10-21 When it is to be used for splenorenal bypass, the splenic artery is exposed

retroperitoneally by mobilizing spleen and left colon.

References 17. Mell MW, Archer CW, Hoch JR, et al. Outcomes af-
ter endarterectomy for chronic mesenteric ischemia.
1. Zeller T, Macharzina R. Management of chronic athero - J Vasc Surg. 2008;48:32–38.
sclerotic mesenteric ischemia. Vasa. 2011;40;99–107. 18. Wyers MC, Powell RJ, Nolan BW, et al. Retrograde mes-
2. Valentine RJ, Martin JD, Myers SI, et al. Asymptom- enteric stenting during laparotomy for acute occlusive
atic celiac and superior mesenteric artery stenoses mesenteric ischemia. J Vasc Surg. 2007;45:269–275.
are more prevalent among patients with unsuspected 19. McVay CB. Thoracic walls. In: McV ay CB, ed.
renal artery stenoses. J Vasc Surg. 1991;14:195–199. Anson and McVay’s Surgical Anatomy. Philadelphia,
3. Thomas JH, Blake K, Pierce GE, et al. The clinical PA: WB Saunders; 1984:343–384.
course of asymptomatic mesenteric arterial stenosis. 20. Stoney RJ, Schneider PA. Technical aspects of vis-
J Vasc Surg. 1998;27:840–844. ceral artery revascularization. In: Bergan JJ, Yao
4. Grotemeyer D, Duran M, Iskandar F , et al. Median JST, eds. Techniques in Arterial Surgery. Philadel-
arcuate ligament syndrome: vascular sur gical ther- phia, PA: WB Saunders; 1990:271–283.
apy and follow-up of 18 patients. Langenbechs Arch 21. Schneider DB, Nelken NA, Messina LM, et al. Iso -
Surg. 2009;394:1085–1092. lated inferior mesenteric artery revascularization for
5. Duffy AJ, Panail L, Eisenberg D, et al. Management chronic visceral ischemia.J Vasc Surg. 1999;30:51–58.
of median arcuate ligament syndrome: a new para - 22. Fry WJ. Occlusive arterial disease: upper aortic branches.
digm. Ann Vasc Surg. 2009;23:778–784. In: Nora PF, ed. Operative Surgery: Principles and Tech-
6. Glovicszi P, Duncan AA. Treatment of celiac artery niques. Philadelphia, PA: Lea & Febiger; 1980:763–777.
compression syndrome: does it really exist? Perspect 23. Cambria RP, Brewster DC, L ’Italien GJ, et al. The
Vasc Surg Endovasc Ther. 2007;19:259–263. durability of different reconstructive techniques for
7. Tulloch AW, Jiminez JC, Lawrence PF , et al. Lapa - atherosclerotic renal artery disease. J Vasc Surg.
roscopic versus open celiac ganglionectomy in pa- 1994;20:76–87.
tients with median arcuate syndrome. J Vasc Surg. 24. Geroulakos G, Wright JG, Tober JC, et al. Use of the
2010;52:1283–1289. splenic and hepatic artery for renal revascularization
8. Soman S, Sudhakar SV , Keshava SN. Celiac axis in patients with atherosclerotic renal artery disease.
compression by median arcuate ligament on com- Ann Vasc Surg. 1997;11:85–89.
puted tomography among asymptomatic patients. 25. Lerussi G, O’Brien N, Sessa C, et al. Hepatorenal
Indian J Gastroenterol. 2010;29:121–123. bypass allowing fenestrated endovascular repair of
9. Wyers MC. Acute mesenteric ischemia: diagnostic juxtarenal aortic aneurysm: a case report. Eur J Vasc
approach and surgical treatment. Semin Vasc Surg. Endovasc Surg. 2010;39:529–536.
2010;23:9–20. 26. Hanish M, Geroulakos G, Hughes DA, etal. Delayed
10. Berland T, Oldenburg WA. Acute mesenteric isch- hepato-renal-splenal bypass for renal salvage fol-
emia. Curr Gastroenterol Rep. 2008;10:341–346. lowing malposition of an infrarenal aortic endograft.
11. Trompeter M, Brazda T, Remy CT, et al. Non-occlu- J Endovasc Ther. 2010;178:326–331.
sive mesenteric ischemia: etiology, diagnosis, and in- 27. Moncure AC, Brewster DC, Darling RC, et al. Use of
terventional therapy. Eur Radiol. 2002;12:1179–1187. the splenic and hepatic arteries for renal revascular-
12. Brown DJ, Schemerhorn ML, Powell RJ, et al. Mes- ization. J Vasc Surg. 1986;3:196–203.
enteric stenting foe chronic mesenteric ischemia. 28. Chibara EA, Libertino JA, Novick AC. Use of the
J Vasc Surg. 2005;42:268–274. hepatic circulation for renal revascularization. Ann
13. Biebl, Oldenburg WA, Paz-Fumagalli R, et al. Endo- Surg. 1984;199:406–412.
vascular treatment as a bridge to successful revascu- 29. Moncure AC, Brewster DC, Darling RC, et al. Use of
larization for chronic mesenteric ischemia. Am Surg. the gastroduodenal artery in right renal artery revas -
2004;70:994–998. cularization. J Vasc Surg. 1988;8:154–159.
14. Savassi-Rocha PR, Veloso LF. Treatment of superior 30. Brewster DC, Darling RC. Splenorenal anasto-
mesenteric artery embolism with a fibrinolytic agent: mosis for renovascular hypertension. Ann Surg.
case report and literature review. Hepatogastroenter- 1979;189:353–358.
ology. 2002;49:1307–1310. 31. Novick AC, Banowsky LHW, Stewart BH, et al. Spl-
15. Jiminez JG, Huber TS, Ozaki CK, et al. Durabil - enorenal bypass in the treatment of stenosis of the re-
ity of antegrade synthetic aortomesenteric by- nal artery. Surg Gynecol Obstet. 1977;144:891–898.
pass for chronic mesenteric ischemia. J Vasc Surg. 32. Khauli RB, NovickAC, Ziegelbaum M. Splenorenal by-
2002;35:1078–1084. pass in the treatment of renal artery stenosis: experience
16. Park WM, Cherry KJ Jr ., Cua HK, et al. Current with sixty-nine cases. J Vasc Surg. 1985;2:547–551.
results of open revascularization for chronic mes- 33. Valentine RJ, Rossi MB, Myers SI, et al. Splenic
enteric ischemia: a standard for comparison. J Vasc infarction after splenorenal arterial bypass. J Vasc
Surg. 2002;35:853–859. Surg. 1993;17:602–606.

Renal Arteries
11
Surgical Anatomy of the Renal Arteries first two lumbar vertebrae (Fig. 11-1). The left is
usually slightly more cephalad than the right, and
The renal arteries arise from the abdominal aorta supernumerary vessels are not uncommon. Because
at approximately the level of the disc between the the aorta is elevated on the promontory of the spinal
L1
L2
Fig. 11-1 The renal arteries arise from

the aorta at approximately the level of
the disc between L1 and L2. Accessory
renal arteries, present in approximately
one-fourth of individuals, usually enter
a pole of the kidney.
295
column and the kidneys rest in the adjacent gutters, Fasciae
the angle formed by the renal vessels with the aorta
is almost 90° (Fig. 11-2). The position of the aorta The kidneys are embedded in a layer of fat and en-
to the left of midline makes the right renal artery closed by fascial layers in front and back. These an-
longer than the left. terior and posterior renal fasciae fuse laterally with
Inferior
pancreaticoduodenal a. and v.
Portal v.
Middle
Superior mesenteric v. colic a. and v. Inferior mesenteric v.
Duodenum Gastroduodenal a. Superior Splenic v.
mesenteric a. Splenic a.
Left
Right renal v. Hepatic a. gastric a.
Peritoneum
Anterior
Celiac a.
renal
orifice
fascia
Left renal v.
Renal a’s
Posterior renal fascia
Fig. 11-2 The renal arteries drape posteriorly over the spinal column. The right renal
artery often divides behind the inferior vena cava.

each other and with the posterior parietal perito- The layers of the renal fascia taper above to
neum. The anterior and posterior renal fasciae con- enclose the adrenal glands on each side and taper
tinue loosely across the midline ventral and dorsal below to ensheath the proximal ureters (Fig. 11-3).
to the great vessels, respectively. The posterior layer The anterior renal fascia is partly covered by the
lies on the transversalis fascia. posterior parietal peritoneum. The remaining part of
Fig. 11-3 The kidneys and perinephric fat are enclosed by an envelope of renal fascia that
tapers around the adrenals above and the ureters below.
RENAL ARTERIES | 297
the fascia over the right kidney is covered by the of the anterior renal fascia not in contact with the
second portion of the duodenum and the hepatic peritoneum is covered by the tail of the pancreas, the
flexure of the colon (Fig. 11-4). On the left, the part spleen, and the splenic flexure of the colon.
Fig. 11-4 The relationships of the renal arteries and kidneys to overlying organs are shown.

Vessels divides into four or five branches that enter the kid-
ney between the vein branches anteriorly and the
The renal arteries lie posterior to the corresponding calyces posteriorly.
renal veins on each side, and the right renal artery The left renal vein serves as a landmark for lo-
passes behind the inferior vena cava where the first cating the level of the renal artery origins. The left
branch points are commonly found (Fig. 11-5). The renal artery is usually found beneath the left renal
left renal artery is most commonly found near the vein near the cephalad margin of the vein. The right
cephalad border of the long left renal vein. Each renal vein and artery junctions with the inferior vena
renal artery usually sends a small branch to the ip- cava and aorta are slightly caudal to the left. Both
silateral adrenal gland, complementing the aortic renal veins may receive a lumbar vein. In addition,
and inferior phrenic artery branches to those or- the left renal vein receives the left adrenal and left
gans. Near the hilum of each kidney, the renal artery gonadal veins.
Right adrenal v.
Left adrenal v.
Gonadal a’s and v’s
Fig. 11-5 The branches of the renal arteries and veins are shown.
Exposure of the Renal Arteries After routine exploration of the peritoneal cav-
ity, the transverse colon and omentum are packed
Surgical exposure of the renal arteries may be nec- in moist laparotomy pads and lifted onto the ante-
essary to treat traumatic injuries, aneurysms, or rior abdominal wall at the superior end of the inci-
chronic stenoses. A common indication for isolation sion. The small intestine is eviscerated and packed
of the renal artery in the traumatized patient is to in moist laparotomy pads or placed in a bowel bag
obtain vascular control before exploring a parenchy- and mobilized to the right side of the incision. The
mal injury. Vascular repair of a renal artery injury infrarenal aorta is exposed by incising the ligament
is indicated only for pseudoaneurysms or dissection of Treitz and other duodenal attachments, allowing
with preserved flow. Because most injuries result mobilization of the distal duodenum and proximal
in thrombosis and irreversible ischemia, reported jejunum to the right side. The posterior parietal
outcomes for vascular repair are similar to nephrec- peritoneum overlying the aorta is opened, and inter-
tomy.1,2 The indications for repair of renal artery vening lymphatics are ligated to prevent the devel-
aneurysms are detailed elsewhere.3,4 These lesions opment of lymphoceles or chylous ascites.10,11 When
are often located in the distal arterial branches or the the anterior periadventitial plane is reached, expo-
renal hilum; therefore, advanced techniques such as sure proceeds superior to the level of the left renal
extracorporeal repair should be available when sur- vein (Fig. 11-6). The left renal vein crosses anterior
gery is indicated.5 Chronic renal artery stenoses may to the aorta in approximately 97% of cases,12 and
be due to fibromuscular dysplasia (10%) or athero- its superior border is nearly always superimposed
sclerosis (90%). Percutaneous balloon angioplasty on the origin of the left renal artery.13 It is impor-
without a stent is considered the treatment of choice tant to recognize several venous anomalies that oc-
for renovascular hypertension due to fibromuscular cur in this area, including circumaortic left renal
dysplasia.6 Regardless of the type of intervention, veins (up to 8.7%), retroaortic left renal veins (up to
long-term cure rates are lower for atherosclerotic le- 3.4%), left-sided venae cavae (0.2% to 0.5%), and
sions. The clinical evidence summarizing the effec- double inferior venae cavae (1% to 3%) ( see also
tiveness of angioplasty versus medical therapy for Chapter 19).12 To expose the left renal vein as far as
treating atherosclerotic renal artery stenosis is pub- the left renal hilum, the posterior peritoneal incision
lished elsewhere.7 Many surgeons favor open renal can be extended to the left along the inferior border
artery revascularization over angioplasty and stent- of the pancreas (Fig. 11-7). The inferior mesenteric
ing, especially after failed percutaneous therapy.8,9 vein should be ligated during this maneuver.
The following discussions concern exposure of the Mobilization of the left renal vein is neces-
renal arteries using midline and lateral approaches. sary to expose the origins of both renal arteries. The
As sources of inflow, exposure of the aorta and iliac inferior border of the pancreas is retracted crani-
arteries is considered in Chapter 12. Exposure of the ally, allowing exposure and dissection of the supe-
splenic and hepatic arteries for extraanatomic by- rior border of the left renal vein. The vein should
pass is discussed in Chapter 10. be carefully encircled with a vascular tape for re-
traction. The left gonadal and left adrenal branches
Midline Exposure of the Renal Arteries at Their Origins should be ligated and divided to prevent avulsion
during the retraction. A large lumbar vein branch of-
The patient is placed in the supine position with the ten enters the posterior wall of the left renal vein and
entire abdomen, lower chest, and both groins prepped requires ligation to prevent injury during renal vein
and draped. The abdomen is entered through a long, retraction. The left renal vein can now be retracted
vertical midline incision made from the xiphoid pro- either superiorly or inferiorly to expose the origins
cess to a point 5 to 7 cm below the umbilicus. As an of the left renal artery. In some cases, it may be nec-
alternative approach, some surgeons prefer to use a essary to divide the left renal vein. Many surgeons
transverse supraumbilical incision that extends into have stressed the importance of restoration of vein
both flanks. continuity14 at the completion of the procedure to

Fig. 11-6 The left renal vein is exposed
anteriorly by mobilizing the fourth portion of
the duodenum.
Fig. 11-7 The left adrenal, gonadal, and

lumbar branches of the left renal vein are Inferior
ligated and divided as necessary to mobilize mesenteric v.
the renal vein and expose the underlying left
renal artery.
Left
adrenal v.
Lumbar v.
Left gonadal v.
reduce the risk of renal compromise and hematuria, Lateral retraction of the vena cava above or below
but at least one recent series suggests that this may the left renal artery, combined with respective in-
be unnecessary.15 ferior or superior retraction of the left renal vein,
To isolate the right renal artery at its origin, the exposes the proximal right renal artery at the aortic
medial wall of the vena cava should be mobilized. junction (Fig. 11-8).
Fig. 11-8 The origins of both renal arteries can be approached between the left renal vein
and inferior vena cava.

Exposure of the Left Renal Artery margin and superior iliac crest (Fig. 11-9). After
routine exploration of the peritoneal cavity, the ab-
The patient is placed in the supine position with dominal viscera are wrapped in warm, moist lapa-
the left flank elevated on a rolled sheet. The lower rotomy pads and retracted to the right. Exposure
chest, abdomen, both groins, and anterior thighs are of the left renal vessels proceeds in the relatively
prepped and draped. The incision may be midline bloodless retroperitoneal plane between the left co-
or transverse. If the latter is chosen, the abdomen lon mesentery and the anterior surface of Gerota’s
is opened through a transverse supraumbilical in- fascia. This plane is developed by incising the lat-
cision extending from the right midclavicular line eral peritoneal attachments of the left colon from the
to the left posterior axillary line between the costal level of the sigmoid to the splenic flexure, allowing
Fig. 11-9 A transverse supraumbilical incision affords good exposure of the renal artery
on each side.
medial reflection of the colon with its mesentery. colon, and mesocolon are reflected to the midline
The spleen is mobilized in the superior wound by over the aorta (Fig. 11-10).
dividing the splenophrenic and splenorenal liga- The left renal vein can be located easily as it
ments. A plane between the posterior surface of the crosses anterior to the aorta. The vein is encircled
pancreas and the anterior surface of Gerota’s fascia with a vascular tape and mobilized by ligating go-
is developed bluntly, and the spleen, pancreas, left nadal, adrenal, and lumbar branches to permit wide
Left renal v.
Spleen
Left
colon
Fig. 11-10 Mobilization of the spleen, tail of the pancreas, and splenic flexure of the colon
provides retroperitoneal exposure of the left renal vessels.

retraction (Fig. 11-11). The left renal artery lies di- a vascular tape. To ensure that the main trunk of
rectly beneath the cephalad border of the left renal the left renal artery is isolated rather than a distal
vein in most cases.13 The artery is readily dissected branch, proximal exposure of the artery should pro-
from surrounding lymphatics and encircled with ceed to its aortic origin.
Fig. 11-11 The left renal vein is mobilized to expose the renal artery.
Exposure of the Right Renal Artery After routine peritoneal exploration is com-
pleted, the small intestines are wrapped in moist
The patient is placed supine, with the right flank laparotomy pads and retracted to the left. Lateral
elevated on a rolled sheet. The lower chest, abdo- peritoneal attachments of the right colon are in-
men, both groins, and anterior thighs are prepped cised from the cecum to the hepatic flexure, and
and draped. As noted above, the incision may be the right colon and mesentery are reflected medi-
midline or transverse. The transverse supraumbili- ally. The duodenum is similarly mobilized by incis-
cal incision is begun at the left midclavicular line ing retroperitoneal attachments to the level of the
and extended to the right posterior axillary line be- hepatoduodenal ligament superiorly (Kocher ma-
tween the costal margin and the superior iliac crest, neuver), permitting extensive medial reflection of
crossing the midline 3 to 5 cm above the umbilicus. the duodenum and pancreas to the left (Fig. 11-12).
Duodenum
Head of
pancreas
Right
colon
Fig. 11-12 Retroperitoneal exposure of the right renal vessels is accomplished by mobiliz-

ing the duodenum, head of the pancreas, and hepatic flexure of the colon.

This maneuver exposes the inferior vena cava. exposed, proximal isolation of the right renal artery
The right renal vein is easily identified and encircled should be carried out to its aortic origin. This re-
with a vascular tape. The right renal artery can be quires careful leftward retraction of the lateral wall
dissected and isolated in the retroperitoneal tissues of the vena cava, either directly above or directly be-
behind the right renal vein just lateral to the vena low the junction of the right renal vein (Fig. 11-13).
cava. To ensure that the main renal artery trunk is Lumbar veins entering the vena cava just below the
Lumbar v.
(ligated)
Fig. 11-13 The right renal vein is mobilized, and the vena cava is retracted to the left to
expose the right renal artery to its origin. Lumbar branches of the vena cava are ligated as
necessary.
renal veins should be carefully ligated. Bypasses to In cases involving correction of ostial le-
the right renal artery most often lie best when routed sions, the right renal artery can be isolated in the
behind the vena cava from the aorta or right iliac ar- small space between the inferior vena cava and the
tery. In some situations, the graft lies better in front aorta. This can be accomplished through either a
of the vena cava, routed posteriorly to the right renal midline transperitoneal approach (see above) or
artery beneath the caudal border of the overlying re- the right retroperitoneal approach described in this
nal vein (Fig. 11-14). section.
Fig. 11-14 Several bypass options are available for renal artery revascularization. Bypass
grafts may originate from the aortoiliac system (A–E) or from branches of the celiac artery
(F–H) if significant aortic disease is present.

A

Common hepatic a.
Splenic a.

References 8. Balzer KM, Pfeiffer T, Rossbach S, et al. Prospec-
tive randomized trial of operative vs interventional
1. Sangthong B, Demetriades D, Martin M, et al. treatment for renal artery ostial occlusive disease
Management and hospital outcomes of blunt re- (RAODD). J Vasc Surg. 2009;49:667–674.
nal artery injuries: analysis of 517 patients from 9. Balzer KM, Neuschafer S, Sagban TA, et al. Renal
the National Trauma Data Bank. J Am Coll Surg. artery revascularization after unsuccessful percuta-
2006;203:612–617. neous therapy: a single center experience. Langen-
2. Elliott SP, Olweny EO, McAninch JW. Renal becks Arch Surg. 2012;397:111–115.
artery injuries: a single center analysis of man- 10. Garrett HE Jr, Richardson JW, Howard HS, et al.
agement strategies and outcomes. J Urol. Retroperitoneal lymphocele after abdominal aortic
2007;178:2451–2455. surgery. J Vasc Surg. 1989;10:245–253.
3. Pfieffrer T, Reiher L, Grabitz K, et al. Reconstruction 11. Williams RA, Vetto J, Quinones-Baldrich W, et al.
for renal artery aneurysm: operative techniques and Chylous ascites following abdominal aortic surgery.
long-term results. J Vasc Surg. 2003;37:293–300. Ann Vasc Surg. 1991;5:247–252.
4. Henke PK, Cardneau JD, Welling TH III, et al. Re- 12. Malaki M, Willis AP, Jones RG. Congenital
nal artery aneurysms: a 35-year clinical experience anomalies of the inferior vena cava. Clin Radiol.
with 252 aneurysms in 168 patients. Ann Surg. 2012;67:165–171.
2001;234:454–462. 13. Valentine RJ, MacGillivray DC, Blankenship CL,
5. Crutchley TA, Pearce JD, Craven TE, et al. Branch et al. Variations in the anatomic relationship of the
renal artery repair with cold perfusion protection. left renal vein to the left renal artery at the aorta. Clin
J Vasc Surg. 2007;46:405–412. Anat. 1990;3:249–255.
6. Olin JW. Recognizing and managing fibromuscu- 14. AbuRahma AF, Robinson PA, Boland JP, et al. The
lar dysplasia. Cleve Clin Med. 2007;74:273–274, risk of ligation of the left renal vein in resection of
277–282. the abdominal aortic aneurysm. Surg Gynecol Obstet.
7. Eisenberg Center at Oregon Health & Sciences Uni- 1991;173:33–36.
versity. Management of Atherosclerotic Renal Artery 15. Samson RH, Lepore MR, Showalter DP, et al. Long-
Stenosis. Comparative Effectiveness Review Sum- term safety of left renal vein division and ligation to
mary Guides for Clinicians. Rockville, MD: AHRQ expedite complex abdominal aortic surgery. J Vasc
Comparative Effectiveness Reviews; 2007. Surg. 2009;50:500–504.
Renal a.
Common
iliac a.
L5
Internal
iliac a.
External
iliac a.
Fig. 12-1 The lower aortic segment rides the crest of the lumbar vertebrae.

Infrarenal Abdominal
Aorta, Pelvic Arteries,
and Lumbar
Sympathetic Chain
12
Surgical Anatomy of the Infrarenal Aorta and Iliac fourth vertebral bodies. The fifth lumbar arteries
Arteries lie below the bifurcation and may arise from the
common iliac arteries or the middle sacral artery.
The lower aortic segment between the renal ar- The inferior mesenteric artery is the only vis-
tery origins at the cephalad end of the second ceral branch arising in this segment of aorta (see
lumbar vertebra and the bifurcation at the fourth Chapter 10).
lumbar vertebra lies slightly to the left of midline The common iliac arteries diverge from the
(Fig. 12-1). Paired lumbar arteries arise from the aorta and descend a short distance to the lip of
back wall of the aorta and girdle the first through the true pelvis where they bifurcate into internal
315
and external branches (Fig. 12-2). The internal Figs. 19-20 and 19-21). The external iliac arteries
iliac arteries dive into the bowl of the true pelvis hug the pelvic brim medial to the psoas muscles
where they immediately divide in a highly vari- and give off only the small inferior epigastric and
able pattern, sending branches to the pelvic viscera deep circumflex iliac branches near the inguinal
and the external pelvic muscles (see Chapter 19, ligament.
Internal iliac a.
Superior
gluteal a.
External iliac a.
Lateral
sacral a. Obturator a.
Uterine a.
Inferior
gluteal a.
Deep circumflex iliac a.
Middle Inferior
rectal a. epigastric a.
Inferior Aberrant
vesicle a. obturator a.
Internal
pudendal a.
Fig. 12-2 The iliac vessels lie around the lip and in the bowl of the true pelvis.

Iliac Veins elsewhere.1 Adhesion between the bifurcations of the
aorta and vena cava is not uncommon, making ma-
The bifurcation of the aorta is separated from the nipulation of these vessel segments hazardous. These
fourth lumbar vertebra by the left common iliac vein. vessel segments are also vulnerable to injury during
The vein crosses beneath the right iliac artery and posterior lumbar disc surgery when the rongeur inad-
joins the right iliac vein to form the vena cava on the vertently bites through the anterior longitudinal liga-
right side of L5 (Fig. 12-3). Left common iliac vein ment. Arterial, venous, and combined injury resulting
compression from the overlying right common iliac in arteriovenous fistulae have been reported.2 The
artery can lead to venous hypertension and increased iliac veins lie medial and deep to the common and ex-
potential for thrombosis (May–Thurner syndrome), ternal iliac arteries, occupying a position deep in the
an anatomic variant that has been well described groove between the psoas muscle and pelvic brim.
Inferior
vena
cava
Aorta
Left common
iliac v.
Fig. 12-3 The more proximal aortic bifurcation overrides the bifurcation of the vena cava
and may be adherent.
INFRARENAL ABDOMINAL AORTA, PELVIC ARTERIES, AND LUMBAR SYMPATHETIC CHAIN | 317

Retroperitoneal Relationships The root of the sigmoid mesocolon crosses the left
iliac vessels, and the right iliac vessels lie directly
The gonadal vessels and ureters lie along the psoas beneath the peritoneum.
muscles in the paravertebral gutters and cross an- The lumbar branches of the aorta and vena
terior to the iliac vessels in the pelvis (Fig. 12-4). cava pass beneath the sympathetic chains and the
Right kidney Left kidney
Aorta Inferior
mesenteric a.
Inferior
vena Ureter
cava
Superior
L. common rectal a.
iliac v.
Sacral
promontory L. gonadal
vessels
R. external
iliac v. L. external
iliac a.
Fig. 12-4 Peritoneal relationships of the aorta are shown.

fibrous arches between slips of psoas origin and the lateral border of the vena cava and psoas on
hug the vertebral bodies deep to the psoas mus- the right. The sympathetic trunks pass behind the
cles (Fig. 12-5). Occasional venous tributaries common iliac vessels into the sacral hollow of the
may overlie the sympathetic trunks. The lumbar pelvis.
sympathetic trunks lie more anteriorly on the ver- The paired lumbar veins are interconnected.
tebral bodies than do their thoracic counterparts. The major communications are the large ascending
The lumbar trunks occupy a position between lumbar veins that lie far posterior in the angle be-
the anterior edges of the psoas muscles and the tween the vertebral bodies and the transverse pro-
great vessels. Because of the offset arrangement cesses, deep to the psoas muscles. Smaller anterior
of the great vessels toward the right, there is a venous interconnections may lie superficial to the
slightly greater space between the lateral border sympathetic trunks and make access to the trunks
of the aorta and psoas on the left than between and ganglia more difficult.
Inferior Aorta
vena
cava
R. sympathetic trunk Gonadal a. L. sympathetic trunk
Psoas m.
Quadratus
lumborum m.
Ascending lumbar v.
Fig. 12-5 The lumbar vessels lie between the vertebral bodies and the psoas muscles.

Nerves the lumbar plexus (Fig. 12-7). The ventral rami of
the first three and part of the fourth lumbar nerves
The lumbar spinal nerves emerge from the verte- contribute to the lumbar plexus. The two major mo-
bral foramina posterior to the ascending lumbar tor nerves derived from the lumbar plexus are the
veins and enter the posterior portion of the psoas femoral nerve to the quadriceps of the thigh and the
muscle (Fig. 12-6). There they interconnect to form obturator nerve to the adductor group.
Aortic plexus
Aorta
Sympathetic
ganglion
Inferior
vena
Ascending cava
lumbar v.
Lumbar spinal n.
Psoas m.
Quadratus
lumborum m.
Fig. 12-6 The spinal nerves pass behind the ascending lumbar veins and pass through the
psoas muscle.

L1
L2
Iliohypogastric n.
L3
Ilioinguinal n.
L4
Lateral
Genitofemoral n. femoral
cutaneous n.
L5
Femoral n.
Obturator n.
Lumbosacral
trunk
Fig. 12-7 The lumbar plexus lies within the psoas muscle.

The lumbar sympathetic chain consists of two all the lumbar nerves. Lumbar splanchnic branches
to six ganglia in a variable pattern (Fig. 12-8). The travel from the sympathetic chain to the aortic
ganglia receive sympathetic efferents from the first plexus where they are joined by postganglionic fi-
two lumbar nerves and send afferent gray rami to bers from the celiac plexus. An additional plexus
Aortic
plexus
Sympathetic
ganglion
Inferior
mesenteric
ganglion
Ascending
lumbar v.
Superior
hypogastric
plexus
Hypogastric
nerves to
pelvic
plexus
Fig. 12-8 The lumbar sympathetic chains lie on the anteromedial portions of the vertebral
bodies.

is formed around the inferior mesenteric artery. is still favored by many surgeons. Compared with
Visceral branches from the plexus travel along the the retroperitoneal approach, it is simpler, requires
inferior mesenteric artery to the structures supplied less retraction, and allows examination of the in-
by the artery. A variable number of hypogastric traabdominal cavity for unsuspected pathology.3
nerves coalesce from fibers caudal to the inferior Because the transperitoneal approach is more rap-
mesenteric plexus. These nerves pass over the aortic idly performed by most surgeons, it is the approach
bifurcation to form the superior hypogastric plexus of choice for ruptured abdominal aortic aneurysms.
in the sacral hollow. Autonomic fibers then pass to However, gastrointestinal complications are preva-
the inferior hypogastric plexus and from there join lent after transperitoneal aortic operations.4 The
the pelvic plexus. retroperitoneal approach has been associated with
Interruption of sympathetic outflow from the shorter duration of intestinal ileus, fewer pulmo-
first two lumbar ganglia through the hypogastric nary complications, and shorter hospital stays than
nerves and plexuses impairs ejaculation in males. the transperitoneal approach.5,6 Retroperitoneal ex-
posure is particularly useful in patients with com-
plex aortic problems such as juxtarenal aneurysms,
Exposure of the Aorta below the Renal Arteries inflammatory aneurysms, and horseshoe kidneys.7,8
Although visceral arteries can be readily repaired
Most aortic pathology is confined to the infrarenal using left retroperitoneal incisions, the right external
segment, allowing placement of proximal occlud- iliac and renal arteries are difficult to isolate. Aortic
ing clamps below the renal arteries during operative operations involving concomitant repair of aortic
repair. Infrarenal aortic occlusion has significant and right external iliac lesions should be performed
physiologic advantages over occlusion proximal to transperitoneally or through separate left flank and
the renal arteries. Exposure of the infrarenal aorta is right lower quadrant retroperitoneal incisions. Left
eminently easier than exposure of the aorta above retroperitoneal incisions are inappropriate for right
the renal arteries, which usually requires extensive renal artery reconstruction.
dissection (see Chapter 9).
Infrarenal aortic exposure can be obtained Transperitoneal Exposure of the Infrarenal Aorta
through simple abdominal or flank incisions. There
are two popular approaches: transperitoneal (i.e., in- There are two commonly used incisions that provide
traperitoneal) and retroperitoneal. The transperito- adequate transperitoneal exposure of the abdomi-
neal approach has been popular for many years and nal aorta below the renal arteries: the longitudinal

midline and the transverse infraumbilical ap- rates are similar for both incisions at 1 to 6 years of
proaches (Fig. 12-9). The midline incision is more follow-up.9
rapidly made and is less likely to cause superficial After the peritoneal cavity has been entered,
nerve damage. However, transverse incisions may the transverse colon and greater omentum are dis-
be associated with decreased postoperative pain in placed from the abdomen, wrapped in moistened
the upper abdomen, permitting increased ventilation laparotomy pads, and reflected onto the superior
and a more effective cough mechanism in patients abdominal wall. The small intestine is eviscerated
with chronic pulmonary disease. Reported hernia and placed in a sterile plastic sac or wrapped in
Fig. 12-9 Midline and transverse infraumbilical incisions provide adequate

transperitoneal exposure of the infrarenal abdominal aorta.

moistened laparotomy pads and retracted into the be ligated to prevent chylous leaks.10 The periadven-
right side of the abdomen. The retroperitoneal space titial plane over the glistening surface of the anterior
is entered through an incision in the posterior pa- aorta is exposed by incising a thin layer of fibrous
rietal peritoneum near the duodenum (Fig. 12-10). tissue. The incision is continued superiorly to the
This incision is carried superiorly to include divi- level of the left renal vein, which crosses anterior to
sion of the ligament of Treitz, allowing the third and the aorta in 97% of cases11 and is a useful landmark
fourth portions of the duodenum to be reflected to- for identifying the juxtarenal aorta (see Chapter 11).
ward the right side. Any identifiable lymphatic tis- The incision through the posterior peritoneum
sue overlying the anterior surface of the aorta should and preaortic tissue is continued inferiorly near the
Superior
mesenteric a.
Left
renal v.
Duodenum
Inferior
mesenteric a.
Fig. 12-10 The fourth portion of the duodenum is mobilized, and the aorta is exposed from
the left renal vein to the bifurcation.

base of the small bowel mesentery to the level of and renal collars (i.e., circumaortic left renal veins)
the aortic bifurcation. The incision should be made are especially prone to injury if unrecognized.14
to the right side of the aortic midline to avoid in- Mobilization of the aortic bifurcation is dangerous
juring the inferior mesenteric artery and other ves- because the iliac vein confluence is often adherent
sels in the sigmoid mesentery. Confining division of to the posterior wall of the aorta from periaortic fi-
preaortic tissues to the right side also reduces the brosis. Control of the distal aorta is best carried out
risk of injuring the preaortic autonomic plexus with at the level of the common iliac arteries (see below).
the resulting sexual dysfunction.12 Mobilization of
the posterior wall of the aorta should be performed Retroperitoneal Exposure of the Infrarenal Aorta
with great care to avoid injury to venous structures.
Aortic mobilization just below the renal arteries re- The patient is placed in a modified thoracotomy po-
quires careful finger dissection close to the posterior sition with the left shoulder angled approximately
aortic wall, avoiding lumbar arterial branches. A 60° from the operating table and the hips rotated
lumbar venous plexus lies in the retroaortic tissues posteriorly as far as possible toward the horizontal
near the vertebral column and is prone to rapid hem- position (Fig. 12-11). Posterior hip rotation is im-
orrhage when injured.13 Retroaortic left renal veins portant to expose the groins for possible femoral
Fig. 12-11 Torsion of the trunk facilitates the retroperitoneal approach to the infrarenal aorta.

anastomoses, and the axial alignment lessens retrac- rectus sheath are divided. The left rectus is divided
tion requirements. The chest should be secured with next, taking care to ligate branches of the inferior
wide tape, and a vacuum beanbag apparatus may be epigastric artery lying on the posterior surface of the
of value in maintaining the axial alignment. muscle. After dividing the internal oblique and trans-
An oblique left flank incision is made from the versus abdominus muscle layers, the retroperitoneal
tip of the 11th or 12th rib to the abdominal midline space is entered in the lateral wound. The transver-
4 to 5 cm below the level of the umbilicus. The inci- salis fascia lateral to the rectus sheath is opened, and
sion can be extended across the right rectus sheath the underlying peritoneal surface is stripped away
in patients who require exposure of the right com- from the transversalis fascia as the latter is divided
mon iliac artery or in whom passage of a graft to for the length of the wound (Fig. 12-12). The poste-
the right femoral space is necessary. The incision is rior rectus sheath is incised medially, and the peri-
deepened through subcutaneous tissue, and the ex- toneum is stripped from its posterior surface. As the
ternal oblique muscle, aponeurosis, and left anterior peritoneum is often adherent to the posterior rectus
Fig. 12-12 The retroperitoneal dissection is begun in the lateral wound.

sheath, it may be necessary to stop the incision 2 to anterior to the left kidney, the ureter is best left in
5 cm from the linea alba to avoid inadvertent perito- the posterior retroperitoneal tissues as the posterior
neal entry. Any small tears inadvertently made in the peritoneal surface is retracted forward. Mobilizing
peritoneum should be closed. the left ureter forward with the peritoneum brings
A retroperitoneal plane is developed by strip- the proximal ureter directly in front of the juxtarenal
ping the peritoneum from the abdominal wall lat- aorta and renders exposure inconvenient.
erally and posteriorly, staying anterior to Gerota’s The peritoneal sac is mobilized medially and
fascia over the left kidney. Extension of the plane cephalad until the aorta is exposed from the left renal
behind Gerota’s fascia with anterior mobilization vein to the left iliac artery bifurcation (Fig. 12-13).
of the left kidney should be performed in cases This requires that the inferior mesenteric artery be
when suprarenal exposure of the aorta is desired ligated and divided near the anterior aortic wall. The
(see Chapter 9). When the plane is developed left gonadal vein should be ligated and divided near
Inferior
mesenteric a.
Left renal v.
Left ureter
Left gonadal v.
Fig. 12-13 The inferior mesenteric artery and left gonadal vessels are divided to complete
retroperitoneal exposure of the aorta.

its junction with the renal vein to prevent avulsion Transperitoneal Exposure of the Iliac Arteries
injury. The peritoneum can be mobilized far to the
patient’s right side to expose the origin of the right Patient positioning, abdominal incision, and vis-
common iliac artery. Vascular control of the left iliac ceral displacement proceed as described for trans-
artery is easily obtained, but the right iliac artery is peritoneal exposure of the aorta. The posterior
often obscured from view by large aneurysms or peritoneum is incised over the anterior aortic sur-
other local pathology. In these cases, it may be easier face just to the left of the fourth portion of the
to obtain vascular control from within the lumen of duodenum. The peritoneal incision is continued
the aorta using Fogarty catheters.15 Retroperitoneal caudally on the right side of the aortic midline
exposure of the right external iliac artery should be and extended over the anterior surface of the right
obtained through a separate transverse incision in common iliac artery (Fig. 12-14). Using blunt dis-
the right lower quadrant (see below). section, the anterior periadventitial plane of the
Duodenum
Inferior vena cava
Inferior
mesenteric a.
R. common iliac a.
Right external
iliac a.
Ureter Right internal
iliac a.
Fig. 12-14 The peritoneal incision is extended to expose and control the right iliac vessels.

common iliac artery is located and opened to the arteries are then isolated and encircled with vessel
level of the aortic bifurcation. The artery is next tapes. The corresponding internal and external iliac
encircled with a vascular tape, taking care to avoid veins lie on the posteromedial surfaces of their re-
injury to the common iliac vein that lies on its pos- spective arteries.
terolateral surface. Distal exposure of the common The left common iliac artery and its branches
iliac artery proceeds to its bifurcation. The right are exposed by laterally retracting the left side of
ureter courses in the periadventitial tissues over the the incised posterior peritoneum (Fig. 12-15). The
common iliac artery adjacent to the bifurcation; it posterior peritoneum and associated periadventitial
should be identified and retracted laterally with the tissues should not be incised over the aortic bifurca-
associated periadventitial tissues. When mobilization or the left common iliac artery in males because
tion of the ureter away from the bifurcation is dif- sympathetic nerve disruption leading to ejaculatory
ficult, it may be encircled with a vessel loop and dysfunction can result. The left side of the posterior
retracted laterally. The internal and external iliac peritoneal incision is retracted laterally to identify
Left common
iliac a.
External
iliac a.
Internal
iliac a.
Ureter
Iliac v’s
Sigmoid
mesentery
Fig. 12-15 Peritoneal retraction on the left side permits isolation of the left iliac vessels.

the common iliac artery and its branches, taking surface by incising peritoneal attachments. A rela-
care to identify the left ureter. If posterior perito- tively avascular plane is developed posterior to the
neal retraction from the midline does not permit ad- sigmoid and its mesentery, which are reflected me-
equate exposure, a lateral approach will be required. dially to expose the left common iliac artery and its
The sigmoid colon is mobilized along its lateral branches (Fig. 12-16).
Fig. 12-16 The left iliac vessels may also be approached by opening the lateral side of the
root of the sigmoid mesocolon.

Retroperitoneal Exposure of the Iliac Arteries through subcutaneous tissues, ligation of the super-
ficial epigastric and superficial circumflex iliac ar-
The patient is placed in the supine position with the teries should be performed to prevent troublesome
ipsilateral hip elevated 10° on a rolled sheet. The hemorrhage from the wound edges.
entire abdomen and flank are prepped and draped. The aponeuroses of the external oblique and
An oblique skin incision is begun at the lateral bor- internal oblique muscles are next divided parallel
der of the rectus muscle approximately 3 cm above to the wound axis. Laterally, the internal oblique
the inguinal ligament and extended to the midaxil- muscle should be bluntly split apart in the direction
lary line halfway between the subcostal margin and of its fibers. The transversus abdominus and trans-
iliac crest (Fig. 12-17). As the wound is deepened versalis fascia are opened in the lateral half of the
Fig. 12-17 A low, oblique anterior flank incision is used for extraperitoneal exposure of
the iliac arteries.

wound, gaining access to the retroperitoneal space attached to the posterior peritoneal surface, where it
(Fig. 12-18). The retroperitoneal space is most eas- is safely retracted along with the peritoneal sac into
ily entered in the wound’s lateral aspect because the the medial wound. The external iliac artery can be
peritoneum may be fused to the transversalis fascia identified in the lower wound and traced proximally
near the midline. The peritoneum is carefully stripped to identify the common and internal iliac segments.
from the lateral pelvic wall and retracted medially to Proximal exposure can be accomplished to the level
expose the psoas muscle and iliac vessels on the me- of the terminal abdominal aorta with further medial
dial side of the psoas muscle. The ureter is best left retraction of the peritoneum.
Fig. 12-18 The retroperitoneal space is entered laterally.

Extraperitoneal Exposure of the External Iliac Artery epigastric and superficial circumflex iliac vessels be
ligated in the subcutaneous layer.
The patient is positioned and prepped as previously The external and internal oblique aponeuroses
described. The incision is made 2 cm above and are divided, and the fibers of the internal oblique mus-
parallel to the inguinal ligament, extending from cle in the lateral wound are split apart. The transversus
the lateral rectus sheath to a point 2 cm cephalad to muscle and transversalis fascia are opened in the lat-
the anterior superior iliac spine (Fig. 12-19). Again, eral wound, where separation of the peritoneum from
proper hemostasis requires that the superficial the anterior abdominal wall is easier. Entry into the
Fig. 12-19 The external iliac artery can be exposed through a more limited suprainguinal
incision.

retroperitoneal space is gained laterally, and the peri- the peritoneal sac superomedially. Distal exposure to
toneum is carefully stripped away from the anterior the level of the inguinal ligament can be obtained by
abdominal wall in the inferior wound (Fig. 12-20). caudal retraction of the inferior wound margin. Care
Superior retraction of the peritoneum reveals the should be taken to avoid injuring the deep circum-
external iliac artery in the center of the wound; the flex iliac and inferior epigastric vessels during distal
external iliac vein lies on the artery’s posteromedial dissection. Exposure of arterial segments below the
surface. Proximal exposure of the external iliac artery inguinal ligament should be performed through a sep-
can be gained all the way to its origin by retracting arate vertical groin incision (see Chapter 15).
Psoas m.
External iliac a.
Inferior
epigastric a. and v.
Fig. 12-20 Care is taken to avoid the small distal abdominal wall branches of the external
iliac artery during peritoneal retraction.

Exposure of the Lumbar Sympathetic Chain crest and extended to the lateral border of the rectus
sheath (Fig. 12-21). In large or obese individuals,
Sympathetic denervation procedures were first advo- the incision can be extended to the 12th rib laterally
cated for treatment of lower extremity vascular disor- or across the rectus sheath medially.
ders more than a century ago.16 The improved results After the wound is deepened through the sub-
obtained with modern revascularization procedures cutaneous tissues, a muscle-splitting technique, as
have relegated lumbar sympathectomy to a limited originally described by Pearl,21 is employed. The ret-
secondary role in the treatment of a small subgroup roperitoneal space is most easily entered in the lateral
of patients with a particular pattern of vascular occlu- wound, and the peritoneum is bluntly stripped away
sive disease.17 Other currently accepted indications from the lateral and posterior abdominal walls. The
include causalgia, reflex sympathetic dystrophy, and peritoneal sac and its contents are retracted medi-
hyperhidrosis.18–20 It is not indicated as a routine ad- ally, while retroperitoneal exposure continues along
junctive procedure after aortic bypass. Lumbar sym- the posterior abdominal wall. The psoas muscle is
pathectomy is currently performed using minimally readily identified, as are the ilioinguinal and genito-
invasive techniques such as retroperitoneoscopy; the femoral nerves that course downward along the lat-
following discussion of open lumbar sympathectomy eral side of the psoas. Identification of these nerves
is included for the sake of completion. is important so that they may be distinguished from
The patient is placed in the supine position the lumbar sympathetic chain. The ureter should
with the ipsilateral flank elevated 15° to 20° on a also be identified and protected; this is most easily
rolled sheet. A transverse skin incision is made mid- accomplished by allowing it to be gently retracted
way between the costal margin and the superior iliac with the peritoneal sac.
Fig. 12-21 A transverse midflank incision provides access to the lumbar sympathetic chain.

The sympathetic chain is exposed medial to crest. It is useful to identify all other lumbar gan-
the psoas muscle, along the bodies of the lumbar glia by following the sympathetic trunk retrograde.
vertebrae (Fig. 12-22). The chain lies just under the The first lumbar ganglion may be partly concealed
lateral border of the inferior vena cava on the right by the medial lumbocostal arch; exposure may be
side and is adjacent to the lateral border of the aorta gained by vertically incising the overlying diaphrag-
on the left. It is identified most easily by palpation matic tissues.
of a nodular string that gives a characteristic “snap”
as it is plucked.18 Overlying fatty tissue should be
gently swept away to achieve adequate visualiza- Vascular Exposure of the Lumbar Spine
tion. Lumbar vessels that course anterior to the sym-
pathetic chain should be meticulously ligated and Improvement of vertebral stabilization devices for
divided to prevent troublesome hemorrhage in the anterior disc replacement or fusion (anterior lumbar
retroperitoneal tissues. The lateral edge of the infe- interbody fusion/ALIF) has led to a resurgence of
rior vena cava may require medial retraction for ad- interest in the anterior approach for treatment of de-
equate visualization of the right sympathetic chain. generative or malignant spine disease. Used alone
The most distal lumbar ganglion is easily identified or in combination with posterior fusion, the anterior
as the last accessible distal ganglion near the iliac approach has been used for spinal decompression
Fig. 12-22 The sympathetic chain is identified on the vertebral bodies between the anterior
edge of the psoas muscle and the aorta (or vena cava).

or tumor resection from T11 to S1.22 Although the The following discussion considers anatomic ex-
anterior retroperitoneal approach affords excellent posure of the anterior spine at the L5/S1 and L4/5
visualization of the anterior spine and vertebral levels.
discs, operative exposure often requires extensive
dissection and mobilization of the aorta, iliac arter- L5/S1 Exposure
ies, inferior vena cava, and iliac veins (Fig. 12-23).
The vascular surgeon may be called upon to provide The patient is positioned supine on a radiolucent table,
safe exposure for the spine surgeon and be avail- and the left flank is elevated on a lumbar back roll.
able in the event of injury to the great vessels. The The L5/S1 disc space is localized with fluoroscopy,
L4/L5 and L5/S1 disc spaces are common sites of and a radio opaque skin marker may help determine
exposure, and the vascular surgeon should be inti- the extent of incision, level of dissection, and angle
mately aware of the anatomic peculiarities and the of instrumentation in coordination with the spine
vascular structures at risk for injury at these levels. surgeon. Although a number of incisions have been
Lumbar sympathetic chain
Inferior mesenteric a. Gonadal vessels

Ilioinguinal n.
Ureter
Genitofemoral n.
Middle
sacral
vessels
Hypogastric
plexus
Vas
Inferior deferens
epigastric
vessels
Fig. 12-23 The anatomy related to the lower lumbar spine is shown.

described, our experience suggests that the left para- anterior rectus sheath is incised longitudinally leaving
median incision is the most direct anterior approach wide flaps for closure. The rectus abdominis muscle
that best accommodates modern stabilization de- is mobilized from its medial attachments the length
vices (Fig. 12-24). The incision is extended from the of the incision and retracted laterally (Fig. 12-25).
level of the umbilicus to the pubis. The underlying Small feeding vessels, encountered at the junction of
Fig. 12-24 The position of the lower left paramedian

incision is shown.
Posterior rectus sheath

Arcuate line
Rectus muscle
Anterior rectus sheath
Inferior epigastric
pedicle
Fig. 12-25 Lateral mobilization of the left rectus muscle exposes the arcuate line at the
termination of the posterior rectus sheath. Caudal to the arcuate line, only transversalis
fascia covers the preperitoneal fat plane. The inferior epigastric pedicle lies deep to the
caudal end of the rectus muscle.

tendinous inscriptions and midline should be meticu- end of the incision. The retroperitoneal plane is de-
lously ligated. veloped under the retracted left rectus muscle, with
The transversalis fascia is delicately entered at a combination of blunt and sharp dissection. The
the caudal end of the incision and opened up to the envelope of parietal peritoneum including the left
arcuate line, exposing the preperitoneal fat plane colon is mobilized from lateral to medial to expose
(Fig.12-26). The posterior rectus sheath and under- the retroperitoneal space in the midline as far as the
lying transversalis fascia are opened to the cephalad great vessels of the abdomen (Fig. 12-27). As the
Fig. 12-26 The relationships of the preperitoneal Iliac vessels Transversalis fascia
plane are shown.

Parietal peritoneum
Ureter
Parietal peritoneum
Rectus sheath
Left colon
Left ureter
Left gonadal
vessels
Fig. 12-27 Retraction of the peritoneal envelope,

ureter and gonadal vessels is shown.

peritoneal mobilization progresses, the inferior epi- control bleeding from small paraspinous bleeding
gastric vessels are gently retracted laterally with the vessels may reduce the risk of inadvertent nerve in-
rectus muscle. Deep in the wound, the psoas muscle jury in this area. In women, the round ligament can
is exposed, and the overlying genitofemoral and il- be divided as necessary to improve exposure.
ioinguinal nerves are left in situ on the muscle’s an- A self-retaining retractor such as the Omni
terior surface. The ureter is carefully identified as or Bookwalter retractor is placed for optimal ex-
it crosses the junction of external and internal iliac posure of the L5/S1 disc space. The space is eas-
arteries and is mobilized with the peritoneum. The ily exposed between the left common iliac vein and
gonadal vessels are similarly elevated with the peri- right common iliac artery. Mobilization of the left
toneum. Care is taken to protect the nerve elements common iliac vein requires ligation and division of
that cross the external iliac artery origin, to prevent the left medial iliosacral vein (Fig. 12-28) that is of-
retrograde ejaculation. Using bipolar cautery to ten encountered on the medial border just distal to
Lumbar vessels Inferior

mesenteric a.
Middle sacral
vessels
Lateral
iliosacral v.
Medial
iliosacral v.
Fig. 12-28 The common position of the aortic and vena caval bifurcations

bracketing the L4/L5 disc space is shown.

the iliac vein bifurcation. To complete mobilization the aorta and distal iliac vessels may be required.
of the right common iliac artery, the middle sacral Lumbar arteries and unnamed venous tributaries
artery and vein should be divided with a combina- should be carefully controlled and ligated in these
tion of bipolar electrocautery, surgical clips, and/or circumstances.
silk ligatures. The remaining soft tissue covering After the right common iliac artery and left
the L5/S1 disc is carefully mobilized with the use common iliac vein have been adequately mobi-
of a Cobb elevator. Inflammatory changes associ- lized, positive identification of the L5/S1 inter-
ated with degenerative disc disease can cause ad- space should be confirmed radiologically. The
herence of the vessels to the underlying vertebrae spine surgeon places a radio-opaque marker in the
and make mobilization difficult and hazardous. In disc space, and the spinal level is assessed using
these cases, more extensive mobilization including a straight lateral fluoroscopic view (Fig.12-29).
Fig. 12-29 Pin marker placement for fluoroscopic confirmation of the L5/S1 disc space
is shown.

After confirmation of the disc space, a combi- Upon completion of the discectomy and fusion
nation of ring retractors and/or Steinmann pins by the spine team, the retraction system is carefully
(Fig. 12-30) are secured with the assistance of removed. If a Steinmann pin was used for the retrac-
the spine surgeon to secure a stable view for the tion, the catheter is held against the vertebral body as
discectomy and implant placement. The retractors the point is withdrawn to prevent laceration of the left
elevate and widen the space between the common iliac vein as it returns to its normal location. After he-
iliac vessels, exposing the L5/S1 disc. The Stein- mostasis is secured, the peritoneal envelope is allowed
mann pin must be sheathed with a red rubber to gently fall back into position. Any peritoneal tears
catheter to prevent injury to the vessels by direct can be carefully closed. Distal pulses are confirmed.
contact with the metal. Care must be exercised It is not necessary to reconstruct the posterior sheath
to avoid unnecessary traction/compression of the or arcuate line, although, if possible, it does help fa-
iliac vessels to prevent injury or potential stasis cilitate closure of the anterior rectus sheath. Anterior
and thrombosis. rectus sheath and skin are closed in standard fashion.
L5
Fig. 12-30 Exposure of the L5/S1 disc is shown.

L4/L5 Exposure overstated. Other tributaries, especially the L4/L5
lumbar artery and vein also require ligation as the
Anterior retroperitoneal exposure of the L4/L5 disc iliac vessels are mobilized.
space proceeds in the same manner as for the L5/S1 The optimal exposure of the L4/L5 disc
exposure described above. The L4/L5 exposure re- space depends on the degree of surrounding in-
quires mobilization of the distal aorta and left iliac flammation and the location of the aortic and
vessels from left to right. The left lateral iliosacral caval bifurcations. With the bifurcations in their
vein branch (Fig. 12-28) tends to pin the iliac vein most common position bracketing the L4-5 disk
tightly to the lumbosacral structures and should be level, the vessels may be retracted to the right
carefully suture ligated and clipped to facilitate ad- (Fig. 12-31A). When the bifurcations ride higher,
equate mobilization of the iliac vein. This is an area the left common iliac vessels can be retracted
of frequent anomalies, and the surgeon must be alert to the patient’s left to an almost horizontal po-
for additional branches. A left medial iliosacral vein sition (Fig. 12-31B), or can be separated apart
is often encountered just distal to the confluence of (Fig. 12-31C). Regardless of the retraction con-
the iliac veins. This vein should be carefully configuration, flow in the distal external iliac artery
trolled and suture ligated, which may be difficult should be confirmed by pulse or with a Doppler
due to chronic surrounding inflammation. Failure probe after the retractors are set. To complete the
to control this vessel can lead to injury during me- exposure of the disc space, the remaining soft tis-
dial retraction of the left iliac vein. The challenge of sue covering the L4/L5 disc space can be mobi-
controlling hemorrhage from this injury cannot be lized with the use of a Cobb elevator.
Fig. 12-31 A–C: Approaches to the L4/L5 disc

space are shown.
L4
L5


Positive identification of the L4/L5 disc space 10. Aalami OO, Organ CH Jr. Chylous ascites: a collec-
is made by placing a radio-opaque marker into the tive review. Surgery. 2000;128:761–768.
disc space and confirming with a lateral fluoro- 11. Valentine RJ, MacGillivray DC, Blankenship CL,
scopic view. After confirmation, a combination of et al. Variations in the anatomic relationship of the
ring retractors and Steinmann pins are carefully se- left renal vein to the left renal artery at the aorta. Clin
Anat. 1990;3:249–255.
cured with the assistance of the spine surgeon to
12. van Schaik J, van Baalen JM, Visser MJT, et al.
create a stable view for discectomy and implant Nerve-preserving aortoiliac reconstruction surgery:
placement. Any further manipulation of the vascu- anatomical study and surgical approach. J Vasc Surg.
lar retractors should be performed by the vascular 2001;33:983–989.
team as the potential for vascular injury in this case 13. Davis RA, Milloy FJ, Anson BJ. Lumbar, renal, and
is even greater than the exposure for the L5/S1 disc associated parietal and visceral veins based upon
space. a study of 100 specimens. Surg Gynecol Obstet.
Steinmann pins are removed with the same 1958;107:1–22.
precautions noted above, and closure is the same as 14. Malaki M, Willis AP, Jones RG. Congenital
above. anomalies of the inferior vena cava. Clin Radiol.
2012;67:165–171.
15. Williams GM, Ricotta J, Zinner M, et al. The ex-
References tended retroperitoneal approach for treatment of ex-
tensive atherosclerosis of the aorta and renal vessels.
1. Suwanabol PA, Tefera G, Schwarze ML. Syndromes Surgery. 1980;88:846–855.
associated with the deep veins: phlegmasia ceru- 16. Jaboulay M. Le traitement de quelques troubles tro-
lea dolens, May-Thurner syndrome, and nutcracker phiques du pied et de la jambe par la dénudation de
syndrome. Perspect Vasc Surg Endovasc Ther. l’artère fémorale et de la distension des nerfs vascu-
2010;22:223–230. laires. Lyon Med. 1899;91:467.
2. Seeley SF, Hughes CW, Jahnke EJ Jr. Major ves- 17. Collins GJ, Rich NM, Clagett GP, et al. Clini-
sel damage in lumbar disk operations. Surgery. cal results of lumbar sympathectomy. Am Surg.
1954;35:421–429. 1981;47:31–35.
3. Wachenfeld-Wahl C, Engelhardt M, Gengenbach 18. Haimovici H. Lumbar sympathectomy. In: Haimov-
B, et al. Transperitoneal versus retroperitoneal ap- ici H, ed. Vascular Surgery: Principles and Tech-
proach for treatment of infrarenal aortic aneurysms: niques. Norwalk, CT: Appleton-Centuy-Crofts;
is one superior? Vasa. 2004;33:72–76. 1984:925–939.
4. Valentine RJ, Hagino RT, Jackson MR, et al. Gastro- 19. Rieger R, Pedevilla S, Pochlauer S. Endoscopic lum-
intestinal complications after aortic surgery. J Vasc bar sympathectomy for plantar hyperhidrosis. Br J
Surg. 1998;28:404–412. Surg. 2009;96:1422–1428.
5. Borkon MJ, Zaydfudim V, Carey CD, et al. Retro- 20. Bandyk DF, Johnson BL, Kirkpatrick AF, et al. Sur-
peritoneal repair of abdominal aortic aneurysms of- gical sympathectomy for reflex sympathetic dystro-
fers postoperative benefits to male patients in the phy syndromes. J Vasc Surg. 2002;35:269–277.
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Belg. 2008;108:557–562. posure: operative technique and results. Ann Vasc
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Spine. 2012;37(20):1785–1789.

Inferior Vena Cava
13
Surgical Anatomy of the Inferior by the root of the small bowel mesentery, the first
Vena Cava and third portions of the duodenum, and the head
of the pancreas (see Figs. 10-5 and 12-4). The vena
The distal inferior vena cava begins at the con- cava is separated from the portal vein anteriorly by
fluence of the common iliac veins anterior to the the cleft of the epiploic foramen. The position of
fifth lumbar vertebra to the right of the midline the vena caval trunk deviates slightly more to the
(Fig. 13-1). It penetrates the membranous portion of right above the renal veins as the vessel traverses the
the diaphragm at the level of T8 and immediately liver, partially embedded between the caudate and
drains into the right atrium. The vena cava is crossed right lobes.
349
Inferior phrenic v’s
Hepatic v’s
Esophageal
hiatus
Right
adrenal v.
Abdominal
aorta
Cysterna
Subcostal v.
chyli
Right
renal v. Left
adrenal v.
Left renal v.
Right
gonadal v. Left gonadal v.
Psoas m. (cut)
Lumbar v.
Ascending
lumbar v.
Lumbar n.
Iliolumbar v.
Median
sacral v. Lateral
sacral v.
Deep
circumflex
iliac v.
Inferior
epigastric v.
Fig. 13-1 The inferior vena cava lies to the right of midline between the levels of the
eighth thoracic and fifth lumbar vertebrae.

Iliac Veins The ureter, ductus deferens (male), and round liga-
ment of the uterus and ovarian vessels (female)
The external iliac veins draining the lower extremi- cross the external iliac vessels. The sympathetic
ties begin behind the inguinal ligaments and run trunk and obturator nerve from the lumbar plexus
around the brim of the true pelvis medial to the pass beneath the common iliac veins. The aortic bi-
psoas muscles. The internal iliac veins, which drain furcation is slightly more cephalad than that of the
all the pelvic viscera except the rectosigmoid area, vena cava. The iliac arteries cross the iliac veins in
join the external iliac veins adjacent to the sacro- such a way that the arteries end up straddling and
iliac joints to form the common iliac veins. The embracing the veins (Fig. 13-2). The bifurcation of
common iliac veins ascend to unite in front of L5. the inferior vena cava is crossed anteriorly by the
Inferior
mesenteric
plexus
Iliohypogastric n.
Ilioinguinal n.
Ureter
Gonadal a. and v.
Genitofemoral n.
Right
common
iliac a.
L. external
iliac a.
Femoral n.
Ductus
deferens
Great
saphenous v.
Fig. 13-2 The external iliac veins

are enfolded by the limbs of the iliac
arteries and lie medial to the arter-
ies beneath the inguinal ligaments.
INFERIOR VENA CAVA | 351

right common iliac artery. Thus, the arteries are pelvis and with the azygous and hemiazygous veins
always lateral to the veins at the groin. Where the of the chest. There are other variable connections
bifurcations overlap, there is often dense adherence between this system and veins of the posterior body
between the arteries and veins. wall as well as occasional connections with renal
and adrenal veins. In addition, vein branches drain-
Infrarenal Vena Cava ing the spinal canal anastomose with the paraver-
tebral plexus via the intervertebral foramina. These
The only anterior branch of the infrarenal vena cava spinal vein branches extend along the length of the
is the small right gonadal vein. The paired lumbar spinal canal as an extensive valveless plexus drain-
veins are situated posteriorly and contribute to an ing both bone and neural structures. This complex,
extensive paravertebral venous plexus (Fig. 13-3). described by Batson, is thought to facilitate metas-
Longitudinal ascending lumbar veins within this tasis and spread of infection to the spinal column
plexus connect with the lateral sacral veins of the and brain.
Anterior
intervertebral Posterior
plexus intervertebral
plexus
Sympathetic
trunk
Lumbar v.
Spinal n.
Ascending lumbar v.
Fig. 13-3 The lumbar veins communicate with an extensive paravertebral network of veins.

Perirenal Vena Cava Retrohepatic Vena Cava
The renal veins enter the vena cava at the level of The portion of inferior vena cava traversing the
L2 and are usually single. The right renal vein fol- liver is enfolded on three sides by liver substance
lows a short path anteromedially (see Fig. 11-2) (Fig. 13-4). There are several small branches
from the renal hilum. The left renal vein arches draining from the caudate lobe directly into the
across the aorta in the acute angle formed by the vena cava. At the dome of the liver, the vena cava
takeoff of the superior mesenteric artery and joins receives the large hepatic veins, usually three
the vena cava at a 90° angle. The anterior relation- in number. The hepatic vein–vena cava junc-
ships of this segment of vena cava are described in tion is located at the anterior angle of the dia-
Chapter 11. mond-shaped bare area bounded by the coronary
Hepatoduodenal lig.
Portal v.
Impression of
hepatic flexure Common
of colon hepatic
duct
Hepatic a.
Ligamentum teres
Gastrohepatic lig.
Renal
impression
Gastric
impression
Right
triangular lig.
Inferior Caudate
Right vena lobe
posterior cava
coronary lig.
Left triangular lig.
Fig. 13-4 The retrohepatic segment of vena cava is partially embedded in the liver.

ligaments (see Fig. 10-5). The proximity of these inferior vena cava may provide adequate exposure
structures must be kept in mind when dividing the in these circumstances; however, due to the pos-
left triangular ligament and falciform ligament sibility of associated bowel and/or aortic injury,
lest the veins be entered. the midline transabdominal approach is generally
preferred.
Exposure of the inferior vena cava is also in-
Exposure of the Infrahepatic Vena Cava dicated in the extraction of intraluminal renal carci-
noma extensions,5,6 in the management of traumatic
The popularity of intraluminal devices for the injuries,7 and, rarely, in reconstructive venous op-
treatment of venous thrombosis has rendered elec- erations.8,9 Midline transperitoneal approaches are
tive surgical exposure of the inferior vena cava most appropriate in these circumstances.
virtually obsolete. These devices are effective and
extremely convenient as they can be inserted per- Extraperitoneal Approach
cutaneously through the jugular or femoral vein
with low associated morbidity.1 Modern filter de- The patient is placed in the supine position with the
vices can be placed permanently or on a temporary right flank elevated 15° to 20° on rolled sheets. The
basis; indications and outcomes are well described lower chest, abdomen, and right flank are prepped
elsewhere.1,2 Despite the ease of placement, com- and draped. General anesthesia is recommended be-
plications have been described from filter migra- cause complete muscle paralysis greatly enhances
tion, including filter embolization, strut fracture, this approach.
and vena cava perforation.3 Open extraction has A transverse incision is made from the lat-
become necessary in some cases involving retro- eral border of the right rectus muscle just above
peritoneal bleeding, bowel perforation, or aortic the level of the umbilicus and is extended later-
puncture.3,4 The retroperitoneal approach to the ally to the tip of the 11th rib (Fig. 13-5). The
Fig. 13-5 The vena cava is accessible through a right flank approach.

external oblique aponeurosis is incised, and fi- The retroperitoneal plane is developed to the
bers of the external oblique muscle are divided inferior vena cava by bluntly dissecting the right
in the lateral wound. The underlying internal colon and peritoneum away from the transversa-
oblique muscle is split in the direction of its fi- lis fascia and underlying psoas muscle posteriorly
bers and freed on its undersurface to permit wide (Fig. 13-6). The ureter is allowed to remain attached
retraction. The transversus abdominis muscle to the peritoneal surface, which is retracted anteri-
and transversalis fascia are opened in the lateral orly and to the left.
portion of the incision where separation of the The inferior vena cava is located anteromedial
peritoneum from the overlying fascia is rela- to the right psoas muscle in the deep wound. With
tively simple. These layers can then be opened good retraction, complete exposure of a 6-cm seg-
medially to the rectus muscle as the peritoneum ment of vena cava is possible using this approach.
is bluntly separated away. Any peritoneal rents Vascular control of the vena cava should be obtained
should be sutured closed. just cephalad to the highest lumbar veins.
Ureter
Sympathetic
chain
Psoas m.
Fig. 13-6 The peritoneum with the ureter attached is elevated to expose the vena cava.

Intraperitoneal Approach and its mesentery. The second and third portions of
the duodenum are also mobilized by incising ret-
The patient is placed in the supine position, and the roperitoneal attachments. The underlying inferior
lower chest and abdomen are prepped and draped. vena cava is exposed from the iliac bifurcation to
A vertical midline incision is preferred in trauma the level of the caudate lobe by reflecting the duode-
cases;10 in elective cases, a subcostal incision may num and head of the pancreas medially (Fig. 13-7).
be used. Before mobilization of the infrarenal vena cava is
After the peritoneal cavity is entered and rou- attempted, areolar tissue and lymphatics should be
tine exploration has been completed, the small in- cleared from the anterior and lateral caval surfaces.
testines are retracted to the patient’s left. Lateral The infrarenal vena cava can then be encircled with
peritoneal attachments of the right colon are in- a vascular tape just below the renal veins in prepara-
cised, allowing medial reflection of the right colon tion for more extensive mobilization.
Hepatic flexure
Duodenum
Hepatoduodenal
lig.
Caudate
lobe
Ureter
Gonadal a. and v.
Fig. 13-7 The perirenal vena cava is unroofed by mobilizing the right colon, duodenum,
and head of the pancreas.

In elective circumstances, the posterior wall of these vein branches permit full mobilization of
of the infrarenal vena cava can be exposed by roll- the infrarenal vena cava. This maneuver is not rec-
ing the lateral surface anteriorly (Fig. 13-8). Care ommended for control of injuries to the posterior
should be taken to control the lumbar veins draining vena cava wall because avulsion of lumbar veins is
into the posterior caval wall; ligation and division likely. Such injuries may be repaired by enlarging
Fig. 13-8 Ligating adjacent lumbar veins allows a segment of the back wall of the vena
cava to be visualized.

the anterior wound and closing the posterior wound should be identified and controlled to prevent avul-
from within the vena cava (Fig. 13-9).10 sion during this maneuver. Because this short seg-
The vena cava cephalad to the renal veins and ment of vena cava is tethered by the renal veins
inferior to the caudate lobe of the liver can be en- below and by the liver above, extensive mobiliza-
circled with a vascular tape. The right adrenal vein tion is not possible.
Fig. 13-9 Posterior wounds of the inferior vena cava can be repaired from inside the
vessel.

Exposure of the Retrohepatic Inferior the right lobe of the liver and allows rapid control
Vena Cava of the supradiaphragmatic inferior vena cava within
the pericardium should this become necessary (see
The patient is placed in the supine position, and the below).
entire abdomen, anterior chest, and lower neck are A vertical midline incision is made from the
prepped and draped. Some surgeons prefer a thora- xiphoid process to the pubis. After the peritoneal
coabdominal incision to expose this portion of the cavity is entered, self-retaining retractors should be
vena cava,11 but others recommend a midline abdom- placed in the upper wound margins on both sides to
inal approach with superior extension into a median elevate the costal margins superiorly (Fig. 13-10).
sternotomy, if necessary.12 The median sternotomy The right triangular ligament is divided
greatly enhances exposure of the area posterior to to expose the bare area of the liver. Peritoneal
Fig. 13-10 Firm retraction of the lower rib cage is necessary for exposure of the perihe-
patic vena cava.

attachments of the lateral and posterior surfaces of retracting it medially. A variable number (three to
the right hepatic lobe are divided as the right lobe eight) of small hepatic vein branches enters the in-
is retracted medially by an assistant (Fig. 13-11). ferior vena cava from the posterior surface of the
If the retroperitoneal portion of the liver is diffi- right and caudate lobes; these should be carefully
cult to visualize using these maneuvers, a median ligated and divided to prevent troublesome bleed-
sternotomy should be performed at this time (see ing. Three large hepatic veins enter the vena cava
Chapter 3). from the posterior surface of the upper liver. Expo-
The retrohepatic vena cava is visualized by sure and control of these larger veins are discussed
completely mobilizing the right hepatic lobe and in the following section.
Fig. 13-11 The right triangular and coronary ligaments of the liver are divided, and the
right lobe of the liver is gently rotated to the left to visualize the retrohepatic vena cava.

Exposure of the Hepatic Veins resection of the right hepatic lobe necessitates con-
comitant exposure of the retrohepatic vena cava (see
Exposure of hepatic veins is indicated in emergency above).
control of exsanguinating injuries and in elective Patient preparation and incision options are
liver resections. In emergency situations, consider- described in the above section. After the perito-
ation should be given to surgically isolating the ret- neal cavity has been entered and anterior vena cava
rohepatic vena cava using the Schrock technique13 exposure has been adequately obtained, the round
or temporarily occluding the vena cava with large ligament of the liver is divided, and the cut ends
balloons. The Shrock shunt is time consuming, tech- are ligated. The falciform and coronary ligaments
nically difficult and seldom successful. In unstable above the liver are widely incised, exposing the
patients, it may be prudent to pack the abdomen to bare area. The liver should be retracted caudally,
allow a brief period of resuscitation before proceed- allowing identification of two or three large hepatic
ing with vena cava exposure. For major hepatic veins within the areolar tissues of the bare area
trauma, damage control packing, ICU resuscitation, (Fig. 13-12). These veins should be carefully dis-
followed by return to the OR for liver resection is sected and encircled near their junctions with the
often the safest strategy. In elective circumstances, suprahepatic vena cava.
Fig. 13-12 The falciform and anterior coronary ligaments are opened, and the dome of the
liver is gently retracted downward to expose the hepatic veins and suprahepatic vena cava.

Exposure of the Suprahepatic Vena Cava within the Adequate exposure requires a median ster-
Pericardial Sac notomy (see Chapter 3). After the sternal edges are
separated, the glistening pericardial sac is opened
Isolation of the inferior vena cava above the liver vertically in the midline. To enhance exposure, the
is hampered by the presence of hepatic veins below divided pericardial edges can be retracted laterally
the diaphragm and the close proximity of the peri- with sutures (Fig. 13-13). The terminal portion of the
cardium above the diaphragm. Although the short inferior vena cava can be identified as it enters the
supradiaphragmatic segment can be isolated inferior right atrium near the inferior corner of the pericar-
to the pericardial sac by incising the central tendon dial space on the patient’s right side. Loose areolar
of the diaphragm, control is easier and more rapid tissue within Gibbon’s space behind the vena cava
within the pericardial sac. is easily separated using blunt dissection, permitting
passage of a vascular tape.
Fig. 13-13 The intrapericardial portion of the inferior vena cava can be isolated at its junc-
tion with the right atrium through a median sternotomy.

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1. Fairfax LM, Sing RF. Vena cava interruption. Crit trauma. J Vasc Surg. 1997;25:398–404.
Care Clin. 2011;27:781–804. 8. Quinones-Baldrich W, Alktaifi A, Eilber F, et al.
2. Angel LF, Tapson V, Galgon RE, et al. Systematic Inferior vena cava resection and reconstruction
review of the use of retrievable inferior vena cava for retroperitoneal tumor excision. J Vasc Surg.
filters. J Vasc Interv Radiol. 2011;22:1522–1530. 2012;55:1386–1393.
3. Belenotti P, Sarlon-Bartoli G, Bartoli MA, et al. Vena 9. Caso J, Seigne J, Back M, et al. Circumferential re-
cava filter migration: an underappreciated complica- section of the inferior vena cava for primary and re-
tion. About four cases and review of the literature. current malignant tumors. J Urol. 2009;182:887–893.
Ann Vasc Surg. 2011;25:1141. e9–e14. 10. Perry MO. Injuries to the inferior vena cava. In: Thal
4. Shang EK, Nathan DP, Carpenter JP, et al. Delayed ER, Weigelt JA, Carrico CJ, eds. Operative Trauma
complications of inferior vena cava filters: case re- Management: An Atlas, 2nd ed. New York, NY:
port and literature review. Vasc Endovascular Surg. McGraw-Hill, 2002:316–321.
2011;45:290–294. 11. Bower TC, Nagorney DM, Cherry KJ Jr, et al. Re-
5. Wang GJ, Carpenter JP, Fairman RM, et al. Single- placement of the inferior vena cava for malignancy:
center experience of caval thrombectomy in patients an update. J Vasc Surg. 2000;31:270–281.
with renal cell carcinoma with tumor thrombus ex- 12. Fullen WD, McDonough JJ, Popp MJ, et al. Sternal
tension into the inferior vena cava. Vasc Endovascu- splitting approach for major hepatic or retrohepatic
lar Surg. 2008;42:335–340. vena cava injury. J Trauma. 1974;14:903–911.
6. Helfand BT, Smith ND, Kozlowski JM, et al. Vena 13. Schrock T, Blaisdell FW, Mathewson C Jr. Manage-
cava thrombectomy and primary repair after radical ment of blunt trauma to the liver and hepatic veins.
nephrectomy for renal cell carcinoma: single-center Arch Surg. 1968;96:698–704.
experience. Ann Vasc Surg. 2011;25:39–43.

Left gastric
(coronary) v. Left gastric a.
Round lig.
of liver
Right gastric v.
Highest short
gastric v.
Splenic v.
Portal v.
L. gastroepiploic v.
Superior
mesenteric v.
Right Inferior
gastroepiploic v. mesenteric v.
Middle
colic v.
Superior rectal v.
Middle rectal v.
Inferior rectal v.
Fig. 14-1 The main venous trunks feeding into the portal vein are the superior and inferior mes-
enteric veins and the splenic vein.

Portal Venous
System 14
Surgical Anatomy of the Portal Vein veins at the level of the second lumbar vertebra.
Most commonly, the inferior mesenteric vein joins
The portal venous system drains the viscera the proximal splenic vein, but it may alternatively
supplied by the celiac, superior, and inferior mes- join the superior mesenteric vein or form a common
enteric arteries and normally carries the blood to junction with the other two veins. These three veins
the liver (Fig. 14-1). The portal vein is formed by drain the areas supplied by their corresponding
the confluence of splenic and superior mesenteric named arteries.
365
Anatomically, the superior mesenteric and border of the gland. The splenic vein is cradled in a
splenic veins lie close to their corresponding arter- groove running the length of the upper border of the
ies (Fig. 14-2). The superior mesenteric vein lies to posterior surface of the pancreas (inset). Numerous
the right of the artery in the root of the small bowel small branches drain from the tail and body of the
mesentery and ascends over the third portion of the pancreas into the apposed surface of the vein.
duodenum and uncinate process of the pancreas. The inferior mesenteric vein lies deep to the
The vein passes behind the neck of the pancreas left posterior parietal peritoneum and ascends in
and is joined by the splenic vein near the cephalad close proximity to the underlying infrarenal aorta.
Left gastric (coronary) v. Splenic a. and v.
Portal v.
Right gastric v.
Superior
mesenteric v.
Inferior mesenteric v.
Middle colic v.
Left renal v.
Fig. 14-2 The relationships of the main trunks of the portal system to the surrounding
structures are shown.

It courses beneath the root of the transverse me- mesenteric veins (Fig. 14-3). The right gastric vein
socolon and dives under the inferior border of the lies along the lesser curvature of the stomach be-
pancreas where it joins the splenic or superior mes- neath the gastric root of the gastrohepatic omentum.
enteric vein or their junction. From the confluence The left gastric vein spans the distance between the
of these branches, the portal vein ascends within esophagogastric junction and the posterior wall of
the thickened edge of the gastrohepatic ligament the omental bursa lying alongside the left gastric
accompanied by the hepatic artery and common artery. It descends diagonally over the celiac trunk
bile duct. beneath the posterior peritoneum of the omental
Another component of the portal system is the bursa to reach the portal vein. The apex of this loop
circuit formed by the left (coronary) and right gastric receives drainage from the lower esophageal veins.
veins that empty into the left side of the portal vein Small pyloric and duodenal veins also enter the por-
just proximal to the junction of splenic and superior tal vein near the gastric veins.
Left gastric (coronary) v.

Right gastric v.
Portal v.
Splenic v.
Superior mesenteric
a. and v.
Duodenum
Splenic a. and v.
Left renal a. and v.

Inferior
vena cava
Aorta
Fig. 14-3 The gastric vein circuit consists of the right gastric vein along the lesser curve
of the stomach and the left gastric or coronary vein beneath the posterior peritoneum of
the lesser sac.
PORTAL VENOUS SYSTEM | 367

Secondary Portal Venous Connections The second of these circuits is formed by connec-
tions between peripheral branches of the supe-
There are three more peripheral circuits through rior mesenteric, inferior mesenteric, and middle
which major branches of the portal system colic veins around the mesenteric margin of the
communicate (Fig. 14-4). The gastroepiploic arch colon. The final connection is between the short
connects the terminal splenic vein with the supe- gastric branches of the terminal splenic vein and
rior mesenteric vein and runs in the gastrocolic branches of the gastric circuit across the cardia of
omentum where it receives drainage from the the stomach.
omentum and greater curvature of the stomach.
Short gastric
arcade
Gastroepiploic
arcade
Middle colic v./

superior mesenteric v.
arcade
Middle colic v./

inferior mesenteric v.
arcade
Fig. 14-4 Peripheral links between limbs of the portal system are shown.

Portosystemic Venous Connections systemic venous circulations often become clini-
cally apparent.
Portal hypertension occurs as a result of increased There are several peripheral connections be-
portal vein resistance or, on rare occasions, from tween the portal system and the systemic circula-
increased portal vein flow. It is associated with a tion that become enlarged as a result of abnormally
number of hepatic and extrahepatic disorders that elevated portal pressure (Fig. 14-5). Peripheral dila-
have been well described elsewhere.1 Among other tion is most dangerous in the submucosal esopha-
consequences of increased pressure in the portal geal plexus connecting the portal circulation to the
system, the thin-walled veins become engorged. azygous system. Resultant esophageal varicosities
Normally small connections between the portal and are in danger of erosion and massive hemorrhage.
Esophageal varices
Gastric varices
Caput
medusa
Retroperitoneal
connections
Hemorrhoids
Fig. 14-5 Important portosystemic connections are found in the esophageal, periumbilical,

and rectal veins. Multiple small retroperitoneal communications are also found when portal
pressure is elevated.

Hemorrhoids are visible manifestations of the esophageal varices has evolved significantly in the
connection between superior rectal veins and mid- past two decades, however. Liver transplant is now
dle and inferior rectal veins. Caput medusae results considered definitive therapy for portal hyperten-
from engorgement of connections between the para- sion, and there are numerous temporizing options
umbilical veins and veins of the anterior abdominal that can achieve hemostasis and prevent rebleed-
wall, connecting to the portal system via the recana- ing, including endoscopic variceal sclerotherapy or
lized umbilical vein in the edge of the falciform lig- banding, transjugular intrahepatic portosystemic
ament. Multiple small retroperitoneal connections shunts (TIPs), and devascularization procedures.1–3
between the two systems (veins of Retzius) may Operative shunts are rarely performed in the mod-
lead to increased bleeding during retroperitoneal ern era, and may be contraindicated because they
dissection and tissue mobilization. interfere with the anatomy in patients who may
be eligible for liver transplant. However, some
surgeons believe that surgical shunts represent a
Exposure of the Portal Circulation reasonable alternative in patients who are not can-
didates for liver transplant or who fail attempts at
Historically, the main indication for exposure of TIPs.1,3 A wide variety of surgical options is avail-
the portal circulation was to create a portosystemic able for the treatment of patients who have had
shunt for surgical decompression of portal hyper- one or more variceal bleeds3 (Fig. 14-6). Surgical
tension. The management of patients with bleeding outcome is better when operations are performed
Superior mesenteric v.
Portal v.
Splenic v.
Inferior vena
cava
Left renal v.
Fig. 14-6 Surgical decompression of the portal system into the systemic venous system
is accomplished by connecting the portal or superior mesenteric veins to the inferior vena
cava or the splenic vein to the left renal vein.

electively in patients with less advanced liver mesocaval, and proximal splenorenal anastomoses
disease. (Fig. 14-7). These shunts prevent recurrent bleeding
Therapeutic portal decompression shunts can if they remain patent but do not improve survival
generally be divided into two categories: nonse- rates or quality of life because of the high associ-
lective and selective. Nonselective shunts include ated rates of hepatic encephalopathy.1,3 Selective
portacaval (both end-to-side and side-to-side), shunts include the Warren distal splenorenal shunt4
Fig. 14-7 Nonselective portacaval shunts are shown in the top row of three drawings, and
nonselective mesocaval and central splenorenal shunts are shown in the two drawings on
the lower left. Selective shunts include small-caliber variations of nonselective shunts and
the distal splenorenal shunt shown on the lower right.

(Fig. 14-8) and variations of the nonselective shunts in consideration of performing decompression pro-
(e.g., Sarfeh small-diameter portacaval H graft5 and cedures, repair of traumatic injuries, or reconstruc-
Johansen small-diameter portacaval anastomosis6). tion in patients with invasive pancreatic cancer.
Beyond portal decompression surgery, there
are two modern indications for exposure of the Exposure of the Portal Vein
portal venous system: repair of traumatic injuries7,8
and resection and reconstruction of the portal and The patient is placed in the supine position with
superior mesenteric veins in patients with invasive the right flank elevated 15° to 20° on rolled sheets.
pancreatic tumors.9,10 The following discussion con- The entire abdomen, lower chest, and right flank are
cerns exposure of the portal vein and its tributaries prepped and draped. An extended right subcostal
Nonselective Selective
Fig. 14-8 The selective distal splenorenal shunt isolates the drainage of the esophageal
venous plexus from the portal system, preserving portal flow to the liver undisturbed.

incision is made 2 to 3 cm below the right costal After the peritoneal cavity is entered, routine
margin, extending across both rectus muscles and exploration of the abdominal contents is carefully
into the right flank (Fig. 14-9). The incision should performed. In patients with portal hypertension, the
not be placed below this level in patients who have umbilical vein and falciform ligament are divided
hepatomegaly because exposure of the porta hepatis to interrupt an important source of collateral flow
is more difficult through lower incisions. Alterna- between the portal and systemic venous circula-
tively, a midline incision may be more appropriate tions. The portal pressure can be determined mano-
in patients undergoing exploratory laparotomy for metrically at this time through a mesenteric vein
trauma or pancreaticoduodenectomy for cancer. branch.
Fig. 14-9 An extended right subcostal incision provides good exposure of the portal vein.

The porta hepatis is exposed by retracting the and second portions of the duodenum are mobilized
right lobe of the liver cephalad and the hepatic flex- next by dividing lateral and posterior peritoneal at-
ure downward (Fig. 14-10). The hepatic flexure of tachments up to the right edge of the gastrohepatic
the colon may occasionally require mobilization ligament. Downward traction of the mobilized duo-
to enhance exposure, but unnecessary dissection denum greatly enhances exposure of porta hepatis
should be avoided to minimize blood loss. The first structures.
Fig. 14-10 Elevation of the right lobe of the liver and caudal retraction of the hepatic flex-
ure of the colon expose the hepatoduodenal ligament. The line of the peritoneal incision for
mobilizing the duodenum is shown.

The portal vein is best exposed along the right the peritoneum over the posterior wall of the por-
posterior border of the hepatoduodenal ligament, tal vein where it forms the anterior margin of the
away from the anterior aspect where distended foramen of Winslow. It is important to place the
lymphatics with large blood vessels are commonly incision posteriorly and not too close to the free
present11 (Fig. 14-11). It is not necessary to expose margin of the hepatoduodenal ligament.11 The inci-
the common duct using this approach. The portal sion is carefully extended superiorly as far as the
vein is usually distended and easily palpable as liver hilum and inferiorly as far as the head of the
the most posterior structure in the hepatoduode- pancreas. Using careful blunt dissection, the portal
nal ligament.11 A longitudinal incision is made in vein is encircled with a vessel tape in the midpoint
Gallbladder
Portal v.
Inferior
vena cava
Free edge of
hepatoduodenal
lig.
Right
kidney
Duodenum
Fig. 14-11 The portal vein is exposed on the posterolateral surface of the hepatoduodenal

ligament.

of the hepatoduodenal ligament. Gentle traction the pancreas to its bifurcation at the liver hilum.
placed on the portal vein exposes major branches, Dissection of the portal vein behind the pancreas is
including the pyloric, duodenal, right gastric, and difficult because of dense vascular, lymphatic, and
coronary veins, that drain into its medial surfaces connective tissues located in the area.11 In patients
(Fig. 14-12). Inferiorly, the large coronary vein can with invasive pancreatic cancer, separate expo-
often be found at the portal vein’s medial surface sure of the superior mesenteric and splenic veins
near its intersection with the splenic vein. After below the pancreas allows vascular control during
meticulous ligation and division of all portal vein tumor resection.9 It is important to bear in mind that
tributaries are ensured, the portal vein can be ex- anomalous right hepatic arteries pass near the por-
posed and completely mobilized from the level of tal vein (see Chapter 19).
Fig. 14-12 The portal vein is isolated, and venous tributaries draining into the origin of the
portal vein are ligated and divided.

Exposure of the Superior Mesenteric Vein entry into the engorged umbilical vein. A transverse
midabdominal incision is a useful alternative but may
The patient is placed in the supine position, and the en- be associated with increased blood loss from venous
tire abdomen and lower chest are prepped and draped. collaterals in the abdominal wall.
A midline abdominal incision made from a point half- After the peritoneal cavity has been entered
way between the umbilicus and xiphoid process to and carefully examined, the transverse colon is el-
the top of the pubis provides excellent exposure and evated and retracted superiorly to expose the root of
can be extended superiorly as necessary. The incision the mesocolon (Fig. 14-13). The small intestine is
should be carried to the left of the umbilicus to prevent retracted inferiorly, placing the intestinal mesentery
Fig. 14-13 The superior mesenteric vein overlying the

uncinate process of the pancreas is exposed by incising
the peritoneum at the junction of transverse colon and
small bowel mesenteries.

under slight tension. The superior mesenteric artery with a vessel tape (Fig. 14-14). Dissection should
can be palpated at the base of the transverse meso- proceed superiorly to the point where the middle
colon; the vein lies to the right of the artery near colic vein enters the superior mesenteric vein as the
the midline. A 7-cm transverse incision is made in latter courses over the uncinate process.11 Numer-
the peritoneum at the root of the transverse meso- ous tributaries entering the vein on the anterior and
colon, and the superior mesenteric vein is carefully left lateral surfaces must be ligated and divided. To
exposed. If necessary, a superior T extension can be gain more proximal exposure, the superior mesen-
made onto the transverse mesocolon for additional teric vein can be further isolated to the point where
exposure. Multiple well-vascularized lymphatics it disappears under the inferior border of the pan-
overlying the vein require careful dissection and creatic neck by dividing the middle colic branch.
meticulous control to avoid hemorrhage.11 After the Distally, the vein can be isolated for only a short
vein is freed on all sides, it is carefully encircled distance before it branches into tributaries too small
Middle colic v.
Superior
mesenteric v.
Fig. 14-14 The superior mesenteric vein is controlled, and branches are ligated to provide
space for the anastomosis. The right colic vein may be divided, if necessary.

for bypass construction. Still, enough of the supe- surface of the vena cava should curve beneath the
rior mesenteric vein can usually be isolated over duodenum to reach the anterolateral surface of the
the uncinate process to permit creation of a large large, single trunk of the superior mesenteric vein
anastomosis.11 over the uncinate process, assuming a C shape.
In the patient undergoing a portosystemic Alternatively, a short H-graft configuration can be
shunt, direct access to the inferior vena cava can brought more directly from the vena cava to the pos-
be obtained by opening the posterior peritoneum terior surface of the superior mesenteric vein. The
over the third part of the duodenum to the right latter is less desirable because the superior mesen-
of the mesenteric vein. Careful upward mobiliza- teric anastomosis is made at a more distal location
tion of the duodenum exposes the underlying vena where the vein is of smaller caliber and has multiple
cava (Fig. 14-15). Grafts brought from the anterior branches.
Superior
mesenteric v.
Duodenum
Inferior vena cava
Fig. 14-15 Mobilization of the duodenum to the right of the superior mesenteric vein pro-
vides direct access to the underlying inferior vena cava.

Alternate exposure of the inferior vena cava brought to the mesenteric vein from the vena cava
can be obtained by mobilizing the right colon (see in this fashion are routed around the third portion of
Chapter 13). A tunnel from the vena cava to the su- the duodenum and again anastomosed to the ante-
perior mesenteric vein should be carefully created rior surface of the superior mesenteric vein over the
in the base of the right colon mesentery to the right uncinate process.
of the superior mesenteric vein (Fig. 14-16). Grafts
Superior
mesenteric v.
Right
colon
(mobilized)
Inferior
vena cava
Fig. 14-16 The alternative approach of mobilizing the right colon provides wider exposure
of the inferior vena cava. The graft is then brought through a tunnel in the mobilized right
colon mesentery to reach the superior mesenteric vein over the uncinate process.

Exposure of the Splenic Vein Approach through the Lesser Sac
There are two popular approaches to the splenic The patient is placed in the supine position with
vein: a direct approach through the lesser sac12 and the lower chest and abdomen prepped and draped.
an inferior approach beneath the root of the mesoco- Warren and Millikan12 advocate a “hockey stick”
lon.13 The former approach offers the advantages of incision 1 to 2 cm below the left costal margin, ex-
simultaneous gastric venous devascularization and tending across the midline to the lateral border of
complete exposure of the pancreatic body and tail, the right rectus muscle (Fig. 14-17). An alternative
but dissection is often carried out through a deep, is the upper midline approach; thoracoabdominal
narrow hole into the retroperitoneum. The latter ap- incisions are too extensive and associated with
proach is associated with reduced retraction require- needless morbidity. On entering the abdominal
ments and a more central approach to the splenic cavity, the falciform ligament and the umbilical
vein, but isolation of the entire splenic vein to effect vein are ligated and divided. The lesser sac is en-
a complete splenopancreatic disconnection12 is more tered by dividing the gastrocolic ligament between
difficult. the gastroepiploic arcade and the greater curvature
Fig. 14-17 An extended left subcostal incision provides good exposure of the splenic vein.

of the stomach, taking care to ligate all gastric the short gastric veins intact because they repre-
branches (Fig. 14-18). The gastrocolic ligament sent the principal conduit for decompression of
should be divided from the pylorus to the low- esophageal varices. After dividing adhesions be-
est short gastric vein, and the right gastroepiploic tween the posterior wall of the stomach and the
vessels should be ligated. This reduces portosys- pancreas, the greater curvature of the stomach is
temic collateralization without compromising the elevated, allowing cephalad retraction of the pos-
blood supply of the stomach.12 It is crucial to leave terior stomach.
Short gastric v’s
Right gastroepiploic
a. and v. (divided)
Pancreas
Left
gastroepiploic
a. and v.
Transverse
mesocolon
Fig. 14-18 The gastroepiploic arcade is disconnected from the stomach, and the right gas-
tric artery and vein are divided to approach the splenic vein through the lesser sac.

The inferior border of the pancreas is mobi- proceeds medially along the vein’s inferior bor-
lized next (Fig. 14-19). The posterior parietal peri- der to its superior mesenteric junction. A cluster of
toneum between the pancreas and the duodenum is vein branches frequently drains into this area, and
relatively avascular and should be incised from the meticulous ligation and division are necessary for
level of the superior mesenteric vessels to the tail safe isolation of the splenic–mesenteric–portal vein
of the pancreas.12 Elevation and cephalad retraction juncture.12 The splenic vein should be completely
of the inferior border of the pancreas allow palpa- isolated and encircled at its junction with the portal
tion of the splenic vein along the posterior aspect vein. The coronary and right gastric veins should be
of the gland. Dissection of the vein commences by sought near the upper angle of the junction and care-
incising the adventitial tissues directly overlying the fully ligated. The inferior mesenteric vein should
vein’s posterior surface. After the posterior surface also be ligated and divided near its termination at
has been exposed for its entire length, dissection the splenic or superior mesenteric vein.
Fig. 14-19 The lower border of the pancreas is mobilized to expose the splenic vein.

Lateral dissection of the splenic vein can now of the pancreas (Fig. 14-20). Meticulous, unhurried
be performed along its superior margin, taking dissection is required to prevent branch avulsion and
great care to control and ligate the multiple small rapid associated blood loss. The splenic vein should
branches that drain directly from the posterior wall be dissected totally free of the pancreas.12
Fig. 14-20 Multiple small pancreatic branches are divided to free the splenic vein.

To create a distal splenorenal (Warren) wide mobilization. In preparation for anastomo-
shunt, the left renal vein is isolated in the retro- sis, the splenic vein should be divided as close
peritoneal tissues inferior and deep to the splenic to the splenic–portal–mesenteric junction as pos-
vein. The left adrenal and gonadal branches sible and brought directly to the left renal vein
should be divided close to the renal vein to permit (Fig. 14-21).
Fig. 14-21 The left renal vein is exposed, and the splenic vein is ligated and divided as
proximally as possible.

Approach beneath the Mesocolon left renal vein is identified as it crosses the aorta in
the superior incision. The vein is encircled, and its
The patient is positioned and prepped as previously gonadal and adrenal branches are divided to permit
described. An upper midline incision provides ex- wide mobilization.
cellent exposure, although a supraumbilical trans- To locate the splenic vein, the posterior pari-
verse incision may be used instead. etal incision is extended to the left along the root of
After entry into the peritoneal cavity, the trans- the mesocolon, parallel to the inferior border of the
verse mesocolon is elevated, and the small intestines pancreas (Fig. 14-22). The inferior mesenteric vein
are wrapped in moist laparotomy pads and retracted should be identified as it courses along beneath the
to the patient’s right side. The retroperitoneal space posterior parietal peritoneum to the left of the aorta
is entered through a vertical incision in the poste- and traced superiorly to locate the splenic vein.
rior peritoneum over the infrarenal aorta. The inci- Anterior and cephalad retraction of the inferior bor-
sion is carried superiorly to include division of the der of the pancreas exposes the splenic vein coursing
ligament of Treitz, allowing rightward reflection of along the posterior pancreatic surface. The remainder
the third and fourth portions of the duodenum. The of the dissection proceeds as previously described.
Splenic v.
Left renal v.
Fig. 14-22 The splenic and renal veins may also be reached through the root of the transverse mesocolon.

References 8. Fraga GP, Bansal V, Fortlage D, et al. A 20-year ex-
perience with portal and superior mesenteric venous
1. Rosemurgy AS, Zorros EE. Management of variceal injuries: has anything changed? Eur J Vasc Endovasc
hemorrhage. Curr Prob Surg. 2003;40:255–343. Surg. 2009;37(1):87–91.
2. Rana SS, Bjasin DK. Gastrointestinal bleeding: 9. Lee DY, Mitchell EL, Jones MA, et al. Techniques
from conventional to nonconventional. Endoscopy. and results of portal vein/superior mesenteric vein
2008;40:40–44. reconstruction using femoral and saphenous vein
3. Wright AS, Rikkers LF. Current management of during pancreaticoduodenectomy. J Vasc Surg.
portal hypertension. J Gastrointest Surg. 2005;9: 2010;51:662–666.
992–1005. 10. Fleming JB, Barnett CC, Clagett GP. Superficial
4. Livingstone AS, Koniaris LG, Perez EA, et al. 507 femoral vein as a conduit for portal vein reconstruc-
Warren-Zeppa distal splenorenal shunts: a 34-year tion during pancreaticoduodenectomy. Arch Surg.
experience. Ann Surg. 2006;243:884–892. 2005;140:698–701.
5. Sarfeh IJ, Rypins EB, Fardi M, et al. Clinical impli- 11. Smith GW. Portal hypertension. In: Shackelford
cations of portal hemodynamics after small-diameter RT, Zuidema GD, eds. Surgery of the Alimen-
portacaval H graft. Surgery. 1984;96:223–229. tary Tract. Philadelphia, PA: WB Saunders; 1983:
6. Johansen K, Eide B, Carrico CJ. Enhanced survival 513–604.
in patients with variceal bleeding after elective portal 12. Warren WD, Millikan WJ. Selective transsplenic de-
decompression. Am J Surg. 1983;145:596–598. compression procedure: changes in technique after
7. Asensio JA, Petrone P, Garcia-Nunez L, et al. 300 cases. Contemp Surg. 1981;18:11–26.
Superior mesenteric venous injuries: to ligate 13. Zapolanski A, Siminovitch J, Cooperman AM. A sim-
or to repair remains the question. J Trauma. plified method and approach to the distal splenorenal
2007;62(3):668–675. shunt. Surg Gynecol Obstet. 1980;150:405–406.

VESSELS OF THE
LOWER EXTREMITY
389
Psoas major m.
Iliacus m.
Inguinal
ligament
Tensor fasciae
latae m.
Pectineal
lig.
Lacunar lig.
Sartorius m.
Pectineus m.
Vastus lateralis m.
Rectus femoris m.
Adductor brevis m.
Adductor longus m.
Gracilis m.
Fig. 15-1 The femoral vessels pass beneath the inguinal ligament medial to the bulk of
the iliopsoas muscle. After crossing the pectineal line of the pubis, the vessels cross the
pectineus muscle en route to the subsartorial femoral canal.
390 | VESSELS OF THE LOWER EXTREMITY

Common Femoral
Artery 15
Surgical Anatomy of the Femoral Region the inguinal ligament, within a triangular passage
between the pelvis and thigh. This femoral vascu-
The femoral artery is the principal channel sup- lar aperture is bounded laterally by the iliopsoas
plying blood to the lower extremity. The boundary muscles, medially by the reflected fibers of the
marking the transition between the external iliac inguinal ligament (forming the lacunar ligament),
and common femoral arteries is the inguinal liga- and posteriorly by the superior ramus of the pubis
ment. The artery lies just medial to the midpoint of (Fig. 15-1).
COMMON FEMORAL ARTERY | 391

The proximal femoral artery and vein are the pectineus muscle. Anteriorly and medially, the
wrapped in a fibrous covering called the femoral sheath is a tubular extension of the transversalis en-
sheath. This sheath is made up of several compo- doabdominal fascia lining the anterior abdominal
nents (Fig. 15-2). The lateral part of the sheath ad- wall. Within the sheath, there is a well-developed
jacent to the femoral nerve is the continuation of septum separating the artery from the vein. The
the iliac fascia covering the iliopsoas muscle. The sheath fits snugly around the vessels except on the
posterior portion of the sheath is the fascia covering medial side, where a narrow channel (femoral canal)
Psoas major m.
Iliac fascia
Pectineal lig.
Pectineus m.
Pectineal fascia
Transversalis
fascia
Femoral
canal
Fig. 15-2 The femoral sheath enclosing the vessels is a continuation of the endoabdominal

fascia. The components of this fascia contributing to the sheath are named transversalis,
iliac, and pectineal fascia. The femoral canal is the space within the sheath medial to the
femoral vein.

accommodates the passage of lymphatics. The pel- with the adventitia of the vessels at the origin of the
vic end of this channel is covered with weak fascia deep femoral artery and vein. The sheath is perfo-
and is the site through which a femoral hernia passes rated by small arterial branches and the great saphe-
(Fig. 15-3). The femoral sheath becomes continuous nous vein.
Psoas major m.
Pectineal lig.
Iliac fascia
Pectineus m.
Deep circumflex
iliac a. and v.
Femoral canal
(proximal end)
Femoral canal
(distal end)
Fig. 15-3 The proximal end of the femoral canal is covered with loose fascia, which is
violated when a femoral hernia forms. The hernia dissects and breaches the medial femoral
sheath below the inguinal ligament to protrude. Peritoneum overlies both the vessels and
the endoabdominal fascia.

Wrapped in their sheath, the femoral vessels by muscular boundaries (Scarpa’s triangle). The
lie cradled in a bed of muscles (Fig. 15-4). The lateral margin of the triangle is formed by the sar-
course of the vessels in the proximal third of the torius muscle, the medial margin by the adduc-
thigh lies within another triangular space defined tor longus muscle, and the cephalad base of the
Ureter
Testicular a. and v.
Genitofemoral n.
Internal iliac a.
External iliac a. and v.
Deep circumflex
iliac a. and v.
Ductus deferens
Inferior epigastric
Superficial a. and v.
circumflex iliac a.
Superficial epigastric a.
Superficial external
pudendal a.
Deep external
pudendal a.
Superficial femoral
Great saphenous v.
a. and v.
Adductor longus m.
Sartorius m.
Fig. 15-4 Removing the pelvic fascia and femoral sheath reveals the relationships of other
retroperitoneal structures to the vessels and exposes the small external iliac and common
femoral branches above and below the inguinal ligament, respectively.

triangle by the inguinal ligament. Between these The fascia lata forms an anterior roof over the
boundaries, the triangle appears as a depressed femoral triangle and attaches to the inguinal liga-
plane when the thigh is flexed in external rotation ment. It is breached by an oval opening (fossa ovalis)
(Fig. 15-5). through which lymphatics and the great saphenous
Fig. 15-5 Flexion and external rotation of the thigh make the muscular margins of the
femoral triangle stand out. The sartorius muscle forms the lateral boundary, and the adduc-
tor longus muscle forms the medial border.

vein pass (Fig. 15-6). The fossa ovalis is covered by nodes parallels the inguinal ligament. These nodes
the poorly defined cribriform fascia, which supports lie in the path of an anterior groin incision onto the
one of two groups of superficial subinguinal lymph femoral artery, and the rich plexus of lymphatic
nodes (Fig. 15-7). The more cephalad group of channels surrounding these nodes increases the
Deep circumflex
iliac a. and v. Inferior epigastric
a. and v.
Superficial circumflex
iliac a. and v.
Superficial epigastric
a. and v.
Cribriform fascia
pudendal a. and v.
Great saphenous v.
Deep external
pudendal a. and v.
Fig. 15-6 Anteriorly, the fascia lata attaches to the inguinal ligament. It is perforated by

branches of the femoral artery and by cutaneous nerves. Venous channels reach the femoral
vein through the loosely capped fossa ovalis.

risk of lymphocele after incisions in this area. Both penetrate both the femoral sheath and fascia lata to
groups of nodes drain to the deep subinguinal nodes reach the subcutaneous tissue of the lower abdomen
found in the fatty areolar tissue within the femoral and upper thigh. These are the superficial external
triangle, and from there lymph drains through the pudendal, superficial circumflex iliac, and superfi-
femoral canal to the external iliac chain. cial epigastric arteries. Their accompanying veins
Three superficial branches of the femoral ar- converge on the great saphenous vein near its junc-
tery arise just distal to the inguinal ligament and tion with the femoral vein. These vessels should be
Fig. 15-7 The superficial inguinal lymph nodes are clustered beneath the inguinal liga-
ment and around the fossa ovalis.

protected if possible when incising directly down to we should briefly look at the relationships of the
the femoral artery. The superficial epigastric pedicle external iliac artery just inside the abdominal wall
has long been used to support an axial lower abdom- to anticipate the major route through which bypass
inal skin flap. The superficial external pudendal ar- grafts to the femoral artery must pass.
tery crosses the femoral vein immediately adjacent Just inside the abdominal wall, the external il-
to the saphenofemoral junction. iac artery gives off two small branches that run in the
Before peeling back the fascia lata to exam- plane between the peritoneum and the transversalis
ine the deeper structures of the femoral triangle, fascia (Fig. 15-8). The inferior epigastric artery runs
Transversus abdominis m.
Inferior epigastric
a. and v. Deep circumflex
iliac a. and v. Testicular a. and v.
Rectus abdominis m.
Falx inguinalis
Deep inguinal ring
Femoral a.
Femoral v.
Inguinal lig.
Femoral ring
Pectineal lig.
Obturator nerve
and vessels
Pubis Ductus deferens
Obturator internus m.
Levator ani m.
Fig. 15-8 A medial view of the right superior pubic ramus stripped of peritoneum shows
the relationships of the femoral and obturator vessels.

toward the umbilicus, penetrating the transversalis be injured in creating the tunnel for the bypass graft.
fascia below the arcuate line of the posterior rectus The resultant bleeding is annoying and increases the
sheath to reach the lower third of the rectus abdomi- risk of infection. In addition, approximately 20% of
nis muscle. Immediately after its origin, the inferior patients have an obturator artery that arises from the
epigastric sends a small branch with the internal inferior epigastric rather than from the internal iliac
oblique fibers that form the cremasteric covering artery (Fig. 15-9 and see Fig. 19-21). This aberrant
of the spermatic cord in the male. The second small vessel descends across the pelvic end of the femo-
branch of the terminal external iliac artery is the deep ral canal and across the pectinate line of the pubis
circumflex iliac artery, which runs behind the lateral to reach the obturator canal. There is a potential for
portion of the inguinal ligament. Any of these small injury of this vessel during graft tunneling, a lesson
arteries and especially their accompanying veins may learned from repair of femoral and inguinal hernias.
Fig. 15-9 A surgically treacherous origin of the obturator artery from the inferior epigastric
artery is found in nearly one-fifth of individuals.

The floor of the femoral triangle beneath joint is demonstrated by the occasional joint infec-
the femoral vessels consists of the pectineus mus- tion after femoral arteriography when sterile tech-
cle medially and the iliopsoas muscle arching nique is broken. Deep to the pectineus muscle lies
over the anterior aspect of the hip joint laterally the obturator foramen, covered by a dense mem-
(see Fig. 15-1). The proximity of the underlying hip brane in all but its cephalad portion (Fig. 15-10).
Pectineus m.
Obturator
externus m.
Iliopsoas
tendon
Adductor
brevis m.
Adductor
longus m.
Adductor
magnus m.
Gracilis m.
Fig. 15-10 The relationships of obturator membrane, obturator canal, obturator externus

muscle, and surrounding adductor muscle origins make the obturator membrane a practical
route for bypass grafts.

The attachments of the adductor muscles around the membrane, and the obturator nerve and ves-
the bony margins of the obturator foramen form sels pass from the pelvis to the thigh through the
the rim of a cone, with the obturator membrane as more cephalad obturator canal. The obturator mem-
its base. Within this cone, the obturator externus brane provides an alternate route for bypass grafts
muscle has its broad origin from the lower part of to the femoral artery (Fig. 15-11).
Fig. 15-11 The obturator bypass route is com-

pared with the more common inguinal route.
Note that the center of the obturator membrane
away from the obturator canal is used to avoid
injury to the obturator vessels and nerve that
lie in the superomedial corner of the foramen.
Obturator
canal
Obturator
membrane

The common femoral artery crosses the pec- superior and inferior gluteal arteries (Fig. 15-12).
tineus muscle diagonally and divides into the super- The superficial femoral artery reaches the inverted
ficial and deep femoral arteries. The deep femoral apex of the femoral triangle and then traverses the
(profunda femoris) artery provides the majority of thigh in the adductor canal (Hunter’s canal) be-
blood flow to the thigh muscles, supplemented by tween the quadriceps and adductor muscles, giving
the obturator artery and descending branches of the off only minor muscular branches (see Fig. 15-4).
Inferior
Superior gluteal a.
gluteal a.
Obturator a.
Medial femoral
circumflex a.
Medial
Superficial femoral
femoral a. circumflex a.
Perforating
branch
Deep
femoral a.
Fig. 15-12 Branches of the gluteal arteries and the obturator artery supplement the deep
femoral in providing blood supply to the thigh.

Near the adductor hiatus, the superficial femoral ar- distal to the inguinal ligament. The deep femoral ar-
tery gives off the highest genicular artery that may tery usually arises on the lateral side of the parent
assume importance as a collateral channel in femo- vessel. Shortly after its origin, the deep femoral ar-
ral occlusive disease (see Chapter 17). tery gives rise to the lateral and medial femoral cir-
The common femoral artery gives off the small cumflex vessels (Fig. 15-13). Either of these vessels
deep external pudendal artery before giving rise to may less commonly arise from the common femoral
the large deep femoral branch approximately 4 cm artery and be confused with the deep femoral trunk.
Iliacus m.
Psoas m.
Sartorius m.
Tensor fasciae
latae m.
Vastus
lateralis m. Superficial circumflex
iliac a.
Superficial epigastric a.
pudendal a.
Deep external
pudendal a.
Lateral Pectineus m.
femoral
circumflex a.
Deep Medial
femoral a. femoral
circumflex a.
Adductor
brevis m.
Vastus
intermedius m.
Adductor
longus m.
Gracilis m.
Fig. 15-13 In this medial view, the posterolateral origin of the deep femoral artery gives
rise to the medial and lateral femoral circumflex arteries to the surrounding muscles. Either
or both may at times arise from the common femoral artery.

Such variant branches must be identified to obtain artery enters the substance of the vastus lateralis
control of this segment for anastomosis. where it anastomoses with genicular collaterals.
The origin of the deep femoral artery is crossed Branches of the medial femoral circumflex artery
by the lateral femoral circumflex vein (Fig. 15-14). supply the proximal adductor compartment. These
Branches of the lateral femoral circumflex artery vessels anastomose with each other, with the in-
supply the proximal quadriceps muscle. The de- ferior gluteal artery, and with the first perforating
scending branch of the lateral femoral circumflex branch of the deep femoral artery.
Common
femoral a.
Deep femoral a.
Superficial
femoral a.
Lateral
femoral
circumflex a.
Lateral
femoral Medial femoral
circumflex v. circumflex a. and v.
Fig. 15-14 The origin of the deep femoral artery is crossed by the lateral femoral circum-
flex vein that may be divided for exposure.

The continuation of the deep femoral ar- adductor muscles and sends four perforating ves-
tery turns posteromedially toward the femur and sels through openings in the adductor brevis and
enters the plane posterior to the adductor lon- magnus muscles. The first two branches usu-
gus where it closely parallels the femoral shaft ally perforate both muscles, whereas the lower
(Fig. 15-15A, B). It supplies the bodies of the branches penetrate only the tendinous attachment
Common
iliac a.
Deep circumflex Internal iliac a.

iliac a.
Superior gluteal a.
Inferior gluteal a.
Obturator a.
Lateral femoral
circumflex a.
Ascending br.
Transverse br. Medial femoral

circumflex a.
Descending br.
Deep
femoral a.
Perforating br.
Fig. 15-15 A: Anterior view of the rich collateral circulation around the hip joint and
proximal femur.

of the adductor magnus muscle along the medial and provide blood to the hamstring muscles of the
lip of the linea aspera of the femur. The last perfo- flexor compartment. The second perforator usually
rator is the termination of the deep femoral artery. provides a major nutrient vessel to the femur, and
The perforators anastomose with each other along the distal perforators anastomose with branches of
the posterior side of the adductor magnus muscle the popliteal artery.
Internal iliac a.
Superior gluteal a.
Inferior gluteal a.
Obturator a.
Lateral femoral
circumflex a.,
ascending br.
Sciatic vasa
nervorum
Medial femoral Cruciate

circumflex a. anastomosis
Lateral femoral
circumflex a.,
transverse br.
Perforating br.
Deep femoral a.
Lateral femoral
Linea aspera circumflex a.,
descending br.
Fig. 15-15 B: Posterior view of the rich collateral circulation around the hip joint and
proximal femur.

Exposure of the Femoral Artery in the Groin the underlying femoral head. Retrograde puncture
of the common femoral artery is simple and af-
The segmental nature of atherosclerosis has been fords direct catheter access to the aorta and most
recognized for many years.1,2 Although the patho- branches, including the arteries of the head and
logic factors leading to atherosclerosis probably neck. Antegrade puncture is more difficult, but
affect all arteries equally in a given individual, some permits direct access to arteries of the ipsilateral
arteries tend to remain patent until proximal occlu- extremity using shorter catheter lengths and re-
sive disease is far advanced. The common femoral duced radiation doses. The prevalence and risk fac-
artery is one such vessel. Because of a rich network tors for local complications related to access site
of collateral branches anastomosing with the distal have been detailed elsewhere.3
iliac and deep femoral arteries, the common femo-
ral and deep femoral arteries remain patent in all Exposure of the Common Femoral Artery
but the most advanced cases of aortoiliac occlusive
disease, embolic occlusion, or trauma. Surgeons The patient is placed in the supine position, and
have learned to take advantage of this tendency by the leg and lower abdomen are prepped and draped
using the easily accessible femoral artery for bypass from the level of the umbilicus to the knee. The en-
anastomosis. tire abdomen and chest should be prepped in cases
The femoral artery is also an important access involving concomitant exposure of more proximal
site for percutaneous peripheral and coronary arteries. Wide exposure of the femoral vessels and
interventions. Although improved catheter and wire their branches is most readily obtained through
design also permit safe access through the radial, a vertical incision. For endovascular procedures
brachial, and axillary arteries, the femoral artery is requiring limited exposure of the common femoral
preferred in most cases due to its relatively large artery above its bifurcation, an oblique incision may
size and the ability to compress the artery against be associated with fewer wound complications.4,5

The vertical skin incision is made directly of the inguinal ligament7 (Fig. 15-16). The oblique
over the femoral pulse and extended above the incision is made parallel to the inguinal ligament
groin crease such that one-third of the incision is just above the groin crease (Fig. 15-17A). In
above the inguinal ligament, and two-thirds are obese patients, the oblique incision allows place-
below it.6 When there is no palpable pulse in the ment of the endovascular device through an ad-
femoral artery, the incision should extend verti- ditional incision for tunneling to the arteriotomy
cally from a point slightly medial to the midpoint (Fig 15-17B).
Fig. 15-16 The vertical skin incision allows com-

plete exposure of the common femoral artery and
its branches. The incision is made slightly medial
to the midpoint of the inguinal ligament. It begins
cephalad to the inguinal ligament and extends
down toward the apex of the femoral triangle.

Fig. 15-17 A: An oblique skin incision may be pre-
ferred in cases involving limited exposure of the
common femoral vessels. The incision parallels the
inguinal ligament just above the inguinal crease.
B: Endovascular devices can be introduced through a
separate incision in obese patients.

On deepening the incision, one encounters the risk of a lymphocele developing postoperatively8
small superficial epigastric and superficial circum- (Fig. 15-18). The fascia lata is opened along the me-
flex iliac branches of the femoral vessels in the sub- dial margin of the sartorius muscle, and the incision
cutaneous tissue. These branches should be divided is extended proximally to the level of the inguinal
and ligated to gain access to deeper structures. In ad- ligament. Lateral retraction of the sartorius muscle
dition, time spent in ligating all lymphatics associ- exposes the underlying femoral triangle and vessels
ated with the superficial inguinal nodes reduces the within the funnel-shaped femoral sheath (Fig. 15-19).
Fig. 15-18 Careful ligation of inguinal lymphatics helps to prevent postoperative lymphocele.

Fig. 15-19 In this view, the skin and subcutaneous fat have been removed to show the inci-
sion in the fascia lata along the medial border of the sartorius muscle.

Further proximal exposure can be obtained by The common femoral artery divides into two
cephalad retraction of the inguinal ligament. major trunks, the deep (profunda) and superficial
Direct access to the common femoral artery is femoral arteries, which are best exposed by dis-
gained by opening the femoral sheath (Fig. 15-20). secting distally on the anterior surface of the par-
Separation of areolar tissue is all that is necessary ent trunk. Few branches will be encountered on the
to encircle this vessel. One should take great care to anterior surface of the artery, and the deep femoral
avoid entry into the femoral vein that lies medial to artery will not be injured using this approach. The
the artery in the femoral sheath. On occasion, there superficial femoral artery is easily isolated in the
may be inflammatory changes within the femoral distal wound. The origin of the deep femoral artery
sheath that render the vessels difficult to separate. is most often found laterally about 3.5 cm below the
Fig. 15-20 The femoral sheath is opened directly over the artery; the artery is mobilized
by blunt dissection and encircled for control.

inguinal ligament, although it may occasionally be origins of the deep and superficial femoral arteries.
more proximal or more distal7 (Fig. 15-21). The lat- The vein should be divided when more extensive
eral femoral circumflex vein crosses anterior to the exposure of the deep femoral artery is necessary.
deep femoral artery at this level and should be iden- In 25% of cases, the medial femoral circum-
tified during dissection. Injury to this vein can oc- flex artery arises directly from the common fem-
cur during dissection at the “crotch” formed by the oral trunk, as does the lateral femoral circumflex
Common
femoral a.
Lateral femoral
circumflex v.
Deep femoral a.
Superficial
femoral a.
Fig. 15-21 The deep femoral artery normally arises laterally off the common femoral trunk
about 3.5 cm distal to the inguinal ligament. Its origin is crossed by the lateral femoral
circumflex vein.

artery in 20% of cases7 (Fig. 15-22). It is important backbleeding that occurs from the opened, cross-
to identify and control these anomalous branches clamped femoral artery is usually from one of these
before opening the femoral artery: significant branches.
Lateral femoral
cirumflex a.
Fig. 15-22 The lateral or medial femoral circumflex arteries may arise from the common
femoral trunk and cause troublesome backbleeding if unrecognized.

Anatomy of Inflow to the Femoral Artery any of these procedures because the deep femoral
artery (which is often devoid of stenoses) has been
Atherosclerotic occlusive disease is commonly shown to be an adequate recipient vessel in these
found in the infrarenal aorta and iliac arteries. situations.9
Bypasses around flow-limiting stenoses or occlu- The aortofemoral bypass is the most popular
sions of these arteries can be accomplished with a inflow procedure to the femoral artery. Suitable ex-
variety of procedures that use the femoral artery as traanatomic alternatives include the femorofemoral
the outflow vessel to the leg. Concomitant occlu- bypass, the axillofemoral bypass, and the obturator
sive lesions in the common or superficial femoral foramen bypass to the femoral or popliteal artery
arteries do not necessarily contraindicate the use of (Fig. 15-23). The following discussion concerns the
Fig. 15-23 Aortoiliac occlusive disease is

most commonly revascularized by the aor-
tofemoral route, but femorofemoral and ax-
illofemoral routes are useful extraanatomic
alternatives.

anatomy of tunnels to the femoral artery; exposures of the femoral artery in the periadventitial plane
for proximal anastomoses at the aorta and axillary (Fig. 15-24). Alternatively, the tunnel may begin in
artery are covered in other chapters. the empty space medial to the femoral vein. Grafts
brought through the latter tunnel are routed across the
Anatomy of the Aortofemoral Bypass Tunnel vein for anastomosis with the femoral artery. Either
tunnel passes deep to the inguinal ligament and enters
This tunnel connects the incisions used to expose the the pelvis on the anterior aspect of the external iliac
abdominal aorta and the femoral artery. The most artery. The inferior epigastric and deep circumflex il-
popular route follows the natural course of the iliac iac veins cross anterior to the external iliac artery and
and femoral arteries, allowing the graft to remain may be injured during this blind dissection. Direct vi-
protected in the retroperitoneal tissues. Tunneling is sion under the retracted inguinal ligament may aid in
begun with finger dissection on the anterior aspect identifying these vessels when they are injured.
Fig. 15-24 The aortofemoral bypass

tunnel is begun with finger dissec-
tion in the periadventitial plane be-
neath the inguinal ligament.

The proximal tunnel is begun in the abdomen Finger dissection begins in the periadventitial
on the anterior surface of the common iliac artery. plane near the aortic bifurcation and continues on
The correct plane is found by opening the perito- the anterior surface of the common iliac artery. The
neum overlying the distal aorta and aortic bifur- dissecting finger should be advanced blindly on the
cation. This maneuver may be aided by reflecting anterior surface of the external iliac artery to meet
the duodenum off the aorta as described elsewhere. the finger passing upward from the groin incision
The tissues overlying the ventral surface of the (Fig. 15-25). Care should be taken to ensure that
aorta are incised down to the periadventitial plane, the tunnel passes posterior to the ureter to prevent
and the incision is carried distally to the level of compression between the native iliac artery and the
the aortic bifurcation. graft.
Ureter
Fig. 15-25 Through an opening in the peritoneum overly-

ing the distal aorta, periadventitial finger dissection down the
external iliac artery creates a path beneath the ureter. Proximal
and distal tunnels meet along the external iliac artery.

Anatomy of the Axillofemoral Bypass Tunnel long tunneling instrument (Fig. 15-26). The tunnel-
ing instrument should be guided so that it reaches
The route from the axillary artery to the ipsilateral the inferior border of the pectoralis major muscle
femoral artery is a long subcutaneous tunnel that anterior to the midaxillary line, where it is pushed
traverses the lateral trunk.10 Exposure of the axil- through the axillary fascia into the subcutaneous tis-
lary artery is considered in more detail in Chapter 5. sue of the lateral chest wall. An intermediate incision
Tunneling is best begun near the axillary artery and may be needed just below the costal margin in cases
routed beneath the pectoralis major muscle with a in which the tunneling instrument does not reach the
Fig. 15-26 The axillofemoral bypass runs deep to the pectoralis major muscle proximally
and then in the subcutaneous plane to reach the groin. An intermediate incision between
costal margin and iliac crest facilitates formation of the tunnel. Many surgeons use a
transverse jump incision. The graft may be brought laterally over the iliac crest when the
midgroin must be avoided (dashed line).

groin from the axillary incision. The distal tunnel potential damage to autonomic genital supply,
continues down the lateral abdominal wall ante- which are associated with aortofemoral bypass.
rior to the midaxillary line. It terminates in a gentle However, the long-term success of this technique
curve toward the groin by passing medial to the an- is inferior to that of aortofemoral reconstruction.12
terior superior iliac spine. The tunnel should enter A steal phenomenon may occur if the donor iliac
the superolateral aspect of the open groin wound. artery system is compromised and the recipient ar-
In cases of groin wound infection, when the anas- terial system has a lower resistance than the donor
tomotic site must be created away from the groin, limb. Proof of the adequacy of inflow to the donor
tunnels can be routed more laterally. These tunnels femoral artery is necessary; angiography is often
can cross over the iliac crest with little concern for unreliable. Physiologic tests to determine the sig-
undue pressure on grafts11 to reach the deep femoral nificance of inflow lesions are considered in detail
artery away from the femoral sheath (see above). elsewhere.13 Transluminal angioplasty of the donor
Because of the long distances involved with artery can be used to correct inflow stenoses with-
this bypass technique, synthetic grafts (8 to 10 mm) out compromising long-term patency of the femo-
are preferred over autogenous saphenous veins. Use ral bypass graft.14
of grafts supported with external rings may provide The femoral arteries are exposed through bilat-
additional protection against kinking. These grafts eral groin incisions as described above. The femoro-
are introduced through the tunnel described above femoral bypass can be constructed with prosthetic
and routed into the deeper tissues of the femoral tri- or autogenous tissue.15,16 The graft tunnel is begun
angle for anastomosis with the respective femoral in the subcutaneous tissue just superficial to the
artery. medial part of the inguinal ligament of one incision
and passed subcutaneously in an inverted U fash-
Anatomy of the Femorofemoral Bypass ion cephalad to the pubis. It is introduced into the
superomedial aspect of the contralateral groin inci-
A patent femoral artery may serve as the source sion by passing over the inguinal ligament on that
of blood flow to the contralateral vessel. Cross- side. The graft is routed from the subcutaneous tun-
femoral bypass is an attractive option for revas- nel directly into the deep tissues of both incisions
cularization because it avoids laparotomy and for femoral anastomoses (Fig. 15-27). Alternatively,
Fig. 15-27 The femorofemoral bypass is usually brought subcutaneously over the pubis.

the graft may be tunneled posterior to the rectus ab- contralateral inguinal ligament (Fig. 15-28). Graft
dominis sheath, offering a less awkward trajectory ends are brought across the respective femoral veins
through several tissue layers and possibly improved for femoral artery anastomoses.
graft protection. The tunnel is begun medial to the The precise site of femoral artery anastomosis
femoral vein (in the empty space) and introduced has been shown to be a determining factor in long-
under the inguinal ligament. The tunnel is routed in term patency of femorofemoral bypasses. A superior
the properitoneal space cephalad to the dome of the patency rate has been demonstrated when both anas-
bladder and reaches the opposite incision under the tomoses are created at the bifurcation of the common
Fig. 15-28 The bypass may also be placed deep to the rectus abdominis muscle for added
protection.

femoral arteries rather than at the iliac level.17,18 The branches (Fig. 15-29). In cases involving occlusion
ends of the graft are best anastomosed to respec- of the superficial femoral artery, the anastomosis
tive common-superficial femoral artery junctions may be created directly with the deep femoral artery
on the side opposite the orifices of the deep femoral trunk (Fig. 15-30).
Fig. 15-30 When the superficial femoral artery is

occluded, the anastomosis is made directly over the
Fig. 15-29 The femoral graft anastomosis is placed origin of the deep femoral artery.
opposite the orifice of the deep femoral artery for optimal
outflow hemodynamics into both the deep and superficial
branches.

Anatomy of the Obturator Foramen Bypass intended incision. If infected, the groin area should
be carefully isolated from the sterile field using bar-
The obturator bypass brings direct blood flow to the rier drapes. The patient should then be prepped and
femoral artery from the ipsilateral iliac system. This draped from the upper abdomen to the lower leg.
extraanatomic procedure is an excellent option for Exposure of the recipient vessel is performed
managing septic complications of the femoral ar- first. Surgeons have performed successful bypasses
tery, such as localized graft infections or mycotic to a variety of arteries with this technique, including
aneurysms of the femoral artery in substance abus- the superficial femoral, deep femoral, supragenicu-
ers. The technique has also been championed in late popliteal, and infrageniculate popliteal arteries.
cases of suppurative groin lymphadenopathy, radia- Exposure of these vessels is discussed in detail in
tion necrosis, and severe scar tissue in the groin after other sections.
previous surgery. If an ipsilateral aortofemoral limb A retroperitoneal approach is preferred for
proximal to the affected groin is proposed as the in- exposure of the inflow artery or graft. A curvi-
flow source for the obturator bypass, it is important linear transverse incision is made approximately
to establish that the infection does not extend to this 4 cm above and parallel to the inguinal ligament
portion of the graft. (Fig. 15-31). The muscles of the anterior abdomi-
The patient is placed in the supine position nal wall are next divided. The external oblique is
with a rolled sheet under the flank on the side of the split in the direction of its fibers, and the internal
Fig. 15-31 The iliac vessels can be approached retroperi-

toneally through a lower quadrant incision proximal and
parallel to the inguinal ligament. The peritoneal envelope
is best elevated from lateral to medial.

oblique, transversus abdominus, and transversa- separation of the peritoneum from the transversalis
lis fascia are divided up to the edge of the rectus fascia. The peritoneum and its contents should be
sheath. Division of a few centimeters of lateral retracted medially along with the ureter.
rectus sheath may occasionally enhance medial The iliac vessels are found along the me-
wound exposure. Access to the retroperitoneal tis- dial prominence of the psoas muscle at this level
sues is most easily gained in the lateral wound, (Fig. 15-32). Grafts usually lie most comfortably
where abundant extraperitoneal fat permits easy just anterior to the external iliac artery. The obturator
External Fig. 15-32 This sagittal section through the

iliac a. and v. lower quadrant incision shows the iliac vessels
along the medial prominence of the psoas muscle
at the brim of the true pelvis. The pelvic fascia
is opened, and the ureter is retracted medially.
Ureter
Gonadal a. and v.
Obturator a. and v.
Obturator
internus m.
Levator ani m.

foramen is palpated under the superior ramus of the reached by incising the endopelvic fascia and bluntly
pubic bone. The obturator vessels and nerve traverse separating a portion of the underlying obturator in-
the obturator canal superolaterally; the bypass tunnel ternus and levator ani muscle fibers (Fig. 15-33). An
should be created centrally to avoid these structures. opening is made on the medial aspect of the tough
The medial portion of the obturator membrane is obturator membrane. A curved tunneling instrument
Fig. 15-33 A tunnel is made through the obturator internus muscle to reach the center of
the obturator membrane for the obturator bypass.

is passed through the opening and routed behind the Hunter’s canal (exposure, see Chapter 16) or directed
pectineus and adductor muscles into the midthigh. through the adductor magnus muscle to reach the vi-
There it may be brought through the adductor lon- cinity of the adductor hiatus for anastomosis with
gus muscle to reach the superficial femoral artery in the suprageniculate popliteal artery (Fig. 15-34).
Fig. 15-34 The obturator bypass graft may be brought through the adductor longus muscle
to reach the superficial femoral artery in midthigh or through the adductor magnus muscle
to reach the popliteal artery.

Bypasses to the deep femoral artery can be the adductor brevis muscle to reach clean lateral
brought through tunnels that pierce the surface of groin incisions (see above) (Fig. 15-35).
Pectineus m.
Iliopsoas
insertion
Obturator
externus m.
Adductor
brevis m.
Adductor
longus m.
Adductor
magnus m.
Superficial
femoral a.
Deep
Adductor longus m. femoral a.
Fig. 15-35 The obturator pathway may also be used to bring a graft laterally to avoid a contaminated medial groin
field. The deep femoral artery is exposed and kept under direct vision to avoid injury as the tunneler is passed
through the adductor brevis muscle.

References 9. Pearce WH, Kempczinski RF. Extended autogenous
profundaplasty and aortofemoral grafting: an alter-
1. Haimovici H. Patterns of arteriosclerotic lesions of native to distal synchronous bypass. J Vasc Surg.
the lower extremity. Arch Surg. 1967;95:918–933. 1984;1:455–458.
2. Darling RC, Brewster DC, Hallett JW, et al. 10. Landy GL, Moneta GL, Taylor LM Jr, et al. Axillo-
Aortoiliac reconstruction. Surg Clin North Am. femoral bypass. Ann Vasc Surg. 2000;14:296–305.
1979;59:565–579. 11. Connoly JE, Kwaan JHM, Brownell D, et al. Newer
3. Sambol EB, McKinsey JF. Local complications: developments of extra-anatomic bypass. Surg
endovascular. In: Cronenwett JL, Johnston KW, eds. Gynecol Obstet. 1984;159:415–418.
Rutherford’s Vascular Surgery, 7th ed. Philadelphia, 12. Schneider JR, Besso SR, Walsh DB, et al. Femoro-
PA: Saunders Elsevier; 2010:697–715. femoral versus aortofemoral bypass: outcome and
4. Beirne C, Martin F, Hynes N, et al. Five years’ hemodynamic results. J Vasc Surg. 1994;19:43–57.
experience of transverse groin incision for femo- 13. Schneider JR. Aortoiliac disease: extra-anatomic
ral artery access in arterial reconstructive surgery: bypass. In: Cronenwett JL, Johnston KW, eds.
parallel observational longitudinal group compari- Rutherford’s Vascular Surgery, 7th ed. Philadelphia,
son study. Vascular. 2008;16:207–212. PA: Saunders Elsevier; 2010:1633–1652.
5. Swinnen J, Chao A, Tiwari A, et al. Vertical or 14. Perler BA, Williams GM. Does donor iliac artery
transverse incisions for access to the femoral percutaneous transluminal angioplasty or stent place-
artery: a randomized control study. Ann Vasc Surg. ment influence the results of femorofemoral bypass?
2010;24:336–341. Analysis of 70 consecutive cases with long-term
6. Bergan JJ. Occlusive arterial disease—femoral follow-up. J Vasc Surg. 1996;24:363–370.
and popliteal. In: Nora PF, ed. Operative Surgery: 15. Rinckenbach S, Guelle N, Lillaz J, et al. Femoro-
Principles and Techniques. Philadelphia, PA: Lea & femoral bypass as an alternative to a direct aortic
Febiger; 1980:788–800. approach in daily practice: appraisal of its current
7. Gabella G. Arteries of the lower limb. In: Bannister indications and midterm results. Ann Vasc Surg.
LH, Berry MM, Collins P, et al., eds. Gray’s 2012;26:359–364.
Anatomy: The Anatomic Basis of Medicine and 16. D’Addio V, Ali A, Timaran C, et al. Femorofemo-
Surgery, 38th ed. New York, NY: Churchill Living- ral bypass with femoral popliteal vein. J Vasc Surg.
stone; 1995:1564–1574. 2005;42:35–39.
8. Schwartz MA, Schanzer H, Skladany M, et al. A 17. Lamerton AJ, Nicolaides AN, Eastcott HHG. The
comparison of conservative therapy and early selec- femorofemoral graft: hemodynamic improvement
tive ligation in the treatment of lymphatic compli- and patency rate. Arch Surg. 1985;120:1247–1278.
cations following vascular procedures. Am J Surg. 18. Plecha FR, Plecha FM. Femorofemoral bypass grafts:
1995;170:206–208. ten-year experience. J Vasc Surg. 1984;1:555–561.

Rectus
femoris m.
Iliopsoas m.
Pectineus m.
Adductor
brevis m. Adductor
longus m.
Adductor
magnus m.
Fig. 16-1 The adductor muscles of the thigh fan out to attach along the linea aspera of the femur.

Vessels of the
Thigh 16
Surgical Anatomy of the Thigh of the femur. The deepest of these muscles, the
adductor magnus, attaches to the full length of the
Muscles linea aspera beginning below the lesser trochanter
and ending at the adductor tubercle. It is interrupted
Between the bifurcation of the common femoral by four small apertures through which perforating
artery in the femoral triangle and the beginning of branches of the deep femoral artery reach the poste-
the popliteal artery at the adductor hiatus, the deep rior compartment, and by the large adductor hiatus
and superficial divisions of the femoral artery tra- at the lower third of the femur through which the su-
verse the thigh anteromedial to the femoral shaft, perficial femoral artery passes. The lower part of the
in intimate contact with the adductor muscles. The adductor brevis muscle is located between the mag-
adductor muscles (Fig. 16-1) originate from the in- nus and the adductor longus muscles. The pectineus
ferior ramus of the pubis and ischium and fan out muscle, from the superior pubic ramus, covers the
to attach to the linea aspera along the posterior side superior part of the adductor brevis muscle.
429
The posterior view of the adductor magnus The anterior compartment of the thigh consists
muscle (Fig. 16-2) shows the more horizontal direc- of the quadratus femoris muscle, which is made up
tion of the pubic fibers and the predominantly lon- of four heads: rectus femoris, vastus medialis, vastus
gitudinal ischial fibers. The tendinous openings can lateralis, and vastus intermedius (Fig. 16-3). These
be seen along the linea aspera. muscles enlarge from tapered origins proximally to
Gluteus
minimus m.
Pectineus m.
Obturator
internus m. Iliopsoas m.
Quadratus
femoris m.
Adductor
longus m.
Adductor
magnus m.
Adductor
magnus m.
Sartorius m.
Vastus Vastus
lateralis m. intermedius m.
Rectus
Vastus femoris m.
lateralis m.
Vastus
medialis m.
Fig. 16-2 In this posterior view, perforating branches of the

deep femoral artery can be seen passing through openings Fig. 16-3 The anterior compartment of the thigh consists
in the tendinous portion of the adductor magnus muscle. of the bulky quadratus femoris muscle.

a bulky teardrop form distally. The deep and superfi- tuberosity to the tibia and fibula. They lie across the
cial femoral vessels lie in the cleft between the vas- lower portion of the posterior surface of adductor
tus medialis and adductor muscles. magnus muscle. The upper portion of the adductor
Posteriorly, the long hamstrings, the biceps magnus muscle is covered by the insertion of the
femoris, semimembranosus, and semitendinosus gluteus maximus muscle into the upper part of the
muscles run the length of the thigh from the ischial linea aspera (Fig. 16-4).
Gluteus
Gluteus medius m.
maximus m.
Sciatic n.
Quadratus
femoris m.
Ischial
tuberosity
Adductor
magnus m.
Adductor
magnus m.
Biceps femoris m.
Long head
Gracilis m.
Short head
Semitendinosus m.
Semimembranosus m.
Sartorius m.
Fig. 16-4 The posterior thigh musculature is shown.
VESSELS OF THE THIGH | 431

The medial adductor compartment forms a su- (Fig. 16-6), the bulky adductor magnus muscle has a
periorly based pyramid between the quadriceps mus- roughly triangular profile, with a narrow linear medial
cle and the hamstrings (Fig. 16-5). In cross section attachment along the medial lip of the linea aspera.
Vastus Rectus Adductor

medialis m. femoris m. longus m. Pectineus m. Iliopsoas m.
Adductor Semimembranosus m. Semitendinosus m.

hiatus
Fig. 16-5 The medial adductor compartment is interposed between the quadratus femoris

and hamstring muscles. The body of the adductor magnus has been resected in this view.
Adductor longus m.
Adductor magnus m.
Fig. 16-6 The adductor magnus muscle tapers medially to form a narrow linear attachment
along the linea aspera of the femur.

Vessels branches. The superficial branch crosses the ad-
ductor longus muscle to lie beneath the sartorius
The common femoral artery enters the femoral tri- muscle. The deep (profunda) branch passes between
angle beneath and slightly medial to the midpoint the pectineus and adductor longus muscles to lie be-
of the inguinal ligament (Fig. 16-7). Within the neath the latter muscle.
femoral triangle it divides into deep and superficial
Femoral n.
Iliopsoas m.
Common
femoral a.
Superficial
femoral a.
Adductor
longus m.
Pectineus m.
Gracilis m.
Adductor
brevis m. Deep
femoral a.
Adductor
magnus m.
Fig. 16-7 The relationship between the branches of the femoral artery and thigh musculature is shown.

The superficial femoral artery supplies the ad- At the apex of the femoral triangle, the su-
jacent adductor muscles and the quadriceps muscle perficial femoral artery enters a triangular fascia-
(Fig. 16-8). The deep femoral branch supplies the lined cleft, the adductor (Hunter’s) canal, between
adjacent adductor muscles and sends three perforat- the vastus medialis, the sartorius, and the adductor
ing branches and its termination through the tendon longus (upper portion) and adductor magnus (lower
of the adductor magnus muscle to supply the ham- portion) muscles. The canal takes a 90° twist as it
strings in the posterior compartment. descends toward the knee (Fig. 16-9). The roof of
Pectineus m.
Common
femoral a.
Deep
femoral a. Adductor
longus m.
Adductor
brevis m.
Adductor Adductor
longus m. magnus m.
Superficial
femoral a.
Adductor
Adductor
magnus m.
(Hunter’s)
canal
Sartorius m.
Vastus
medialis m.
Adductor
hiatus
Fig. 16-8 The deep and superficial femoral branches are Fig. 16-9 Hunter’s canal twists 90° as it descends
separated by the adductor longus muscle. toward the knee.

the adductor canal is a sling of tough fascia cross- The deep femoral vessels (Fig. 16-10) lie close
ing from the vastus medialis to adductor muscles ly- to the femur beneath the adductor longus muscle.
ing just deep to the sartorius muscle. The superficial They first lie on the adductor brevis muscle, then
femoral artery lies superficial to the robust accom- directly on the adductor magnus muscle. Its upper
panying superficial femoral vein. Two branches of perforating branch or two transverse both deeper
the femoral nerve, the sensory saphenous nerve and adductor muscles, whereas the lower branches pen-
the motor nerve to the vastus medialis muscle, ac- etrate only the tendon of the magnus to reach the
company the superficial femoral vessels in the canal. posterior compartment.
Superficial Adductor
femoral a. longus m. Pectineus m.
Adductor Deep Adductor Adductor

magnus femoral a. magnus brevis m.
tendon (linea aspera
insertion)
Fig. 16-10 The relationship of the deep femoral vessels to the adductor muscles is shown.

Cross sections of the thigh show the relation- adhesion between the surface of the adductor longus
ships of the vessels to the muscular compartments muscle and the adjacent vastus medialis muscle that
(Fig. 16-11). The lateral intermuscular septum of the requires sharp dissection to separate. The remain-
thigh between the vastus lateralis and biceps femoris ing interfaces between muscle groups are less well
muscles is dense and well developed. There is firm defined.
RF VM
S
a.
VI v.
AL
AB
VL G
GM AM
SN SM
B
RF ST
VM
VI S
a.
v.
VL AL Key:
a = artery
G AB = adductor brevis m.
B(S)
AL = adductor longus m.
AM
AM = adductor magnus m.
SN
SM B = biceps femoris m.
B(L) (L) = long head
ST (S) = short head
Tn G = gracilis m.
GM = gluteus maximus m.
V PN = peroneal nerve
RF = rectus femoris m.
a.
S = sartorius m.
SM = semimembranosus m.
VM SN = sciatic nerve
ST = semitendinosus m.
TN = tibial nerve
AM v = vein
VI = vastus intermedius m.
B VL = vastus lateralis m.
S
VM = vastus medialis m.
PN
SM ST
Fig. 16-11 Cross-sectional (caudal) views of the thigh demonstrate the relationship of the

femoral vessels to the surrounding musculature.

The superficial femoral-popliteal vein (SFPV) hiatus (Fig. 16-12). Within the adductor canal, it
begins on the medial side of the popliteal artery lies deep to the artery before assuming a medial
below the knee, passes posterior to the popliteal ar- position again at the groin. Multiple branches drain
tery at the knee joint, and comes to lie on the lateral the adductor and quadriceps muscles along its
side of the superficial femoral artery at the adductor course.
Femoral a.
Femoral v.
Fig. 16-12 The posterior view shows the relationship between the femoral veins and their
accompanying arteries.

For purposes of clarification, Veith1 described includes the segment extending to the second perfo-
three anatomic subdivisions of the deep femoral ar- rating branch, and the distal zone extends from the
tery (Fig. 16-13). The proximal zone extends from second perforating branch to the artery’s termina-
the artery’s origin to the portion just distal to the tion. The sartorius muscle overlies the middle and
lateral circumflex femoral artery. The middle zone distal zones of the artery.
Proximal
Middle
Distal
Fig. 16-13 The deep femoral artery can be divided into

three anatomic zones. The middle and distal zones lie
beneath the sartorius muscle and require rotation of the
sartorius muscle for exposure.

Exposure of the Superficial Femoral Vessels in the Thigh the purpose of vein harvest. More localized expo-
The SFPV is an excellent conduit for large artery sure of the superficial femoral vessels can be gained
bypasses. This graft has proven to be durable for in through a more limited thigh incision.
situ replacement of infected aortic grafts,2 femoral The patient is placed in the supine position with
arterial bypass,3 central venous reconstruction, thigh the leg externally rotated and the knee flexed 30°.
arteriovenous fistula, carotid artery reconstruction, When bilateral vein harvest is anticipated, the legs
and mesenteric artery revascularization.4 The SFPV should be placed in a “frog-leg” position, with the
creates an excellent size match with the infrarenal knees flexed as close to 90° as possible. Full expo-
abdominal aorta, and we have used it for primary sure of the superficial femoral vessels is most easily
aortofemoral revascularization in young patients achieved through a longitudinal thigh incision that
with small aortas.5 SFPV harvest has been associ- parallels the lateral border of the sartorius muscle.
ated with surprisingly minimal sequelae.6 However, The incision should extend from the lateral groin to
the large size of the SFPV makes it unsuitable for the knee (Fig. 16-14). Lateral placement of the inci-
bypass to the infrageniculate arteries. The following sion is necessary to avoid interrupting the segmental
discussion involves exposure of the entire SFPV for blood supply to the sartorius muscle, which enters
Fig. 16-14 The incision is made parallel to the lateral border of the sartorius muscle.

the muscle on its inferomedial edge.7 The incision carefully protected during dissection to prevent sa-
is deepened through the fascia lata, and the sartorius phenous neuralgia (Fig. 16-16).
muscle is reflected medially to expose the underly- The superficial femoral vein should always be
ing roof of the adductor canal (Fig. 16-15). Entry mobilized proximally to the level of the common
into this overlying fascia exposes the superficial femoral vein confluence. If the vein is to be har-
femoral vessels. The vein and artery can be care- vested for use as a bypass graft, it is critically impor-
fully separated using sharp dissection to incise loose tant to transect and oversew the vein flush with the
areolar tissue. The superficial femoral vein has mul- deep femoral vein so that there is no residual stump
tiple large branches that require secure ligation with of superficial femoral vein that may serve as a nidus
double ligatures or transfixing sutures to prevent for a pulmonary embolus (Fig. 16-17). The vein can
disastrous bleeding complications when used in the be mobilized distally to the level of the knee joint
arterial circulation.8 The saphenous nerve is easily and transected just proximal to the popliteal vein
recognized within the adductor canal and should be confluence.
Saphenous n.
Adductor
canal
Fascia
Sartorius
Fig. 16-15 Medial retraction of the sartorius exposes the fascial roof overlying the adductor canal.

Saphenous n.
Fig. 16-16 The saphenous nerve traverses the adductor canal alongside the superficial
femoral vessels.
Fig. 16-17 The superficial femoral vein should be

transected flush at its confluence with the common
Superficial femoral vein to prevent the creation of a residual
femoral v. stump.

Lateral Approach to the Middle and Distal Segments of the Deep sartorius muscle provides access to the deep femo-
Femoral Artery ral artery distal to the femoral sheath. This technique
Each of the three segments of the deep femoral may also be preferred to the direct approach through
artery can serve as an excellent source of inflow the femoral sheath in vascular procedures involving
for infrainguinal bypass procedures.9 Locating the graft infection, excessive postoperative scarring, or
proximal anastomosis in the middle or distal seg- previous radiation to the groin.10,11
ments allows the bypass length to be shortened in The patient is placed in the supine position,
patients whose saphenous veins are inadequate to and the lower abdomen and entire leg are prepped
reach the groin. Direct exposure of the proximal and draped. A vertical incision is made paral-
segment of the deep femoral artery is best obtained lel to the lateral border of the sartorius muscle at
through a vertical groin incision (see Chapter 15). the lower end of the femoral triangle (Fig. 16-18).
A vertical incision along the lateral border of the After the wound is deepened through the fascia lata,
Femoral
triangle
Sartorius m.
Fig. 16-18 The incision is made lateral to the

border of the sartorius muscle at the lower end
of the femoral triangle.

the sartorius muscle is mobilized along its lateral muscle allows exposure of the lateral circumflex
border and reflected medially. The incision is fur- branches of the deep femoral vessels (Fig. 16-19).
ther deepened through a tough fascia that extends One or two branches of the femoral nerve will be
between the vastus medialis and adductor longus seen coursing over the lateral femoral circumflex
muscles. Lateral retraction of the rectus femoris vessels; the nerves should be identified and moved
Femoral n.
Sartorius m.
Rectus
femoris m.
Deep femoral a.
Lateral femoral
circumflex a. and v.
Fig. 16-19 The deep femoral artery may be approached laterally between the sartorius and
rectus femoris muscles when a surgically compromised groin must be avoided.

laterally in the wound (Fig. 16-20). Division of the to the level of the second perforating branch, where
lateral femoral circumflex vein provides exposure the artery dives posterior to the adductor longus
of the trunk of the deep femoral artery. Medial dis- muscle. Exposure of the artery between the level of
section exposes the origin of the deep femoral ar- the second perforating branch and its termination as
tery at its junction with the common femoral artery. the fourth perforator requires division of the adduc-
Dissection distal to the lateral femoral circumflex tor longus insertion on the linea aspera (Figs. 16-21
vein exposes the trunk of the deep femoral artery and 16-22).
Fig. 16-20 Retraction of femoral nerve branches and division of the lateral femoral cir-
cumflex vein expose the deep femoral artery.

Fig. 16-21 Exposure of the deep femoral artery distal
to the second perforating branch (distal zone) requires
division of the adductor longus muscle.
Adductor
brevis m.
Rectus
femoris m.
Sartorius m.
Adductor
longus m.
Adductor
magnus m.
Vastus
medialis m.
RF
VI
S
VM
AL
VL
AM
Fig. 16-22 A cross-sectional view (caudal view, r. thigh) B

SM
demonstrates exposure of the deep femoral vessels distal
to the second perforating branch (see key for Fig. 16-11). ST

Posterior Approach to the Deep Femoral Artery
Secondary revascularizations are often required for
limb salvage in patients who have developed bypass
graft thrombosis. These procedures are complicated
by the presence of scarring or infection, mak-
ing novel bypass routes attractive. Bertucci et al.12
described a direct posterior approach to the middle
and distal zones of the deep femoral artery. This
technique can be combined with posterior exposure
of the popliteal (see Chapter 17) or infrageniculate
arteries (see Chapter 18) for creation of an all-
posterior bypass.
The patient is placed in the prone position, and
the entire leg and ipsilateral buttock are prepped and
draped. The hamstring muscle group constitutes the
important landmark for this approach. A long verti-
cal incision is made parallel to the lateral edge of
the biceps femoris muscle, the most lateral muscle
in the hamstring group. The incision should extend
approximately 6 cm superior to and 10 cm inferior
to the gluteal crease12 (Fig. 16-23). The gluteus
maximus muscle is mobilized extensively along its
inferior border and retracted superomedially. This
maneuver exposes the proximal portion of the bi-
ceps femoris muscle and the sciatic nerve. The ad-
ductor magnus muscle is exposed in the deep wound
by retracting the biceps femoris muscle medially.
Gentle medial retraction of the sciatic nerve may
be required to improve visualization of the adductor
magnus muscle at this level.12 The distal segments
of the deep femoral artery are exposed by making a
longitudinal incision in the adductor magnus mus-
cle, using the muscular openings for the perforat-
ing branches as a guide (Fig. 16-24). Full exposure
requires longitudinal division of the adductor bre-
vis muscle lying just beneath the adductor magnus
muscle in this approach (Fig. 16-25).
Fig. 16-23 The incision for posterior exposure of the

deep femoral artery is shown.

Fig. 16-24 The gluteus maximus muscle is retracted
superomedially, and the biceps femoris muscle is re-
tracted medially to expose the adductor magnus mus-
cle. The deep femoral vessels are exposed by incising
the adductor magnus muscle near its insertion on the
Gluteus linea aspera.
maximus m.
Sciatic n.
Adductor
magnus m.
Deep
femoral a.
Linea
aspera
VM
RF S
Biceps VI
femoris m.
AL
AB
VL
AM
GM
SM
Fig. 16-25 A cross-sectional view (caudal view, ST

r. thigh) demonstrates posterior exposure of the deep
femoral vessels (see key for Fig. 16-11). BF

References 7. Valentine RJ. Harvesting the superficial fem-
oral vein as an autograft. Semin Vasc Surg.
1. Veith FJ. Alternative approaches to the deep femoral, 2000;13:27–31.
popliteal, and infrapopliteal arteries in the leg and 8. Smith ST, Clagett GP. Femoral vein harvest for vas-
foot: part I. Ann Vasc Surg. 1994;8:514–522. cular reconstructions: pitfalls and tips for success.
2. Chung J, Clagett GP. Neoaortoiliac system (NAIS) Semin Vasc Surg. 2008;21:35–40.
procedures for the treatment of infected aortic graft. 9. Darling RC III, Shah DM, Chang BB, et al. Can
Semin Vasc Surg. 2011;24:220–226. the deep femoral artery be used reliably as an in-
3. D’Addio V, Ali A, Timaran C, et al. Femorofemo- flow source for infrainguinal reconstruction?
ral bypass with femoropopliteal vein. J Vasc Surg. Long-term results in 563 procedures. J Vasc Surg.
2005;42:35–39. 1994;20:889–895.
4. Brahmanandam S, Clair D, Benja J, et al. Adjunc- 10. Naraysingh V, Karmody AM, Leather RP, et al. Lat-
tive use of the superficial femoral vein for vascular eral approach to the profunda femoris artery. Am
reconstructions. J Vasc Surg. 2012;55:1355–1366. J Surg. 1984;147:813–814.
5. Jackson MR, Ali AT, Bell C, et al. Aortofemoral 11. Nunez AA, Veith FJ, Collier P, et al. Direct ap-
bypass in young patients with premature atheroscle- proaches to the distal portions of the deep femo-
rosis: is superficial femoral vein superior to Dacron? ral artery for limb salvage bypasses. J Vasc Surg.
J Vasc Surg. 2004;40:17–23. 1988;8:576–581.
6. Modrall JG, Hocking JA, Timaran CH, et al. Late 12. Bertucci WR, Mairn ML, Veith FJ, et al. Posterior
incidence of chronic venous insufficiency after deep approach to the deep femoral artery. J Vasc Surg.
vein harvest. J Vasc Surg. 2007;46:520–525. 1999;29:741–744.

Popliteal Artery
17
Surgical Anatomy of the Popliteal Vessels
The popliteal artery is a short but vital segment of Adductor

the major arterial conduit of the leg situated between magnus m. Linea
the adductor hiatus and the lower border of the pop- aspera
liteus muscle posterior to the knee joint (Fig. 17-1).
Adductor hiatus
Supra-
geniculate Adductor
magnus tendon
Medial Popliteal a.
supracondylar line
Superior
genicular
branches
Mid- Muscular
popliteal branches
Inferior
genicular
branches
Popliteus m.
Infra-
geniculate
Soleus m.
Fig. 17-1 The popliteal artery extends

from the adductor hiatus to the lower
border of the popliteus muscle.
449
Because the relationships of the adjoining of varying thickness known as the fascia lata
segments of artery and the muscle groups attach- (Fig. 17-2). It is particularly thick along the ilio-
ing around the knee are vital to understanding tibial band of the lateral thigh and around the knee
the approaches to the popliteal artery, they are in- joint, where it serves as a retinaculum holding the
cluded as an integral part of the following anatomic hamstring tendons and the origins of the gastroc-
description. nemius muscle snugly around the popliteal neuro-
vascular bundle.
Fasciae Two prominent septa connecting the fascia lata
to the supracondylar lines of the femur divide the
Beneath skin and superficial fascia, the lower quadriceps muscle of the thigh from the adductor
extremity is wrapped in an aponeurotic girdle muscles medially and from the hamstring muscles
Sartorius m.
Lateral
intermuscular
septum
Superficial
femoral a.
Adductor canal
Iliotibial band Medial

intermuscular
Vastus septum
intermedius m. Fascia lata
Vastus lateralis m.
Vastus
Rectus femoris m. medialis m.
Fig. 17-2 The fascia lata forms a complete sheath around

the thigh and attaches to septa that extend to the femur
and divide the muscle mass into compartments.

posteriorly. These septa are closely applied to the Muscle Groups Attaching at the Knee
vastus medialis and vastus lateralis muscles near the
femur. There is an additional sling of fascia bridging The bulky quadriceps muscles of the anterior
the cleft between the vastus medialis and adductor thigh insert into the superior aspect of the patella
muscles. The sartorius muscle lies superficial to this (Fig. 17-3). The wedge-shaped adductor group fans
sling, and the superficial femoral vessels occupy the out from its origins on the inferior pubic ramus to
cleft beneath the sling. This passage is known as the the medial edge of the linea aspera, medial supra-
adductor canal (Hunter’s canal). condylar ridge, and adductor tubercle of the femur.
Deep femoral a.
Adductor
longus m.
Superficial
femoral a. Adductor
magnus m.
Adductor
hiatus
Adductor magnus tendon
Adductor tubercle
Fig. 17-3 The anterior quadriceps muscle group and the medial adductor muscles of the
thigh cradle the superficial femoral artery at their common border.
POPLITEAL ARTERY | 451
Several centimeters above the adductor tubercle, the The deep head of the biceps muscle originates from
tendon of the adductor magnus splits to form the ad- the lower third of the lateral lip of the linea aspera
ductor hiatus through which the superficial femoral and joins the superficial head to insert on the head
artery and vein pass to become the popliteal vessels. of the fibula. The semimembranosus muscle inserts
The hamstring muscles of the posterior thigh into the posterior lip of the medial tibial condyle.
originate at the ischial tuberosity and separate into The semitendinosus muscle, along with the gracilis
the medial semimembranosus and semitendinosus and sartorius muscles, insert on the anterior aspect
and the lateral biceps femoris muscles (Fig. 17-4). of the medial tibial condyle.
Tibial n.
Adductor
magnus m.
Semitendinosus m.
Biceps
femoris m.
Semimembranosus m. (short head)
Biceps
femoris m.
(long head)
Peroneal n.
A B C
Fig. 17-4 The hamstring muscles of the posterior thigh frame the upper borders of the
popliteal fossa.

The tibial and peroneal nerves lie between the The gastrocnemius muscle’s origins from the
hamstring and the adductor magnus muscles. The medial and lateral supracondylar flare of the femur
peroneal nerve spirals around the biceps insertion interdigitate with the insertions of the hamstring
to reach the lateral aspect of the leg, and the tibial muscles (Fig. 17-5). The confluence of these two
nerve descends to the popliteal space where it is sets of muscle attachments results in the deep,
loosely associated with the popliteal artery and vein. diamond-shaped popliteal fossa.
Tibial n.
Common peroneal n.
Sural a. and n.
Small saphenous v.
Medial sural n.
Fig. 17-5 The heads of the gastrocnemius muscle interdigitate with the insertions of the
hamstring muscles and form the lower borders of the popliteal fossa. The gastrocnemius
muscle is supplied by sural branches from the midpopliteal artery.
Popliteal Artery artery, which pierces the subsartorial fascial sling
along with the saphenous nerve (Fig. 17-6). The su-
At the distal end of the adductor canal, the superfi- perficial femoral vessels pass through the adductor
cial femoral artery gives off the highest genicular hiatus to reach the popliteal space.
Fascial roof
of adductor
canal
Adductor magnus m.
Highest
genicular a. Semimembranosus m.
Saphenous n.
Adductor
Gracilis m.
hiatus
Semitendinosus m.
Sartorius m.
Biceps femoris m.
Fig. 17-6 The superficial femo-

ral vessels in the adductor canal
are covered by a fascial sling
between the vastus medialis and
adductor muscles.

The popliteal vessels are enclosed in a firm from the supracondylar hollow of the popliteal
connective tissue sheath to which the tibial nerve is fossa by a small fat pad that facilitates surgical
loosely attached (Fig. 17-7). This sheath is separated mobilization.
Fig. 17-7 The popliteal vessels are enclosed in a firm fibrous sheath and are separated by
a fat pad from the posterior face of the femur.
Muscular branches of the proximal popliteal sural vessels, arise from the midpopliteal artery and
artery to the lower hamstring muscles anastomose pass to the heads of the gastrocnemius muscle with
with terminal branches of the profunda femoris ar- the sural branches of the tibial nerve.
tery (Fig. 17-8). Additional muscular branches, the
Hamstring branches
communicating with
deep femoral a.
Descending
musculoarticular
Biceps femoris m.
branch of highest
(short head)
genicular a.
Descending branch
of lateral femoral
Medial circumflex
intermuscular
septum Lateral
intermuscular
septum
Adductor magnus
tendon Superior
genicular arteries
Sartorius m.
Semimembranosus m. Plantaris m.
Semitendinosus m.
Gastrocnemius m.
Gracilis m.
Medial genicular a.
Oblique popliteal lig. Sural branches

to gastrocnemius m.
Biceps femoris m.
Popliteal a.
Popliteus m.
Anterior tibial a. Anterior tibial

recurrent a.
Soleus m.
Tibioperoneal trunk
Peroneal a.
Posterior tibial a.
Fig. 17-8 The popliteal artery gives rise to muscular and articular branches.

In addition to the muscular branches, the pop- This network is linked with important collat-
liteal artery gives rise to several vessels surrounding eral channels. It consists of paired superior and infe-
and supplying the knee joint (Fig. 17-9). rior genicular arteries and a middle genicular artery.
Lateral femoral
circumflex
Femoral a.
Branches to
hamstrings
Popliteal a. Musculo-
Lateral articular br.
superior Medial
genicular a. superior
genicular a.
Lateral Saphenous br.
inferior
genicular a.
Medial
Anterior tibial inferior
recurrent a. genicular a.
Fig. 17-9 The network of popliteal branches around the knee makes important collateral
connections proximally and distally.
The short distal segment of the popliteal through a hiatus in the origin of the soleus
artery lies between the heads of the gastrocne- muscle.
mius and popliteus muscles (Fig. 17-8). There The path of the popliteal vessels behind the
are no major branches from this segment, and it knee can be visualized by dividing and reflecting
is approachable from both the medial and lateral the posteromedial thigh muscles and the medial
sides of the leg. The popliteal artery disappears head of the gastrocnemius muscle (Fig. 17-10).
Adductor magnus m.
Biceps femoris m.
Soleus m. Semimembranosus m. Sartorius m.
Semitendinosus m. Gracilis m.
Gastrocnemius m.
(medial head)
Fig. 17-10 Division of muscular attachments on the medial side of the knee exposes the
full length of the popliteal artery.

Surgical Approaches to the Popliteal Artery of the popliteal artery is usually gained through me-
dial incisions, although lateral approaches have been
The various options for surgical access to the pop- described (Fig. 17-11). A direct posterior approach
liteal artery can be considered in terms of three is used to expose the midpopliteal section. This clas-
anatomic sections (Fig. 17-1): suprageniculate, in- sic approach has virtually been abandoned for use in
frageniculate, and midpopliteal. The suprageniculate bypass surgery, but it is ideal for surgery involving
and infrageniculate sections are used in bypassing correction of intrinsic pathology of the midpopliteal
obstructions of more proximal vessels, usually the artery, such as entrapment, cystic adventitial dis-
superficial femoral artery. Access to these sections ease, and localized aneurysms or intimal flaps.
Fig. 17-11 Approaches to the popliteal artery

are tailored to the level of pathology. The five
described routes allow exposure of the popliteal
artery from every conceivable angle.
Exposure of the Suprageniculate Popliteal Artery suprageniculate popliteal artery for patients who are
undergoing secondary vascular operations, when
This section of the popliteal artery is the preferred infection or surgical scarring render the medial ap-
position for the distal anastomosis of a femoropop- proach inconvenient.
liteal bypass, providing that the arterial tree below
this level is devoid of flow-limiting stenoses. Sur- Technique of Medial Suprageniculate Exposure
geons generally favor autogenous tissue, such as The patient is placed in the supine position with
the saphenous vein, for the bypass graft. The use of the leg externally rotated and the knee flexed 30°
synthetic graft material for bypasses to the popliteal (Fig. 17-12). The entire leg should be shaved and
artery above the knee is also acceptable,1–3 but the prepped to facilitate movement during the dissection
ischemic consequences of a failed bypass are worse and to ensure that other areas are available for dis-
with prosthetic graft than with autogenous vein.4 section should the popliteal artery prove inadequate.
The suprageniculate popliteal artery is most An incision is made in the distal third of the me-
easily approached through a medial incision. dial thigh along the anterior border of the sartorius
Veith et al.5 popularized a lateral approach to the muscle.
Fig. 17-12 The incision for medial suprageniculate exposure lies along the anterior border
of the sartorius muscle.

The fascia over the sartorius muscle is adductor tendon and semimembranosus muscles
incised, and the muscle is retracted posteriorly may require division to expose the underlying ves-
(Fig. 17-13). The popliteal vessels are identified sels. Additional exposure of the popliteal artery
by retracting the vastus medialis muscle anteriorly. can be obtained by dividing the thickened adductor
A fascial bridge of varying thickness between the magnus tendon forming the border of the adductor
Adductor magnus
tendon
Sartorius m.
Semimembranosus m. Saphenous n. and
superior genicular a.
Fig. 17-13 With the sartorius and gracilis muscles retracted posteriorly, the adductor mag-
nus tendon is separated from the semimembranosus muscle to expose the popliteal vessels
as they emerge through the adductor hiatus. The saphenous nerve and superior genicular
artery emerge through the roof of the adductor canal and cross the edge of the adductor
magnus muscle to reach the cleft between the sartorius and gracilis muscles.
hiatus (Fig. 17-14). Fascial connections between opening the sheath. The vein is often paired,
the adductor magnus tendon and the medial inter- and connecting channels that bridge the artery
muscular septum anterior to it may require division must be carefully divided to obtain exposure
to expose the anterior surface of the adductor hia- (Fig. 17-15).
tus. Care should be taken to preserve the highest Grafts to the suprageniculate popliteal artery
genicular artery and the saphenous branch of the are best brought through the adductor canal with a
femoral nerve. A tough fibrous sheath envelops the blunt tunneling instrument (Fig. 17-16). The graft
popliteal artery and vein. is thus situated in a natural anatomic plane where it
The artery is situated medial to the vein at is protected by the sartorius muscle and overlying
this level and therefore is encountered first on fascia lata.
Deep fascia
septum
Gracilis m.
Cut end of adductor
Semimembranosus m. magnus tendon
Sartorius m.
Fig. 17-14 The adductor magnus tendon can be divided to expose the proximal popliteal
vessels more completely. There is a fascial connection between the distal adductor tendon
and the medial intramuscular septum that must be divided to obtain the exposure shown.

Adductor magnus
tendon (cut)
Fig. 17-15 Within the vascular sheath, the artery must be carefully separated from sur-
rounding veins. Mobilization must be adequate for safe exposure and may be aided by the
use of soft vessel tapes.
Fig. 17-16 The optimal course for grafts to the suprageniculate

popliteal artery is within the adductor canal. For clarity, the skin
is not illustrated.
Technique of Lateral Suprageniculate Approach origin of the short head of the biceps femoris muscle
The leg is internally rotated and flexed at the knee ends several centimeters above the lateral femoral
(Fig. 17-17). A longitudinal incision is made in the condyle, leaving a loophole6 between muscle and
distal third of the thigh between the biceps femoris bone through which the vessels may be reached
muscle and the iliotibial tract. The fascia lata is in- (Fig. 17-19).
cised posterior to the junction of iliotibial tract and When this space is opened, the tibial and pero-
lateral intermuscular septum. An incision that is too neal nerves remain in a posterior plane bound to the
anterior leads into the vastus lateralis muscle in front hamstring muscles by loose fascia, and the vessels
of the lateral intermuscular septum (Fig. 17-18). The are found directly beneath the femur (Fig. 17-20).
Fig. 17-17 The incision for the lateral supra-

geniculate approach lies between the biceps
femoris muscle and iliotibial tract.
Lateral intermuscular
septum
Iliotibial band
“Loophole”
Biceps femoris m.
Fig. 17-18 The path to the popliteal
vessels from the lateral side of the
thigh lies through the deep fascia
posterior to the junction of the ilio-
tibial band and lateral intermuscular
septum (dashed line). An incision
anterior to this line leads into the
quadriceps muscles (upper arrow).

Fig. 17-19 The origin of the short head of the biceps
muscle ends several centimeters above the femoral
condyle. The distal part of the short head is connected
to the femur by a thin sheet of fascia. Opening this thin
fascia exposes the popliteal vessels.
Biceps femoris m.
Short head
Long head
Biceps femoris m.
Adductor
magnus
tendon
Semimembranosus m.
Tibial n.
Fig. 17-20 Above the knee, the tibial and
peroneal nerves are separated from the proxi-
Peroneal n.
mal popliteal vessels by loose fascia bridg-
ing the hamstring muscles. They are retracted
Semitendinosus m.
posteriorly with the muscles in the lateral
approach to the vessels.
The popliteal vein (which may be paired) is encoun- with atherosclerotic plaque. The preferred conduit is
tered first in the vascular sheath. It is mobilized and ipsilateral saphenous vein, which has superior long-
retracted posteriorly with the biceps femoris muscle term patency compared with prosthetic graft.7 When
(Fig. 17-21). ipsilateral saphenous vein is unavailable, suitable
alternatives include contralateral great saphenous
Exposure of the Infrageniculate Popliteal Artery vein, arm vein, or spliced small saphenous vein seg-
ments. In the rare patient without suitable autoge-
The infrageniculate popliteal artery is used more nous vein, use of prosthetic graft or endovascular
commonly in bypass surgery than the proximal pop- options may be preferable to amputation, even for
liteal segments because it is less likely to be involved TASC IID lesions.8–10
Lateral intermuscular
septum
Popliteal a.
Biceps femoris m.
Fig. 17-21 The popliteal vein is encountered first in the vascular sheath and is best
retracted posteriorly with the biceps muscle.

Exposure of the infrageniculate popliteal artery (Fig. 17-22). The entire leg is shaved and prepped as
is most easily carried out through a medial incision. in the previous exposures. A longitudinal incision is
For some patients undergoing complex secondary made approximately 1 cm behind the posterior bor-
vascular procedures, the lateral approach popular- der of the tibia, extending a third of the way down
ized by Veith et al.5 may be appropriate. the calf from the lower posterior edge of the medial
tibial condyle. Care should be exercised to avoid in-
Technique of Medial Infrageniculate Approach juring the great saphenous vein, which may course
The patient is placed in the supine position with directly through this area. The great saphenous vein
the leg externally rotated and the knee flexed 30° is found 1 to 2 cm posterior to the medial border of
Fig. 17-22 The incision for the medial infrageniculate approach lies approximately 1 cm

behind the posterior border of the tibia. The proximity of the saphenous vein requires
careful dissection. The vein usually remains with the posterior flap.
the tibia and is most conveniently retracted with the aspect of the incision (Fig. 17-24). More proximal
posterior wound edge. Anterior perforating branches exposure can be obtained by dividing the tendons of
from the saphenous vein may require ligation to en- the semitendinosus, gracilis, and sartorius muscles,
sure safe retraction. but the divided ends should routinely be marked
The crural fascia is incised 1 cm posterior with suture tags and reapproximated at the end
to the tibia, and the fascial incision is extended of the procedure to preserve knee stability. More
proximally to the level of the semitendinosus distal exposure can be obtained by dividing the
tendon (Fig. 17-23). The underlying medial head of tibial attachments of the soleus muscle, which lies
the gastrocnemius muscle is retracted posteriorly, deep to the gastrocnemius muscle in the incision
exposing the neurovascular bundle in the proximal (Fig. 17-25).
Sartorius m.
Gracilis m.
Semitendinosus m.
Gastrocnemius m.
(medial head)
Soleus m.
Fig. 17-23 After the crural fascia is incised, the underlying medial head of the gastrocne-
mius muscle is retracted posteriorly.

Fig. 17-24 The neurovascular bundle can be located deep
in the proximal aspect of the incision.
Popliteal a. and v.
Fig. 17-25 Additional exposure can be ob-

tained distally by dividing the tibial attach-
ments of the soleus muscle. More proximal
exposure can be obtained by dividing the
tendons of the semitendinosus, gracilis, and
sartorius muscles.
Anterior tibial a.
Soleus m.
Gastrocnemius m. POPLITEAL ARTERY | 469

The first structure encountered on enter- popliteal artery, and any small arterial branches can
ing the neurovascular sheath is the popliteal vein be ligated with impunity. Exposure of the artery is
(Fig. 17-26). This structure is more often paired facilitated by the use of vessel tapes to elevate the
than single, and bridging veins must be divided to artery above the vein into the incision. The tibial
gain access to the underlying popliteal artery. Few nerve lies posteromedially and should be carefully
important collateral vessels occur at this level of the protected during arterial dissection.
Fig. 17-26 The first structure encountered on entering the neurovascular sheath is one of

the paired popliteal veins. After careful dissection, the artery is elevated into the incision
using soft vessel tapes.

Grafts to the infrageniculate popliteal artery taken to ensure that the graft is brought between the
are best routed through the adductor canal, then heads of the gastrocnemius muscle at the level of
tunneled posterior to the knee between the femoral the knee joint; grafts routed through this muscle tis-
condyles (Fig. 17-27). Because the tunnel is created sue may be compressed during muscle contraction.
blindly, the actual pathway through the musculature The distal anastomosis is created in a plaque-free
of the thigh can only be estimated. Care should be segment of the popliteal artery.
Fig. 17-27 Grafts to the infrageniculate popliteal artery should be routed through the
adductor canal and tunneled posterior to the knee between the femoral condyles and
heads of the gastrocnemius muscle.
Fig. 17-28 The incision for the lateral infrageniculate
approach lies over the head and proximal third of the fibula.
Fig. 17-29 The common peroneal

nerve should be identified as it emerges
Common peroneal n.
posterior to the biceps tendon and
courses anteriorly around the neck of
the fibula, deep to the peroneus longus
muscle. This peroneus longus muscle Peroneus longus m.
must be divided in preparation for
mobilizing the nerve. Crural fascia
Biceps femoris Head of

tendon fibula
Soleus m.

Technique of Lateral Infrageniculate Approach the superior aspect of the fibular head (Fig. 17-29).
The patient is placed in the supine position with the The common peroneal nerve should be identified as
leg internally rotated and flexed at the knee. A verti- it emerges posterior to the biceps tendon and courses
cal incision is made over the fibular head and ex- anteriorly around the neck of the fibula. The biceps
tended distally over the proximal third of the fibula tendon is divided, and the common peroneal nerve
(Fig. 17-28). On deepening the incision, one notes with its deep and superficial branches is carefully
the tendon of the biceps femoris muscle inserting on dissected and retracted anteriorly (Fig. 17-30).
Deep peroneal n.
Superficial peroneal n.
Fibular collateral lig.
Fig. 17-30 The peroneal nerve with its deep and superficial branches is carefully retracted
away from the fibula. The biceps tendon and fibular collateral ligament are divided to be-
gin mobilization of the head of the fibula.
The upper third of the fibula is then removed deep to the fibula is enhanced by retracting the freed
from its bed. This is most easily accomplished by fibular head into the wound (Fig. 17-31). The fibular
dividing the ligamentous attachments of the fibular shaft can then be transected with rib shears and the
head and shaft, staying close to the bone. Blunt dis- bone removed from its bed. The popliteal artery is
section of the muscular and ligamentous attachments encountered just deep to the fibular bed (Fig. 17-32),
Fig. 17-31 The proximal third of the fibula is stripped of attachments to the soleus and pero-
neus longus muscles. A periosteal elevator may aid in the disarticulation of the tibiofibular joint.
Transsection of the fibular shaft with rib shears is aided by elevation of the proximal fibula.

Anterior compartment
Tibialis posterior m. Anterior tibial a. Deep peroneal n. Lateral compartment
Tibioperoneal trunk
Long
saphenous v. Peroneus longus m.
Superficial
peroneal n.
Tibial n. Fibula (cut)
Soleus m.
Gastrocnemius m.
Short saphenous v. Medial sural n.
Fig. 17-32 The lateral infrageniculate approach exposes the distal popliteal artery and its
branches.
and its superficial location facilitates separation from from the femoral artery are brought across the an-
the adjacent vein (Fig. 17-33). terior thigh (Fig. 17-34). To prevent kinking, grafts
Grafts brought to the popliteal artery using this should be routed such that they cross the knee at the
approach are best routed subcutaneously.5Bypasses midpoint of the lateral femoral condyle.11
Anterior tibial a.
Interosseous membrane
Popliteal a. Tibialis posterior m.

Tibioperoneal trunk
Peroneal a
Posterior tibial a.
Fig. 17-33 The vessels are found deep to the fibular bed and posterior to the interosseous
membrane.

Fig. 17-34 The most direct route between the femoral vessels and the lateral infragenicu-
late incision is a subcutaneous path across the anterior thigh.
Exposure of the Midpopliteal Artery the muscle boundaries of the popliteal fossa. The
need to reposition patients intraoperatively adds to
There is a group of disorders peculiar to the sec- the inconvenience of this approach for procedures
tion of the popliteal artery that traverses the knee involving arterial bypasses.
joint (midpopliteal artery). These disorders include
popliteal entrapment syndrome, cystic adventitial Technique of Posterior Approach
disease, and traumatic intimal flaps from posterior The patient is placed in the prone position with
knee dislocations. Aneurysms may sometimes be the knee slightly flexed. An S-shaped incision is
confined to the midpopliteal artery, allowing a rela- preferred to avoid the deforming scar contractures
tively limited dissection for correction of the pathol- associated with simple vertical incisions across
ogy. The posterior approach may also be useful in the posterior knee (Fig. 17-35). The superior lon-
cases of reoperative arterial surgery.12 gitudinal portion of the incision is made on the
The use of the posterior approach is contra-
indicated in procedures designed to correct more
diffuse vessel pathology. Exposure of the suprage-
niculate and infrageniculate arteries is hampered by
Fig. 17-35 The incision for posterior exposure of the popliteal vessels is S shaped to

minimize scar contractures associated with simple vertical incisions.

posteromedial aspect of the lower thigh, and the The first structure to be identified in the subcuta-
horizontal portion is brought across the flexion neous tissue is the small saphenous vein, which
crease. The inferior longitudinal extension of the in- should be ligated and divided (Fig. 17-36). The
cision is made laterally, for a distance of 6 to 8 cm. deep fascia is incised vertically, and the underlying
Small saphenous v.
Fig. 17-36 The small saphenous vein is identified in the subcutaneous tissue just superficial
to the deep fascia.
medial sural nerve is retracted for clear access to biceps femoris tendon obliquely toward the head of
the major neurovascular structures (Fig. 17-37). the fibula. Distal exposure may be enhanced at this
The tibial nerve is the most superficial major midpoint by retracting the two heads of the gastrocne-
line structure, and the peroneal nerve follows the mius muscle apart; this may require vertical division
Medial sural n.
Popliteal a.
Popliteal v.
Tibial n.
Small saphenous v.
Fig. 17-37 A vertical incision of the deep fascia exposes the contents of the popliteal
space. The medial sural cutaneous nerve should be divided for clear access to the major
neurovascular structures.

of a fusion seam in some patients6 (Fig. 17-38). The small saphenous vein is an excellent landmark and
tibial and peroneal nerves are best retracted later- can be traced craniad to identify the popliteal vein.
ally, exposing the ensheathed popliteal vessels ly- The artery lies medially in the sheath and slightly
ing medial to the tibial nerve. The stump of the deep to the vein.
Popliteal v.
Popliteal a.
Small Peroneal n.
saphenous v.
(divided)
Gastrocnemius
(lateral head)
Tibial n.
Fig. 17-38 The tibial nerve is the most superficial major midline structure and should be
retracted laterally to expose the ensheathed popliteal vessels.
References 7. The TransAtlantic Inter-Society Consensus (TASC)
Working Group. Management of peripheral arterial
1. Takaqi H, Goto SW, Matsui M, et al. A contemporary disease (PAD). J Vasc Surg. 2000;31:S217–S225.
meta-analysis of dacron versus polytetrafluoroethyl- 8. Parsons RE, Suggs WD, Veith FJ, et al. Polytetraflu-
ene graft for femoropopliteal bypass grafting. J Vasc oroethylene bypasses to infrapopliteal arteries with-
Surg. 2010;52:232–236. out cuffs or patches: a better option than amputation
2. Twine CP, McLain AD. Graft type for femoropop- in patients without autologous vein. J Vasc Surg.
liteal bypass surgery. Cochrane Database Syst Rev. 1996;23:347–356.
2010;12:CD001487. 9. Baril DT, Marone LK, Kim J, et al. Outcomes
3. Van Det RJ, Vriens BH, van der Palen J, et al. Dacron of endovascular interventions for TASC IIB
or PTFE for femoro-popliteal above-knee bypass and C femoropopliteal lesions. J Vasc Surg.
grafting: short-and long-term results of a multicen- 2008;48:627–633.
tre randomized trial. Eur J Vasc Endovasc Surg. 10. Baril DT, Chaer RA, Rhee RY, et al. Endovascular
2009;37:457–463. interventions for TASC IID femoropopliteal lesions.
4. Jackson MR, Belott TP, Dickason T, et al. The con- J Vasc Surg. 2010;51:1406–1412.
sequences of a failed femoropopliteal bypass graft- 11. Ouriel K, Rutherford RB. Femoral infrapopliteal
ing: comparison of saphenous vein and PTFE grafts. bypass with contralateral saphenous vein. In:
J Vasc Surg. 2000;32:498–505. Ouriel K, Rutherford RB, eds. Atlas of Vascular
5. Veith FJ, Aster E, Gupta SK, et al. Lateral approach Surgery: Operative Procedures. Philadelphia, PA:
to the popliteal artery. J Vasc Surg 1987;6:119–123. WB Saunders; 1998:34–39.
6. Henry AK. The back of the thigh and the leg. In: Henry 12. Gelabert HA, Colburn MD, Machleder HI. Posterior
AK, ed. Extensile Exposure, 2nd ed. Edinburgh, exposure of the popliteal artery in reoperative vascu-
England: Churchill Livingstone; 1973:241–259. lar surgery. Ann Vasc Surg. 1996;10:53–58.

Vessels of the Leg
18
Surgical Anatomy of the Leg
The popliteal artery branches in the proximal leg to

ultimately form the anterior tibial, posterior tibial,
and peroneal trunks. The older term “trifurcation”
is a misnomer because the common tibioperoneal Adductor magnus m.
trunk is interposed between the origin of the ante-
rior tibial artery and the bifurcation of the other two
vessels some 2 to 3 cm more distally (Fig. 18-1).
The popliteal artery terminates in a true trifurcation
approximately 3% of the time.1,2 To understand the Popliteal a.
relationships of these arteries, it is necessary to re-
view the muscle groups and fascial girdle of the leg.
Then the nerves and vessels can be conceptually laid Anterior tibial a.
in place. Tibioperoneal trunk
Interosseous membrane
Posterior tibial a.
Peroneal a.
Fig. 18-1 The division of the leg vessels distal to the popliteal

artery normally occurs in two stages. The anterior tibial artery
arises first, leaving a common tibioperoneal trunk that bifurcates
into the posterior tibial and peroneal arteries.
483
Fascia of the Leg around the knee joint and ankle joint. Thickened
bands of this fascia form retinacula at the ankle
A dense fascial layer, continuous with the fas- that restrain the extensor (dorsiflexor), flexor
cia lata of the thigh, encircles the leg. This cru- (plantar flexor), and peroneal (evertor) tendons
ral fascia is adherent to underlying structures (Fig. 18-2).
Superior
peroneal
retinaculum
Inferior
peroneal
retinaculum
Fig. 18-2 A, B: Thickened bands of the dense crural fascia form restraining retinacula at
the ankle over the extensor, flexor, and peroneal tendons. The two principal neurovascular
bundles lie beneath the extensor and flexor retinacula.

Superior extensor
retinaculum
Inferior extensor
retinaculum
Flexor
retinaculum
VESSELS OF THE LEG | 485

Strong septa join the crural fascia to the fibula anterior from the posterior space. In addition, a
and partition the leg into anterior, posterior, and secondary septum arches from the tibia to the fibula
lateral compartments (Fig. 18-3). The tough inter- posteriorly, creating a deep and superficial posterior
osseous membrane completes the division of the compartment.
Interosseous
membrane
Superficial
posterior
compartment Deep posterior
Lateral compartment
compartment Anterior
compartment
Fig. 18-3 Strong septa between the crural fascia and the bones of the leg separate the leg
into discrete compartments.

Interestingly, the three primary arterial trunks tibial and peroneal arteries lie in the deep posterior
of the leg occupy only two of the four spaces compartment and send penetrating branches to the
(Fig. 18-4). The anterior tibial artery lies in the overlying superficial posterior compartment and to
compartment of the same name. Both the posterior the adjacent lateral compartment.
Popliteal a.
Anterior
tibial a.
Peroneal a.
Posterior
tibial a.
Fig. 18-4 The major arteries of the leg lie in the anterior and deep posterior compartments
and supply adjacent compartments through perforating branches.

The nerve distribution differs slightly from the pressure is normally zero. Trauma such as fracture,
arterial pattern in that a discrete trunk enters each ma- severe compression, or prolonged ischemia can re-
jor compartment. The tibial nerve supplies the poste- sult in compartmental edema that increases tissue
rior compartment flexor muscles. The peroneal nerve pressure. As the pressure exceeds lymphatic and
divides into a superficial branch to the peroneal mus- then venous closing pressure, any egress of fluid
cles (peroneus longus and brevis) and a deep branch from the leg is blocked, and the pressure escalates
to the anterior compartment muscles (Fig. 18-5). more quickly. Such compartment syndromes can
The unyielding nature of the crural fascia and result in irreversible neuromuscular damage if not
its tight adherence at the knee and ankle make the relieved by prompt fasciotomy. Four-compartment
closed compartmental spaces susceptible to buildup fasciotomies are usually performed through sepa-
of pressure after leg injury. Intramuscular tissue rate medial and lateral leg incisions (Fig. 18-6).
Common
peroneal n.
Deep
peroneal n.
Superficial
peroneal n.
Posterior
tibial n.
Fig. 18-5 A major nerve trunk runs in each major

compartment of the leg.

Anterior
compartment
Lateral Deep
compartment posterior
compartment
Superficial
posterior
compartment
Fig. 18-6 Four-compartment fasciotomy
can be performed through separate medial
and lateral leg incisions.

Alternatively, all compartments can be simultane-
ously decompressed through a single lateral incision
combined with a fibulectomy (Fig. 18-7).
Fig. 18-7 A septum of each compartment attaches to the fibula, allowing universal com-
partment decompression by fibulectomy.

Musculoskeletal Relationships dorsiflexors, and evertors of the foot. The gastroc-
nemius muscle group (including the small plantaris
The muscle groups of the leg are composed of the muscle) attaches to the calcaneus through the large
large posterior gastrocnemius/soleus complex and Achilles tendon (Fig. 18-8).
three groups of long muscles: the plantar flexors,
Tibial n.
Popliteal a.+v.
Peroneal n.
Gastrocnemius m.
Soleus m.
Flexor
digitorum
longus m.
Fig. 18-8 The powerful gastrocnemius and soleus muscles occupy the superficial poste-
rior compartment of the leg.

The other three groups of muscles cross the (Fig. 18-9) consist of the tibialis posterior, flexor
ankle joint closely applied to bony structures. digitorum longus, and flexor hallucis longus mus-
Their tendons lie beneath thickenings of the deep cles. Their tendons pass behind the medial malleo-
fascia of the leg that prevent bowstringing of the lus under the flexor retinaculum (lacinate ligament)
long tendons at the ankle. The plantar flexors (Fig. 18-10).
Tibial n.
Popliteal a.
Peroneal n.
Gastrocnemius m.
Popliteus m.
Anterior
tibial a.
Tibioperoneal
trunk
Soleus m.
Posterior
tibial a. Peroneal a.
Tibialis
posterior m.
Flexor
digitorum
longus m.
Flexor
hallucis
longus m.
Fig. 18-9 Muscles of the deep posterior compartment are shown.

Flexor digitorum
longus m.
Tibialis posterior m.
Posterior
tibial a.
Tibialis anterior m.
Tibial n.
Flexor
hallucis
Extensor hallucis longus m.
longus m.
Flexor
retinaculum
Lateral
plantar a.
Medial plantar a.
Flexor hallucis
brevis m. Flexor digitorum
Abductor
hallucis m. brevis m.
Fig. 18-10 Tendons of the plantar flexor muscles pass behind the medial malleolus under
the flexor retinaculum.

The dorsiflexors (Fig. 18-11) consist of the extensor hallucis longus muscles. Their tendons
tibialis anterior, extensor digitorum longus, and are held by the superior extensor retinaculum
Tibialis
anterior m.
Peroneal n.
Anterior
tibial a. & v.
& deep
peroneal n.
Extensor
digitorum
longus m.
Extensor
hallucis
longus m.
Dorsalis
pedis a.
Fig. 18-11 Muscles of the dorsiflexor group are shown.

above the ankle and the inferior extensor retinacu- the foot evertors, the peroneus longus and brevis
lum below the ankle (Fig. 18-12). The tendons of muscles, pass behind the lateral malleolus and are
Extensor digitorum longus m.

Extensor hallucis longus m.
Peroneus
Superior extensor retinaculum
longus m.
Anterior tibial a.
Peroneus
brevis m.
Superior Inferior extensor retinaculum

peroneal
retinaculum Dorsalis pedis a.
Inferior Peroneus
peroneal tertius m.
retinaculum
Fig. 18-12 Tendons of the dorsiflexors are held at the ankle and foot by the superior and
inferior extensor retinacula.

held by the superior and inferior peroneal retinacula the bones of the ankle and foot form sheathlike com-
(Fig. 18-13). Deep attachments of the retinacula to partments for the tendons.
Peroneus
longus m.
Peroneus
brevis m.
Lateral
malleolus
Fig. 18-13 Tendons of the foot evertors pass behind the lateral malleolus.

Anterior Compartment extensor hallucis longus, and peroneus tertius mus-
The anterior, or extensor, compartment is enclosed cles. The anterior tibial vessels and deep peroneal
by the crural fascia attaching to the lateral subcuta- nerve lie between these muscular columns and are
neous margin of the tibia and the anterior septum directly accessible from an anterior approach. The
from the fibula to the crural fascia. It contains two arched origin of the anterior tibial vessels, pass-
parallel muscle masses (Fig. 18-14). The large tibi- ing through the proximal hiatus in the interosseous
alis anterior muscle lies adjacent to the tibia, arising membrane, can be made more accessible by remov-
from that bone and the adjacent interosseous mem- ing the head of the fibula. The distal anterior tibial
brane. Lateral to the tibialis anterior is a column of artery continues beneath the Y-shaped inferior ex-
muscles originating sequentially from the fibula and tensor retinaculum to reach the dorsum of the foot
adjacent interosseous membrane. From proximal as the dorsalis pedis artery lateral to the tendon of
to distal, these are the extensor digitorum longus, extensor hallucis longus muscle.
Anterior
tibial a.
Deep Tibialis
peroneal n. anterior m.
Extensor
digitorum
longus m.
Extensor
hallucis
Peroneus longus m.
tertius m.
Fig. 18-14 The anterior tibial artery and deep

peroneal nerve lie between the tibialis anterior
and extensor digitorum longus muscles in the
proximal leg and between the tibialis anterior and
extensor hallucis longus muscles in the distal leg.
All cross sections are shown from a caudal view.

Posterior Compartment subcutaneous border of the tibia, the tibial origin
The superficial posterior compartment contains the descends vertically to the midpoint of the tibia. The
bulky superficial gastrocnemius/soleus complex diagonal muscle fiber disposition of the lateral and
that fuses to form a common termination in the cal- medial origins should be used to advantage when
caneal tendon (Fig. 18-15). The hoodlike origin of stripping the muscle off the bone.
the soleus muscle blocks direct access to the under- Between the superficial and deep posterior mus-
lying posterior tibial and peroneal arteries. From the cle groups, there is a fascial layer that is less dense
apex at the fibular head, the shorter lateral fibular than the crural fascia and septa. Within and beneath
origin descends in a straight line down the fibula. this layer lie the posterior tibial and peroneal ves-
The tibial head is in two parts. The proximal diag- sels. Although the arteries are usually single trunks,
onal portion originates from the soleal line of the the tendency of accompanying veins to be multiple
tibia and is interrupted by the hiatus for the popli- is pronounced in the leg. Exposure of the arteries re-
teal vessels and tibial nerve. On reaching the medial quires careful dissection of the surrounding veins.
Gastrocnemius m.
Popliteus m.
Anterior
tibial a.
Tibioperoneal Tibialis posterior m.

trunk
Soleus m.
Soleus m. (fibular origin)
(tibial
origin) Peroneal a.
Flexor hallucis
Posterior longus m.
tibial a.
Fascia
of deep
posterior
compartment
Flexor digitorum
longus m.
Fig. 18-15 A thin fascial septum covers the muscles and

neurovascular structures of the deep posterior compartment.

The deep layer of posterior muscles consists Lateral Compartment
of the central tibialis posterior muscle, running the The peroneus longus and brevis muscles origi-
length of the interosseous membrane and into the nate from the lateral border of the proximal and
foot, flanked by the shorter flexor digitorum longus distal fibula, respectively (Fig. 18-16). Their ten-
muscle medially and the short flexor hallucis longus dons pass under the superior peroneal retinaculum
muscle laterally. Both the proximal posterior tibial posterior to the lateral malleolus. The importance
and peroneal arteries descend on the tibialis poste- of this muscle group in vascular surgery lies in
rior muscle. The distal third of the peroneal artery the fact that it must be mobilized from the fibula
runs within and behind the belly of the flexor hallu- to resect that bone for lateral access to the poste-
cis longus muscle. It terminates in a variable branch rior compartment vessels and when simultaneous
perforating through the distal interosseous mem- decompression of all compartments through a single
brane and in calcaneal branches. The posterior tibial incision is necessary.
neurovascular bundle reaches the ankle posterior to Henry3 emphasized fine points for liberating
the tendons of tibialis posterior and flexor digitorum the fibula without damaging adjacent nerves and
longus muscles beneath the flexor retinaculum. vessels. Proximal exposure is obtained by gently
Peroneus
longus m.
Peroneus brevis m.
Fig. 18-16 The peroneal muscles of the lateral compartment

must be mobilized for access to the fibula and deep posterior
leg arteries.

elevating the common peroneal nerve posterior to the (Fig. 18-17). The length of the muscle origins are
biceps femoris tendon. The overlying origin of the then elevated laterally to medially, creating a long
peroneus longus is divided to expose the branches trapdoor with an intact superficial peroneal nerve
Fig. 18-17 The path of the peroneal nerve and its branches is dissected free of overlying
muscles to protect the nerve during mobilization of the fibula.

(Fig. 18-18). The bias of the muscle fibers dictates stripping in the opposite direction. Confining dissec-
stripping upward toward the knee, whereas the dom- tion to the periosteal plane in the distal leg prevents
inant bias of the interosseous membrane mandates damage to the nearby peroneal vessels.
Fig. 18-18 A long flap of peroneal muscles is created by shaving the muscles off the fibula
distally to proximally. The interosseous membrane strips best in the opposite direction.

Cross-Sectional Anatomy running from the lateral peroneal septum to the tibia
medially. The superficial compartment containing
The muscle groups are compartmentalized by septa the gastrocnemius and soleus muscles is separated
connecting the deep fascia to the tibia and fibula from the deep posterior compartment containing the
and by the interosseous membrane between the two plantar flexors by the deep septum spanning from
bones. At the level of the calf (Fig. 18-19), the dor- the tibia to the fibula. The posterior tibial and pero-
siflexors lie in the anterior compartment of the leg neal vessels and the tibial nerve lie between the deep
along with the anterior tibial artery and deep branch muscles and deep septum at the level of the calf.
of the peroneal nerve. The neurovascular bundle lies The long saphenous vein and saphenous nerve lie
on the interosseous membrane. The peroneal com- in the anteromedial subcutaneous tissue. The small
partment is bounded by septa connected to the fib- saphenous vein lies subcutaneously in the posterior
ula, and contains the superficial peroneal nerve lying midline, soon to be joined by the sural nerve, seen
close to the bone at this level. The posterior com- here deep to the fascia between the gastrocnemius
partment is bounded externally by the deep fascia bellies.
Anterior
Anterior tibial a.
compartment
Deep
Deep posterior
peroneal n.
compartment
Lateral
compartment
Posterior
tibial a.
Superficial
peroneal n.
Tibial n.
Peroneal a.
Superficial
posterior
compartment
Fig. 18-19 In the midcalf, the neurovascular structures are grouped in the central portion
of the leg.

In the lower leg (Fig. 18-20), the unified gas- right down to the ankle. The peroneal artery, which
trocnemius/soleus tendon is enclosed by the deep is beginning to diminish above the distal tibiofibu-
fascia posteriorly and the deep intermuscular sep- lar syndesmosis, lies on the interosseous membrane
tum anteriorly. The narrowed span of the deep fas- covered by the mass of the flexor hallucis longus
cia over the Achilles tendon puts the medial fusion muscle. The peroneal tendons lie posterior to the
point posterior to the tibia, allowing direct access fibula on the lateral side of the Achilles tendon. The
to the deep compartment directly over the plantar deep peroneal nerve remains in the anterior com-
flexors and posterior tibial neurovascular bundle. partment with the anterior tibial artery, whereas
The tibialis posterior and flexor digitorum longus branches of the superficial peroneal nerve have pen-
muscles are mostly tendinous in the relatively larger etrated the deep fascia of the lateral compartment
deep posterior compartment, whereas the flexor hal- to lie in the subcutaneous plane. The anterior tibial
lucis longus muscle remains fleshy and muscular artery is moving anteriorly over the flare of the tibia.
Deep peroneal n.
Tibialis
Anterior tibial a. anterior
tendon
Extensor hallucis
longus m.
Superficial
peroneal n. br. Great
Extensor digitorum saphenous v.
longus m.
Peroneal a.
Flexor hallucis longus m.

Tibialis
posterior m.
Peroneus longus tendon
Flexor
digitorum
Peroneus brevis m. longus m.
Posterior
Sural n. tibial a.
Small saphenous v.
Tibial n.
Fascia of deep
posterior compartment Plantaris tendon
Achilles tendon
Fig. 18-20 In the distal leg, the anterior and posterior tibial neurovascular structures
become more superficial.

Just above the ankle joint (Fig. 18-21), the ten- foot as the dorsalis pedis artery. The peroneus lon-
don groups are tightly bound by thickened bands of gus tendon lies posterolateral to the peroneus brevis
deep fascia, the inferior extensor retinaculum ante- muscle as they pass behind the medial malleolus.
riorly, the flexor retinaculum posteromedially, and The partially tendinous flexor hallucis longus mus-
the superior peroneal retinaculum posterolaterally. cle remains a posterior midline structure right down
The tendon of the extensor hallucis longus muscle to the ankle joint. The tibial nerve lies posterior to
crosses over the anterior tibial neurovascular bun- the posterior tibial artery as the neurovascular bun-
dle, and the artery continues onto the dorsum of the dle enters the foot.
Extensor
hallucis
longus Deep peroneal n.
Dorsalis pedis a.
Tibialis
anterior Peroneus tertius
Extensor digitorum
longus
Great
saphenous v.
Superficial peroneal n.
Tibialis
posterior
Perforating br. peroneal a.
Flexor Peroneus longus

digitorum
longus Peroneus brevis
Sural n.
Posterior
tibial a.
Small saphenous v.
Tibial n. Calcaneal tendon
Fig. 18-21 Cross section demonstrates the anatomic relationships at the level of the ankle.

Vessels of the Lower Leg The continuation of the tibial nerve passes through
the hiatus in the tibial attachment of the soleus
The tibial nerve joins the popliteal vessels in the mid- muscle, along with the popliteal vessels. At the up-
popliteal space (Fig. 18-22) and sural neurovascular per end of the interosseous membrane, the anterior
bundles splay out to the heads of the gastrocnemius tibial artery passes into the anterior compartment.
muscles at the junction. Below the gastrocnemius The tibioperoneal trunk lies on the upper part of the
branches, the small saphenous vein joins the pop- tibialis posterior muscle and divides into the smaller
liteal vein, and the median sural nerve branch runs peroneal artery laterally and the posterior tibial ar-
along the course of the vein, tightly bound to it. tery medially. The anterior tibial artery lies on the
RIGHT LEG
MEDIAL
Tibial n.
Popliteal v.
Popliteal a.
Sural n’s
Sural n.
Popliteus m.
Small
saphenous v.
Anterior
tibial a.
Soleus m.
(tibial head
cut)
Tibialis Soleus m.
posterior m. (fibular head)
Flexor
Tibial n.
digitorum
longus m.
Peroneal a.
Posterior
tibial a.
Fig. 18-22 The tibial nerve joins the

popliteal vessels in the midpopliteal space.

interosseous membrane, first between tibialis ante- artery is progressively covered by, and sometimes
rior and extensor digitorum longus muscles and then within, the belly of the flexor hallucis longus muscle
between the tibialis anterior and extensor hallucis as that muscle expands from its low origin.
longus muscles that arise lower down. The posterior At the ankle, the anterior tibial artery and deep
tibial artery lies on tibialis posterior and flexor digi- peroneal nerve emerge between extensor digitorum
torum longus muscles, medial to flexor hallucis lon- longus and extensor hallucis tendons after passing
gus muscle, down the length of the leg. The peroneal under the latter medially to laterally (Fig. 18-23).
Extensor
digitorum
longus m. Tibialis
anterior m.
Peroneus
longus m. Extensor
hallucis
longus m.
Peroneus
brevis m.
Anterior
Superior
tibial a.
extensor
retinaculum
Deep peroneal n.
Inferior Dorsalis
extensor pedis a.
retinaculum
Fig. 18-23 The dorsalis pedis artery and deep peroneal nerve emerge at the ankle between
the tendons of the extensor digitorum longus and extensor hallucis longus muscles.

They run along the lateral border of the extensor beneath the flexor retinaculum to enter the foot
hallucis muscle beneath the deep fascia of the foot. (Fig. 18-24). Posterolaterally, calcaneal branches
Posteromedially, the posterior tibial artery and of the peroneal artery pass down from beneath the
tibial nerve lie between the flexor digitorum longus lower muscular border of the flexor hallucis longus
and flexor hallucis longus muscles before passing muscle.
Flexor digitorum
longus m.
Flexor hallucis
longus m.
Peroneus
Tibialis
longus m.
posterior m.
Tibial n.
Peroneus
brevis m.
Posterior tibial a.
Fig. 18-24 The posterior tibial artery and tibial nerve lie posterior to the medial malleolus
in a groove between the flexor digitorum longus and flexor hallucis longus tendons.

With the flexor hallucis longus muscle par- be seen lying on the interosseous membrane just
tially cut away, the course of the peroneal artery can medial to the fibula (Fig. 18-25).
Posterior tibial a.
Tibial n.
Peroneal a.
Flexor digitorum
longus m.
Communication br.
Perforating br.
Flexor hallucis
longus m.
Fig. 18-25 The peroneal artery lies on the interosseous membrane on the medial side of the fibula.

Vessels of the Foot The lateral plantar artery bows laterally, crosses be-
neath the proximal metatarsals, and joins the plantar
Two of the leg vessels, the anterior and posterior branch of the dorsalis pedis artery. The anterior tib-
tibial arteries, enter the foot and form a major anas- ial artery gives off medial and lateral anterior mal-
tomotic loop between dorsal and plantar aspects4 leolar branches that anastomose with corresponding
(Fig. 18-26). The anterior tibial artery becomes branches of the peroneal and posterior tibial arteries.
the dorsalis pedis artery, which runs medial to the In the midfoot, the dorsalis pedis artery gives off a
extensor hallucis longus tendon down to the proxi- lateral tarsal artery that anastomoses with branches
mal space between the first and second metatarsals. of the anterior lateral malleolar artery and the more
There it sends a deep plantar continuation between distal arcuate branch of the dorsalis pedis artery, as
the heads of the first dorsal interosseous muscle. well as with the lateral plantar artery. Small medial
After passing beneath the flexor retinaculum, the tarsal branches anastomose with the anterior medial
posterior tibial artery divides into a larger lateral malleolar and medial plantar arteries. Calcaneal
plantar artery and a smaller medial plantar branch. branches arise from the terminus of the peroneal
Peroneal a. Posterior
tibial a.
Deep peroneal n. Anterior

tibial a.
Perforating
Anterior
br.
medial
malleolar a.
Anterior
lateral
malleolar a.
Calcaneal
plexus Medial
tarsal a’s.
Lateral
tarsal a. Dorsalis
pedis a.
Lateral Medial
plantar a. plantar a.
Deep
plantar
Arcuate a. br.
Plantar arch.
Fig. 18-26 The two arteries of the

foot form a major anastomotic loop
with interconnecting branches.

artery and the posterior tibial artery and anastomose vessels originate from the arcuate artery and plan-
with plantar branches in the hindfoot as well as with tar arterial arch, the latter being dominant. There are
the malleolar plexuses. The peroneal artery sends a communicating branches between vessels of the two
perforating branch through the distal interosseous arches, passing between the metatarsals proximally
membrane. This branch anastomoses with the ante- and distally.
rior lateral malleolar artery and occasionally is the The relationships of the vessels of the foot to
origin of the dorsalis pedis artery in the absence of the bones of the foot are shown in Fig. 18-27. The
a dominant anterior tibial artery (see Chapter 19). dominance of the inflow to the plantar arterial arch
There is a communicating branch between peroneal varies somewhat as do the origins of dorsal and
and posterior tibial arteries above the ankle. Digital plantar digital vessels.
Plantar
arch
Medial
plantar a. Arcuate a.
Dorsalis
Lateral
pedis a.
plantar a.
Lateral
Medial tarsal a.
tarsal a’s.
Anterior
tibial a.
Peroneal a.
Fig. 18-27 The relationships between the arteries and

bones of the foot are shown.

The arteries on the dorsum of the foot lie deep peroneal nerve branches supply most of the dorsum
to the long extrinsic and short intrinsic extensor of the foot, the sural nerve supplies the lateral bor-
tendons of the toes (Fig. 18-28). The deep pero- der of the foot, and the saphenous nerve (the only
neal nerve accompanying the dorsalis pedis artery nerve not of sciatic origin below the knee) supplies
supplies sensation to the web space between the the medial ankle and foot. The latter two nerves
great and second toes. Loss of sensation at this lo- are bound to the small and great saphenous veins,
cation may be the first indication of increased pres- respectively, and care should be taken to avoid in-
sure within the anterior compartment where the juring the nerves when harvesting or mobilizing
proximal portion of this nerve lies. The superficial the veins.
Extensor
hallucis
longus
Extensor
digitorum
Extensor longus
hallucis tendons
brevis m.
Arcuate a.
Tibialis
anterior
Medial
tarsal a. Lateral
tarsal a.
Peroneus
Dorsalis tertius
pedis a.
Extensor
Deep peroneal n. digitorum
brevis m.
Tibialis
posterior Peroneus
brevis
Flexor
digitorum longus Peroneus
longus
Posterior tibial a.
Tibial n.
Fig. 18-28 The dorsal foot arteries lie deep to
Flexor hallucis longus
the extensor tendons of the toes.

Plantar Vessels anterior deflection of the hallucis tendon. The ar-
tery and nerve split at the lower border of the reti-
The posterior tibial neurovascular bundle, consist- naculum, just at the upper border of the abductor
ing of the posterior tibial artery, tibial nerve, and hallucis muscle. The medial plantar branch passes
accompanying veins, passes through the tarsal anteriorly and superficially to the flexor hallucis
tunnel beneath the flexor retinaculum to enter the longus muscle, crossing diagonally and superfi-
foot (Fig. 18-29). The bundle emerges between cially to the flexor digitorum longus tendons. The
the flexor digitorum longus and flexor hallucis lateral plantar bows toward the lateral side of the
longus muscles and passes beneath the retinacu- foot before crossing back to the first metatarsal in-
lum between these two tendons. At the lower end terspace to anastomose with the plantar branch of
of the retinaculum, the bundle lies posterior to the the dorsalis pedis artery.
Flexor digitorum longus m.
Posterior tibial a.
Flexor
retinaculum
Medial plantar a.
Lateral plantar a.
Abductor
hallucis m.
Plantar
fascia
Flexor
digitorum
Quadratus brevis m.
plantae m.
Fig. 18-29 The lateral plantar artery courses deep to the flexor digitorum brevis muscle
and pierces the first metatarsal interspace to anastomose with the deep plantar branch of
the dorsalis pedis.

With the Achilles tendon removed, the directly behind the medial malleolus to gain access
relationships of the posterior tibial neurovascular to the posterior tibial artery. The thickened con-
bundle can be seen (Fig. 18-30). As the Achilles tinuation of the deep fascia is the flexor retinac-
tendon narrows, the attachment of the posterior ulum. The plantar branches turn beneath the foot
investing fascia moves posteriorly and fuses with deep to the abductor hallucis muscle and run in the
the fascia of the deep posterior compartment rather plane between the flexor hallucis longus and flexor
than extending all the way to the tibia. Thus, the digitorum longus tendons and the flexor digitorum
deep posterior compartment fascia can be incised brevis muscle.
Flexor retinaculum
Fascia of
(lacinate lig.)
deep posteriot
compartment
Tibialis posterior
Posterior
tibial a.
Tibial n.
Flexor
digitorum
longus
Flexor
Abductor
hallucis
hallucis
longus
Flexor hallucis brevis m.

Flexor hallucis longus Calcaneal
Flexor digitorum longus tendon
Medial plantar a.
Lateral plantar a.
Flexor digitorum brevis m.
Abductor hallucis m. (cut)
Fig. 18-30 The posterior tibial artery and tibial nerve are located just beneath the deep
posterior compartment fascia as they curve posterior to the medial malleolus.

There are three layers of plantar muscles and abductor digiti minimi muscles. These three
(Fig. 18-31). The deep layer consists of the flexor muscles are covered on their plantar surface by the
hallucis brevis, adductor hallucis, and flexor digiti plantar fascia, which is thick centrally and thins to
minimi brevis muscles. The flexor hallucis brevis the sides. The deep plantar neurovascular structures
muscle lies between the first metatarsal and the are the critical elements for the integrity of the fore-
flexor hallucis longus tendon. The adductor hallucis foot. After the split, the medial and lateral plantar
muscle has an oblique head and a transverse head. vessels and nerves at first lie in the plane between
The second layer consists of the long flexor tendons the superficial muscles and the second group, the
(the hallucis and digitorum longus muscles and the long flexors. The plantar arch, as it recurves medi-
lumbrical muscles and quadratus plantae of the lat- ally, passes deep to the oblique head of the adductor
ter). These tendons maintain the longitudinal arch of hallucis muscle, and deep to the lateral part of the
the foot. The most superficial layer consists of the flexor hallucis brevis muscle on its course to join
abductor hallucis, central flexor digitorum brevis, with the plantar branch of the dorsalis pedis artery.
Flexor
hallucis
longus
Adductor
hallucis m.
(oblique
head)
Plantar Flexor
arch hallucis
brevis m.
Flexor
Abductor
digitorum
hallucis m.
longus
Lateral
plantar a.
Quadratus Tibialis
plantae m. posterior
Abductor Medial
digiti plantar a.
minimus m.
Flexor
digitorum
Plantar brevis m.
aponeurosis
Abductor
hallucis
(cut) Fig. 18-31 A plantar view demonstrates the
relationship of the plantar arch to the three
layers of plantar muscles.

Exposure of the Arteries of the Leg vessel in patients with almost any distal occlusive
pattern.
The durability of vein bypasses to infrageniculate
arteries has been firmly established. Excellent pa- Exposure of the Posterior Tibial Artery
tency rates can be achieved using a number of au-
togenous graft alternatives, including in situ great The posterior tibial artery is easily accessible
saphenous vein, reversed great saphenous vein, through medial leg incisions. Access is particularly
transposed great saphenous vein, spliced small convenient when performing a saphenous vein by-
saphenous vein, arm vein, and composite vein pass because the posterior tibial artery can be ex-
from different sources.5 All three infrageniculate posed through the same medial skin incision used
arteries have been shown to be suitable recipient for vein harvest (Fig. 18-32). The following discus-
vessels for bypass, provided that there is suitable sion considers exposure of the posterior tibial artery
outflow to the foot.5–9 The following sections con- at the proximal and midleg levels. Exposure of the
sider exposure of the infrapopliteal arteries at sev- posterior tibial artery at the ankle is considered in the
eral levels, giving the surgeon access to a suitable section dealing with arteries of the foot and ankle.
Tibialis
Extensor anterior m.
digitorum Tibialis
longus m. posterior m.
Anterior tibial a.
Deep peroneal n.
Superficial Great saphenous v.

peroneal n. Posterior tibial a.
Posterior tibial n.
Peroneus
longus m. Soleus m.
Peroneal a. Gastrocnemius m.
Medial sural
Small
cutaneous n.
saphenous v.
Fig. 18-32 Medial approaches to the posterior tibial artery also provide access to the great
saphenous vein when performing an in situ bypass.

Exposure of the Posterior Tibial Artery in the Proximal Leg is made 2 cm behind the posterior border of the tibia
This approach provides access to the posterior tibial just below the knee joint and extended distally for
artery at its most proximal point, the segment just 10 to 15 cm. The incision is deepened through sub-
distal to the bifurcation of the tibioperoneal trunk. cutaneous tissue, taking care to avoid injury to the
Bypasses may be brought here preferentially in saphenous vein that may course through this area
cases of popliteal artery obstruction, when the prox- (see Chapter 17). The deep fascia is then incised,
imal posterior tibial artery is patent. This technique exposing the underlying fibers of the medial head
is an extension of that used to expose the infrage- of the gastrocnemius muscle (Fig. 18-33). Posterior
niculate popliteal artery through a medial incision retraction of the gastrocnemius muscle exposes the
(see Chapter 17). The patient is placed in the supine distal popliteal vessels that penetrate the origin of
position with the leg externally rotated and flexed the soleus muscle. The fibers of the soleus muscle
60° at the knee. A supporting roll should be placed originating on the tibia should be sharply divided
laterally to hold the knee in position. The entire leg, to expose the underlying vessels running distally in
groin, and foot are prepped and draped. An incision the leg.
Gastrocnemius m.
(medial head)
Soleus m.
Fig. 18-33 The approach to the proximal posterior tibial artery first requires separation of
the gastrocnemius and soleus muscles to expose the distal popliteal artery penetrating the
origin of the soleus.

Division over a right-angle clamp placed be- trunk. The accompanying veins are paired and
tween the vessels and muscle fibers is invaluable sometimes multiple; a complex interconnecting
in preventing vessel injury (Fig. 18-34). Imme- network of venous branches overlies the arter-
diately beneath the proximal soleus lie the ori- ies and must be carefully divided during arterial
gins of the anterior tibial artery and tibioperoneal dissection.
Anterior
tibial a. and v.
Soleus m.
Tibioperoneal
trunk
Fig. 18-34 Division of the tibial origin of the soleus exposes the underlying proximal leg vessels.

The tibioperoneal trunk bifurcates approxi- the posterior tibial artery may be isolated and pre-
mately 2.5 cm beyond the anterior tibial artery, al- pared for bypass at any point distal to the bifurcation
though this is variable.1,2 The proximal segment of (Fig. 18-35).
Posterior
tibial a.
Fig. 18-35 Careful dissection and judicious ligation of surrounding veins allow exposure

and isolation of the posterior tibial artery.

Exposure of the Posterior Tibial Artery in the Midleg extended for approximately 10 cm (Fig. 18-36).
The patient is positioned and surgically pre- After the incision is deepened through the sub-
pared as above. A medial incision is made 2 cm cutaneous tissue and crural fascia, the tibial
behind the posterior margin of the tibia and attachments of the soleus muscle are divided.
Flexor Flexor
hallucis digitorum
longus m. longus m.
Posterior
tibial a.
Fig. 18-36 The incision for approaching the posterior tibial artery in the midleg is illustrated.

The soleus muscle is retracted posteriorly, and tibialis posterior muscle. The artery is often sur-
a plane is developed between the flexor digi- rounded by a plexus of vein branches connecting
torum longus and soleus muscles (Fig. 18-37). the main venous trunks; several vein branches
The posterior tibial vessels are bound in loose may require division and ligation to expose an
areolar tissue on the posterior surface of the adequate length of the artery for bypass.
Fig. 18-37 The posterior tibial artery is found on the surface of the flexor digitorum longus
muscle beneath the thin fascia enclosing the deep posterior compartment. The extensive
mobilization shown in the cross section for purposes of illustration would not be done
clinically to preserve important collateral branches.

Exposure of the Posterior Tibial Artery Using a Posterior Approach This is more easily accomplished with the patient in
Occlusive disease may occasionally be confined to the the supine position, before being turned prone.
tibial arteries, with preservation of adequate inflow Posterior exposure requires that the patient be
at the popliteal level. In these select circumstances, positioned prone, with the knee in full extension. The
popliteal–crural bypass may be desirable, especially leg and thigh should be prepped circumferentially
if the great saphenous vein can be preserved. Ouriel10 and draped to the level of the buttock. A vertical
popularized the posterior approach to the crural ves- incision is made directly over the small saphenous
sels, noting that this approach preserves the great sa- vein. The vein begins posterior to the lateral mal-
phenous vein and minimizes the required length of leolus, courses lateral to the calcaneus tendon, and
the arterial conduit. The approach may also minimize ascends medially toward the midline of the popliteal
wound-healing problems associated with medial fossa. It runs on the surface of the crural fascia in the
incisions. If one plans to use the small saphenous vein calf and ankle before penetrating through the deep
as a conduit, it is important to document the adequacy fascia near the popliteal fossa to join the popliteal
of the vein during the preoperative period. Patients vein. The incision should be carried to the level of
without adequate small saphenous veins may require the popliteal fossa, but the distal extent can vary ac-
preliminary harvest of the great saphenous vein. cording to the length of vein needed (Fig. 18-38).
Fig. 18-38 The incision for posterior exposure of the posterior tibial artery should be
made directly over the small saphenous vein.

The distal segment of the popliteal artery is ex- slightly deep to the vein (see Chapter 17). The crural
posed first. The proximal incision should be deep- arteries are located by following the popliteal artery
ened through the crural fascia to expose the popliteal to its terminus.10 Exposure can be enhanced by di-
artery between the two heads of the gastrocnemius viding the fusion seam of the gastrocnemius muscle
muscle. The tibial nerve is the most superficial ma- bellies and incising the tibial insertion of the soleus
jor midline structure and should be reflected later- muscle (Fig. 18-39). The muscular branches of the
ally to expose the underlying artery and vein. The tibial nerve and associated crossing veins should be
artery lies medially in the neurovascular sheath and carefully avoided during this dissection.10
Anterior
Popliteal a.
tibial a.
Tibial n.
Soleus m.
(divided)
Tibio-
peroneal Peroneal a.
trunk
Posterior
tibial a.
Fig. 18-39 The crural arteries are located by following the

popliteal artery to its terminus.

The posterior tibial artery is exposed in the separating the deep and superficial posterior muscle
distal third of the calf through a separate vertical compartments at this level. The posterior tibial ar-
incision created medial to the calcaneus tendon tery can be located on the medial side of the flexor
(Fig. 18-40). The neurovascular bundle is exposed digitorum longus muscle, just anterior to the tibial
by incising the crural fascia and a fascial layer nerve.
Posterior
tibial a.
Fascia of
deep posterior
compartment Tibial n.
Posterior tibial a.
Tibial n.
Flexor digitorum
longus
Flexor hallucis
longus
Fig. 18-40 Exposure of the posterior tibial artery

at the ankle.

Exposure of the Anterior Tibial Artery Exposure of the Anterior Tibial Artery in the Midleg
The patient is placed in the supine position with the
The major portion of the anterior tibial artery leg internally rotated and the knee flexed 30°. Af-
courses in the anterior compartment of the leg and ter surgical preparation of the entire leg and groin, a
is most easily accessible through anterolateral leg vertical incision is made in the anterolateral leg mid-
incisions. The anterior tibial artery can be isolated way between the tibia and fibula (Fig. 18-41). The
at its origin through a medial incision (see above), crural fascia is incised along the lateral border of
but constructing bypasses to this section of the ar- the tibialis anterior muscle. Development of a plane
tery is awkward and inconvenient compared with between the tibialis anterior and extensor digitorum
other available options. The following discussion longus muscles allows access to the neurovascular
considers exposure of the artery in the midleg, dis- bundle lying on the interosseous membrane in the
tal leg, and foot. upper third of the leg. Distal to the origin of the
Tibialis
anterior m.
Extensor
digitorum
longus m.
Extensor
hallucis
longus m.
Fig. 18-41 The anterior tibial artery is easily

accessible through a longitudinal incision into the
anterior compartment.

extensor hallucis longus muscle, the plane between tunnel through the interosseous membrane. The
the tibialis anterior and extensor hallucis longus interosseous membrane can be penetrated from ei-
muscles should be developed. The vein is the most ther direction; we prefer to pass a blunt tunneling
anterior structure in the neurovascular bundle, with instrument from the deep posterior to the anterior
the artery lying just behind. The deep peroneal nerve compartments. The posterior tibial vessels are ex-
lies most posterior. Isolation of the anterior tibial ar- posed through the medial incision and protected by
tery requires careful dissection because of the mul- anterior retraction on the tip of the surgeon’s index
tiple overlying venous branches. finger (Fig. 18-42). The tunneling instrument is in-
Vein grafts are brought from medial leg introduced through the interosseous membrane under
cisions to the anterior compartment by creating a direct vision in the anterior compartment at the level
of the intended anastomosis. The tunneler is directed
distally at a 45° angle to meet the index finger in the
medial wound. The tunnel will traverse the tibialis
posterior muscle, which is broadly attached to the
posterior surface of the interosseous membrane. The
tunnel should be sufficiently wide to ensure that the
graft is not compressed as it courses between the
compartments; in most cases, the tunnel should be
made wide enough to admit at least two fingers.
Fig. 18-42 Vascular grafts from the medial

leg reach the anterior compartment through
the interosseous membrane. The vessels on
each side of the membrane are protected as
the tunneler is passed.

Exposure of the Anterior Tibial Artery in the Distal Leg communication, 1989) prefers to route bypasses
In the distal third of the leg, the anterior tibial ar- through the subcutaneous tissue anterior to the tibia;
tery courses anteriorly, leaving the interosseous however, others have found that the vein graft may
membrane to lie on the anterior surface of the lateral become compressed against the anterior tibial bor-
tibial flare (Fig. 18-43). It is considered separately der.9 There are three alternatives for routing vein
because its position on the tibia places vein bypasses bypasses into the distal anterior compartment. The
at risk of early failure: bypasses brought through the vein can be routed through the interosseous mem-
interosseous membrane at this level will kink on brane in the proximal leg and brought to the distal
the posterolateral border of the tibia as they wind anterior tibial artery through the anterior compart-
around the bone toward the artery.11 Veith (personal ment11 (Fig. 18-44). It can be routed in a hole drilled
Extensor digitorum
longus m.
Superior extensor
retinaculum
Extensor hallucis
longus m.
Anterior
medial
Peroneal a. malleolar a.
perforating
branch
Anterior Inferior
lateral extensor
malleolar a. retinaculum
Fig. 18-43 At the ankle, the anterior tibial artery crosses the anterior tibial surface beneath
the extensor retinacula.

through the distal tibia to reach the artery directly.12 the tibialis anterior and extensor hallucis longus
The third alternative is to create a superficial gut- muscle tendons. Division of the superior extensor
ter in the cortex of the anterior tibial border.13 Vein retinaculum facilitates separation of the tendons.
grafts can be laid in the gutter and routed anteriorly The anterior tibial vessels are isolated deep in the
to the tibia into the anterior compartment for anas- wound on the anterolateral surface of the tibia.
tomosis with the anterior tibial artery. The anasto- Exposure of the tibia is performed in the lateral
mosis is protected anteriorly by the tibialis anterior wound by mobilizing the tibialis anterior muscle
muscle. and retracting it anteriorly. Medial exposure of the
The patient is placed in the supine position bone is accomplished in the incision used to expose
with the leg internally rotated and flexed 30° at the the saphenous vein. The anterior skin and subcuta-
knee. A vertical incision is made over the anterior neous tissue of the incision are retracted, exposing
compartment in the distal third of the leg and deep- sufficient bony surface to allow a hole to be drilled
ened through the crural fascia. The anterior tibial to create a tunnel through the bone or a tibial gutter
vessels are located by developing a plane between at the anterior bone margin.
Fig. 18-44 Three options for routing bypass grafts

to the distal anterior tibial artery are illustrated.

Exposure of the Peroneal Artery Medial Approach to the Peroneal Artery
The patient is placed in the supine position with the
The suitability of the peroneal artery as a recipi- leg externally rotated and the knee flexed 30°. The
ent vessel in bypass operations for lower limb sal- entire leg, thigh, and groin are prepped and draped
vage has been well documented.6–8 Patency rates as before. A vertical incision is made 2 cm behind
approaching those of bypasses to the anterior and the posterior border of the tibia in the middle third
posterior tibial arteries justify its use; however, the of the leg and extended for approximately 10 cm
peroneal artery is relatively difficult to isolate and (Fig. 18-45). The incision is deepened through the
has only indirect communications with the arteries of crural fascia, and the tibial attachments of the so-
the foot. It should not be used in preference to suit- leus muscle are divided. Posterior retraction of the
able tibial arteries.8 The artery lies deep in the lateral soleus muscle exposes the flexor digitorum longus
leg in apposition to the fibula and may be approached muscle posterior to the tibia. To facilitate dissection,
through medial or lateral incisions. Lateral incisions Graham and Hanel14 recommended entry into the
are preferred in obese individuals and in secondary
deep posterior compartment of the leg by incising the
bypass procedures but require resection of the fibula.
fascia covering the flexor digitorum longus muscle
Peroneal a.
Fig. 18-45 The medial approach to the peroneal artery uses the same incision as the medial
approach to the posterior tibial artery.

(Fig. 18-46). The plane of dissection is developed by the wound, the peroneal vessels are located on the
posterior retraction of the fascia. To prevent injury anterior surface of the flexor hallucis longus muscle.
to muscular branches of the posterior tibial vessels, Occasionally these vessels are enveloped within the
the neurovascular bundle is best left in the loose muscle belly, requiring minimal superficial dissec-
areolar tissues overlying the soleus muscle. Deep in tion in the muscle fibers for exposure.14
Flexor
digitorum
Tibia longus m.
Posterior
Peroneal a. tibial a.
Soleus m. Flexor
hallucis
longus m.
Fig. 18-46 By retracting the posterior tibial vessels and nerve posteriorly with the soleus
muscle, the deeper lying peroneal artery anterior to the flexor hallucis longus muscle is
exposed.

Lateral Approach to the Peroneal Artery and extending 10 to 15 cm. The incision is contin-
The patient is placed in the supine position with the ued through the subcutaneous tissue and deep fas-
leg internally rotated and the knee flexed 60°. An cia. The common peroneal nerve is identified and
incision is made in the lateral leg over the fibula, carefully protected in the proximal wound, where
centered over the area of intended anastomosis it winds around the neck of the fibula (Fig. 18-47).
Fig. 18-47 The peroneal nerve is isolated in preparation for the lateral approach to the
peroneal artery.

All muscular attachments to the fibula are then simple stripping of the muscular fibers. Great care
separated bluntly, as described above (Fig. 18-48). should be exercised during dissection on the medial
Some authors advocate a subperiosteal dissec- surface of the fibula because the peroneal vessels
tion to facilitate this maneuver15 as opposed to are in close proximity and therefore prone to injury.
Fig. 18-48 The peroneal muscles are elevated to expose the fibula for excision.

After an adequate segment of fibula has been cleared be performed using the small saphenous vein; expo-
of surrounding attachments, the bone is resected and sure of the popliteal artery and small saphenous vein
removed from its bed. Veith et al.16 recommended are described above.
drilling holes through the fibula at the lines of in- The patient is placed in the supine position,
tended division to help gain a clean division of the and the entire leg and thigh are prepped and draped.
bone with rib shears. The peroneal vessels are lo- A vertical incision is made directly over the small
cated deep to the fibular bed (Fig. 18-49). saphenous vein. As noted above, the vein begins
posterior to the lateral malleolus, courses lateral to
Posterior Approach to the Distal Peroneal Artery the calcaneus tendon, and ascends medially toward
As noted above, a minority of patients with periph- the midline of the popliteal fossa. The incision is
eral vascular disease has occlusive lesions confined made in the distal third of the calf along the lateral
to the tibial vessels, with preserved inflow to the side of the calcaneus tendon and deepened through
level of the popliteal artery. In rare cases, the distal the crural fascia (Fig. 18-50). The peroneal artery
peroneal artery may be the only remaining outflow is identified by retracting the calcaneus tendon me-
vessel supplying the ankle and foot.7 Medial ap- dially and the flexor hallucis longus muscle later-
proaches to the distal peroneal artery are hampered ally. The artery is located on the medial side of the
by the widening flare of the tibia in the distal leg. fibula, which serves as an excellent landmark.10 The
A posterior approach is desirable because it is more peroneal artery can be isolated as far distally as its
direct and may be associated with fewer wound bifurcation into perforating and communicating
complications.10 A popliteal–peroneal bypass may branches.
Peroneal a.
Fig. 18-49 The proximal peroneal artery is located deep to the fibular bed.

Anterior
Peroneal a.
Tibialis
Lateral
posterior
Flexor Flexor
hallucis digitorum
longus longus
Posterior
tibial a.
Achilles tendon
Tibialis
posterior
Peroneal a.
Flexor
digitorum
longus
Felxor
hallucis
longus
Fig. 18-50 The peroneal artery can be

exposed as far distally as its bifurcation above
the ankle. In this view, the Achilles tendon is
beneath the left-hand retractor (cross section
of right leg, caudal view).

Exposure of Arteries of the Foot and Ankle The patient is placed in the supine position
with the leg externally rotated and flexed 60° at the
knee. The entire leg, groin, and foot are prepped and
Exposure of the Posterior Tibial Artery at the Ankle draped. A vertical incision is made approximately
1 cm posterior to the distal tibia and curved around
Long vein bypasses to arteries at the level of the the medial malleolus onto the foot. Division of the
ankle and foot have been shown to have patency flexor retinaculum exposes the neurovascular bun-
rates similar to those of bypasses involving more dle lying in the groove between the tendons of the
proximal infrageniculate arteries.17,18 The superfi- flexor digitorum longus and flexor hallucis longus
cial location of the posterior tibial artery at the ankle muscles (Fig. 18-40). The posterior tibial artery lies
greatly simplifies exposure, making it a very attrac- anterior to the tibial nerve at this level. Isolation of
tive option for bypass (Fig. 18-51). the artery is aided by mobilization and anterior re-
traction of the flexor digitorum longus tendon.
Extensor Anterior
hallucis
Tibialis
longus
anterior
Long
Extensor saphenous v.
digitorum
longus
Lateral Tibialis
posterior
Peroneus
Flexor
brevis
digitorum
Peroneus longus
longus Posterior
Calcaneal tibial a.
tendon
Posterior
Flexor tibial n.
hallucis
longus
Fig. 18-51 The posterior tibial artery is found just deep to the crural fascia at the ankle and
is easily accessible for distal bypass (cross section of right leg, caudal view).

Exposure of the Medial and Lateral Plantar Arteries The leg is positioned as above, with the
knee externally rotated and the foot raised on a
Bypasses to the distal branches of the posterior tibial soft pad behind the lateral malleolus to widen
artery are associated with good patency rates and the space between the medial malleolus and the
long-term limb salvage, even in patients with gan- calcaneus bone.19 A curvilinear incision is made
grene.19,20 The medial and lateral plantar arteries can beginning midway between the medial malleolus
be exposed below the level of the medial malleolus. and the calcaneus tendon, extending longitudi-
Although either may be used for bypass, the lateral nally along the instep for a distance of 4 to 5 cm16
plantar artery is usually the larger of the two. (Fig. 18-52).
Flexor hallucis longus

Flexor digitorum longus
Tibialis posterior
Posterior tibial a.
Flexor retinaculum
Lateral plantar a.
Medial plantar a.
Abductor hallucis
Fig. 18-52 The incision for exposure of the posterior tibial artery branches is shown.

The posterior tibial artery is exposed by muscle.19 Exposure of the plantar branches is
dividing the flexor retinaculum. As the artery obtained by incising the abductor hallucis mus-
is traced distally, the bifurcation will be found cle in the direction of the lateral plantar artery
on the superior border of the abductor hallucis (Fig. 18-53).
Flexor digitorum
longus m.
Flexor hallucis
longus m.
Medial
planter a.
Abductor
hallucis m.
(cut)
Lateral
plantar a.
Fig. 18-53 The bifurcation of the posterior tibial artery is located on the superior border of
the abductor hallucis muscle.

Exposure of the Dorsalis Pedis Artery between the first and second metatarsal bones. This
allows creation of a narrow skin flap that will cover
As noted previously, long vein bypasses to arterial the anastomosis if the skin incision fails to heal.
segments at the ankle and foot have patency rates The dorsal branch of the superficial peroneal nerve
similar to bypasses to more proximal leg arteries.4–7 should be identified and retracted laterally. After in-
The dorsalis pedis artery is readily accessible and cising the deep fascia, the neurovascular bundle is
provides an excellent option for bypass when more exposed by retracting the extensor hallucis longus
proximal arteries are not suitable. and brevis muscles apart (Fig. 18-54). The dorsalis
The patient is placed in the supine position, pedis artery lies lateral to the deep peroneal nerve.
and the leg, foot, and groin are surgically prepared. Isolation of the artery may require control of medial
A vertical incision is made on the dorsal foot lateral and lateral tarsal artery branches, which should be
to the location of the dorsalis pedis artery midway left intact.21
Superficial
peroneal n.,
medial dorsal
branch
Lateral Medial
tarsal a. tarsal a.
Deep
peroneal n. Extensor hallucis
Extensor longus tendon
hallucis
brevis m.
Arcuate a.
Fig. 18-54 The dorsalis pedis artery is exposed between the extensor hallucis longus
tendon and the extensor hallucis brevis muscle.

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1994;60:238–246. gutter: a protected route for bypass to the distal ante-
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MD: Urban & Schwarzenberg; 1988:426–427. artery. Surgery. 1981;89:264–268.
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PA: Lippincott Williams & Wilkins; 1997:756–778. the infrapopliteal arteries in the leg and foot.
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come after tibial arterial bypass. Surg Gynecol Ob- 1989;10:511–521.
stet. 1993;177:283–287. 20. Brochado-Neto FC, Cury MV, Bonadiman SS, et al.
10. Ouriel K. The posterior approach to popliteal-crural Vein bypass to branches of pedal arteries. J Vasc
bypass. J Vasc Surg. 1994;19:74–80. Surg. 2012;55:746–752.
11. Tiefenbrun J, Beckerman M, Singer A. Surgical anat- 21. Veith FJ. Alternative approaches to the deep femoral,
omy in bypass of the distal part of the lower limb. popliteal, and infrapopliteal arteries in the leg and
Surg Gynecol Obstet. 1975;141:528–533. foot: part II. Ann Vasc Surg. 1994;8:599–603.

VASCULAR
VARIATION
539
Anatomic Variation
of the Blood
Vessels 19
Vascular Anatomic Variation course of embryologic development and the arrest

of development short of the mature human pattern.
In this book, as in any description of normal anat- These deviations frequently resemble the pat-
omy, it is important to recognize that the common terns found in lower animals because embryology
vascular patterns depicted will only be encoun- reflects evolution. The term variation suggests a mild
tered 50% to 70% of the time in clinical practice. deviation from the typical pattern, whereas the term
Some vessels, particularly those supplying the ab- anomaly implies a more marked deviation from the
dominal viscera, are more likely to deviate from standard. The terms malformation and abnormal carry
the prevalent pattern. Many of these variations a graver connotation, suggesting a dysfunctional pat-
can be understood in the context of the vascular tern that may be injurious to the individual. Such a
embryology described in the Introduction. The pattern may divert or disrupt needed blood flow or
variables include the origin and number of vessels may impinge on adjacent structures and disrupt their
supplying particular structures and the course, function. The more severe the malformation, the
size, and shape of the vessel. These variations more likely it will be symptomatic and discovered
may be as simple as the tortuosity of an internal during life. An additional risk exists for even benign
carotid artery or as drastic as the total deletion of variations, such as an aberrant obturator artery that
a vessel. can be easily injured by an unwary surgeon.
There has been considerable discussion of se- There is an almost limitless variety of vascular
mantic distinctions in classifying types of variation. patterns ranging from the simple to the bizarre. For-
The different terms that have been applied basically tunately for the clinician, 95% to 98% of patterns
reflect the degree of atypia and the functional im- presented by a particular vessel can be accounted
plications of the altered pattern. These terms should for among two or three variations. To keep this fact
be noted in passing, keeping in mind the broad in perspective, we focus on the common variations
spectrum of patterns that are being differentiated. of major vessels and clinically important vessels in
Terms such as atavism and reversion suggest the the following discussion and briefly note the more
persistence of a pattern that occurred in the normal obscure patterns.
541
Thoracic Aorta subclavian artery arising as the fourth branch of the
aortic arch. This vessel most commonly passes pos-
Aortic Arch terior to the esophagus and may cause esophageal
Anomalies of the aortic arches are rare and are usu- compression and dysphagia (dysphagia lusoria).3
ally the result of atypical segmental regression of Regression of the distal left arch results in a
the paired arches present at approximately the sev- right-sided aortic arch that is the mirror image of
enth embryonic week1 (Fig. 19-1). Many of these the common pattern (Fig. 19-2C), and regression
anomalies are asymptomatic and are discovered in- of the left carotid-subclavian segment results in a
cidentally. Aortic rings, for example, are often to- right arch with an aberrant left subclavian artery4
tally asymptomatic but may cause dysphagia and (Fig. 19-2D). Partial persistence of any of the in-
dyspnea in the neonatal period. voluted segments as a hypoplastic channel or fi-
Aortic arch anomalies have been classified brous band results in a vascular ring surrounding
into four groups and 24 subgroups by Stewart et the trachea and esophagus. In addition, connec-
al.2 The variety of forms seems confusing at first tion of the sixth arch to the dorsal continuation of
glance but yields to logical analysis when one con- the fourth arch may persist on one or both sides,
siders the segments of the paired fourth arches that adding a variety of ductus arteriosus anomalies to
involute (Fig. 19-2). Regression of the distal seg- the basic aberrant arch patterns. The mirror image
ment of the right fourth arch results in the normal variants of each of these patterns accounts for the
pattern of the brachiocephalic, left common carotid, number of described anomalies. Although some
and left subclavian arteries arising from a left-sided variations of aberrant aortic arch branch patterns
arch (Fig. 19-2A). Regression of the right arch seg- are consequences of basic arch anomalies, many
ment between the common carotid and right subcla- others are seen with the common form of a simple
vian arteries (Fig. 19-2B) results in an aberrant right left-sided arch.
Common
carotid a.
Subclavian a.
Fig. 19-1 Aortic arch anomalies usually result from disturbances of normal segmental

regression of the paired aortic arches in the 7-week embryo.
542 | VASCULAR VARIATION
B
D
A B
C D
Fig. 19-2 Many aortic arch anomalies are understandable by visualizing the regression of

one of four segments (A–D).
ANATOMIC VARIATION OF THE BLOOD VESSELS | 543

Coarctation of the Thoracic Aorta anywhere along the distal aorta (coarctation of the
The transitional segment of thoracic aorta in the re- abdominal aorta is discussed below).
gion of the ductus arteriosus may be congenitally Coarctation has great clinical significance. It
narrow or even absent.5 Such narrowing, called co- is a common cause of hypertension in children who
arctation, makes up 6% to 10% of all major cardio- may be asymptomatic until the overworked ven-
vascular malformations and occurs in between one tricles enlarge and ultimately fail. Early correction,
and six per 10,000 live births.1 The narrowing may however, leads to a normal functional state and life
also take the form of a fibrotic cord, diaphragm, or span. The defects have been classified based on the
complete interruption. Most commonly, coarctation length, position relative to the ductus arteriosus,
occurs just distal to the left subclavian artery. In rare patency of the ductus, ventricular hypertrophy, and
cases, the narrowing may be found in the arch or degree of collateral circulation (Fig. 19-3).
Transverse Thyrocervical
cervical a. trunk Internal
thoracic a.
Suprascapular a.
Costocervical
a.
Subscapular
a.
Lateral
thoracic
a.
Intercostal a.
Fig. 19-3 Collateral channels through scapular and chest wall vessels enlarge in response
to the pressure gradient created by an aortic coarctation.
Primary Branches of the Aortic Arch a common root with the brachiocephalic trunk7
The major branches of the aortic arch vary in their (Fig. 19-4). These two patterns, along with an-
position on the arch, their distance from each other, other (the left vertebral artery arising from the
the number of their primary stems, and their course arch between the left common carotid and sub-
and tortuosity. In addition, a number of branches clavian arteries [2.5% to 5% of cases]), account
that are usually secondary may originate instead di- for 95% to 97% of aortic arch branch patterns.
rectly from the aorta.6 A large variety of other patterns comprise the re-
Although the common pattern of branching maining few percent of aberrations, with the ab-
is seen approximately 70% to 80% of the time, errant right subclavian artery mentioned above
as many as one-fourth of the population has a appearing frequently in combination with other
left common carotid originating from or sharing anomalies.
64.9%
27.1%
2.5%
1.2%
1.1%
Fig. 19-4 In addition to the common aortic arch branch pattern, origin of the left common
carotid from the brachiocephalic and left vertebral artery origin from the arch comprise
almost 95% of all arch patterns.

Brachiocephalic Artery both sides, in which case the branches of the missing
The brachiocephalic artery exhibits some variability vessel arise from the opposite external carotid or the
in the level at which it bifurcates into right subcla- common carotid.7
vian and right common carotid arteries. When the
point of division is high, the brachiocephalic artery Internal Carotid Artery
can rise above the manubrium of the sternum (12%) In addition to the rare origin directly from the aor-
and may be medial enough to pose a danger dur- tic arch, the internal carotid may be absent in ap-
ing tracheostomy.7 A low point of division results proximately 0.1% of individuals.7 Rare instances of
in longer subclavian and carotid segments. In the external carotid branches arising from the internal
extreme case, the right subclavian and right com- carotid have been reported. The internal carotid may
mon carotid may arise directly from the arch with no also exhibit tortuosity.
brachiocephalic trunk (0.5%).
Subclavian Artery
Common Carotid Artery The right subclavian artery is anomalous in approx-
In addition to the major variations discussed above, imately 1% of individuals. It may originate in any
the common carotid arteries have variable points of position from the first to the fourth relative to the
bifurcation, are occasionally tortuous, and occasion- other arch vessels, may rise higher or lower in the
ally give rise to branches normally originating else- neck, and may vary in position relative to the sca-
where. The variant bifurcation is more commonly lene muscles.7 Origin of the right subclavian artery
found high than low and may be as high as the level as the first aortic arch branch implies the absence
of the hyoid bone and more rarely as low as the cri- of the brachiocephalic trunk. More commonly, the
coid cartilage.6 Tortuosity of the common carotid ar- right subclavian artery originates as the fourth aor-
tery is occasionally found and in rare instances may tic branch and passes behind or between the trachea
form a complete loop in the neck. Branches of the and esophagus (Fig. 19-5) as discussed previously.
external carotid artery sometimes found originat- In its course, the right subclavian artery may rise
ing from the normally branchless common carotid as high as 4 cm above the clavicle, depending on
include the superior and inferior thyroid, thyroidea the level of brachiocephalic bifurcation. The sub-
ima, and ascending pharyngeal arteries. Rarely, a clavian artery may rarely be found anterior to the
vertebral artery arises from a common carotid. anterior scalene muscle together with the subcla-
vian vein (occasionally the vein is found between
the anterior and middle scalene muscles with the
Arteries to the Head and Neck artery), may penetrate the middle scalene, or may
pass between the middle and posterior scalene mus-
External Carotid Artery cles. In rare instances, the subclavian artery may
There is great variability in the number and origins divide at the medial border of the scalene muscle
of external carotid artery branches. The external ca- into radial and ulnar arteries instead of continuing
rotid artery may occasionally be absent on one or into the axillary artery.
Middle
scalene m.
Subclavian a.
Fig. 19-5 When the right subclavian artery arises distally, it passes behind or between
the trachea and esophagus to reach the right side (posterior view). The passage of the
subclavian artery through the scalene muscles may vary.

Branches of the Subclavian Artery The internal thoracic artery, like the vertebral
The vertebral artery arose from the posterior superior artery, follows the usual pattern in a relatively
surface of the subclavian artery between 0.5 and 2 cm high percentage of cases (79%). Several com-
medial to the thyrocervical trunk 83% of the time in mon variations include origin as a common trunk
the series of Daseler and Anson.8 The most common with the thyrocervical trunk and origin from the
variation of this vessel is an origin greater than 2 cm suprascapular, inferior thyroid, transverse cervical,
medial to the thyrocervical trunk, close to the origin or a combination of these vessels. The point of
of the subclavian artery (Fig. 19-6). In addition, the origin from the subclavian artery also varies from
vertebral artery may arise from the thyrocervical or proximal to distal.
costocervical trunk, from the left common carotid, or The origins and branching patterns of the
directly from the aorta in rare instances. thyrocervical and costocervical trunks are so highly
The vertebral artery enters the sixth vertebral variable among individuals and between sides that
transverse foramen 88% of the time, the fifth and the most common pattern for each is found in less
seventh with equal frequency (7%), and rarely even than half of the population.8
as high as the second foramen.
8%
3%
83%
7% C5
88% C6
7% C7
Fig. 19-6 The origins of the vertebral arteries vary somewhat

as does that of the transverse foramen entered by the vessel.
Arteries of the Upper Extremity Brachial Artery
Major variations of the brachial artery have been
Axillary Artery found in 20% to 25% of individuals.7 These varia-
The main trunk of the axillary artery is fairly con- tions most often take the form of high branching in
stant. Significant variations include rare early the proximal third of the arm. Two-thirds of these
branching into radial and ulnar arteries and the pres- are unilateral, and most of the remaining bilateral
ence of a latissimus muscle slip over the third part anomalies were different from side to side. Five pat-
of the vessel. The branches of the axillary artery, terns of early brachial artery branching have been
conversely, are so variable that the most common suggested (Fig. 19-7): radial and ulnar common in-
pattern occurred in only 20 of 47 bodies studied by terosseous trunks; ulnar and radial common inter-
Hitzrot.9 Those contemplating mobilizing a pectoralis osseous trunks; common interosseous or persistent
musculocutaneous flap based on the pectoral branch median artery and radioulnar trunk; radial, ulnar,
of the thoracoacromial artery or a latissimus dorsi and common interosseous trunks; and a normal bra-
flap based on the thoracodorsal branch of the chial artery with a long, thin aberrant branch that
subscapular artery should review this reference. runs superficial to the median nerve and ends in the
D Fig. 19-7 Five patterns of

high brachial artery branch-
ing: radial and ulnar common
interosseous trunks (A); ulnar
and radial common interos-
seous trunks (B); common
interosseous or persistent
median artery and radioulnar
E trunk (C); radial, ulnar, and
common interosseous trunks
(D); and a normal brachial ar-
tery with a long, thin aberrant
branch that runs superficially
to the median nerve and ends
in the biceps muscle (E).

biceps muscle. There are minor variations among fascia and, in rare cases, subcutaneously.7 A persistent
the profunda, superior, and inferior ulnar collateral median artery may supplement or replace the radial
branches of the brachial artery in which they may or ulnar artery. The common interosseous artery and
arise from each other, share a common trunk, or its volar and dorsal branches are variable in their
replace each other. origins, size, and terminations.
Arteries of the Hand

Arteries of the Forearm The superficial palmar arch is quite variable in
The radial and ulnar arteries may have high origins, form. Coleman and Anson,10 in fact, found that
as noted previously. When this occurs, the vessels in an incomplete ulna-based arch is more common
the forearm often lie in a more superficial plane than than the normal textbook description of a com-
normal, usually just beneath the deep antebrachial plete arch (Fig. 19-8). In addition, a median artery
Superficial arch
34%
13%
4%
37%
Deep arch
36%
13%
51% Fig. 19-8 The superficial palmar

1%
arch varies more than the deep arch
and is most commonly incomplete.
completed or contributed to the arch in 5% of indi- aorta are among the most variable in the body, in
viduals. The deep arch is less variable than the su- both their origin and course.
perficial arch. Either arch may supplement small or
missing branches of the other. The princeps pollicis Branches of the Abdominal Aorta
and radial indicis arteries, in particular, may arise Numerous minor variations are found in the paired
from either or both arches. somatic branches of the abdominal aorta. The infe-
rior phrenic arteries may arise independently or from
a common stem, may have supernumerary branches,
Abdominal Aorta and may arise from the aorta or from the celiac ar-
tery or its branches. The lumbar arteries also vary in
Variations and anomalies of the abdominal aorta are their origins and number.
rare and mostly minor. These include variations in The visceral branches of the abdominal aorta
the level of bifurcation, tortuosity, and direct origin are so highly variable that Nelson et al.13 found that
of normally secondary visceral branches. The most the celiac, superior mesenteric, and inferior mesen-
clinically significant abdominal aortic anomaly is teric arteries followed the classic description in less
the rare occurrence of coarctation (0.5% to 2% of all than one-fourth of cases.
coarctations).11,12 The narrowing is more diffuse than
in the thoracic aorta and often involves stenosis of Celiac Trunk and Its Branches
one or both renal arteries, making correction more The typical three-branched celiac trunk has been
complex. The secondary branches of the abdominal found in 60% to 89% of bodies (Fig. 19-9).
5–8%
60–89%
Fig. 19-9 Variations of the celiac trunk vessels are

shown.

A gastrosplenic trunk with the hepatic artery arising The common hepatic artery arose from the
from the aorta or superior mesenteric artery is the celiac trunk more than 80% of the time in the se-
most common variant (5% to 8%). Hepatosplenic ries of Daseler et al.,14 but multiple variations in
and hepatogastric trunks are somewhat less com- the origins of the right and left hepatic branches
mon variants. In rare instances, the superior mesen- result in the classic description being found in
teric artery is combined with the celiac trunk. only one-third of cases (Fig. 19-10). The most
The left gastric artery is relatively constant in frequent variation of the common hepatic artery
its origin from the celiac trunk. The most frequent in this series was its absence in 12% of cases. In
and significant variation of the left gastric artery is 4.4% of cases, it arose from the superior mes-
the origin of a branch to the left lobe of the liver in as enteric artery. When the common hepatic ar-
many as one-fourth of specimens. This may supple- tery is absent, the right and left hepatic arteries
ment or replace the left hepatic branch of the proper arise independently from the celiac trunk or its
hepatic artery. Inferior phrenic artery branches may branches, the aorta, or the superior mesenteric
also arise from the left gastric artery. artery.
83%
12%
Fig. 19-10 The most frequent anomaly

of the common hepatic artery is absence.
4% The right and left hepatic arteries then
arise from the aorta, the remaining celiac
0.2% branches, or the superior mesenteric artery.
The common variations in origins of the right the time. Most often the aberrant vessel replaces the
and left hepatic arteries are shown in Figure 19-11. An standard branch off the proper hepatic artery, and the
aberrant vessel is found for each artery one-fourth of remaining aberrant vessels are accessory branches.
12–20%
5%
0.8%
0.01%
83%
11%
5%
2%
0.02%
Fig. 19-11 Anomalous origins of the hepatic arteries are shown.

The cystic artery most commonly (70%) arises In addition, accessory cystic arteries, also aris-
from a normal right hepatic artery (Fig. 19-12), with ing most often from the right hepatic artery, were
the remainder arising from several alternative sources. found 11% of the time by Daseler et al.
12%
10%
70%
8%
71%
2% 27%
13.1%
12%
4%
4% 3%
Fig. 19-12 The right hepatic artery varies in position relative to the common hepatic duct
(top), and the origin and course of the cystic artery vary (bottom).
The gastroduodenal artery arises from the with three other variations accounting for 94% of
common hepatic artery in three-fourths of cases, instances14 (Fig. 19-13).
75%
10%
5%
4%
Fig. 19-13 Anomalous gastroduodenal artery origins are often secondary to hepatic artery

anomalies.

In the series of Daseler et al., the right gastric of celiac branching discussed previously. It may
artery arose from the common hepatic artery 50% of arise from the superior mesenteric artery, and it
the time, the left hepatic 32%, the gastroduodenal may give rise to the left gastric, middle colic, or
9%, and the right hepatic 4% (Fig. 19-14). left hepatic artery. There may be two splenic ar-
The tortuous splenic artery exhibits sev- teries, with one or both arising directly from the
eral variations in addition to the permutations aorta.
50%
30%
9%
4%
Fig. 19-14 Variations in the origin of the right gastric artery are shown on a single hepatic
artery stem for simplicity.
Superior Mesenteric Artery may replace or supplement the usual right hepatic.
The superior mesenteric artery, like the other un- The superior mesenteric artery may also provide
paired visceral branches of the abdominal aorta, has accessory branches to the stomach, pancreas, or
many variations. It may originate from the celiac spleen. It may also provide left colic and superior
trunk or as two separate trunks from the aorta. It rectal branches that replace the inferior mesenteric
may give rise to the splenic, right, left, or common artery. The greatest variability in the superior mesen-
hepatic artery or a combination of these vessels. teric artery is found in its colic branches. Sonneland
A right hepatic artery from the superior mesenteric et al.15 divided these variations into seven types
artery has been found in 12% to 20% of cases and (Fig. 19-15).
Middle colic a.
Right
colic a. M
12%
Iliocolic a. 68% I
M
M
R
9% R
I
6%
I
M M
L
R R
R
4% 0.4%
0.5% I
I I
Fig. 19-15 Colic branches of the superior mesenteric artery vary by their absence or duplication.

Inferior Mesenteric Artery upper polar branch was found 13% of the time. Two
The origin and position of the inferior mesenteric hilar vessels were present in 11% of cases, there was
artery vary little.16 The branching into left colic and a hilar artery with an upper pole branch arising from
superior rectal trunks was also relatively constant. the aorta in 6%, and 3% had a hilar and an aortic
The variability arises in the origins of sigmoidal lower polar branch (Fig. 19-16). In 2.7% of cases,
vessels from the two primary branches and the there were two hilar vessels, one of which had an
interconnections between these vessels. Rare anom- upper polar branch, and in 1.7%, there were three
alies include duplication, absence, origin from the hilar vessels. It is not uncommon to find a single
left common iliac, and contribution of accessory vessel on one side and multiple vessels on the other.
branches to the liver or kidneys.7 The left renal artery can be located using the
left renal vein as a landmark. The artery is most
Renal Arteries commonly found deep to the cephalad border of the
The number, source, and course of the renal arter- vein.17 The level of the renal arteries is usually be-
ies exhibit a moderate degree of variation. In a re- tween 2 cm above and below the L1-2 intervertebral
view of 45 series documenting vascular patterns in disc. The renal artery may divide into anterior and
10,967 kidneys,7 a single artery to each kidney was posterior trunks anywhere along its course and has
found 72% of the time. A single artery having an between two and five branches at the renal hilus.
72.1%
13% 11%
3%
6%
2.7% Fig. 19-16 Renal artery anomalies consist of

1.7%
additional hilar and/or polar vessels.
Suprarenal Arteries renal polar vessel. The inferior suprarenal artery
A large variety of patterns characterizes the superior, may arise from the renal (46%) or aorta (30%) or
middle, and inferior suprarenal arteries (Fig. 19-17). both (23%), may be absent (12%), and is multiple
The superior suprarenal arteries invariably (96%) 11% of the time (average of three).
come from the inferior phrenic arteries (recall the
variable origins of the inferior phrenics), and there Gonadal Vessels
may be three to 30 branches. The middle suprare- The gonadal vessels may be multiple and may
nal is single 85% of the time and may arise from originate anywhere along the abdominal aorta and
the aorta, inferior phrenic, renal, celiac, or superior its branches.
Fig. 19-17 Alternate sites of origin of the middle and inferior suprarenal arteries are shown.

Mesenteric Vascular Compression Compression of the celiac trunk by the median
Two additional conditions involving aortic visceral arcuate ligament (Fig. 19-18) may cause a critical re-
branches should be noted: median arcuate ligament duction of blood flow that is manifested by abdominal
syndrome and superior mesenteric artery syndrome. pain and an upper abdominal bruit. It is likely that an
Median
arcuate
lig.
Fig. 19-18 The celiac trunk may be compressed by a low-lying median arcuate ligament.
unusually low placement of the arcuate ligament rather angle (Fig. 19-19) has been attributed to an extrinsic
than a high celiac trunk is the primary pathology.18 source of compression, such as a body cast or pro-
Compression of the third portion of the duo- longed bed rest in a supine position.19 Other postu-
denum by the superior mesenteric artery may cause lated causes include spinal curvature, rapid weight
duodenal obstructive symptoms and weight loss. loss (with loss of the angular fat pad), or a combina-
In some cases, narrowing of the mesenteric-aortic tion of anatomic idiosyncrasies.
Fig. 19-19 Compression of the duodenum by the superior mesenteric artery is poorly

understood.

Arteries of the Pelvis a middle colic, umbilical, obturator, or circumflex
iliac branch.
Common Iliac Arteries
The length of the common iliac arteries depends Internal Iliac Artery
on the levels at which the aorta and common iliac The internal iliac artery has a highly variable
arteries bifurcate. In the extreme case, both the ex- branching pattern. It may or may not divide into
ternal and internal iliac arteries may arise directly anterior and posterior divisions. Braithwaite20 docu-
from the end of the aorta without a common trunk. mented the branching patterns of the parietal ves-
The common iliac occasionally gives rise to lum- sels, that is, the internal pudendal and superior and
bar, sacral, renal, or gonadal branches and rarely to inferior gluteal arteries (Fig. 19-20). The visceral
Common
iliac a.
External
iliac a.
Internal
iliac a.
59%
Superior
gluteal a. (SG)
Inferior
gluteal a. (IG) SG
Internal IG
pudendal a. (P) 23%
P
SG
IG
P
15%
SG
1.2%
IG
Fig. 19-20 Parietal branch patterns of the internal iliac artery are shown.
branches (vesicle, uterine, and middle rectal) and alternate sites of origin and frequencies are shown
the obturator artery frequently appear in varying in Figure 19-21. The most clinically significant
combinations.6 The most variable branch of the in- variation is the inferior epigastric origin in one
ternal iliac is the obturator, which is most often a of five individuals, which poses a danger during
direct branch of the anterior division.20 The multiple herniorrhaphy (see Fig. 15-9).
Common
iliac a.
Inferior
epigastric a.
External
iliac a.
20%
Internal iliac a.
1%
Anterior Superior gluteal a.
division of
internal
iliac a.
Obliterated
umbilical a.
10%
Superior vesical a. 10%
Obturator a.
Inferior gluteal a.
4%
5%
Internal
pudendal a.
Fig. 19-21 Origins of the highly variable obturator artery include virtually every pelvic vessel.

In rare instances, a persistent sciatic artery down to the popliteal21 (Fig. 19-22). In such cases,
from the inferior gluteal may constitute the major the external iliac artery ends as the profunda femoris
arterial supply to the lower extremity, continuing artery in the thigh.
Superior
gluteal a.
Inferior
gluteal a.
Sciatic a.
Deep
Femoral a.
Fig. 19-22 Persistence of the sciatic artery may be associated with absence of the superficial
femoral artery.
External Iliac Artery artery in the adductor canal and leaves the canal to
The external iliac artery exhibits little variability. It accompany the great saphenous vein at the knee.7
may be tortuous or reduced in the presence of the
persistent sciatic artery mentioned previously. One Profunda Femoris Artery
of its two usual branches, the inferior epigastric ar- In one-third of individuals, the profunda femoris
tery, may arise as many as several centimeters proxi- arises closer than 2.5 or farther than 5.1 cm from
mal to the inguinal ligament. The other branch, the the inguinal ligament. In 89% of cases, the profunda
deep circumflex iliac, may be absent, multiple, or arises lateral to the posterior midline of the common
arise in common with the inferior epigastric artery femoral and courses laterally. The vessel is directly
and may give rise to the external pudendal, medial, posterior in 37%, directly lateral in 12%, and pos-
or lateral femoral circumflex artery. terolateral in 40%.22 The other 11% of the time, the
profunda arises toward the medial side of the com-
Arteries of the Lower Extremity mon femoral artery.
In 50% to 60% of cases, the medial and lateral
Common and Superficial Femoral Arteries femoral circumflex arteries arise from the proximal
The common femoral artery may give rise to branches profunda. The medial and lateral circumflex arteries
more commonly originating from contiguous ves- arise from the common femoral artery 20% and 13%
sels (e.g., inferior epigastric, deep circumflex iliac, of the time, respectively23 (Fig. 19-23). The pro-
circumflex femoral vessels). Occasionally a greater funda has between two and six perforating branches
saphenous artery arises from the superficial femoral excluding the termination of the artery.
Common femoral a.
60%
Deep femoral a.
Superficial
femoral a.
Medial
Lateral femoral
femoral circumflex a.
circumflex a.
Descending
branch
20%
12%
Fig. 19-23 One of the circumflex femoral vessels

often arises from the common femoral artery.

Popliteal Artery artery arises abnormally high, it may pass deep to
Intrinsic variations of the popliteal artery involve its the popliteus muscle and be compressed. Approxi-
terminal branching pattern. Most often the anterior mately 3% of the time, the popliteal artery may end
tibial artery branches off first, leaving a tibiopero- in a true trifurcation.7,24 Rarely, the peroneal artery
neal trunk that divides into posterior tibial and pe- may arise from the anterior tibial artery or have a
roneal arteries (Fig. 19-24). When the anterior tibial low origin.
Geniculate br.
Popliteal a.
Anterior
tibial a.
Tibioperoneal
trunk
Posterior
tibial a. Peroneal a.
Anterior
tibial a.
Popliteus m.
Fig. 19-24 Branch patterns of the leg vessels include a high origin of the anterior tibial
artery that then passes deep to the popliteus muscle.
An extrinsic anatomic variant involving the through the muscle (Fig. 19-25D), and in addition
popliteal artery occurs when the vessel follows may pass deep to the popliteus (Fig. 19-25E). In-
an aberrant course relative to the calf muscles25 termittent compression may cause calf claudication
(Fig. 19-25). The artery may pass medial to a nor- and degenerative changes in the vessel. This condi-
mal or abnormal origin of the medial head of the tion should be suspected in young patients with calf
gastrocnemius (Fig. 19-25B and C), may pass claudication.
A B
Fig. 19-25 The normal popliteal course is shown (A). The most common cause of
popliteal entrapment is medial displacement of the artery around a normal medial head of
the gastrocnemius muscle (B).

C D
Fig. 19-25 The vessel may be diverted by an abnormal muscle origin (C), pass through the
muscle (D), or pass beneath the popliteus muscle (E).
Popliteus m.

Arteries of the Leg arteries continuing into the foot. Approximately
In addition to the variations in their origins, each 5% of the time, the posterior tibial artery is ab-
of the three vessels of the leg may be enlarged, re- sent and the plantar vessels are a continuation of
duced, or absent7 (Fig. 19-26). The most common the peroneal artery (Fig. 19-26B). Four percent of
pattern (Fig. 19-26A) is anterior and posterior tibial the time, the anterior tibial may be small or absent
Popliteal
Anterior
tibial T-P
trunk
Absent
PT
(5%)
Posterior
tibial
Peroneal
A B
Fig. 19-26 Branch patterns of the leg arteries. In the most common form, the anterior tibial
and posterior tibial arteries are continuous to the foot (A). Variations include the absence
of the posterior tibial artery with plantar vessels continuing from the peroneal artery (B),
absence of the anterior tibial artery with the dorsalis pedis artery continuing from the per-
forating branch of the peroneal artery (C), and the posterior tibial artery passing through
the interosseous membrane to join the anterior tibial artery, with plantar arteries continuing
from the peroneal artery (D).
(Fig. 19-26C). The dorsalis pedis artery in such the anterior tibial artery (Fig. 19-26D). The plantar
cases is a continuation of the perforating branch of vessels then arise from the peroneal artery. When
the peroneal artery. Occasionally, the posterior tib- one vessel is reduced, its territory is supplied by
ial penetrates the interosseous membrane and joins one or more of the companion vessels.
Small or
absent
AT
PT through
interosseous
mbr. to join
AT
DP from
perforating
br. of
peroneal Plantars
(4%) from peroneal
C D

Arteries of the Foot the veins accompanying major arteries is to be
The dorsalis pedis artery is usually a continuation multiple.
of the anterior tibial artery, and the plantar vessels Farther in the periphery, the venous pattern be-
are usually a continuation of the posterior tibial ar- comes less and less predictable. Major variations in
tery with the previously noted exceptions.7 There the large veins of the trunk occur and are usually
is minor variation in the branching of the dorsalis traceable to embryonic events. These major anoma-
pedis artery. The lateral plantar artery is usually lies may have clinical significance.
the dominant side of the plantar arch, but there is
some variation in relative contributions between Superior Vena Cava
the lateral plantar and dorsalis pedis arteries. The Failure of the left anterior and common cardinal
extent and size of communications between the veins to regress after the eighth week of embryonic
dorsal and plantar vessels vary slightly. There life results in a left-sided superior vena cava. This
are minor variations in the origins of the digital vessel receives the internal jugular and subclavian
vessels.26 veins on that side, descends anterolateral to the aor-
tic arch, and anterior to the hilum of the left lung.
Veins It most commonly drains into the coronary sinus
(Fig. 19-27). When both superior venae cavae are
Beyond the secondary branching away from the present (0.16% of individuals), the left brachioce-
venae cavae, the normal anatomic condition for phalic vein may be vestigial or absent.1 In cases in
Left superior
vena cava
Coronary
sinus
Fig. 19-27 A left-sided superior vena cava

most often drains into the coronary sinus.
which the right-sided cardinal vein elements have smaller than the right and communicates with the
regressed, only the left superior vena cava remains. right through a preaortic anastomosis at or below
In such cases, the right side drains to the left in a mir- the level of the renal veins (Fig. 19-28). The two
ror image of the normal anatomy, and the azygous venae cavae may also be joined by an iliac commu-
veins are also reversed. This condition is not neces- nication at their caudal end. This latter communica-
sarily associated with other visceral transpositions. tion is sometimes preaortic. In addition, there may
be a retroaortic left renal vein (2%) with or without
Inferior Vena Cava and Renal Veins a normal anterior left renal vein. In the presence of
Persistence of the left subcardinal vein results in a both, a circumaortic renal collar is formed.
double inferior vena cava in as many as 2% to 3% A left-sided inferior vena cava is a compo-
of individuals and a single left-sided inferior vena nent of situs inversus but may be present as an iso-
cava in 0.2% to 0.5%.1 The left vein is commonly lated anomaly. In the case of bilateral subcardinal
Fig. 19-28 Vena caval anomalies include doubling, left-sided position, and a circumaortic

renal venous collar.

involution and absence of the inferior vena cava, is a constant branch of the left renal vein and may
blood from the lower half of the body and liver receive the left gonadal vein.
drains through large ascending lumbar veins to the
azygous system and into the superior vena cava. Portal Vein
The incidence of clinically discovered inferior The portal vein is quite constant, with rare instances
vena cava anomalies (0.6% to 2.1%) corresponds al- of the vein being located anterior to the duodenum,
most exactly to the findings in anatomic specimens common bile duct, and hepatic artery. Only a few
and complicates surgical procedures, particularly cases of congenital absence of the portal vein have
abdominal aortic aneurysm repair.27,28 been reported.7 There is variability in the point at
The renal veins may receive lumbar branches, which the inferior mesenteric vein joins the other
and the left renal vein may communicate with the portal tributaries (Fig. 19-29). In addition, the left
splenic vein. The right renal vein may be multiple gastric vein, whose disconnection is important in
in one-fourth to one-third of individuals, but the left selective shunts, drains into the portal vein (54%),
renal vein is usually single. The left suprarenal vein splenic vein (29%), or their junction (16%).7
54%
29%
16%
Fig. 19-29 The junction of the inferior mesenteric

vein with the other portal tributaries is variable as is
the junction of the left gastric vein.
References A study of 500 specimens. Surg Gynecol Obstet.
1947;85:47–63.
1. Gray SW. Embryology for Surgeons: The Embryo- 15. Sonneland J, Anson BJ, Beaton LE. Surgical anatomy
logical Basis for the Treatment of Congenital De- of the arterial supply to the colon from the superior
fects. Philadelphia, PA: WB Saunders; 1972. mesenteric artery based upon a study of 600 speci-
2. Stewart JR, Kincaid GW, Edwards JE. An Atlas mens. Surg Gynecol Obstet. 1958;106:385–389.
of Vascular Rings and Related Malformations of 16. Zebrowski W, Augustyniak E, Zajac S. Variation of
the Aortic Arch System. Springfield, IL: Charles origin and branches of the inferior mesenteric ar-
C Thomas; 1964. tery and its anastomoses. Folia Morphol (Praha).
3. Valentine RJ, Carter DJ, Clagett GE. A modified ex- 1971;30:510–517.
trathoracic approach to the treatment of dysphagia 17. Valentine RJ, Blakenship CL, MacGillivray DC, et al.
lusoria. J Vasc Surg. 1987;5:498–500. Variations in the relationship of the left renal vein to
4. Edwards FH, Wind G, Thompson L, et al. Three- the left renal artery. Clin Anat. 1990;3:249–255.
dimensional image reconstruction for planning of 18. Stanley JC, Fry WJ. Median arcuate ligament syn-
a complex cardiovascular procedure. Ann Thorac drome. Arch Surg. 1971;103:252–257.
Surg. 1990;49:486–488. 19. Akin JT, Skandalakis JE, Gray SW. The anatomic ba-
5. Sabiston DC Jr, Spencer FC. Gibbon’s Surgery of the sis of vascular compression of the duodenum. Surg
Chest, 4th ed. Philadelphia, PA: WB Saunders; 1983. Clin North Am. 1974;54:1361–1370.
6. Clemente CD, ed. Gray’s Anatomy of the Human 20. Braithwaite JL. Variations in origin of the pari-
Body, 30th American ed. Philadelphia, PA: Lea & etal branches of the internal iliac artery. J Anat.
Febiger; 1985. 1952;86:423–430.
7. Bergman RA, Thompson SA, Afifi AK, et al. Com- 21. Steele G Jr, Sanders RJ, Riley J, et al. Pulsatile but-
pendium of Human Anatomic Variation. Baltimore, tock masses: gluteal and persistent sciatic artery
MD: Urban & Schwarzenberg; 1988. aneurysms. Surgery. 1977;82:201–204.
8. Daseler EH, Anson BJ. Surgical anatomy of the sub- 22. Uflacker R. Atlas of Vascular Anatomy. Philadelphia,
clavian artery and its branches. Surg Gynecol Obstet. PA: Lippincott Williams & Wilkins; 1997:756–778.
1959;108:149–174. 23. Williams GD, Martin CH, McIntire LR. Origin of
9. Hitzrot JM. A composite study of the axillary artery the deep and circumflex group of arteries. Anat Rec.
in man. Johns Hopkins Hosp Bull. 1901;12:136–145. 1934;60:189–196.
10. Coleman SS, Anson BL. Arterial patterns in the hand 24. Colborn GL, Lumsden AB, Taylor BS, et al. The
based upon a study of 650 specimens. Surg Gynecol surgical anatomy of the popliteal artery. Am Surg.
Obstet. 1961;113:409–424. 1994;60:238–246.
11. Scott HW Jr, Dean RH, Boerth R, et al. Coarctation of 25. Rich NM, Collins GJ Jr, McDonald PT, et al.
the abdominal aorta. Ann Surg. 1979;189:746–755. Popliteal vascular entrapment. Arch Surg.
12. Hallet JW, Brewster DC, Darling RC, et al. 1979;114:1377–1384.
Coarctation of the abdominal aorta. Ann Surg. 26. Laterjet A, Testut L. Traité d’anatomie humaine, 8th
1980;191:430–436. ed. Paris, France: G. Doin a Cie; 1929.
13. Nelson TM, Pollak R, Jonasson O, et al. Anatomic 27. Downey RS, Sicard GA, Anderson CB. Major ret-
variants of the celiac, superior mesenteric and infe- roperitoneal venous anomalies: surgical consider-
rior mesenteric arteries and their clinical relevance. ations. Surgery. 1990;107:359–365.
Clin Anat. 1988;1:75–91. 28. Bartle EJ, Pearce WH, Sun JH, et al. Infrarenal
14. Daseler EH, Anson BJ, Hambley WC, et al. The venous anomalies and aortic surgery: avoiding
cystic artery and constituents of the hepatic pedicle. vascular injury. J Vasc Surg. 1987;6:590–593.

APPENDIX
Selected Anatomic
References
General Texts Putz R, ed. Sobotta Atlas of Human Anatomy, 14th ed.
Munich, Germany: Elsevier Gmbh; 2008.
Hollinshead WH. Textbook of Anatomy, 5th ed. Philadel- Uflacker R. Atlas of Vascular Anatomy: An Angiographic
phia, PA: Harper & Row; 1997. Approach. Philadelphia, PA: Lippincott Williams &
Lockhart RD, Hamilton GF, Fyfe FW. Anatomy of the Wilkins; 1997.
Human Body. Philadelphia, PA: Lippincott Williams &
Wilkins; 1974.
Moore KL, Dalley AF, Agur AMR, et al. Clinically Ori- Cross-Sectional Atlases
ented Anatomy, 6th ed. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins; 2010. Cahill D, Orland MJ. Atlas of Human Cross-sectional
Standring S, ed. Gray’s Anatomy: The Anatomical Basis Anatomy: With CT and MR Images. New York, NY:
of Clinical Practice, 40th ed. Munich, Germany: Wiley Liss; 1995.
Churchill Livingstone/Elsevier GmbH; 2008. El-Khoury GY, Bergman RA, Montgomery WJ, et al.
Woodburne RT. Essentials of Human Anatomy, 9th ed. Sectional Anatomy by MRI and CT with Website,
New York, NY: Oxford University Press; 1994. 3rd ed. Edinburgh, England: Churchill Livingstone;
2007.
Atlases Eycleshymer AC. A Cross-section Anatomy. New York,
NY: D. Appleton; 1911.Reprints from the collection
of the University of Michigan library.
Abrahams H, Boon J. McMinn’s Clinical Atlas of
Kelley LL, Petersen MS. Sectional Anatomy for Imaging
Human Anatomy, 6th ed. Munich, Germany: Elsevier
Professionals, 2nd ed. St. Louis, MO: Mosby/Else-
GmbH; 2008.
vier; 2007.
Agur AMR, Dalley AF. Grant’s Atlas of Anatomy,
Koritke J, Sick H. Atlas of Sectional Human Anatomy,
13th ed. Baltimore, MD: Wolters Kluwer/Lippincott
2nd ed. Baltimore, MD: Urban & Schwarzenberg;
Williams & Wilkins; 2013.
1988.
Bergman RA, Thompson SA, Afifi AK, et al. Compen-
Weir J, Abrahams, P. Imaging Atlas of Human Anatomy,
dium of Human Anatomic Variation. Baltimore, MD:
St. Louis, MO: Mosby/Elsevier; 2010.
Urban & Schwarzenberg; 1988.
Clemente CD. Anatomy, a Regional Atlas of the Human
Body, 6th ed. Philadelphia, PA: Wolters Kluwer/
Lippincott Williams & Wilkins; 2010. Surgical Anatomy
Netter FH. Atlas of Human Anatomy, 5th ed. Philadelphia,
PA: Saunders; 2011. Anson BJ, McVay CB. Surgical Anatomy, 6th ed. Phila-
Pernkopf E. Atlas of Topographic and Applied Human delphia, PA: Saunders; 1984.
Anatomy, 3rd English ed. Baltimore, MD: Urban & Henry AK. Extensile Exposure, 2nd ed. Edinburgh,
Schwarzenberg; 1990. England: Churchill Livingstone; 1973.
577
Scott-Conner CEH, Dawson DL. Operative Anatomy, Virtual Anatomy
Philadelphia, PA: Wolters Kluwer/Lippincott
Williams & Wilkins; 2009. http://www.visiblebody.com
Skandalakis JE, Skandalakis PN. Surgical Anatomy and http://www.anatronica.com
Technique. New York, NY: Springer Sciences; 2008. http://www.interactelsevier.com/netter
Thorek E. Anatomy in Surgery, 2nd ed. Philadelphia, PA: http://www.anatomium.com
Lippincott Williams & Wilkins; 1962. http://www.primalpictures.com
http://www.anatomy.tv/default.aspx
http://www.nextd.com
Musculoskeletal http://www.zygotebody.com/no_webgl.html
http://www.3danatomy.co.uk
Hoppenfeld S. Surgical Exposures in Orthopedics: The https://www.biodigitalhuman.com/default.html
Anatomic Approach. Philadelphia, PA: Lippincott
Williams & Wilkens; 1984.
578 | APPENDIX
Subject index
Page numbers followed by f refer to figures Antebrachial cutaneous nerve Axillary vein, 79f, 120f, 137f, 138f, 142f, 164f,
lateral, 190f, 191f, 218f, 219f 168f, 172f
A medial, 158f, 190f, 201f development of, 13
posterior, 191f, 219f Axis, transverse process of, 71
Abdominal aorta, 236, 237–270, 350f Antegrade puncture, of femoral artery, 407 Azygous vein, 79f, 83f, 87f, 244f
anatomic relationships of, 237–241 Anterior compartment, 475f, 502f development of, 16f, 17f
branches of, variation, 551 Anterolateral thoracotomy, 101–104
coarctation, 551 in trap door thoracotomy, 105–108 B
exposure of, 245–270 Aorta(s), 11f, 150f, 236f, 238f, 244f, 317f,
infrarenal 318f, 319f, 320f, 367f. See also Baroreceptors, 46
exposure of, 323–335 Abdominal aorta; Thoracic aorta Basilar artery, 56f
intraperitoneal approach, 323 development of, 2, 4f, 8f, 17f Basilic vein, 185f, 186f, 187f, 201f
retroperitoneal approach, 323, dorsal, 7–9, 11f development of, 13
326–329 embryonic development of, 3f, 4f Biceps brachii muscle, 170f, 180f, 186f, 192f,
transperitoneal approach, 323–326 intersegmental (dorsal and lateral) branches, 197f, 199f, 203f
surgical anatomy of, 315–323 7 long head, 167f, 176f
retroperitoneal relationships of, 318–319 ventral visceral branch, 7 short head, 156f, 167f, 176f
supraceliac, 242–245 Aortic arch(es), 79f, 103f Biceps brachii tendon, 193f
surgical anatomy of, 237–245 branches of, exposure of, 90–108 Biceps femoris muscle, 60f, 447f, 454f, 456f,
variations, 551–561 development of, 5–6, 5f, 6f 464f, 465f, 466f
Abdominal aortic aneurysms, 323 primary branches of, variations, 545 long head, 431f, 452f, 465f
Abductor digiti minimi muscle, 224f, 514f Aortic bifurcation, 272f short head, 431f, 452f, 456f, 465f
Abductor hallucis muscle, 493f, 512f, 513f, Aortic plexus, 320f, 322f Biceps femoris tendon, 472f
514f, 535f, 536f Aortofemoral bypass, 415 Biceps muscle, 120f, 184f, 186f
Abductor pollicis longus muscle, 195f, anatomy of tunnel for, 416–417 insertion, 176f
209f, 225f Apical growth ridge, 11f long, 156f
Abductor pollicis longus tendon, 227f Arc of Riolan. See Meandering mesenteric short head, 172f
Accessory nerve, 32f, 36f, 37f, 39f, 48f, 70f artery Biceps tendon, 180f, 202f, 473
Achilles tendon, 503f, 533f Arcuate artery, 509f, 510f, 511f, 537f Bicipital aponeurosis, 180f, 199f, 201f
Acute compartment syndrome, 209–210 Arcuate ligament, median, 272f, 274f, 281f Birth, circulation at, 18, 18f
Adductor brevis muscle, 390f, 400f, Arcuate line, 339f Blood vessels
403f, 426f, 428f, 433f, 434f, Ascending pharyngeal artery, 30f anatomic variations of, 541–574
435f, 445f Atlantooccipital membrane, 74, 74f development of, 1–14
Adductor canal (of Hunter), 434f, 440f, 450f posterior, 58f aortic arches, 5–6, 5f, 6f
fascial roof of, 454f Atlas, transverse process of, 71 dorsal aorta, 7–9, 7f, 8f, 9f
Adductor hallucis muscle, oblique head, 514f Auricular artery, posterior, 30f extremities, 10–14, 10f, 11f, 12f, 13f
Adductor hiatus, 432f, 434f, 449f, 451f, 454f Auricular nerve, great, 32f overview of, 1–2, 1f
Adductor longus muscle, 390f, 394f, 400f, Axial artery, 11f primordial, 2–4, 2f, 3f, 4f
403f, 426f, 428f, 432f, 433f, 434f, Axilla Body stalk, 2f, 3f
435f, 445f, 451f fasciae of, 159 Bookwalter retractor. See Omni retractor
Adductor magnus muscle, 400f, 426f, 428f, muscular boundaries of, 156 Botulinum toxin A, 126
430f, 431f, 432f, 433f, 434f, 435f, nerves of, 158–159 Brachial artery, 162f, 176f, 177–187,
445f, 447f, 449f, 451f, 452f, 454f, Axillary artery, 79f, 120f, 137f, 138f, 179f, 180f, 187f, 197f, 198f,
458f, 483f 155–174, 162f, 164f, 168f, 202f, 203f
Adductor magnus tendon, 449f, 451f, 456f, 170f, 172f deep, 157f, 181f, 182f
461f, 462f, 465f anatomy of, 155–159 development of, 12f
Adductor muscle, 430f, 431f branches of, 157 distal, exposure of, 200–203
Adductor pollicis muscle, 224f exposure of, 160–161 exposure of, 185–187
Adductor tubercle, 451f axillary approach to second and third variations, 549–550
Adrenal, 9f parts, 167–169 Brachial cutaneous nerve, medial, 158f
Adrenal vein(s) covered stents, 160 Brachial fascia, 159f, 177
development of, 16–17 deltopectoral approach, 170–174 Brachial muscles, anterior, 179–180
left, 299f, 301f, 350f infraclavicular approach to first part, Brachial nerve, deep, 158f, 178f
right, 299f, 350f 161–166 Brachial plexus, 24, 32f, 55f, 121f, 130f, 137f,
Allantois, 2f, 3f injury, 160 138f, 139f
Alveolar nerve, inferior, 36f mobilization of, 164–166, 164f cords
Amnion, 2f sections of, 160 lateral, 116f, 158f, 172f, 176f
Amnionic cavity, 2f, 3f variations, 549 medial, 158f, 172f, 176f
Anastomotic artery, 12f Axillary fascia, 118f, 159f posterior, 116f, 172f, 176f
Anatomic variations, vascular, 541–574 Axillary nerve, 158f, 178f, 181f divisions, 116f
Anconeus muscle, 195f Axillary sheath, 24f, 159f, 167f, 168f roots of, 116f
Ansa cervicalis, 27f, 29f, 32, 32f, 36f, 39f Axillary sheath fascia, 118f trunks, 116f
Ansa hypoglossi. See Ansa cervicalis Axillary space, 118 Brachial sheath, 118f, 186f
Ansa subclavia, 82f, 122f surgical view of, 120f Brachial vein, 178
579
Brachialis muscle, 179f, 184f, 192f, 193f, 197f, sixth, 54f Coracoacromial ligament, 156f
199f, 203f transverse, 32f Coracobrachialis muscle, 156f, 167f, 168f,
insertion, 176f Cervical plexus, 32 172f, 179f, 180f, 183f
Brachiocephalic artery, 79f, 85f, 87f, 96f, 97f Cervical rib, 113, 124, 124f, 131, 140 Coracoid ligament, 156f
exposure of, 91–92 Cervical spine, 23 Coracoid process, 120f, 154f, 162f, 172f
mobilization of, 96–97 Cervical sympathetic chain, 27, 54, 122 Coronary ligament, posterior, right, 353f
variations of, 546 Cervical sympathetic ganglion Coronary sinus, 572f
Brachiocephalic vein(s) inferior, 32f, 62f Coronary vein, 249f. See also Gastric
development of, 16f middle, 32f, 122f vein(s), left
left, 83f, 87f, 94f, 96f, 97f superior, 27f, 37, 37f, 121f Costocervical artery, 544f
development of, 16f Cervical sympathetic trunk, 29f Costocervical trunks, 8f, 54, 54f
right, 87f, 97f Cervical transverse process, 114f Costoclavicular angle, 123f
Brachioradialis muscle, 179f, 181f, 182f, 184f, Cervical vertebrae Costoclavicular compression, 125f
192f, 194f, 195f, 197f, 198f, 199f, C1. See Atlas Costoclavicular ligament, 114f, 119f, 142f,
203f, 204f, 209f C2. See Axis 144f, 145f, 156f
Brachioradialis tendon, 206f C6, 52f Costoclavicular passage, 123f
Brachium transverse process, 52, 122f Costocoracoid ligament, 123
posterior, 181–182 C7, 114f Cranial nerve(s)
surgical anatomy of, 177–184 Cervicothoracic sympathectomy, 148. See also emergence at base of skull, 37, 37f
Bronchus, left mainstem, 80f Cervical sympathetic chain injury, in carotid surgery, 36
anterior transthoracic approach, 148 in neck, 32, 36–39, 36f, 37f, 38f, 39f
C dorsal Cribriform fascia, 396, 396f
anterior supraclavicular approach, 148–149 Cruciate anastomosis, 406f
C1 transverse process, 70f transaxillary approach, 150 Crural fascia, 472f
palpation of, 72 posterior paravertebral approach, 148 Crus, right, 242f
Calcaneal plexus, 509f Cervicothoracic sympathetic chain of diaphragm, 247f
Calcaneal tendon, 504f, 513f, 534f exposure of, 148–150 Cubital vein, medial, 190f
Capitate bone, 220f Chorion, 2f Cutaneous nerve, 121f
Caput medusa, 369f Chorionic villi, 2f Cysterna chyli, 245f, 281f, 282f, 350f
Cardiac nerves, 122f Circulation. See also Fetal circulation
Carotid artery(ies), 23–49, 27f, 30f, 55f, inception of, 2–4
61f. See also Common carotid Clavicle, 113, 123 D
artery(ies); External carotid artery; Clavicular malunion, 125f
Deltoid muscle, 120f, 156f, 159f, 170f, 172f,
Internal carotid artery Clavipectoral fascia, 118f, 119f, 159f, 162f,
176f, 183f, 184f
exposure of, 90–91 163f, 170f, 172f, 174f
Deltopectoral groove, 183f
extracranial, exposure of, 41–49 Colic artery(ies)
Descending branch, 565f
left, 53f middle, 276f, 284f, 286f, 296f, 559f
Diaphragm, 240f, 242, 246f, 265f,
proximal, exposure of, 91 right, 272f, 276f, 284f, 557f
267f, 268f
right, 53f Colic vein, middle. See Middle colic vein
circumferential division of, 266f
Carotid bifurcation, 39 Colon
motor innervation to, 244
exposure of, 42–46 hepatic flexure of, 356f, 374
neurovascular supply to, 242f
Carotid body, 39 impression of, 353f
origins, 242f
Carotid plexus, 121f left, 304f, 340f
topography, 243
Carotid sheath, 23, 23f, 27, 27f, 29f, 61f right, 238f, 306f
Diaphragmatic crus, 247f
Carotid sinus, 30, 39f, 48f mobilization, for exposure of inferior
right, 242f
innervation, 39 vena cava, 380f
exposure of, 247f
Carotid sinus nerve, 39 transverse, 272f
Digastric muscle, 37f, 70f
Carotid triangle, 29 Colon reflection
divided, 33
Carotid tubercle, 51f, 52f, 66f, 122f left, 240f
posterior belly of, 29, 34f, 39f
Carpal ligament right, 240f
division of, 48f
transverse, 220f, 221f, 222f, 223f, 227f Common bile duct, 274f
Digital artery, 234f
volar, 222f Common cardinal veins, development of, 4f,
Digital nerves, 218f
Caudate lobe, 353f, 356f 14f, 15f, 16f
Digital palmar crease, 218f
Celiac artery Common carotid artery(ies), 30f, 34f, 542f
Digitorum longus muscles. See Extensor
development of, 9f development of, 5f, 8f
digitorum longus muscle; Flexor
orifice, 296f left, 87f, 95f, 96f
digitorum longus muscle
transperitoneal exposure of, at origin, 280–283 origin of, 85f
Dorsal branch, medial, 537f
Celiac ganglion, 281f, 282f proximal, exposure of, 90–91
Dorsal compartment, 210f, 214, 214f
Celiac trunk, 241f, 251f, 272f, 274f, 291f variations of, 545
Dorsalis pedis artery, 494f, 495f, 504f, 506f,
surgical anatomy of, 274–275 right, 87f, 97f
509f, 510f, 511f
variation, 551–556 variations, 546
exposure of, 537
Cephalic vein, 142f, 145f, 159f, 162f, 163f, variations, 546
Ductus arteriosus, 6f, 8f, 18f
170f, 172f, 183f, 190f, 206f, 230f Common flexor origin, 192f, 197f
Ductus deferens, 351f, 394f, 398f
Cervical artery(ies) Common hepatic artery, 275f, 311f
Ductus venosus, 15f, 18f
ascending, 149f Common hepatic duct, 353f
Duodenum, 272f, 277f, 296f, 306f, 325f, 329f,
superficial, 107f, 149f Communicating branch, 508f
356f, 367f, 375f, 379f
transverse, 544f Compartment
Dura mater, 58f
Cervical cardiac nerve, middle, 54f anterior, 486f
Cervical ganglia, middle, 82f deep posterior, 486f
Cervical ganglion lateral, 486f E
inferior, 32f, 54f, 55f, 82f superficial posterior, 486f
middle, 32f, 54f, 55f, 122, 122f Condyloid emissary vein, 72, 73f Ectoderm, 3f
superior, 121f Constrictor muscle Embolus, 279f
Cervical nerve(s), 29f inferior, 33f Embryonic period, vascular development in,
fifth-eighth, 116f middle, 33f 1–13
second, 57f, 70f superior, 33f Endoderm, 3f
580 | SUBJECT INDEX
Epicondyle Facial nerve, 32f, 36f, 37f, 48f Flexor digitorum longus muscle, 491f, 492f,
lateral, 184f exposure of, 49 493f, 498f, 503f, 504f, 505f, 507f,
medial, 176f, 183f ramus mandibularis branch of, 38f 508f, 511f, 512f, 513f, 514f, 519f,
Epigastric artery(ies) Facial vein, 35, 35f, 39f, 44f 523f, 529f, 533f, 534f, 535f, 536f
inferior, 316f, 335f, 394f, 396f, 398f, 563f Falciform ligament, 240f Flexor digitorum profundus muscle, 192f,
superficial, 394f, 396f, 403f Falx inguinalis, 398f 193f, 197f, 207f, 209f, 210,
Epigastric vein(s) Fascia lata, 440f, 450f 226f, 227f
inferior, 335f, 350f, 394f, 396f, 398f Fasciocutaneous flap, elevation of, 212f Flexor digitorum superficialis muscle, 192f,
superficial, 396f Fasciotomy, forearm, 209–214 193f, 194f, 197f, 198f, 199f, 207f,
Erector spinae muscles, 24 Femoral artery(ies), 398f, 407, 437f, 457f 209f, 227f
Esophageal hiatus, 350f branches of, exposure of, 407–426 radial origin, 192f
Esophageal plexus, 82f common, 404f, 413f, 433f, 434f, Flexor hallucis brevis muscle, 493f, 513f, 514f
Esophageal varices, 369f 565, 565f Flexor hallucis longus muscle, 492f, 493f,
Esophagophrenic ligament, 240f, 246f, 247f exposure of, 407–415 498f, 503f, 504f, 507f, 508f, 511f,
Esophagus, 246f, 277f deep, 402f, 403f, 404f, 405f, 406f, 413f, 512f, 513f, 514f, 519f, 523f, 529f,
Extensor carpi radialis brevis muscle, 426f, 433f, 434f, 435f, 443f, 447f, 533f, 534f, 535f, 536f
195f, 209f 451f, 456f, 564f, 565f Flexor pollicis brevis muscle, 224f
Extensor carpi radialis longus muscle, 194f, posterior approach, 446, 446f Flexor pollicis longus muscle, 192f, 193f,
195f, 209f development of, 13f 194f, 209f, 210, 227f
Extensor carpi ulnaris muscle, 195f, 209f exposure of, 407–426 Flexor pollicis longus tendon, 223f
Extensor compartment, 176f in groin, 407–426 Flexor retinaculum, 485f, 493f, 512f, 535f
Extensor digiti minimi muscle, 195f inflow to, anatomy of, 415–416 lacinate ligament, 513f
Extensor digitorum brevis muscle, 511f origin of, 404f Foot
Extensor digitorum communis muscle, 195f perforating branch, 404 arteries of, variation, 572
Extensor digitorum longus muscle, 494f, 495f, superficial, 394f, 402f, 404f, 413f, vessels of, 311–313
497f, 503f, 504f, 506f, 515f, 524f, 426f, 433f, 434f, 435f, 450f, Foramen ovale, 18
526f, 534f 451f, 565, 565f Forearm. See also Upper extremity
Extensor digitorum longus tendons, 511f development of, 13f arteries of, 196–197
Extensor digitorum muscle, 209f Femoral canal, 392f exposure of, 199–214
Extensor hallucis brevis muscle, 511f, 537f distal end, 393f variations, 550
Extensor hallucis longus muscle, 493f, 495f, proximal end, 393f bony anatomy of, 189–193
497f, 503f, 504f, 506f, 511f, 524f, Femoral circumflex artery(ies) compartments, 210, 210f
526f, 534f ascending branch, 406f dorsal, 214, 214f
Extensor hallucis longus tendon, 537f lateral, 403f, 405f, 406f, 414f, 443f, lateral, 213, 213f
Extensor indicis muscle, 195f 457f, 565f volar, 210–211, 210f
Extensor pollicis brevis muscle, 195f, 225f, ascending branch, 406f cubital fossa, 197–198
230f, 231f descending branch of, 456f deep fascia of, 209, 209f
Extensor pollicis longus muscle, 195f, 209f, perforating branch, 406f distal, surgical anatomy of, 198–199
225f, 231f transverse branch, 406f extensor muscles, 195
Extensor retinaculum, 225f medial, 402f, 403f, 404f, 405f, extensor/supinator muscle group, 189, 192
inferior, 485f, 495f, 506f, 526f 406f, 565f fasciotomy, 209–214
superior, 485f, 495f, 506f, 526f variation, 404 compartment syndrome, 209–210
External carotid artery(ies), 34, 34f, 39f, 43f Femoral circumflex vein(s) flexor muscles, 193–194
branches of, 30f lateral, 404f, 413f, 443f deep, 193f
development of, 5f, 6f, 8f medial, 404f intermediate, 193f
variations of, 546 Femoral cutaneous nerve, lateral, 321f origins, 189–193
External iliac artery(ies), 314f, 316f, 330f, Femoral nerve, 321f, 351f, 433f, 443f radial origin, 194
335f, 394f, 423f, 562f, 563f Femoral region, surgical anatomy of, ulnar origin, 194
development of, 12f, 13f 391–406 flexor/pronator muscle group, 189, 192
extraperitoneal exposure of, 334–335 Femoral ring, 398f intermediate muscles, 195
left, 318f, 351f Femoral triangle, 442f muscle groups of, 192–193
right, 329f Femoral veins, 398f, 437f nerves of, 196–197
External iliac vein(s), 394f, 423f superficial, 394f, 441f superficial veins and nerves of, 190
right, 318f Femoral vessels surgical anatomy of, 189–199
External jugular vein, 28f, 29f, 31, 31f, deep, 435 vessels of, 189–214
35f, 42f, 60f, 64f, 106f, superficial, 439–441 Foregut, 3f
128f, 149f Femorofemoral bypass, 415
development of, 16 anatomy of tunnel for, 419–421 G
External oblique muscle, 254f, 264f Fetal circulation, 18, 18f
External pudendal artery(ies) Fibrous arc, 198f Gallbladder, 375f
deep, 394f, 396f, 403f Fibrous digital flexor sheath, 222f Gastric arcade, short, 368f
superficial, 394f, 396f, 403f Fibrous digital sheath, 223f Gastric artery(ies)
External pudendal vein(s) Fibula, 475f left, 248f, 249f, 272f, 274f, 275f, 281f, 296f
deep, 396f head of, 472f right, 274f, 291f
superficial, 396f Fibular collateral ligament, 473f short, 275f
Extraembryonic coelom, 2f, 3f Flexor carpi radialis muscle, 194f, 199f, Gastric impression, 353f
Extremities. See also Lower extremity; Upper 209f, 227f Gastric varices, 369f
extremity Flexor carpi radialis tendon, 205f, 206f, 208f, Gastric vein(s)
axial arteries of, development of, 10–14 222f, 224f left (coronary), 274f, 366f, 367f
development of, 10–14 Flexor carpi ulnaris muscle, 194f, 195f, 198f, divided, 281f
vascular development in, 10–14 199f, 205f, 207f, 208f, 209f, 222f, right, 366f, 367f
224f, 227f short, 382f
F Flexor compartment, 176f Gastrocnemius muscle, 453, 456f, 469f, 475f,
Flexor digiti minimi brevis muscle, 224f 491f, 492f, 498f, 515f
Face, superficial veins of, 35f Flexor digitorum brevis muscle, 493f, 512f, medial head, 458f, 468f, 516f, 567f
Facial artery, 30f, 34f 513f, 514f sural branches to, 456f
SUBJECT INDEX | 581
Gastroduodenal artery, 274f, 275f, 276f, Heart, development of, 2f, 3f, 4f Iliosacral vein
291f, 296f Hemiazygous vein, 83f lateral, 341f
Gastroepiploic arcade, 368f Hemorrhoids, 369f, 370 medial, 341f
Gastroepiploic artery(ies) Hepatic artery(ies), 272f, 274f, 281f, 291f, left, 344
left, 275f, 382f 296f, 353f. See also Common Iliotibial band, 450f, 464f
right, 275f, 276f hepatic artery Incision(s). See also Anterolateral
divided, 382f exposure of, 290–291 thoracotomy; Posterolateral
Gastroepiploic veins hepatorenal bypass, 290 thoracotomy; Trap door thoracotomy
left, 382f left, replaced, 248f antecubital
right Hepatic flexure, 356f, 374 S-shaped, 200f
divided, 382f impression of, 353f transverse, 200f
Gastrohepatic ligament, 353f Hepatic sinusoids, development of, 14–15 anterior cervical, 41f
Gastrohepatic omentum, 247f Hepatic vein(s), 277f, 350f anterior flank, for retroperitoneal exposure
lesser, 248f caudal extension of, 17f of iliac arteries, 332f
Genicular artery(ies) development of, 14–15 carpal tunnel, in forearm, 211–212, 211f
highest, 454f exposure of, 361 deltopectoral, 170f
descending musculoarticular branch shrock shunt, 361 for exposure of common femoral artery, 408f
of, 456f Hepatoduodenal ligament, 277f, 353f, 356f hockey stick, 381
inferior free edge of, 375f initial palmar portion of, 211f
lateral, 457f Hepatorenal bypass, 290 left subcostal, extended, 381f
medial, 457f Hindgut, 3f longitudinal neck, 42f
medial, 456f Horner’s syndrome, 122 for exposure of vertebral artery at
superior, 456f, 461f Humeral circumflex artery C1/C2, 69f
lateral, 457f anterior, 178f postauricular extension of cephalad end
medial, 457f lateral, 157f of, 42f
Genicular branches medial, 157f for medial infrageniculate exposure, 467f
inferior, 449f posterior, 178f, 181f for medial suprageniculate exposure, 460f
superior, 449f Hypogastric plexus, 338f midline abdominal, 377
Geniculate branch, 566f superior, 322f paramedian, for exposure of L5/S1, 339f
Genitofemoral nerve, 321f, 338f, 351f, 394f Hypoglossal muscle, 33f for posterior exposure
Glossopharyngeal nerve, 36, 36f, 37f, 39f, 48f Hypoglossal nerve, 36, 36f, 37f, 39f, 45, 45f, of deep femoral artery, 446f
Gluteal artery 48f, 75f of popliteal vessels, 478f
inferior, 316f, 402f, 405f, 406f, 562f, Hypothenar crease, 218f posterior parietal, 386
563f, 564f Hypothenar fascia, 223f for radial exposure at wrist, 205f
development of, 13f for retroperitoneal approach to iliac
superior, 316f, 402f, 405f, 406f, 562f, I vessels, 422f
563f, 564f for retroperitoneal exposure of infrarenal
Gluteus maximus, 431f, 447f Iliac artery(ies) aorta, 326–329f
Gluteus medius, 431f anterior division of, 563f right flank, 354f
Gluteus minimus, 430f circumflex right subcostal, extended, 373f
Gonad, embryonic, 9f deep, 316f, 393f, 394f, 396f, sternotomy, 91f
Gonadal artery, 299f, 319f, 351f, 356f 398f, 405f supraclavicular, 91
Gonadal vein(s), 299f, 351f, 356f superficial, 394f, 396f, 403f in trap door thoracotomy, 105–108
left, 301f, 328f, 350f common, 314f, 405f, 562f, 563f for supraclavicular approach to first rib, 127f
right, 350f development of, 12f suprainguinal, for extraperitoneal exposure
Gonadal vessel(s), 338f left, 272f, 330f of external iliac artery, 334–335f
left, 318f, 340f right, 329f, 351f thoracic, 90–91. See also Median
variation, 559 variation, 562 sternotomy
Gracilis muscle, 390f, 400f, 403f, 431f, 433f, exposure of thoracoabdominal, 246f
454f, 456f, 458f, 462f, 468f retroperitoneal approach, 332–333 for exposure of suprarenal aorta, 252–254f
Great vessels. See also Aorta(s) transperitoneal approach, 329–331 for transperitoneal exposure of infrarenal
of chest external aorta, 324f
origin of, 79 development of, 13f transverse cervical, 41f
surgical anatomy of, 78f, 79–90 variation, 565 transverse midabdominal, 377
Greater occipital nerve, 72, 73f, 74f internal, variation, 562–564 transverse midflank, for exposure of lumbar
Greater saphenous vein, 351f, 394f, 396f surgical anatomy of, 315–323 sympathetic chain, 336f
Grey column, lateral, 121f Iliac fascia, 392f, 393f transverse supraclavicular, 60f
Gut, embryonic, 5f, 15f Iliac vein(s), 330f Inferior epigastric pedicle, 339f, 340
circumflex Inferior epigastric vessels, 338f
H deep, 350f, 393f, 394f, 396f, 398f Inferior mesenteric artery, 241f, 272f,
superficial, 396f 277f, 314f, 318f, 325f, 328f,
Hamate bone, 220f common 329f, 338f, 341f
hook of, 221f, 227f left, 317, 317f, 318f, 341 development of, 4f, 9f
Hamstrings, branches to, 457f development of, 16 exposure of, 289
Hand development of, 17f surgical anatomy of, 277–278
arteries of surgical anatomy of, 317 variation, 558
aneurysms of, 230 Iliac vessels, 340f Inferior mesenteric artery ligated, 268f
exposure of, 230–234 Iliacus muscle, 240f, 390f, 403f Inferior mesenteric vein, 296f, 301f, 366f
variations, 550–551 Iliocolic artery, 272f, 557f Inferior vena cava, 236f, 238f, 244f, 274f,
bones of, 220–221 Iliohypogastric nerve, 321f, 351f 317f, 318f, 319f, 320f, 329f, 353f,
cutaneous nerves of, 217–219 Ilioinguinal nerve, 321f, 338f, 351f 367f, 370f, 375f, 379f, 380f
fascia of, 222–224 Iliolumbar vein, 350f development of, 18f
intrinsic muscles of, 224–225 Iliopsoas indentation, 240f infrahepatic, exposure of, 354–358
vascular anatomy of, 217–229 Iliopsoas muscle, 428f, 430f, 432f, 433f extraperitoneal approach, 354–355
vessels of, 217–234 insertion, 426f intraperitoneal approach, 356–358
intercommunication among, 229f Iliopsoas tendon, 400f retroperitoneal approach, 354
582 | SUBJECT INDEX
infrarenal, 352 anterior, 29f, 31, 31f Longus colli muscle, 24, 24f, 52f, 53f, 62f, 122f
perirenal, 353 distal, 35, 35f Lower extremity. See also Femoral region;
retrohepatic, 353–354 Leg; Thigh
exposure of, 359–360 fascia, 450
suprahepatic, within pericardial sac, K intermuscular septa
exposure of, 362 lateral, 450f, 456f, 464f, 466f
Kidney
surgical anatomy of, 349–354 medial, 450f, 456f, 462f
embryonic, 9
variation, 573–574 marginal vein, development of, 12
left, 318f
Infrageniculate, 449f vascular development in, 12–13
relationships to overlying organs, 298f
Infrarenal aorta Lumbar arteries, development of, 8
right, 318f, 375f
exposure of Lumbar nerve, 350f
Knee
retroperitoneal, 326–329 Lumbar spinal nerves, 320–323, 320f
interosseous membrane, 476
transperitoneal, 323–326 Lumbar spine
muscular groupings attaching at, 451–453
surgical anatomy of, 315–323 L1, 321f
posterior, dislocation, traumatic intimal
Inguinal ligament, 390f, 398f L2, 321f
flaps from, 478
Inguinal ring, deep, 398f L3, 321f
Kocher maneuver, 306
Intercostal artery, 544f L4, 321f
development of, 8f L5, 314f, 321f
Intercostal veins, development of, 17 L vascular exposure of, 337–346
Intercostobrachial nerve, 116f, 120f, 136f, L4/L5, 344–346, 344–345f
137f, 158f L4/L5 disc, exposure of, 344–346, 344–345f L5/S1, 338–343, 343f
Interdigital space, 223f L5/S1 disc, exposure of, 338–343, 343f retroperitoneal approach, 338
Internal carotid artery, 30, 34, 34f, 37f, 39f, 75f Lacunar ligament, 390f Lumbar sympathectomy, 336
anatomical relationships of, 29 Langer’s axillary arch, 123, 123f Lumbar sympathetic chain, 338f
development of, 5f, 6f, 8f Laryngeal nerve(s) exposure of, 336–337
distal, 39, 74, 75f recurrent, 82f Lumbar vein(s), 255f, 301f, 350f, 352f
exposure of, 45 left, 81f, 97 ascending, 319f, 320f, 322f, 350f, 352f
in upper neck (zone III), exposure of, 47–49 right, 97f development of, 17
variations, 546 superior, 29f, 36f, 39f Lumbar venous plexus, 238f
Internal iliac artery, 314f, 316f, 330f, 394f, Lateral compartment, 210f, 213, 213f, 475f, 502f Lumbar vessels, 341f
405f, 406f, 562f, 563f Latissimus dorsi muscle, 110f, 118f, 120f, Lumbocostal arch
development of, 13 136f, 156f, 176f, 181f, 183f lateral, 242f
right, 329f Leg. See also Lower extremity medial, 242f
Internal jugular vein, 27f, 31, 31f, 35, 37f, 39f, arteries of, 487 Lumbosacral trunk, 321f
43, 43f, 53f, 54f, 55f, 60f, 61f, 95f, exposure, 515–537 Lumbrical muscles, 226f
106f, 107f, 128f, 129f variation, 570–572 Lunate bone, 220f
development of, 16f compartment fasciotomy, 489f Lung buds, 5f, 6
left, 87f compartment syndromes, 489f Lungs, 149f, 150f
Internal maxillary artery, 30f, 34f compartments of Lymph node, 282f
Internal oblique muscle, 254f, 264f anterior, 486f, 497
Internal pudendal artery, 316f, 562f, 563f lateral, 486f, 499–501 M
Internal thoracic artery, 51f posterior, 498–499
development of, 8f deep, 486f Malleolar artery, anterior
Internal thoracic vein superficial, 486f lateral, 509f, 526f
left, 97f fascia of, 484–490 medial, 509f, 526f
right, 97f interosseous membrane, 483f, 486f Malleolus, lateral, 496f
Interosseous artery muscle groups of, 491–496 Mandibular ramus, 40
common, 196f nerve distribution in, 488 Manubrium, 114f
dorsal, 196f surgical anatomy of, 483–561 Marginal artery of Drummond, 278f
volar, 196f vessels of, 483–537 Marginal mandibular nerve, 38, 38f
Interosseous membrane, 476f, 483f, 486f Lesser occipital nerve, 32, 32f Marginal vein, 11f
Interosseous muscle, first dorsal, 225f, 232f Lesser sac Mastoid process, 70f
Interosseous nerve, anterior, 196f lateral recess of, 236f Meandering mesenteric artery, 278f
Interosseous recurrent artery, 196f posterior peritoneum of, 247f Medial supracondylar line, 449f
Interscalene triangle, 123f Levator ani muscle, 398f, 423f Median arcuate ligament, 251f, 560f
Intersegmental arteries, dorsal, 7–9, 12–13 Levator scapulae muscle, 24f, 58f Median artery, development of, 12f
sixth, 11f in exposure of vertebral artery C1/C2 Median nerve, 116f, 158f, 168f, 172f,
Interspace segment, 71f 176f, 179f, 180f, 187f, 196f,
eighth, 259f Lidocaine, 126 197f, 198f, 202f, 203f, 222f,
for exposure of aorta, 110 Ligamentum arteriosus, 18 224f, 227f, 228f
fourth, entry into, 110 Ligamentum nuchae, 24, 26 motor branch, 222f
sixth, 259f Ligamentum teres, 353f palmar cutaneous branch of, 218f, 222f
Intersubcardinal anastomosis, 17f Ligamentum venosus, 18 Median sternotomy, 91–97
Intervertebral foramen, 114f Limb buds, 4, 10 indications for, 90–91
Intervertebral plexus Limbs, axial arteries of, development of, 11 Mediastinum
anterior, 352f Linea aspera, 406f, 447f, 449f contents and anatomical relations of, 78f,
posterior, 352f Lingual artery, 30f 79–83
Investing fasia, 95f. See also Neck, investing Lingual nerve, 36f superior, contents and anatomical relations
fascia Liver, 272f of, 78f, 79f
Ischial tuberosity, 431f left lobe, 246f Mesenteric arteries. See Inferior mesenteric
transplant, 370 artery; Meandering mesenteric
J Liver buds, 4f artery; Superior mesenteric artery
Long thoracic nerve. See Thoracic nerve, long Mesenteric ganglion, inferior, 322f
Jugular foramen, 37 Longissimus capitis muscle, 24f, 58f, 72, 73f Mesenteric plexus, inferior, 351f
Jugular vein(s), 31, 31f. See also External Longitudinal ligament, anterior, 66f, 67f Mesenteric veins. See Inferior mesenteric vein;
jugular vein; Internal jugular vein Longus capitis muscle, 24f, 52f, 53f, 71, 122f Superior mesenteric vein
SUBJECT INDEX | 583
Mesenteric vessels, surgical anatomy of, Ovarian artery, 423f Phrenic nerve(s), 24f, 52f, 55f, 62f, 65f, 66f, 79f,
273–278 Ovarian vein, 423f 80f, 81f, 84f, 88f, 107f, 116f, 128f,
Mesocolon, transverse, 240f, 382f 129f, 138f, 139f, 142f, 147f, 149f
root of, 277f P left, 106, 242f, 243f
Mesoderm, 3f right, 242f, 243f, 244f
Mesonephric folds, 17f Paget–Schroetter syndrome, 142 Phrenic vein, inferior, 242f, 350f
Mesonephros, 9f Palmar aponeurosis, 223f Pisiform bone, 220f, 221f, 227f
Metacarpal ligament, transverse Palmar arch(es), 227–229 Plantar aponeurosis, 514f
deep, 223f deep, 226f, 227f Plantar arch, 509f, 510f, 514f
superficial, 222f, 223f superficial, 227f, 234f lateral, 510f
Metanephros, 9f, 17f exposure of, 233–234 medial, 509f
Middle colic vein, 284f, 286f, 296f, 366f Palmaris brevis muscle, 222f, 233f Plantar artery
Middle colic vein/inferior mesenteric vein Palmaris longus muscle, 194f, 199f, 209f lateral, 493f, 509f, 512f, 513f, 514f,
arcade, 368f Palmaris longus tendon, reflected, 222f 535f, 536f
Middle colic vein/superior mesenteric vein Pancreas, 272f, 281f, 382f exposure of, 535–536
arcade, 368f head of, 306f medial, 493f, 510f, 512f, 513f, 514f,
Middle sacral artery, 14 Pancreaticoduodenal arcade, 278f 535f, 536f
Midgut, 3f Pancreaticoduodenal artery, anterior exposure of, 535–536
Midpalmar space, 223f inferior, 276f, 296f Plantar branch
Muscular branches, 449f superior, 276f deep, 509f
Musculoarticular branch, 457f Pancreaticoduodenal vein, inferior, 296f exposure of, 536
Musculocutaneous nerve, 158f, 172f, 176f, Parietal peritoneum, 340, 340f Plantar fascia, 512f
179f, 197f Parietal pleura, 149f Plantaris muscle, 456f
Musculophrenic artery, 242f Pectineal fascia, 392f Plantaris tendon, 503f
Pectineal ligament, 390f, 392f, 393f, 398f Platysma muscle, 28f, 29f, 60f, 64f, 95f,
Pectineus muscle, 390f, 392f, 393f, 400f, 128f, 149f
N 403f, 426f, 428f, 430f, 432f, 433f, Popliteal artery, 449–481, 449f, 456f, 457f,
434f, 435f 466f, 469f, 476f, 480f, 481f, 483f,
Nasociliary branch, 121f Pectoral fascia, 159f 487f, 491f, 505f, 522f, 566f, 570f
Neck Pectoral nerve articular branches, 456
buccopharyngeal fascia, 25 lateral, 158f, 163f, 164f, 174f development of, 13f
carotid artery. See Carotid artery(ies) medial, 158f, 164f, 174f hamstring branches, 457
carotid sheath. See Carotid sheath Pectoralis major muscle, 118f, 136f, 137f, communicating with deep femoral
cranial nerves in, 36f, 37f, 38f 159f, 162f, 167f, 168f, 172f, 183f artery, 456f
cross-section of, at level of thyroid clavicular origin, 156f infrageniculate
cartilage, 28 insertion, 156f, 170f, 176f, 180f exposure of, 459, 466–477
deep cervical fascia, 26 Pectoralis minor muscle, 118f, 156f, 159f, lateral approach, 467, 473–477
investing fascia, 26, 26f, 29f, 32 163f, 170f, 172f medial approach, 467–472
jugular veins, 31, 31f insertion, 173f grafts to, optimal course for, 472, 476, 477f
middle cervical fascia, 25, 29f Pelvic plexus, hypogastric nerves to, 322f midpopliteal, exposure of, 459, 478–481
nerves of, 32, 32f Perforating branch, 402f, 508f, 509f direct posterior approach, 459, 478
prevertebral fascia of, 24, 24f Pericardiophrenic vessels, 243f, 244f muscular branches, 456
superficial fascia, 28–29, 28f, 29f Pericardium, 243f saphenous branch, 457
surgical anatomy of, 23, 23f Peritoneum, 264f, 265f, 267f, 296f suprageniculate
visceral compartment, 23, 23f parietal, 236f exposure of, 460–466
visceral fascia, 25 visceral, 236f lateral approach, 460, 464–466
Nerve of Herring. See Carotid sinus nerve Peroneal artery, 456f, 476f, 483f, 487f, 492f, medial approach, 460–463
Neural fold, 2f, 3f 498f, 502f, 503f, 505f, 508f, 509f, sural branches to gastrocnemius muscle, 456
Neurovascular bundle, 183f, 210f, 212 510f, 515f, 522f, 528f, 529f, 532f, surgical anatomy of, 454–458
Nutrient artery, to humeral shaft, 178f 533f, 566f, 570f surgical approaches to, 459–481
development of, 13f variation, 566–569
O distal Popliteal ligament, oblique, 456f
posterior approach to, 532 Popliteal veins, 469f, 480f, 481f, 491f, 505f
Obliquus capitis inferior muscle, 57f exposure of, 528–533 Popliteal vessels
Obliquus capitis superior muscle, 57f, lateral approach to, 530–532 fibrous sheath, 455
72, 73f medial approach to, 528–529 genicular branches
Obturator artery, 316f, 402f, 405f, 406f, perforating branch, 504f, 526f inferior, 449
423f, 563f Peroneal nerve(s), 452f, 465f, 491f, 492f, 494f superior, 449
aberrant, 316f common, 453f, 472f, 473, 488f muscular branches, 449
Obturator canal, 401f deep, 473f, 475f, 488f, 494f, 497f, 503f, surgical anatomy of, 449–458
Obturator externus muscle, 400f, 426f 504f, 506f, 509f, 511f, 515f, 537f Popliteus muscle, 449f, 456f, 492f, 498f, 505f,
Obturator foramen bypass, anatomy of, superficial, 473f, 475f, 488f, 504f, 566f, 569f
422–426 515f, 537f Portal circulation, exposure of, 370–386
Obturator internus muscle, 398f, 423f, 430f branch of, 503f, 511 Portal vein, 274f, 296f, 353f, 366f, 367f,
Obturator membrane, 401f Peroneal retinaculum 370f, 375f
Obturator nerve, 321f, 398f inferior, 484f, 495f development of, 15f
Obturator vein, 423f superior, 484f, 495f exposure of, 372–376
Obturator vessels, 398f Peroneus brevis muscle, 495f, 496f, 499f, 503f, surgical anatomy of, 365–370
Occipital artery, 39f, 45f, 48f 504f, 506f, 507f, 511f, 534f variation, 574
Olecranon, 182f Peroneus longus muscle, 472f, 475f, 495f, Portal venous system, 365–386
Omentum, 264f, 272f 496f, 499f, 504f, 506f, 507f, 511f, exposure of, 372
Omni retractor, 341 515f, 534f secondary connections of, 368
Omohyoid muscle, 43f, 55f, 60f, 61f, 64f, 95f, Peroneus tertius muscle, 495f, 497f, 504f, 511f Portosystemic venous connections, 369–370
107f, 149f Pharyngobasilar fascia, 37f Postcardinal veins, 4f, 11f, 16f, 17f
Opponens digiti minimi muscle, 224f Pharynx, anatomical relationship of, 33, 33f Posterior compartment
Opponens pollicis muscle, 224f Phrenic artery, inferior, 242f deep, 502f, 503f, 513f
584 | SUBJECT INDEX
fascia of, 498f Radial neurovascular bundle, 210f Saphenous vein
superficial, 502f Radial recurrent artery, 178f, 196f, 197f lesser, 453f, 479f, 480f
Posterolateral thoracotomy, 109–111 Radialis indicis artery, 227f long, 475f, 503f, 504f, 515f, 534f
Postganglionic sympathetic fibers, Ramus mandibularis, 38, 38f short, 475f, 503f, 504f, 505f, 515f
unmyelinated, 121f Rectal artery(ies) divided, 481f
Precardinal veins, development of, 4f, 14f, 16f middle, 316f Sartorius muscle, 390f, 394f, 403f, 430f, 431f,
Preganglionic fibers, myelinated, 121f superior, 272f, 318f 434f, 440f, 442f, 443f, 445f, 450f,
Preperitoneal fat plane, relationships of, Rectal peritoneal reflection, 240f 454f, 456f, 458f, 461f, 462f, 468f
340, 340f Rectus abdominis muscle, 264f, 339, 339f, 398f Scalene band(s), 124f
Pretracheal fascia, 25, 29f Rectus capitis posterior major muscle, 57f, middle, 124–125f
Prevertebral fascia, 24, 24f, 29f, 118f 72, 73f Scalene fat pad, 61f, 128f, 149f
Primordial vessels, inception of circulation Rectus capitis posterior minor muscle, 57f Scalene muscle(s), 24f, 29f, 123
and, 2–4, 2f, 3f, 4f Rectus femoris muscle, 390f, 428f, 430f, 432f, anomalies, 129–130
Princeps pollicis artery, 227f 443f, 445f, 450f anterior, 52f, 62f, 88f, 89f, 107f, 115f, 122f,
Profunda brachii artery Rectus sheath, 340f 123f, 124f, 128f, 129f, 137f, 138f,
posterior branch, 196f anterior, 339, 339f 139f, 142f, 147f, 149f
radial collateral branch, 196f posterior, 339f, 340 division of, 107f
Profunda femoris artery(ies). See also Femoral Renal artery(ies), 298f, 314f hypertrophy, 124
artery(ies), deep branches of, 311–312f insertions, anomalous, 124–125f
variation, 565 exposure of, 300–312 middle, 52f, 89f, 115f, 122f, 123f, 130f,
Pronator quadratus muscle, 192f, 193f injury, vascular repair of, 300 137f, 138f, 142f, 149f, 547f
Pronator teres muscle, 179f, 193f, 194f, 197f, left, 367f anterior insertion of, 125f
198f, 199f, 202f, 203f exposure of, 303–305 posterior, 52f, 89f, 115f
deep head, 198f retroperitoneal, 303 resection from first rib, 128–129
humeral head, 193f, 197f midline exposure of, at origins, 302–304 Scalene tubercle, 114f
insertion, 192f origins, approach to, 308–311f Scalenectomy, 126
ulnar head, 192f, 193f, 197f relationships to overlying organs, 311f Scaphoid bone, 220f, 221f
Psoas major muscle, 390f, 392f, 393f right, 272f Scapula, 123
Psoas muscle, 238f, 240f, 319f, 320f, 335f, bypass grafts from aorta to, 308–312 Scapular artery, circumflex, 157f, 178f
350f, 355f, 403f exposure of, 306–312 Sciatic artery(ies), 564f
Pterygoid muscle, medial, 37f retroperitoneal, 306 development of, 12f, 13, 13f
Pubis, 398f surgical anatomy of, 295–299 Sciatic nerve, 431f, 447f
Pulmonary artery(ies), 83f variation, 558 Sciatic vasa nervorum, 406f
development of, 5f, 6f, 8f Renal fascia, 267f Semimembranosus muscle, 431f, 432f,
left, 80f anterior, 236f, 296f 452f, 454f, 456f, 458f, 461f,
development of, 8f posterior, 236f, 296f 462f, 465f
inferior, 80f Renal vein(s) Semispinalis capitis muscle, 24f, 57f, 58f,
Pulmonary hilum, 80 development of, 17f 72, 73f
Pulmonary ligament, inferior, 80f, 270f left, 255f, 272f, 274f, 283f, 286f, 287f, 296f, Semitendinosus muscle, 431f, 432f, 452f, 454f,
Pulmonary vein 304f, 325f, 328f, 350f, 366f, 367f, 456f, 458f, 465f, 468f
inferior, 270f 370f, 386f Septum
left, 80f development of, 16–17 lateral intermuscular, 178f, 184f
left, superior, 80f right, 296f, 350f medial intermuscular, 159f, 176f, 178f,
Pupillary dilator, 121f variation, 573–574 180f, 183f
Pylorus, 291f Retrograde puncture, of femoral artery, 407 oblique, 223f
Retromandibular space, 40, 40f Septum transversarum, 14f
Retromandibular veins, 35, 35f Serratus anterior muscle, 110f, 118f, 136f,
Q Retroperitoneal connections, 369f 156f, 264f
Retroperitoneoscopy, 336 Shrock shunt, 361
Quadratus femoris, 430f, 431f
Retrosternal plane, development of, 92f Sibson’s fascia, 88, 149f
Quadratus lumborum muscle, 238f, 240f,
Rib Sigmoid mesentery, 277f, 330f
319f, 320f
eleventh, 254f Sinus venosus, 14f, 15f
Quadratus plantae muscle, 512f, 514f
first, 114f, 129f, 130f, 149f Small bowel mesentery, root of, 240f, 276,
angle, 114f 277f
R body, 114f Soleus muscle, 449f, 456f, 458f, 468f, 469f,
head, 114f 472f, 475f, 491f, 492f, 505f, 515f,
Radial artery, 196f, 197f, 198f, 199f, 204f, incomplete, 125f 516f, 517f, 529f
205f, 206f, 208f, 222f, 224f, 225f, neck, 114f fibular head, 505f
231f, 232f removal of, 126–147 origin
in anatomic snuffbox, exposure of, 230–231 anterior supraclavicular approach, fibular, 498f
to deep arch, 224f 127–133 tibial, 498f
development of, 12f infraclavicular approach, 141–147 Spinal accessory nerve, 39, 73f
in distal hand, exposure of, 232 transaxillary approach, 126–127, Spinal nerves, 352f
dorsal carpal branch, 225f 134–141 Spleen, 304f
exposure of, 204 Splenic artery, 272f, 274f, 275f, 281f, 296f,
in midforearm, exposure of, 204 S 312f, 366f, 367f
path of, 225–226 exposure of, 292–293
superficial branch, 222f, 224f Sacral artery, lateral, 316f splenorenal bypass, 292
at wrist, exposure of, 204–206 Sacral promontory, 318f Splenic vein, 272f, 274f, 281f, 283f, 296f,
Radial bursa, 227f Sacral veins 366f, 367f, 370f, 386f
Radial collateral artery, 178, 178f lateral, 350f exposure of, 381–385
Radial nerve, 116f, 158f, 176f, 179f, 181f, median, 350f approach beneath mesocolon, 386
196f, 197f, 198f, 225f, 230f, 231f Sacral vessels approach through lesser sac, 381–385
deep, 178f, 182f, 196f, 198f middle, 338f, 341f lateral dissection of, 384
superficial, 196f, 197f, 198f, 219f Saphenous branch, 457f Splenius capitis muscle, 24f, 58f, 71,
lateral branch of, 218f Saphenous nerve, 441f, 454f, 461f 72, 73f
SUBJECT INDEX | 585
Splenius cervicis muscle, 58f Supraclavicular nerve, 32f Thoracoepigastric vein, 120f, 136f, 137f
in exposure of vertebral artery C1/C2 Supracondylar fractures, 185 Thoracotomy. See Anterolateral thoracotomy;
segment, 71f Suprarenal arteries, variation, 559 Posterolateral thoracotomy; Trap
Splenorenal anastomosis, proximal, 371f Suprascapular artery, 107f, 149f, 544f door thoracotomy
Splenorenal bypass, 292 Supraspinatus muscle, 156f Thymus, 84f, 94f
Splenorenal ligament, 240f Sural artery, 453f Thyrocervical trunk, 51f, 53f, 55f, 62f, 65f,
Splenorenal shunt, 385 Sural cutaneous nerve, medial, 515f 88f, 132f, 544f
nonselective distal, 372f Sural nerve, 453f, 503f, 504f, 505f development of, 8f
selective distal, 372f medial, 453f, 475f, 480f Thyroid artery(ies)
Steinmann pins, 343 Sympathetic chain, 39f, 337f, 355f inferior, 55f, 62f, 107f, 149f
Stellate ganglion, 82f, 121f, 122f, 149f, 150f Sympathetic ganglion, 83f, 320f, 322f. See superior, 27f, 29f
Sternocleidomastoid muscle, 23, 23f, 31, 55f, also Cervical sympathetic ganglion Thyroid gland, 29f
58f, 64f, 70f, 72, 73f, 95f, 106f communicating rami, 121f Thyroid veins
clavicular head, 60f, 89f, 128f, 149f thoracic component, 121f middle, 27f
sternal head, 89f Sympathetic trunk, 54f, 61f, 352f Tibia, 529f
Sternohyoid muscle, 89f, 94 left, 319f Tibial artery(ies)
Sternothyroid muscle, 89f, 94 right, 319f anterior, 456f, 469f, 475f, 476f, 483f, 487f,
Sternum, division of, 92–94, 93f 492f, 494f, 495f, 497f, 498f, 502f,
Stomach, 264f, 272f T 503f, 505f, 506f, 509f, 510f, 515f,
Strap muscles, 95f 517f, 522f, 566f, 570f
Styloglossus muscle, 33, 33f, 34, 34f Tarsal artery development of, 13f
Stylohyoid ligament, 33, 33f lateral, 509f, 511f, 537f exposure of, 524–527
Stylohyoid muscle, 33, 33f, 34, 34f, 35 medial, 509f, 510f, 511f, 537f in distal leg, 526–527
Styloid process, 33, 34, 37f, 48f Tensor fasciae latae muscle, 403f in midleg, 524–525
Stylopharyngeus muscle, 33, 33f, 34 Teres major muscle, 120f, 156f, 176f, 181f posterior, 456f, 476f, 483f, 487f, 492f, 493f,
Subcardinal veins, 16, 17f Teres minor muscle, 181f, 183f 498f, 502f, 503f, 504f, 505f, 507f,
Subclavian artery(ies), 39f, 51f, 53f, 54f, 62f, Testicular artery, 394f, 398f 508f, 509f, 511f, 512f, 513f, 515f,
129f, 149f, 542f, 547f Testicular vein, 394f, 398f 518f, 519f, 522f, 523f, 529f, 533f,
branches of, variations, 548 Thenar crease, 218f 534f, 535f, 566f, 570f
compression, 126 Thenar fascia, 223f development of, 13f
development of, 6, 6f, 11f, 13 Thenar septum, 223f exposure of, 515–523
left, 85f, 87f, 103f, 106f, 150f Thenar space, 223f at ankle, 534
development of, 8f Thigh, surgical anatomy of, 429–447 in midleg, 519–520
proximal, exposure of, 91, 101–108 Thoracic aorta, 78f, 79–111 in proximal leg, 516–518
right, 87f, 97f coarctation, 544 Tibial nerve, 452f, 453f, 465f, 475f, 480f, 491f,
development of, 6, 6f, 8f, 11f descending 492f, 493f, 502f, 503f, 504f, 505f,
proximal, exposure of, 91, 101 control of, 111 507f, 508f, 511f, 513f, 522f, 523f
variations, 546–547 endovascular approach, 108–109 Tibial recurrent artery, anterior, 456f, 457f
variations, 546 exposure of, 108–111 Tibial vein, anterior, 517f
Subclavian vein(s), 53f, 54f, 61f, 128f, 129f, injury to, 108 Tibialis anterior muscle, 493f, 494f, 495f, 497f,
139f, 142f, 145f, 149f variation of, 542–546 504f, 506f, 511f, 515f, 524f, 526f, 534f
compression, 126 Thoracic aperture, superior, 78f, 79, 88–90, Tibialis anterior tendon, 503f
development of, 11f, 16f 123f. See also Thoracic outlet Tibialis posterior muscle, 475f, 476f, 492f,
exposure of, 106, 106f, 107f Thoracic artery(ies) 493f, 498f, 503f, 504f, 505f, 507f,
right, 87f internal, 79f, 81f, 84f, 88f, 242f, 544f 508f, 511f, 512f, 513f, 514f, 515f,
Subclavius muscle, 88f, 89f, 118f, 119f, 137f, lateral, 116f, 120f, 136f, 157f, 178f, 544f 533f, 534f, 535f
138f, 142f, 156f, 159f, 174f supreme, 116f, 120f, 157f, 178f Tibioperoneal trunk, 456f, 475f, 476f, 483f,
divided, 145f Thoracic duct, 54, 54f, 55f, 83f, 106f, 128f, 492f, 498f, 517f, 522f, 566f
Subcoracoid space, 123f 244f, 245f, 281f Transjugular intrahepatic portosystemic shunts
Subcostal vein, 350f division of, 61f (TIPs), 370
Subscapular artery, 116f, 129f, 157f, 178f Thoracic nerve(s) Transversalis fascia, 236f, 254, 296f, 339f,
Subscapular vein, 120f first, 115–116 340, 340f, 392f, 398f
Subscapularis muscle, 156f, 176f long, 116f, 120f, 130f, 137f, 138f, 139f, 158f Transverse process, 114f
Subsupracardinal anastomosis, 17f Thoracic outlet. See also Thoracic aperture, Transversus abdominus muscle, 254f, 398f
Superficial fascia, 28–29, 28f, 29f superior Trap door thoracotomy, 101, 105–108
Superficial radial nerve, 204f anatomy of, 113–122 Trapezium, 220f, 221f
Superior laryngeal nerve, 48f axillary passages of, 117–120 Trapezius muscle, 23, 23f, 55f, 58f, 72, 73f,
Superior mesenteric artery, 241f, 272f, 274f, bony landmarks of, 114f 89f, 110f
276f, 284f, 286f, 296f, 325f, 367f, cephalad passages of, 113–115 Trapezoid bone, 220f
551, 557 exposure of, 123–147 Trapezoid ligament, 156f
development of, 9f Thoracic outlet decompression, 123–147, 126 Triangular ligament, of liver
exposure of anterior supraclavicular approach, 127–136 left, 246f, 353f
in intestinal mesentery, 284–288 infraclavicular approach, 141–147 right, 240f, 353f
surgical anatomy of, 276–277 passive arm elevation, 135 Triceps muscle, 120f
transperitoneal exposure of, at origin, transaxillary approach, 126–127, 134–141 lateral head, 181f, 182f, 184f
280–283 wrist lock position for holding arm in, 135f long head, 180f, 181f, 182f, 183f, 184f
Superior mesenteric vein, 276f, 296f, 366f, Thoracic outlet syndrome, 113, 126 medial (deep) head, 180f, 181f, 182f, 183f
367f, 370f, 378f, 379f, 380f Thoracic vein(s) Trigeminal nerve, 121f
exposure of, 377–380 internal, 79f, 81f, 84f, 88f Triquetrum, 220f
Superior vena cava, 97f, 572–573 lateral, 120f, 136f Truncus arteriosus, 6f
development of, 16f Thoracic vertebrae, T1, 114f Tunnel of Guyon, 222f
left, 572f Thoracoacromial artery, 157f, 163f, 169f
Supinator muscle, 192f, 193f, 195f, 197f Thoracoacromial vein, 163f U
Supracardinal vein(s), 16–17 Thoracodorsal artery, 120f, 137f, 157f, 178f
right, persistent caudal portion of, 17 Thoracodorsal nerve, 116f, 120f, 137f, 138f, 158f Ulna, 191, 209f, 210f
Supraclavicular fat pad, 106 Thoracodorsal vein, 120f, 137f muscle attachments to, 192f
586 | SUBJECT INDEX
Ulnar artery, 196f, 197f, 198f, 199, 199f, V intracranial (V4 segment),
205f, 207f, 208f, 222f, 227f, 59, 59f
233f, 234f Vagus nerve(s), 6f, 27f, 29f, 36f, 37f, 39f, in neck, exposure of, 59–60
deep branch, 224f 48f, 54f, 55f, 61f, 75f, 84f, proximal and mid-, anterior relations
development of, 12f 88f, 122f of, 55
exposure of, 207–208, 233–234 anterior, 274f suboccipital (V4 segment), 59, 59f
Ulnar bursa, 223f, 227f left, 79f, 81f, 96f, 103f, 104, 247f posterior exposure of, 72–75, 72f, 73f,
Ulnar collateral artery posterior, 244f, 274f 74f, 75f
inferior, 178f, 196f celiac branch of, 274f, 281f surgical anatomy of, 51–58
superior, 178f, 181f, 196f right, 97f surgical segments of, 59, 59f
Ulnar nerve, 116f, 158f, 168f, 172f, 176f, Vas deferens, 338f terminal extracranial, 56–58
178f, 179f, 180f, 181f, 187f, 196f, Vastus intermedius muscle, 403f, Vertebral vein, 54f, 62f, 87f,
197f, 198f, 199f, 207f, 222f, 227f, 430f, 450f 142f, 149f
228f, 233f Vastus lateralis muscle, 403f, 430f, 450f Vesicle artery
deep branch, 224f Vastus medialis muscle, 430f, 432f, 434f, inferior, 316f
dorsal branch, 219f 445f, 450f superior, 563f
palmar cutaneous branch of, 218f Vein(s) Visceral compartment, 23f
Ulnar neurovascular bundle, 210f, 212 embryonic development of, Visceral fascia, 25, 25f
Ulnar recurrent artery, 178f, 197f 14–17 Visceral peritoneum, 236f
posterior, 196f variation, 572–574 Vitelline artery(ies)
Umbilical arteries Vena cava. See Inferior vena cava; Superior development of, 4
development of, 3f, 4f, 12f vena cava embryonic development of, 3f, 4f
obliterated, 563f Vertebral artery(ies), 29f, 51–75, 51f, 52f, 53f, Vitelline vein(s), 15f
Umbilical vein(s) 55f, 57f, 58f, 62f, 65f, 87f, 88f, 107f, development of, 2, 4, 14
development of, 2, 3f, 4f, 14f, 15f 122f, 149f embryonic development of, 3f, 4f
left, communication with hepatic development of, 8f Volar compartment, 210
sinusoids, 15f distal, 56–58 deep, 210f
Upper extremity. See also Forearm distal extracranial (V3 segment), superficial, 210f
deep fascia of, 176f 59, 59f Volar interosseous artery, 224f
intermuscular septum, 176f exposure of, 69–71, 69f Volar plate, 223f
lateral, 176f, 178f, 184f extraosseous (V1 segment), exposure of,
medial, 176f, 180f, 183f 60, 60f
nerves of, 177 anterior cervical approach, 60, W
topography, 182–184 64–65
supraclavicular approach, Warren distal splenorenal shunt, 371
vascular development in, 13
60–63 White ramus, 121f
vasomotor sympathetics, 121–122
Ureter, 238f, 318f, 329f, 330f, 338f, 351f, 355f, injury to, 60
356f, 394f, 417f, 423f interosseous (V2 segment), Y
left, 328f, 340f 59, 59f
Uterine artery, 316f exposure of, 66–68 Yolk sac, 2f, 3f, 9f, 14
SUBJECT INDEX | 587

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Anatomic Exposures

R. James Valentine, M.D., F.A.C.S.

© 2013 by Gary G. Wind and R. James Valentine

Two Commerce Square

Library of Congress Cataloging-in-Publication Data

Vascular Exposure of the Lumbar Spine:

David Whittaker, MD, FACS

INTRODUCTION Embryology of the Arteries and Veins 1

EXTRACRANIAL CIRCULATION OF THE HEAD AND NECK 21

CHAPTER 1 Carotid Arteries 23

CHAPTER 2 Vertebral Arteries 51

VESSELS OF THE CHEST 77

CHAPTER 3 Thoracic Aorta 79

CHAPTER 4 Superior Thoracic Aperture and Cervicothoracic Sympathetic Chain 113

VESSELS OF THE UPPER EXTREMITY 153

CHAPTER 5 Axillary Artery 155

CHAPTER 6 Brachial Artery 177

CHAPTER 7 Forearm Vessels 189

CHAPTER 8 Hand Vessels 217

VESSELS OF THE ABDOMEN 235

CHAPTER 10 Celiac and Mesenteric Arteries 273

CHAPTER 11 Renal Arteries 295

CHAPTER 12 Infrarenal Abdominal Aorta, Pelvic Arteries, and Lumbar

CHAPTER 13 Inferior Vena Cava 349

CHAPTER 14 Portal Venous System 365

CHAPTER 15 Common Femoral Artery 391

CHAPTER 16 Vessels of the Thigh 429

CHAPTER 17 Popliteal Artery 449

CHAPTER 18 Vessels of the Leg 483

VASCULAR VARIATION 539

CHAPTER 19 Anatomic Variation of the Blood Vessels 541

APPENDIX Selected Anatomic References 577

Subject Index 579

Understanding the anatomy of the blood vessels is a highly visual enterprise,

Fig. 1 Rapid vascular development and reorganization

Extra embryonic coelom

EMBRYOLOGY OF THE ARTERIES AND VEINS | 3

Fig. 5 The aortic arches evolve in a cephalad to caudad

Fig. 6 The internal carotid arteries are left as cephalad

EMBRYOLOGY OF THE ARTERIES AND VEINS | 5

EMBRYOLOGY OF THE ARTERIES AND VEINS | 7

EMBRYOLOGY OF THE ARTERIES AND VEINS | 9

EMBRYOLOGY OF THE ARTERIES AND VEINS | 9

Fig. 11 The upper extremity leads the lower extremity in developmental maturity.

EMBRYOLOGY OF THE ARTERIES AND VEINS | 11

EMBRYOLOGY OF THE ARTERIES AND VEINS | 13

EMBRYOLOGY OF THE ARTERIES AND VEINS | 15

Precardinal v’s Superior

Common cardinal v’s

4 weeks 6 weeks 7 weeks 8 weeks

Aorta Supracardinal v. Aorta

EMBRYOLOGY OF THE ARTERIES AND VEINS | 17

Fig. 21 The fetal circulation is dominated by preferential flow of oxygenated umbilical

EMBRYOLOGY OF THE ARTERIES AND VEINS | 19

Surgical Anatomy of the Neck

In the neck, nature has ingeniously compacted an

Fig. 1-1 The three major components of the neck con-

24 | EXTRACRANIAL CIRCULATION OF THE HEAD AND NECK

26 | EXTRACRANIAL CIRCULATION OF THE HEAD AND NECK

Fig. 2‑1 The proximal third of the vertebral