Subclavian Artery

The right subclavian artery is a branch of the brachiocephalic trunk and the left arises directly from the arch of the aorta.

From: Human Anatomy , 2008

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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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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Posterior Circulation

R.J. Wityk , in Primer on Cerebrovascular Diseases (Second Edition), 2017

Subclavian Artery Disease

Atherosclerosis of the subclavian artery also commonly involves the origin of the vertebral artery. "Subclavian steal" refers to a condition in which there is severe stenosis or occlusion of the subclavian artery proximal to the origin of the vertebral artery. Low pressure in the subclavian artery distal to the lesion leads to "stealing" of blood from the vertebral artery [2]. Angiography in this situation shows normal antegrade blood flow in the right vertebral artery, but reversed flow down the left vertebral artery into the subclavian artery.

On examination of a patient with left subclavian steal, for example, one may find a left supraclavicular bruit and decreased amplitude or delay of the left radial pulse. Occasionally patients have symptoms such as dizziness, parethesias, blurred vision, and ataxia, but many have no symptoms at all. Exercise of the affected arm is said to precipitate symptoms (by drawing off more blood into the arm), but this is actually a rare finding. Although patients may have transient neurological symptoms, the risk of stroke is small. Many patients with subclavian stenosis are asymptomatic, and the condition is an incidental finding on examination.

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The Shark

Gerardo De Iuliis PhD , Dino Pulerà MScBMC, CMI , in The Dissection of Vertebrates (Second Edition), 2011

Branches of the Dorsal Aorta

The paired subclavian arteries are the first major branches of the dorsal aorta (Figures 3.28–3.30). These arise usually between the third and fourth efferent branchial arteries. Initially they pass posterolaterally. At the pectoral girdle each subclavian veers lateroventrally, passing deep to the posterior cardinal sinus, along the scapular process. Follow the artery on the side for which the sinus was dissected. It gives rise to two main branches, the brachial and anterior ventrolateral arteries, but it is difficult to neatly dissect the origins of these vessels. The brachial supplies the pectoral fin (do not confuse its spelling with branchial: brachial = arm, branchial = gill). To find it, pull the pectoral fin away from the body and cut through the skin between the body and posteromedial surface of the fin. This will free the fin from the body. Picking away the connective tissue from the medial surface of the fin will soon reveal the brachial artery as it passes along the medial cartilaginous fin support. Trace the artery back toward the subclavian to note the position of its origin. After the origin of the brachial, the anterior ventrolateral artery continues, on the inside of the body wall, passing first slightly anteriorly and then curving markedly posteriorly, about midway between the lateral and midventral lines. Follow it as it continues back, giving off branches that supply the myomeres, and eventually anastomoses with the posterior ventrolateral artery (a branch of the iliac artery; see page 56).

After giving off the subclavian arteries, the dorsal aorta continues posteriorly into the pleuroperitoneal cavity. Return to this cavity to examine the following vessels (Figures 3.29 and 3.31). The first branch of the dorsal aorta in the cavity is the celiac artery, a large, unpaired vessel that continues posteriorly along the right side of the stomach. Near its origin, it gives rise to a pair of testicular (in males) or ovarian (in females) arteries (Figure 3.29) to supply the gonads. The celiac artery continues to the anterior tip of the dorsal lobe of the pancreas, where it divides into the pancreaticomesenteric and gastrohepatic arteries. The latter is a very short branch (sometimes altogether missing) that subdivides almost immediately into a long, narrow hepatic artery and a short, wider gastric artery. The hepatic artery turns anteriorly toward the liver, accompanied by the hepatic portal vein (considered later) and the anterior part of the bile duct. The gastric artery passes to the stomach, where it branches into the dorsal and ventral gastric arteries to the dorsal and ventral parts of the stomach, respectively. Return to the pancreaticomesenteric artery and trace it posteriorly as it passes dorsal to the pylorus and onto the ventral side of the intestine as the anterior intestinal artery. Before doing so it gives off several smaller branches near the pylorus (which you do not need to name).

FIGURE 3.31. Pleuroperitoneal cavity of the shark in ventral view, showing the pattern of the arteries and veins.

Trace the dorsal aorta farther posteriorly. At about the level of the spleen, two arteries arise close together. The anterior one is the anterior mesenteric artery, which extends onto the intestine as the posterior intestinal artery. The posterior artery is the gastrosplenic artery, which mainly supplies the spleen and the posterior part of the stomach. Note that the anterior mesenteric and gastrosplenic arteries lie in the posterior edge of the greater omentum. Sometimes these arteries come off in reverse order (i.e., the gastrosplenic is the more anterior); trace them to identify the arteries in your specimen. After a short distance the dorsal aorta gives off a posterior mesenteric artery, which passes along the anterior edge of the mesorectum and onto the digitiform gland.

The final branches of the dorsal aorta are the paired iliac arteries and the caudal artery (Figure 3.29). At about the level of the cloaca, the iliac arteries arise and pass posterolaterally dorsal to the kidneys. They emerge from under the kidneys and extend toward the pelvic fins. Before entering the fin, each iliac branches into the femoral artery, which enters the fin, and the posterior ventrolateral artery, which turns anteriorly along the body wall and eventually unites with the anterior ventrolateral artery, noted earlier. The caudal artery is the posterior continuation of the dorsal aorta into the tail. Finally, the dorsal aorta gives rise to numerous intersegmental arteries (Figures 3.29, 3.33, and 3.34) to the axial musculature. Free the lateral margin of a kidney and lift it to observe these arteries.

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Neurovascular System

Betsy B. Love , José Biller , in Textbook of Clinical Neurology (Third Edition), 2007

Extracranial Steal Syndromes from Disease of the Aortic Branches

Occlusive disease in the subclavian arteries or the innominate artery can give rise to extracranial steal syndromes. The most defined syndrome is the subclavian steal syndrome. In this condition, occlusive disease in the proximal subclavian artery can lead to a siphoning of blood away from the brain by a reversal of flow down the vertebral artery on the affected side to the ischemic limb. The pulse and blood pressure are diminished in the affected limb. The symptoms may include headache, vertebrobasilar ischemia, and limb claudication, often precipitated by exercise. A bruit may be heard over the subclavian artery. The limb may become cyanotic if it is held above the level of the heart. It should be noted that a majority of people with subclavian steal detected by noninvasive techniques have no neurological symptoms. 25

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Catheter-Based Peripheral Angiography

Christopher J. White , in Vascular Medicine: A Companion to Braunwald's Heart Disease (Second Edition), 2013

Subclavian Angiography

Important branches of the subclavian artery include the vertebral (superior) and internal mammary (inferior) arteries ( Fig. 15-19). The vertebral artery, the first and usually largest branch of the subclavian artery, arises from the superior and posterior surface of the subclavian. The AP view will disclose stenosis in the proximal subclavian artery (the left subclavian artery is affected three to four times as frequently as the right subclavian artery). In patients with a tortuous proximal left subclavian artery, a steep right anterior oblique (RAO) view with caudal angulation may help elucidate a proximal stenosis. If the proximal portion of the right subclavian artery is suspected of having a lesion, the AP view may not show the stenosis because of overlap with the origin of the right common carotid artery. A steep RAO caudal view (40°-60° RAO and 15°-20° caudal) will usually separate the ostia of these two vessels (Fig. 15-20).

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Upper Limb Nerve Supply

Paul Rea MBChB, MSc, PhD, MIMI, RMIP, FHEA, FRSA , in Essential Clinically Applied Anatomy of the Peripheral Nervous System in the Limbs, 2015

2.2.4.2.1 Thoracic Outlet Syndrome

The brachial plexus and the subclavian artery and vein pass through an extremely narrow space between the clavicle and the first rib. This space can become narrowed for a variety of reasons and can include the following:

1.

Congenital: This may result in an extra rib arising from the seventh cervical vertebra. Typically the ribs will originate from the first to twelfth thoracic vertebrae. It can occur on one or both sides. In general, they are asymptomatic, but can present as thoracic outlet syndrome.

Other causes of congenital reasons for thoracic outlet syndrome can be from muscle variations either of the scalenus anterior, or, indeed, a subclavius posticus. There may also be additional fibrous material within the neck resulting in the obstruction.

2.

Trauma: This may result from trauma to the neck or also from repetitive strain. Indeed, for those habitually involved with their hands above their heads when working (e.g., window cleaners, laborers), it may exacerbate the symptoms.

3.

Tumors within the neck

Patient's with thoracic outlet syndrome will typically present with pain in the upper limb, of variable distribution. It can affect the digits, hand or arm, and forearm. Pain can also present in the axilla, superior aspect of the back or over the pectoral region inferior to the clavicle. In addition to the pain, the patient will typically present with a discoloration of the upper limb, generally the hand, and it can be colder to the touch compared to the unaffected side.

If a patient has a swollen, painful and blue tinged upper limb, especially after strenuous exercise, it may indicate compression of the subclavian vein, thoracic outlet compression, and thrombosis. This is referred to as Paget–Schroetter syndrome, but can also be called effort-induced thrombosis.

The treatment of thoracic outlet syndrome can range from conservative measures, to removal of a tumor or extra (cervical rib) if the symptoms are extreme. Therefore, the treatment depends on the cause of the thoracic outlet syndrome.

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Neurovascular Anatomy in Relation to Intracranial Neoplasms

Tasneem F. Hasan , ... Rabih G. Tawk , in Comprehensive Overview of Modern Surgical Approaches to Intrinsic Brain Tumors, 2019

Vertebral Artery

The VA arises from the subclavian arteries bilaterally and can be divided into four divisions. The first division (preforaminal) runs between the longus colli and scalenus anterior (Standring, 2008). The second division (foraminal) runs cranially through the foramina in the cervical transverse processes of C6 to C2 (axis) vertebrae (Standring, 2008). The third division (extradural or atlantic) emerges from the transverse process of C2, curves behind the superior articular process of the C1 (atlas), and lies in a groove on the upper surface of the posterior arch of C1. It enters the vertebral canal beneath the posterior atlanto-occipital membrane before entering in the foramen magnum (Standring, 2008). The fourth division (intradural or intracranial) pierces the dura and courses medially in front of the medulla oblongata before joining the contralateral VA at the lower border of the pons to form the basilar artery (Standring, 2008).

The vertebrobasilar system provides blood supply to the upper spinal cord, brain stem, cerebellum, and posterior aspect of the brain. The anterior spinal artery (ASA) arises from the VA in the region of the medulla oblongata and supplies the anterior two-thirds of the spinal cord. The posterior spinal arteries (PSAs) arise from either the posterior inferior cerebellar or VAs (V3 or V4 segments) and run along the posterolateral aspect of the spinal cord and supply the respective ipsilateral grey and white posterior columns of the spinal cord. The ASA and PSAs anastomose, and at each spinal segment, these arteries can have collateral supply from segmental/radicular branches, with the largest branch being the artery of Adamkiewicz (Hershberger & Cho, 2014). Loss of blood supply anteriorly and posteriorly results in motor and sensory deficits, respectively (Purves et al., 2001). A rare and devastating stroke subtype can arise from the loss of ASA supply and can be seen on MRI as a heart-shaped bilateral medullary pyramidal infarction (Searcy et al., 2017).

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Cerebrovascular Disease

G. David Perkin BA, MB, FRCP , ... Fred H. Hochberg MD , in Atlas of Clinical Neurology (Third Edition), 2011

Subclavian Artery Disease

Severe stenosis or occlusion of the subclavian artery proximal to the origin of the vertebral artery can lead to reduced flow in both vessels. Theoretically, reversed flow from a higher-pressure system (i.e., the basilar artery filled by the contralateral vertebral) may occur to maintain flow in the relevant arm, particularly when it is exercised. In the subclavian steal syndrome, patients present either with symptoms resulting from reduced flow to the upper limb (e.g., a cold hand) or with symptoms such as diplopia or circumoral paresthesia, considered to be the result of blood being stolen from the basilar territory.

Radiologic evidence of the phenomenon is far more common than its clinical declaration. Examination reveals reduced blood pressure and pulses in the relevant arm, often with a bruit over the subclavian artery. The existence of the phenomenon can be confirmed either by noninvasive studies or by angiography (Fig. 4-72).

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Cardiac, Great Vessel, and Pulmonary Injuries

David V. Feliciano , in Rich's Vascular Trauma (Third Edition), 2016

Blunt Trauma

Blunt injuries to the innominate and subclavian arteries most commonly occur in individuals wearing shoulder-harness restraints in frontal motor-vehicle crashes. The proposed mechanism for this injury is direct compression to the upper sternum into the artery itself with partial or complete avulsion off the aortic arch. Another mechanism involves hyperflexion, hypertension, and lateral rotation of the cervical spine away from the side of the shoulder harness. This mechanism occurs as the victim slides under the shoulder harness and may cause stretching and avulsion of the innominate artery. Either mechanism may lead to disruption of the intima with or without injury to part or all of the media and adventitia. Similar mechanisms are proposed to explain blunt injury to the carotid and vertebral arteries in recent years. Disruptive injuries to cervical vertebrae contribute to select patterns of zone I vascular trauma as well.

The etiology of blunt injury to either subclavian artery is slightly different and more likely related to deceleration of the vessel in relation to the first rib and the supraclavicular area fixated under the shoulder-harness restraint itself. Shoulder harness notwithstanding, a sudden posterior movement of the shoulder from blunt trauma may cause disruption of the intima and all or part of the media of this relatively fragile artery. The most common manifestation of the subclavian artery trauma is thrombosis within 3 cm to 5 cm of its origin ( Fig. 9-7).

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