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Subclavian Artery
The subclavian artery, a continuation of the aorta on the left and the
brachiocephalic trunk on the right, accompanies the brachial plexus
through the scalenus anterior and medius muscles of the neck.
From: Core Knowledge in Orthopaedics: Sports Medicine, 2006
Related terms:
 Brachiocephalic Artery
 Vertebral Artery
 Subclavian Vein
 Axillary Artery
 Therapeutic Procedure
 Aortic Arch
 Brachial Plexus
 Inpatient
 Clavicle
 Thorax Outlet Syndrome
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Subclavian, vertebral, and upper limb arteries: a difficult
surgical field
Young-wook Kim, in Vascular Surgery, 2022
Subclavian artery
Anatomically subclavian artery (SCA) is defined from its origin to
the lateral edge of the first rib. The right SCA arises from the
brachicephalic artery and the left SCA arises directly from the aortic
arch (Fig. 5.1).
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Figure 5.1. Branches of aortic arch.

In the courses through the neck base, the anterior scalene muscles
cross the artery, dividing SCA into three parts: the first (prescalene;
proximal to the anterior scalene muscle), the second (retroscalene;
behind the anterior scalene muscle), and the third (postscalene;
distal to the anterior scalene muscle) parts (Fig. 5.2).
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Figure 5.2. The subclavian artery is divided into three parts by

the anterior scalene muscle.

The branches from the first part SCA are vertebral, thyrocervical
trunk, and internal mammary (thoracic) arteries. Among these
arteries, right and left vertebral arteries run toward the head and
unite to make a basilar artery and joining the circle of Willis. The
second part of the SCA lies behind the anterior scalene muscle and
it is in contact with lung apex posteriorly. The costocervical trunk
arises from the second part of the SCA. The dorsal scapular artery
(or descending scapular artery) is an artery that supplies the
levator scapulae, rhomboids, and trapezius muscles. It most
frequently arises from the second or third part of the SCA. The third
part of the SCA extends from the lateral border of anterior scalene
muscle to the lower border of the first rib. The SCA aneurysm
usually involves the third part of SCA, and it is located close to
the subclavian vein. In the practice of vascular surgery, it usually
required to expose the SCA during the decompression of
the thoracic outlet syndrome [1], SCA aneurysm resection, carotid-
to-subclavian bypass, or SCA trauma etc.
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Vascular Compression Syndromes
David A. Rigberg, ... Herbert I. Machleder, in Vascular Medicine,
2006
Arterial Complications of Thoracic Outlet Syndrome
Subclavian artery compression can lead to a number of injuries, and
its presentation is the most varied of all forms of TOS. Damage to
the subclavian artery itself can result in arterial pathology ranging
from a small stenosis to aneurysm formation or complete occlusion.
Each of these occurrences then can have its own sequelae secondary
to embolization or thrombosis or the extremely rare rupture of a
subclavian aneurysm.
Patients not infrequently are misdiagnosed with collagen vascular
disease because of cold sensitivity, Raynaud's phenomena, and
other symptoms. These patients may develop frank ischemic
conditions of the hands, with
parenchymal ulcers or fingertip gangrene. If the subclavian artery is
completely occluded, patients may present with early fatigue of the
involved side. This may be described as “crampy” pain with exercise
and has led to the term “arm claudication.”
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Thoracic Outlet Syndrome
David Rigberg MD, Julie Freischlag MD, in Comprehensive
Vascular and Endovascular Surgery (Second Edition), 2009
Arterial Complications
Because subclavian artery compression can lead to several injuries,
its presentation is the most varied of the three forms of TOS.
Damage to the subclavian artery itself can lead to anywhere from a
small stenosis to aneurysm formation or complete occlusion. Each
of these can then have its own sequelae secondary
to embolization or thrombosis or the extremely rare rupture of a
subclavian aneurysm.
Patients are commonly misdiagnosed with collagen vascular
disease because of the cold sensitivity, Raynaud’s phenomena, and
other symptoms. These patients may go on to have frank ischemic
conditions of the hands, with
paronychial ulcers or fingertip gangrene. If the subclavian artery is
completely occluded, patients may present with early fatigue of the
involved side. This can be in the form of crampy pain with exercise
and has led to the term arm claudication.
As with Paget-Schroetter syndrome, arterial TOS is not usually
accompanied by symptoms of the neurogenic form. This probably
contributes to the difficulty in making this diagnosis.
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Upper Extremity Arteries
In Vascular and Interventional Radiology (Second Edition), 2006
Normal Anatomy
The subclavian arteries originate from the brachiocephalic
(innominate) artery on the right and directly from the aortic
arch on the left (Fig. 7-4). The artery runs posterior to
3,4

the subclavian vein and the anterior scalene muscle. It arches over
the pulmonary apex surrounded by nerves of the brachial plexus.
The subclavian artery has several major branches (Fig. 7-5; see
also Fig. 7-4):
▪
The vertebral artery arises from the superior aspect of the
vessel and travels through the bony canal of the cervical
transverse processes into the skull.
▪
The internal thoracic (mammary) artery arises from the
undersurface of the subclavian artery opposite the vertebral
artery and runs behind the costosternal junctions. The vessel
divides into musculophrenic and superior epigastric branches.
The internal thoracic artery and its musculophrenic branch
give rise to the anterior intercostal arteries. The
musculophrenic and superior epigastric branches
have anastomoses with the inferior phrenic and inferior
epigastric arteries, respectively, in the abdomen.
▪
The thyrocervical trunk takes off beyond the vertebral artery
origin and immediately divides into the inferior thyroid,
suprascapular, and superficial cervical arteries.
▪
The costocervical trunk gives rise to the superior intercostal
artery (supplying the first, second, and, occasionally, third
 posterior intercostal arteries) and the deep cervical artery.
Small branches supply the anterior spinal artery.
▪
The dorsal scapular artery is the final branch of the
subclavian artery.
At the outer edge of the first rib, the subclavian artery becomes
the axillary artery (see Fig. 7-5). The vessel runs behind the
pectoralis major and minor muscles and lateral to the axillary vein.
Its major branches include the superior thoracic, thoracoacromial,
lateral thoracic, subscapular, and anterior and posterior humeral
circumflex arteries. These branches supply muscles of the shoulder
girdle, humerus, scapula, and chest wall.
At the lateral edge of the teres major muscle (approximately the
lateral scapular border), the axillary artery becomes the brachial
artery (Fig. 7-6; see also Fig. 7-5). In the upper arm, the artery lies
in a fascial sheath along with the basilic vein, paired brachial veins,
and the median nerve. Its major branches include the deep brachial
and the superior and inferior ulnar collateral arteries (Fig. 7-7).
At about the level of the radial head, the brachial artery divides into
the radial and ulnar arteries (Fig. 7-8). The radial recurrent artery
and the posterior and anterior ulnar recurrent arteries arise
immediately beyond the origins of their respective arteries to form
anastomoses with branches of the brachial and deep brachial artery
(see Fig. 7-7). The radial artery descends on the radial side of the
forearm. The ulnar artery, which is larger than the radial artery in
most cases, gives off the common interosseous artery and then
descends on the ulnar side of the forearm. The interosseous artery
divides into anterior and posterior branches that run on either side
of the interosseous membrane. In less than 10% of cases, the
anterior interosseous or median artery persists and contributes to
the palmar arch of the hand. 5

The arterial anatomy of the hand is extremely variable, and

deviations from the classic pattern described here are
common. The ulnar artery supplies the superficial palmar arch,
5,6

and the radial artery supplies the deep palmar arch (Figs. 7-9 and 7-
10). The arches often are in continuity with the opposing forearm
artery through small branches at the wrist. The superficial arch is
dominant and usually lies distal to the deep arch. The princeps
pollicis and radialis indicis arteries arise from the radial artery and
supply the thumb and index finger, respectively. The superficial
palmar arch gives off three or four common palmar digital arteries,
and the deep arch gives off the palmar metacarpal arteries. At the
bases of the proximal phalanges, adjacent metacarpal vessels from
each arch join and then immediately divide into proper digital
arteries, which supply apposing surfaces of the fingers. A so-
called incomplete arch, defined by a lack of continuity of the radial
artery with the superficial arch and lack of supply of the thumb and
medial index finger by the ulnar artery, is found in about 20% of the
population in autopsy studies. This pattern is found more
5

frequently in angiographic series. 7

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Vascular Anatomy and Variants
Avinash Kambadakone, in Problem Solving in Cardiovascular
Imaging, 2013
Arterial System
The subclavian arteries constitute the main arterial supply of the
upper limbs. On the right side, the subclavian artery arises
from brachiocephalic trunk; on the left side, it arises from the arch
of the aorta. The subclavian artery has the following branches:
the vertebral artery, the thyrocervical trunk, the costocervical trunk,
the internal mammary artery, and the dorsal scapular artery.
The subclavian artery continues as the axillary artery beyond the
outer border of the first rib. The axillary artery is divided into three
parts and has the following branches: the first part (the highest
thoracic artery), the second part (the thoracoacromial and lateral
thoracic arteries), and the third part (the subscapular, posterior
humeral circumflex, and anterior humeral circumflex arteries). The
axillary artery continues as the brachial artery beyond the teres
major muscle (Fig. 15-28).
The brachial artery terminates by dividing into the radial and ulnar
arteries. The branches of the brachial artery include the deep
brachial (profunda brachii), the superior ulnar collateral, the
inferior ulnar collateral, and muscular branches. The radial
artery has several branches in the forearm (the radial recurrent,
palmar carpal, and superficial palmar branches), two branches in
the wrist (dorsal carpal and first dorsal metacarpal), and three
branches in the hand (princeps pollicis, radialis indicis, and deep
palmar arch). The ulnar artery also has several branches in the
forearm (anterior recurrent, posterior recurrent, common
interosseous, and muscular), two branches in the wrist (palmar
carpal and dorsal carpal), and at the level of hand it contributes to
the superficial palmar arch and deep palmar arch.
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Aortic, Renal, Subclavian, and Carotid Interventions
Jose D. Tafur, Christopher J. White, in The Interventional Cardiac
Catheterization Handbook (Fourth Edition), 2018
Diagnosis of Subclavian/Innominate Artery Stenosis
Screening for S/IA disease is easily performed by obtaining bilateral
arm blood pressure in the office. A systolic blood
pressure difference of 15 mm Hg or greater is highly (≥90%) specific
for diagnosing subclavian stenosis, and this physical finding has
proved to be an independent predictor of adverse cardiovascular
events, including mortality. Noninvasive studies
43,44

include DUS, CTA and MRA.

DUS is an inexpensive and useful method of evaluating S/IA
stenosis. The subclavian artery can be visualized on ultrasound;
additionally, Doppler can measure velocities and direction of flow in
the subclavian artery as well as the vertebral artery, therefore
providing information about the underlying pathophysiologic
process. Reversal of flow in the vertebral artery is seen in cases
of subclavian steal syndrome. CTA and MRA can provide more
anatomic detail, including the aortic arch anatomy, and can give
precise determinations of anatomic relations of the diseased
segments to the ostia of the vertebral and internal mammary
arteries.
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Lower Cervical Level and Supraclavicular Fossa
In Imaging Anatomy: Ultrasound (Second Edition), 2018
Internal Contents
•
Subclavian artery
○
Arises from brachiocephalic trunk on right and aortic arch on
left
○
Major arterial supply to upper limb
○
Contributes to arterial supply to neck structures and brain
via vertebral artery
○
Junction of subclavian artery and CCA is readily identified on
scanning in transverse plane in lower cervical level
–
Location marks root of neck
○
Origin of subclavian artery can be seen by angling transducer
inferiorly behind medial head of clavicle
•
Scalenus anterior muscle
○
Runs inferiorly from transverse processes of cervical spine
○
Passes posterior to IJV to dip behind clavicle
○
Lies between 2nd part of subclavian artery posteriorly
and subclavian vein anteriorly
○
Related posteriorly to scalenus medius muscle
–
BP roots/rami lie between scalenus anterior muscle and
scalenus medius muscle in supraclavicular fossa
–
Scanning inferiorly in transverse plane, BP roots/rami appear
as small, round, hypoechoic structures emerging from behind
lateral border of scalenus anterior muscle
•
BP
○
Formed from ventral rami of C5-T1 ± minor branches from
C4, T2
○
Divided into roots/rami, trunks, division, cords, and branches
–
Roots/rami: Originate from spinal cord levels C5-T1 enter
posterior triangle by emerging between scalenus anterior and
medius muscle
–
Trunks: Upper (C5-C6), middle (C7), lower (C8-T1)
–
 Divisions: Formed by each trunk, dividing into anterior and
posterior branches in supraclavicular fossa
–
Cords: Lateral, medial, posterior cords descend behind clavicle
to leave posterior triangle and enter axilla
–
Branches: In axilla
•
Trapezius muscle
○
Anterior border marks posterior margin of posterior triangle
and supraclavicular fossa and is easily recognized
○
Distal portion is attached to lateral clavicle
•
Inferior belly of omohyoid muscle
○
Runs obliquely from intermediate tendon to traverse inferior
portion of supraclavicular fossa
○
Divides occipital triangle superiorly from supraclavicular
triangle inferiorly
•
Transverse cervical chain lymph nodes
○
Seen adjacent to transverse cervical artery and vein, which
arise from thyrocervical trunk and IJV
○
Related to and just superior to inferior belly of omohyoid
muscle
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The peripheral arteries
Paul L. Allan, Karen Gallagher, in Clinical Doppler Ultrasound
(Second Edition), 2006
Anatomy – upper limb
The subclavian arteries arise from the brachiocephalic trunk on the
right and directly from the arch of the aorta on the left (Fig. 4.5);
however, there is considerable normal variation in the patterns of
their origination. The origin of the right subclavian artery can be
examined behind the right sternoclavicular joint, where the
brachiocephalic trunk divides into the right common carotid
artery and the subclavian artery. The origin of the left subclavian
artery from the aortic arch cannot be demonstrated, although the
more distal segments can be seen as on the right side. The
subclavian artery on each side runs from its point of origin to the
outer border of the first rib where it becomes the axillary artery;
the subclavian vein lies in front of the artery. The main branches of
the subclavian artery are the vertebral arteries, the thyrocervical
trunk, the internal thoracic (mammary) artery and the costocervical
trunk.
The axillary artery runs from the lateral border of the first rib to
the outer, inferior margin of the pectoralis major muscle. It gives
rise to several branches which supply the muscles around the
shoulder; the largest of these are the thoracoacromial trunk,
the lateral thoracic artery and the subscapular artery.
The brachial artery passes down the medial aspect of the upper
arm to the cubital fossa below which it divides into the radial and
ulnar arteries; the point of division sometimes lies higher in the
upper arm. Apart from muscular branches, the main branches of
the brachial artery are the profunda brachii artery, which is given
off in the upper arm and passes behind the humerus; the superior
and inferior ulnar collateral arteries arise from the lower part of the
brachial artery. It divides into the ulnar and radial arteries in the
antecubital fossa.
The radial artery runs down the radial (lateral) aspect of the
forearm to the wrist, where it passes over the radial styloid process,
and over the lateral aspect of the carpus. It then passes down
through the first interosseous space to form the lateral aspect of the
deep palmar arch. It also has a superficial branch
which anastomoses with the equivalent branch of the ulnar artery to
form the superficial palmar arch. In the upper forearm the radial
artery gives off the radial recurrent artery, which anastomoses with
the profunda brachii artery, and several muscular branches in the
forearm and at the wrist.
The ulnar artery passes down the anterior ulnar (medial) aspect of
the forearm to the medial aspect of the wrist, where it runs over the
flexor retinaculum and then divides into superficial and deep
branches which anastomose with the equivalent branches of the
radial artery to form the superficial and deep palmar arches. It gives
off recurrent ulnar arteries below the elbow and the common
interosseous artery, which forms anterior and posterior divisions,
running on either side of the interosseous membrane.
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Cardiovascular Physiology
George J. Crystal, ... Kai Kuck, in Pharmacology and Physiology for
Anesthesia (Second Edition), 2019
B Arteries of the Upper Extremity in an Idealized Anatomic Drawing
The subclavian artery transitions to the axillary artery at the
lateral border of the first rib (Fig. AI2.11B). The axillary
artery then transitions to the brachial artery at the lower border of
the teres major muscle. The anterior and posterior circumflex
arteries form an anastomosing circle around the surgical neck of
the humerus.
The profunda artery arises from the brachial artery at the level of
the proximal humerus and follows the radial nerve.
The superior and inferior ulnar collateral arteries arise from
the brachial artery proximally and anastomose distally with
the ulnar artery. The superior ulnar collateral artery can be
visualized adjacent to the ulnar nerve in the upper arm.
The brachial artery terminates at the neck of the radius by
dividing into the radial and ulnar arteries.
The superficial and deep palmar arches are direct
continuations of the ulnar and radial arteries, respectively.
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Subclavian vessel injuries: Difficult anatomy and
difficult territory
Juan A. Asensio, ... Suresh Agarwal, in Current Therapy of Trauma
and Surgical Critical Care (Third Edition), 2024
Anatomy
The subclavian arteries have different origins according to their
right and left anatomic locations. On the right, the subclavian
artery arises from the innominate artery behind the right
sternoclavicular articulation; on the left side, it originates directly
from the arch of the aorta. The subclavian artery is divided into
three portions. The first portion courses from the origin to the
medial border of the scalenus anterior. The second portion lies
behind this muscle, and the third portion courses from the lateral
border of the scalenus anterior up to the lateral border of the first
rib (Fig. 1).
The first portion of the right subclavian artery arises behind the
upper part of the right sternoclavicular articulation and passes
upward and laterally to the medial margin of the scalenus anterior.
It ascends a little above the clavicle, to a varying extent in different
cases. It is crossed by the internal jugular and vertebral veins, by
the vagus nerve and the cardiac branches of the vagus nerve, and by
the subclavian loop of the sympathetic trunk, which forms a ring
around the vessel. The anterior jugular vein is directed lateralward
in front of the artery but is separated from it by the sternohyoid and
sternothyroid strap muscles.
The first portion of the left subclavian artery arises behind the left
common carotid and at the level of the fourth thoracic vertebra; it
ascends in the superior mediastinum to the root of the neck and
then arches lateralward to the medial border of the scalenus
anterior. Its anatomic relations are as follows: in front, the vagus,
cardiac, and phrenic nerves, which lie parallel with it; the left
common carotid artery; left internal jugular and vertebral veins;
and the commencement of the left innominate vein. It is covered by
the sternothyroid, sternohyoid, and sternocleidomastoid muscles.
The second portion of the left subclavian artery lies behind the
scalenus anterior. It is very short and forms the highest part of the
arch described by the vessel.
On the right side of the neck, the phrenic nerve is separated from
the second part of the artery by the scalenus anterior, and on the left
side it crosses the first part of the artery close to the medial edge of
the muscle. Behind the vessel are the pleura and the scalenus
medius; above are the brachial plexus of nerves; below, the pleura.
The subclavian vein lies below and in front of the artery, separated
from it by the scalenus anterior.
The third portion of the left subclavian artery runs downward and
lateralward from the lateral margin of the scalenus anterior to the
outer border of the first rib, where it becomes the axillary artery.
The external jugular vein crosses its medial part and receives the
transverse scapular, transverse cervical, and anterior jugular veins,
which frequently form a plexus in front of the artery. Behind the
veins, the nerve to the subclavius muscle descends in front of the
artery. The terminal part of the artery lies behind the clavicle and
the subclavius muscle and is crossed by the transverse scapular
vessels. The subclavian vein is in front of and at a slightly lower
level than the artery. Behind, it lies on the lowest trunk of the
brachial plexus, which intervenes between it and the scalenus
medius. Above and to its lateral side are the upper trunks of the
brachial plexus and the omohyoid muscle.
The branches of the subclavian artery are the vertebral, internal
mammary, thyrocervical, and costocervical trunks. On the left side,
all four branches generally arise from the first portion of the vessel;
but on the right side, the costocervical trunk usually originates from
the second portion of the vessel. On both sides of the neck, the first
three branches arise close together at the medial border of the
scalenus anterior; in the majority of cases, a free interval of 1.25 to
2.5 cm exists between the commencement of the artery and the
origin of the nearest branch.
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