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2 Thoracic arteries
2.1 Arteriosclerotic and acquired inflammatory and congenital diseases of the thoracic aorta
Anatomy of the whole aorta: Reinhard Putz
Clinical findings: Friedhelm Beyersdorf and Thomas Zeller
Conservative treatment: Friedhelm Beyersdorf and Thomas Zeller
Endovascular treatment: Friedhelm Beyersdorf
Surgical treatment: Friedhelm Beyersdorf
Fig. 2.1–1 Overview of the whole aorta.
2.1.1 Anatomy of the whole aorta
The body’s main artery, the aorta, is divided into three parts (Fig. 2.1-1): the ascending aorta, the arch of the aorta and the descending aorta. The ascending aorta starts with the slightly dilated aortic bulb at the aortic valve, which with its three semilunar cusps (valvules) prevents backflow of blood during diastole (Fig. 2.1-2). The cusps consist of very firm, taut connective tissue and are covered with endothelium on both surfaces. They are attached to the inner wall of the junction between the left ventricle of the heart and the aorta and have small nodules (lunules) on their free edges. When blood is flowing back toward the heart, the cusps fill up (aortic sinus), pressing the lunules against each other and usually completely blocking backflow. These delicate edges interlock so finely that even slight changes due to various causes can unfortunately lead to insufficiency.
In the area of the aortic bulb, two arteries supplying the heart are typically already given off from the ascending aorta. The right coronary artery arises from the wall of the right sinus of the aortic valve, and the left coronary artery from the left sinus (Fig. 2.1-2).
Fig. 2.1–2 The aortic valve from above, with the origins of the coronary arteries.
Fig. 2.1–3 Origins of the large arteries from the aortic arch (from Lippert and Pabst 1985).
The ascending aorta does not give off any branches along its subsequent course. It passes into the arch of the aorta without a clear boundary. The upper margin of the aortic arch projects onto the manubrium of the sternum. It has an oblique angle and passes dorsally into the descending aorta, lying in the inferior posterior mediastinum. Normally (in 70% of cases), three large vessels arise from the arch of the aorta in a cranial direction, with considerable variation (Fig. 2.1-3). With the exception of branches to the chest, the entire right half of the head and right arm are supplied by the brachiocephalic trunk, which divides after a few centimeters into the right subclavian artery and right common carotid artery.
The left common carotid artery and left subclavian artery are given off separately on the left.
The most frequent variation is a separate origin, as early as at the aortic arch, of the two large arteries on the right side. Not infrequently, the right subclavian artery arises as the last branch from the aortic arch and then courses as the arteria lusoria behind the esophagus to the right side, where it branches further in the normal fashion. (This variant may seem surprising, but it is clearly explained by the development of the branchial arches.)
The subclavian artery leaves the deep cervical region on each side, lying on the first rib behind the scalenus anterior. The common carotid artery courses upward in a common