Blood Vessels of Thorax

The blood travels a total of 19000 km/day ,, Circulatory system stretched distance is about 100000 Km. Circulatory
trip takes only one minute per chambers of heart

Circulatory cycle from heart starts with:

Aorta: Ascending aorta ,, Arch of aorta ,, Descending thoracic aorta
Pulmonary trunk
Superior vena cava

1-aorta: It is a Large artery which carries oxygenated blood from left ventricle to all the parts of the body
After originating from LV (about 3cm in diameter), it ascending for a short distance, arches backward and to the left
side, descends within the thorax on the left side of the vertebral columnHas 4 parts:
Ascending aorta
Arch of aorta
Descending thoracic aorta
Abdominal aorta

1-Ascending aorta
Origin: Arises from the upper end of base of left ventricle on a level with the lower border of the third costal
cartilage behind the left half of the sternum.
Course: It is about 5 cm long, runs upwards and to the right with in the pericardium
Termination: Terminates by continuing as arch of aorta at the level of sternal angle (upper border of right 2nd costal
cartilage)
Branches: Lies in the middle mediastinum , has three aortic sinuses located immediately above the cusps of the
aortic valve, and gives off the
1. right and
2. left coronary artery.

*About 5 cm. in length Passes obliquely upward, forward, and to the right, as high as the upper border of the second
right costal cartilage At its origin, three small dilatations called the aortic sinuses At the union of the ascending aorta
with the aortic arch, the caliber of the vessel is increased, owing to a bulging of its right wall. This dilatation is termed
the bulb of the aorta Only branches of the ascending aorta are the two coronary arteries

Aortic sinus: Dilatations situated at the beginning of ascending aorta 3 in number:

Anterior aortic sinus (gives origin to right coronary artery)
Right posterior aortic sinus Left posterior aortic sinus (gives origin to left coronary artery)
Relations:
Anterior: Infundibulum of the right ventricle, pulmonary trunk, right auricle
Posterior: Left atrium, transverse sinus of pericardium
Right: Superior vena cava, right atrium
Left: Pulmonary trunk

Clinical anatomy Aortic aneurysm:

1. Anuresm in aorta affect esophagus
2. Left atruim hypertrophy affect esophagus
2-Arch of aorta Situated in the superior mediastinum behind the manubrium sterni
Origin: Continuation of ascending aorta Begins behind the upper border of right 2nd costal cartilage
Course: Runs upwards, backwards and to the left in front of trachea. Runs downwards behind the left bronchus
Termination: Continues as descending thoracic aorta, at the lower border of body of 4th thoracic vertebra

*Begins at the level of the upper border of the Rt 2nd sternocostal joint. First runs upward, backward, and to the
left, in front of the trachea, then directed backward on the left side of the trachea and finally passes downward on
the left side of the body of T4, at lower border of which it becomes continuous with the descending aorta Forms two
curvatures: one with its convexity upward, the other with its convexity forward and to the left

Branches:
Brachiocephalic artery (Is the 1st branch It ends behind the RT sternoclavicular joint here it divided into Rt subclavian art Rt
common carotid art)
Left common carotid artery (It passes upwards lt side to trachea Enters the neck by passing behind the lt SC joint)
Left subclavian artery (It runs vertically to the left)

Relations:
1-Superior: 2-Inferior relations:
3 branches of arch of aorta- Brachiocephalic artery,
Bifurcation of pulmonary trunk,
Left common carotid artery, left principal bronchus
Left subclavian artery
Ligamentum arteriosum, superficial cardiac plexus
Left brachiocephalic vein +thymus Left recurrent laryngeal nerve

3-nteriorly and to the left: 4-Posteriorly and to the right

Pleura and lung Trachea and Esophagus
phrenic nerve. left recurrent n.
pericardiacophrenic vessels thoracic duct.
vagus n. deep cardiac plexus

Coarctation of the aorta

sign is seen in aortic coarctation and is formed by prestenotic dilatation of the aortic arch and left subclavian
artery, indentation at the coarctation site (also known as the "tuck"), and poststenotic dilatation of the descending
aorta.
Ortner's syndrome is a rare cardiovocal syndrome and refers to recurrent laryngeal nerve palsy from cardiovascular disease. The
most common historical cause is a dilated left atrium due to mitral stenosis, but other causes, including pulmonary
hypertension,[2] thoracic aortic aneurysms, an enlarged pulmonary artery[3] and aberrant subclavian artery syndrome have been
reported compressing the nerve.[4] Dysphagia caused by a similar mechanism is referred to as dysphagia aortica, or, in the case
of subclavian artery aberrancy, as dysphagia lusoria. Due to compression of recurrent laryngeal nerve it can cause the hoarseness
of the voice which is also one of the sign of the mitral stenosis. A second Ortner's syndrome, Ortner's syndrome II, refers
to abdominal angina
3-Descending thoracic aorta Situated in the posterior mediastinum of thorax
Origin: Continuation of arch of aorta at the level of lower border of body of 4th thoracic vertebra
Course: Runs downwards in the posterior mediastinum and terminates as abdominal aorta at the lower border of
12th thoracic vertebra
Relations:
Anterior: root of left lung, pericardium and heart, esophagus, diaphragm
Posterior: vertebral column. Hemiazygos and accessory
Right: esophagus, right lung and pleura. +azygos and thoracic duct
Left: left lung and pleura

Branches: Visceral Pericardial Bronchial Esophageal Mediastinal

1-bronchial arteries. Parietal Intercostal: usually 9 pairs ,,,Subcostal. Superior Phrenic.
2-oesophageal arteries.
3-posterior intercostal arteries (lower nine spaces).
4-Mediastinal branches
5-superior phrenic artery.
6-pericardial arteries.
7-abdominal aorta.

Aneurysm of the thoracic aortic the ascending aorta is affected in 50% of cases. the aortic arch in 10%.
the descending thoracic aorta (DTA) in 40%. DTA aneurysm is defined as involving any portion of the thoracic aorta
distal to the origin of the left subclavian artery.
The need for surgical treatment is related to size, which is linked to risk of rupture Elective repair should be
considered for aneurysms > 5.0 to 5.5 cm.

Pulmonary trunk Conveys deoxygenated blood from right ventricle to the lungs, 5 cm long, situated within the
pericardium
Origin: Arises from the right ventricle
Termination: Divides into right and left pulmonary arteries at the level of 5th thoracic vertebra
Anatomy of pulmonary arteries The Main pulmonary artery (MPA) is intrapericardial and courses posteriorly and
superiorly from the pulmonic valve. It divides into the left pulmonary artery (LPA) and right pulmonary artery (RPA)
at the level of the 5thT vertebra. The RPA is longer than the LPA and crosses the mediastinum, sloping slightly
inferiorly to the right lung hilus. The LPA represents the continuation of the MPA.
Each pulmonary artery indeed starts by minute capillaries uniting together and forming to pulmonary arteries in the
hilum of the lungs
The pulmonary trunk is a major vessel of the human heart that
originates from the right ventricle. It branches into the right and left
pulmonary arteries, which lead to the lungs. Each of these vessels has
elastic walls similar to those of the aorta, though somewhat thinner, and
they are considered to be arteries even though the blood they carry is not
oxygenated. The trunk itself is relatively short and wide and starts from
right ventricle and ends in the hilum of the lungs
Coarse: The pulmonary trunk is the first and largest vessel within the
pulmonary arterial tree. It originates from the right ventricle and passes
superiorly and posteriorly for about 4-5 cm. During this course, it is
ensheathed by the pericardial sac and initially is anterior to the ascending
aorta. At the level of the inferior margin of the carina, approximately T5,
the pulmonary trunk divides into right and left pulmonary arteries.
Anterior: left second intercostal space , left lung covered by pericardium
Posterior and inferior: ascending aorta, left coronary artery. Posterior and superior: left atrium
inferior: left atrium superior: aortic arch left and right: auricles of atria and respective coronary arteries
Segmental and subsegmental pulmonary arteries
generally parallel segmental and sub-segmental bronchi and run alongside them. This is in contrast to the course of
most pulmonary veins, which run independently of bronchi within interlobular septa. The segmental arteries are
named according to the bronchopulmonary segments that they feed,

Pulmonary veins Carry oxygenated blood from lungs to left atrium 4 in number, each lung has 2 veins –
superior and inferior pulmonary veins Pierce the pericardium and open separately in to the left atrium.
Right pulmonary veins are longer, larger than the left Right pulmonary veins pass behind the superior vena cava and
right atrium Left pulmonary veins run in front of descending thoracic Ao.

Superior vena cava Collects and drains all venous blood from above the diaphragm except that from the heart
and lungs.
Origin: Formed by – union of right and left brachiocephalic veins behind the lower border of right first costal
cartilage
Course: Runs down in the superior mediastinum, Pierces the pericardium.
Termination: and ends at the level of the third right costal cartilage where it drains into the right atrium
Tributaries: Azygos vein Mediastinal and pericardial veins

The superior vena cava (SVC) The SVC is about 7 cm long and 2 cm wide. drains all venous blood from above the
diaphragm except that from the heart and lungs.
It lies anterolateral to the trachea and posterolateral to the ascending aorta, and enters the right atrium
at the level of the third costal cartilage.
*** The superior vena cava (SVC, also known as the cava ) is a short, but large diameter vein (24mm) located in the
anterior right superior mediastinum. Embryologically, the SVC is formed by the left and right brachiocephalic veins
(also known as the innominate veins) that also receive blood from the upper limbs, certain parts of the head, one
being the eyes, and neck. It is the typical site of central venous access (CVA) via a central venous catheter or a
peripherally inserted central catheter

Coarse: It is formed behind the lower border of the first right costal cartilage. at the upper border of the first right
costal cartilage. The junction of the two lines of two innominate veins, indicates the origin of the superior vena cava,
the line of which is continued vertically down to the level of the third right costal cartilage. And receives azygos vein
just before it pierces the fibrous pericardium opposite right second costal cartilage . No valve divides the superior
vena cava from the right atrium. As a result, the (right) atrial and (right) ventricular contractions are conducted up
into the internal jugular vein and, through the sternocleidomastoid muscle, can be seen as the JVP

Relations:
Anterior: anterior wall of thorax, right lung and pleura, pericardium (lower part)
Posterior: trachea with right vagus nerve, root of right lung
Lateral: right phrenic nerve with pericardiophrenic vessels, right lung and pleura
Medial: brachiocephalic trunk (upper part) and ascending aorta (lower part)
Brachiocephalic vein Formed by union of IJV and Subclavian vein behind sternal end of clavicle. Rt vein is
shorter (2.5 cm) and vertical descends to level of sternal end of 1st costal cartilage. Lt is longer (6 cm) and runs
oblique behind sternal end of 1st costal cartilage joins the right vein to form SVC (Branches):

Blood Supply of chest wall:

Anterior intercostal arteries: The first six anterior intercostal arteries stem directly from the internal thoracic artery.
The rest of them branch off the musculophrenic artery.
Posterior intercostal arteries: Two of these arteries branch off the superior intercostal artery in the first two
intercostal spaces, and the remaining posterior intercostal arteries are branches of the descending thoracic aorta.
Anterior intercostal veins: These veins return blood to the internal thoracic and musculophrenic veins.
Posterior intercostal veins: Most of these veins return blood to the azygos and hemiazygos veins.

Intercostal arteries:
1-anterior intercostal arteries
2-posterior intercostal arteries

1-anterior intercostal arteries: each anterior intercostal spaces contain 2 anterior intercostal arteries except in
lower 2 intercostal spaces
*the upper 6 pairs arise from internal thoracic artery
*the 7th, 8th and 9th arise from the musculophrenic artery

Internal thoracic artery:

Origin: from the first part of subclavian artery
Termination: at the oppoite of 6th intercostal space dividing into superior epigastric artery and musculophrenic
artery

2-posterior intercostal arteries: Each posterior intercostal space contain one posterior intercostal artery which
runs at the costal groove and each artery give a collateral branch which runs in the upper border of the rib blow
*the upper 2 posterior intercostal artery comes from the superior intercostal artery which is a branch of the costo-
cervical branch of the 2nd part of the subclavian artery
*from the 3 to 11th posterior intercostal arteries and also subcostal artery come from descending thoracic aorta
 Blood supply of the diaphragm:

1-Superior surface: by pericardiophrenic and

musculophrenic arteries which both are
branches of the internal thoracic artery

2-Inferior surface: inferior phrenic artery

which is branch of the abdominal aorta

Venous drainage of the diaphragm: By

inferior phrenic vein

Venous drainage of thorax: Veins of the thoracic wall The thoracic wall is drained anteriorly by the internal thoracic
vein and posteriorly by the azygos system
1-Internal thoracic vein: it formed by union of two venae comitantes of the internal thoracic artery behind the 3rd
costal cartilage,,, it ascends close to the artery to terminate at the corresponding innominate vein

Posterior intercostal veins:

Right side
1/the first posterior intercostal vein drains into Rt
innominate vein.
2/ second and third posterior intercostal veins join to
form rt superior intercostal vein then it drains into the
azygos
3/the 4th to 11th posterior intercostal veins drain into
azygos
4/Rt subcostal vein drains azygos vein
Note/hemiazygos=inferior hemiazygos ,,,,,, accessory hemiazygos=superior hemiazygos
Left
1/the first post intercostal vein drains into the left
innominate vein
2/the second and third post intercostal veins join to
form the lt superior intercostal vein then it drains into lt
innominate vein
3/from 4th to 8th drain into accessory hemiazygos
4/from 9th to 11th drain into the hemiazygos
5/left subcostal vein drain into the hemiazygos

Azygos system:
The system carries deoxygenated blood to the SVC and IVC The system is consists of :
Azygos vein and its two tributaries Hemiazygos and Accessory hemiazygos

Azygos vein Tributaries

Begins as continuation of right 1. Right superior intercostal vein

ascending lumbar vein Ascending
along the right side of vertebral
column behind of IVC Enters
diaphragm through Aortic opening.
Joins superior vena cava by arching
above right lung root at level of T4
to T5
Receives right posterior intercostal
, Vertebral and subcostal veins plus
some of bronchial, esophageal and
pericardial veins, and hemiazygos
vein.
2. Fourth to 11th right posterior
intercostal veins
3. Hemiazygos vein(T8,9)
4. Accessory hemiazygos (T8)
5. Right bronchial vein
6. Several oesophageal, mediastinum
and pericardial veins
7. Right ascending lumbar & the right
subcostal vein
 Hemiazygos vein
Is formed by union of left
ascending lumbar vein and left
subcostal vein
Tributaries
1. 9th to 11th left intercostal
veins
2. left ascending lumbar vein
and left subcostal vein
Accessory hemiazygos vein
Is formed at the medial end of the
4th and 5th ICS
Tributaries
1. 5th to 8th left intercostal veins
2. left bronchial vein
Cardiac Conducting system The electrical conduction system controls the heart rate. This system creates the
electrical impulses and sends them throughout the heart. These impulses make the heart contract and pump blood.

Intercalated discs Are microscopic identifying features of cardiac muscle. Cardiac muscle consists of individual
heart muscle cells (cardiomyocytes) connected by intercalated discs to work as a single functional organ or
syncytium. Intercalated discs support synchronized contraction of cardiac tissue.

**The muscle cells of the heart are unique and responsible for the electrical stimulation that leads to proper
mechanical function. Myocardial cells have several different electrophysiologic properties: automaticity, excitability,
conductivity, contractility, rhythmicity, and refractoriness.

Components of Conducting system

(Part I) Dominant
-Sinoatrial Node (SA node): located in back wall of the right atrium near the entrance of vena cava. initiates
impulses 70-80 times per minute without any nerve stimulation from brain establishes basic rhythm of the
heartbeat, called the pacemaker of the heart and impulses move through atria causing the two atria to contract.
Same time, impulses reach the second part of the conduction system Blood supply RCA 55% and 45% from
circumflex (L)artery.

In ECG: Atrial polarization presented by “P” wave

(Part II)

➢ Atrioventricular Node (AV node: located in the bottom of the right atrium near the septum. Directly above
tricuspid septal leaflet. cells in the AV node conduct impulses more slowly, so there is a delay as impulses travel
through the node, this allows time for atria to finish contraction before ventricles begin contracting
 On ECG, the PR
interval represent the
onset of
depolarization of the
atriums and the onset
of depolarization of
the ventricles, and is
used as an estimation
of AV nodal
conduction

Repolarization of the ventricular represented by the T wave

blood supply of the AV node :The AV nodal artery provides the blood supply for AV node in majority case 90% it
arises from right coronary artery.

Causes of Prolonged P-R interval: the normal PR interval is about 0.12 to 0.20 seconds
Prolongation of PR interval may occur as a result of (excessive vagal stimulation, drugs affecting AV node, AV nodal
ischemia, or underlying conduction system diseases)

A-V bundle A.K.A. “Bundle of His”

From the AV node, impulses travel through to the right and left bundle branches. These branches extend to the right
and left sides of the septum and bottom of the heart.

***In addition its long refractory period protects the ventricles excessively rapid stimulation which can cause
inadequate diastolic filling time and acute cardiac failure

Atriventricular bundle His-Purkinje system A-V bundle branches enormously to form the Purkinje fibers that
transmit the impulses to the myocardium (muscle tissue) The bundle of His, bundle branches and Purkinje fibers
transmit quickly and cause both ventricles to contract at the same time Like a “phone tree”
A-V bundles
As the ventricles contract, blood is forced out through the semilunar valves into the pulmonary trunk and the aorta.
► After the ventricles complete their contraction phase, they relax and the SA node initiates another impulse to
start another cardiac cycle.
► H-P System represented on ECG by QRS complex.
► Normal QRS width= 0.06-0.10 seconds

Impulse conduction through the heart

Bundle branch block:

Right BBB Left BBB

QRS duration greater than 0.12 seconds QRS duration is greater than 0.12 seconds
Wide S wave in leads 1, V5, and V6 Wide S wave in leads V1 and V2, wide R wave in V5 and V6
 Why SA node leads the heart
Tissue Rate of impulse genration
SA node 70-80/min
AV node 40-60/min
Bundle of HIS 40/min
Purkinje system 24/min

Cardiac nerve supply Heart is supplied by Nerves but under control of brain/Medulla
Heart is supplied by nerves arising from superficial and deep cardiac plexuses, these nerves of cardiac plexuses run
along the coronary arteries and supply the heart these contain sympathetic and parasympathetic nerves:

-sympathetic nerves: are derived from upper 4 or 5 thoracic segments (T1-T4) of spinal cord, they are cardio-
acceleratory and on stimulation increase the heart rate and dilate coronary arteries.

-Parasympathetic nerves: are derived from vagus X which arise from dorsal nucleus of medulla oblongata, they are
cardio-inhibitor and on stimulation slow down the heart rate and constrict coronary artery

1-Superficial cardiac plexus: situated below of the arch of aorta

Formed by:
-sympathetic: superior cervical cardiac branch of the left sympathetic chain
-Parasympathetic: inferior cervical cardiac branch of left vagus nerve

2-deep cardiac plexus: situated in front of treachal bifurcation and

Behind of arch of aorta
Formed by:
-sympathetic: cardiac branches derived from cervical and upper thoracic ganglia of sympathetic chain except cardiac
branch of left superior cervical sympathetic ganglia
-Parasympathetic: cardiac branch of left vagus and left recurrent laryngeal nerve except left cervical cardiac branch
of left vagus
Cardiac pain:
Oxygen deficiency and the accumulation of metabolites, which stimulate the sensory nerve endings in the
myocardium, are assumed to cause the pain originating in the heart as the result of acute myocardial ischemia. The
afferent nerve fibers ascend to the central nervous system through the cardiac branches of the sympathetic trunk
and enter the spinal cord through the posterior roots of the upper four thoracic nerves. The nature of the pain varies
considerably, from a severe crushing pain to nothing more than a mild discomfort. The pain is not felt in the heart
but is referred to the skin areas supplied by the corresponding spinal nerves. The skin areas supplied by the upper
four intercostal nerves and by the intercostobrachial nerve (T2) are therefore affected. The intercostobrachial nerve
communicates with the medial cutaneous nerve of the arm and is distributed to the skin on the medial side of the
upper part of the arm, Myocardial infarction involving the inferior wall or diaphragmatic surface of the heart often
gives rise to discomfort in the epigastrium. One must assume that the afferent pain fibers from the heart ascend in
the sympathetic nerves and enter the spinal cord in the posterior roots of the seventh, eighth, and ninth thoracic
spinal nerves and give rise to referred pain in the T7 to T9 (T789) thoracic dermatomes in the epigastrium. Because
the heart and the thoracic part of the esophagus probably have similar afferent pain pathways, it is not surprising
that painful acute esophagitis can mimic the pain of myocardial infarction.