AORTA SVC IVC AZV HAZV TTHRCSMPTHC 2022.ppt

1
Thoracic Aorta
THE THORACIC
AORTA, SVC,
IVC, AZV, HAZV,
THORACIC PART
OF
SYMPATHETIC
TRUNK

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Thoracic Aorta
Agenda
‫‏‬
Anatomy
‫‏‬
Definitions
‫‏‬
Epidemiology
‫‏‬
Etiology
‫‏‬
Pathophysiology
‫‏‬
Presentation
‫‏‬
Diagnosis
‫‏‬
Natural History
‫‏‬
Treatment
‫‏‬
Prognosis
‫‏‬
Underwriting Considerations

4
Thoracic Aorta
Definitions
‫‏‬
Normal Dimensions
– Mid-descending 26-28 mm
‫‏‬
Dilation (Ballooning, Bulging, Ectasia)
‫‏‬
Aneurysm
– Types
• Saccular
• Fusiform
– Definition
• When the diameter exceeds 4 cm or diameter exceeds 1.5 times normal
‫‏‬
Dissection
– Tear in vessel wall results in false lumen
– Types
• Type A – involves ascending aorta
• Type B – involves descending aorta

5
Thoracic Aorta
Normal Aortic Dimensions
Hager A. et al.; J Thorac Cardiovasc Surg 2002;123:1060-1066

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‫‏‬ THE AORTA AND ITS MAJOR BRANCHES
‫‏‬ The aorta commences at the aortic valve, above the vestibule of the
left ventricle and terminates in the abdomen at the level of the fourth
lumbar vertebra (L4), where it bifurcates to form the right and left
common iliac arteries. It is an elastic artery and it is divisible into
four parts, viz:-
 The Ascending thoracic aorta.
 The Arch of the aorta.
 The Descending thoracic aorta and
 The Abdominal aorta.

‫‏‬ ASCENDING THORACIC AORTA:
‫‏‬ This is located in the middle mediastinum and measures 5cm long. It
has the following branches through which it supplies the heart:
Right coronary artery.
Left coronary artery

‫‏‬ THE ARCH OF THE AORTA:
‫‏‬ This is located in the superior mediastinum.
‫‏‬ It is the continuation of the ascending aorta.
‫‏‬ Its branches are:
• The Brachiocephalic trunk. This gives rise to:
Right Common Carotid artery.
Right Subclavian artery.
• Left Common Carotid artery.
• Left Subclavian artery.

‫‏‬
‫‏‬ Each common carotid artery:
‫‏‬ Bifurcates to give rise to an:
 internal carotid artery and
 external carotid artery.
‫‏‬ The internal carotid continues into the cranial cavity to supply cranial
contents while the external carotid supplies the head and neck
region.

‫‏‬ The Subclavian artery:
‫‏‬ The subclavian artery supplies structures in the head and neck and
the thoracic regions through the following branches:
Vertebral artery.
The thyrocervical artery.
The internal thoracic (Mammary) art.
The costocervical artery
The dorsal scapular artery
‫‏‬ Each Subclavian artery continues as the axillary artery at the outer
margin (Lateral margin) of the first rib.
‫‏‬ The axillary artery is the main arterial supply to the upper limb.

‫‏‬ THE DESCENDING THORACIC AORTA
‫‏‬ This artery is the direct continuation of the arch of the aorta.
‫‏‬ It passes through the posterior mediastinum and terminates
posterior to the median arcuate ligament of the diaphragm at the
level of the 12th thoracic vertebra (T12).
‫‏‬ At this point it continues into the abdominal cavity as the Abdominal
aorta.

‫‏‬ The branches of the Thoracic Aorta
include:
• 9 pairs of Posterior intercostal
arteries.
• A pair of subcostal arteries.
• 2 left bronchial art.
• 2 esophageal art.
• Pericardial branches (Unknown
number).
• Mediastinal branches (Unknown
number).
• A pair of Superior Phrenic art. (Right &
Left).

‫‏‬ THE ABDOMINAL AORTA
‫‏‬ This is the continuation of the
descending thoracic aorta from the
level of T12.
‫‏‬ It is located on the posterior abdominal
wall and terminates at the level of L4.
‫‏‬ Here it bifurcates to give rise to the
right and left Common iliac arteries.

‫‏‬ The branches of the Abdominal Aorta include:
• Coeliac trunk. ( Foregut)
• Superior mesenteric art. (Midgut)
• Inferior mesenteric art. (Hindgut)
• Median sacral art. (Posterior pelvic wall)
• 2 Renal art. (The Kidneys)
• 1 Middle suprarenal art.
• 2 Testicular/Ovarian art.
• 2 Inferior phrenic art.
• 4 pairs of Lumbar art.

‫‏‬ Each of the Common iliac arteries will bifurcate at the level of the
sacroiliac joint to give rise to Internal and External iliac arteries.
‫‏‬ The internal iliac artery will supply the pelvic, perineal(genital) and
gluteal regions.
‫‏‬ The external iliac continues as the Femoral artery beyond the inguinal
ligament to supply the entire lower limb.

20
Thoracic Aorta
Aortic Aneurysm

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Thoracic Aorta
Aortic Aneurysm
(A) Tomodensitometric and (B) echocardiographic views of an aortic root
aneurysm.
Nataf P , Lansac E Heart 2006;92:1345-1352

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Thoracic Aorta
Aortic Aneurysm
http://www.medscape.com/viewarticle/406630_15
Figure 23. Atherosclerotic vascular dis-ease in an
aortic aneurysm. Axial postcontrast image
(window = 440, level = 40) reveals a large
contrast collection projecting from the
undersurface of the aortic arch, consistent with
aneurysm (arrow). the low attention material
within the aneurysm represents thrombus

23
Thoracic Aorta
Aortic Aneurysm
Figure 24. Aortic aneurysm
rupture. Axial postcontrast image
(window = 440, level = 40)
through the aortic arch reveals
an aortic aneurysm with contrast
penetrating the thrombus within
the aneurysm (open arrow).

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Thoracic Aorta
Aortic Dissection

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Thoracic Aorta
Aortic Dissection
Figure 12. Stanford type B (Debakey Type III)
aortic dissection: descending thoracic aorta.
(A) Axial postcontrast image (window = 440,
level = 40) reveals intimal flap (arrow), t = true
lumen, f = false lumen. (B) Oblique sagittal
reconstruction reveals complex nature of the
intimal flap (arrows).

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Thoracic Aorta
Epidemiology
‫‏‬
Thoracic aneurysms
– Prevalence greater than 3-4% of those over 65
– 6 cases per 100,000 person-years
– Incidence increasing
– In the top 15 causes of death
– Thoracic aortic aneurysm – rupture 3.5/100,000 persons
‫‏‬
Thoracic aortic dissection
– 2000 new cases/year
– Acute - 3.5/100,000 persons
– Male:Female ratio 2:1

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Thoracic Aorta
Etiologies
‫‏‬
Underlying Etiologies
– Atherosclerosis
– Marfan’s
– Type IV Ehlers-Danlos
– Infection (syphillis)
– Arteritis (giant cell, Takayasu, Behcet’s)
– Trauma
‫‏‬
Risk Factors
– Smoking
– COPD
– HTN
– Male gender
– Older age
– High BMI
– Abnormal aortic valve (e.g., bicuspid valve)
– Family history

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Thoracic Aorta
Presentation
‫‏‬
Aneurysm
– Most asymptomatic
– Superior vena cava syndrome
– Hoarseness
– Bronchial obstruction
– Dysphagia
– Hemoptysis
– Paralysis/paraplegia
– Lower extremity embolism
‫‏‬
Dissection
– Chest/back/neck pain
– Neurologic signs
– Horner syndrome
– Hoarseness
– Acute aortic regurgitation

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Thoracic Aorta
Diagnosis
‫‏‬
Chest x-ray
– Widened mediastinum
‫‏‬
Echocardiogram
– Transthoracic – aortic root
– Transesophageal – ascending and descending
‫‏‬
Aortography
– Delineates the lumen
‫‏‬
CT scan
– Most widely used diagnostic tool
‫‏‬
MRI
– Avoids contrast dye

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Thoracic Aorta
Echocardiography

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Thoracic Aorta
Natural History
0
5
10
15
20
25
<2.75
cm/m2
2.75-4.25
cm/m2
>4.25
cm/m2
Aortic Size Index (ASI)
Annual
Risk
of
Rupture
http://emedicine.medscape.com/article/242904=print
ASI = aortic dia (cm)/body surface area (m2)

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Thoracic Aorta
Natural History
‫‏‬
Yearly Rupture or Dissection Rates for Thoracic Aortic Aneurysms: Simple
Prediction Based on Size
– 304 patients; 58.9% male; median age 65.8
– Aneurysm size – 43.7% were 4.0-4.9 cm
– Location – 72% ascending
– Follow up – average 43.1 months
– End points
Davies RR, et al. Ann Thorac Surg 2002;73:17
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Death alone
15
Dissection alone
5
Rupture alone
4
Rupture and death (no dissection)
5
Dissection, death (no rupture)
2
Dissection, rupture (no death)
2
Dissection, rupture and death
No. Patients
Events

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Thoracic Aorta
Natural History
Cumulative incidence of acute dissection or rupture as a function of initial aneurysm size.

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Thoracic Aorta
Natural History
Kaplan-Meier cumulative hazard function of rupture or dissection.

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Thoracic Aorta
Natural History
Average yearly rates of negative outcomes during the first 5 years after presentation

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Thoracic Aorta
Natural History
Kaplan-Meier cumulative hazard function of rupture.

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Thoracic Aorta
Natural History
Kaplan-Meier cumulative survival before operative repair.

38
Thoracic Aorta
Natural History
Kaplan-Meier cumulative survival

39
Thoracic Aorta
Natural History

40
Thoracic Aorta
Natural History

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Thoracic Aorta
Treatment - Aneurysm
‫‏‬
Medical
– BP control
– Smoking cessation
– No heavy lifting
‫‏‬
Surgical
– Dacron tube graft
– Ascending – may need to replace valve
– Arch – graft
– Descending – graft, stent grafts

42
Thoracic Aorta
Treatment - Dissection
‫‏‬
Type A
– Surgical
‫‏‬
Type B
– Medical
– Surgical
• Acute with rupture, leak or distal ischemia.

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Thoracic Aorta
Treatment – Indications for Intervention
‫‏‬
Aortic size
– Ascending diameter >5.5 cm
– Descending diameter >6.5 cm
– Growth rate >1 cm/yr (avg ascending 0.07 cm/yr; descending 0.19 cm/yr)
‫‏‬
Symptomatic aneurysm
‫‏‬
Traumatic rupture
‫‏‬
Pseudoaneurysm
‫‏‬
Large saccular aneurysm
‫‏‬
Mycotic aneurysm
‫‏‬
Aortic coarctation
‫‏‬
Bronchial compression
‫‏‬
Aortobronchial or aortoesophageal fistuala

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Thoracic Aorta
Treatment - Surgical
Composite valve and graft replacement.

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Thoracic Aorta
Complications
‫‏‬
Bleeding
‫‏‬
CVA – 2-5%
‫‏‬
CHF
‫‏‬
Respiratory failure
‫‏‬
Graft leaks
‫‏‬
Fistula formation
‫‏‬
Spinal cord damage
‫‏‬
Renal failure

46
Thoracic Aorta
Prognosis
‫‏‬
Aneurysm
– Early post-op mortality 4-10%; lower for descending aneurysm repair; much
higher for aortic arch repair
– Stroke occurs 2-5%
– Renal failure requiring dialysis – 7%
– Spinal cord injury – 3%
‫‏‬
Dissection
– Treated 10-yr survival rate 60%
– Type A
• 30% mortality surgical
• 60% mortality medical
– Type B
• 10% mortality medical
• 30% mortality surgical

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Thoracic Aorta
Underwriting Approach and Considerations
‫‏‬
Obtain cardiology and/or vascular medical records
‫‏‬
Review serial echos/scans as available
‫‏‬
Review blood pressure control
‫‏‬
Higher Risk
– Aneurysm >5 cm
– Poorly controlled blood pressure
– Increase in size >0.5 cm/yr
– Ongoing tobacco usage
– Associated cardiovascular disease (CAD, PVD, carotid disease)
– Non-atherosclerotic vascular disorders (Marfan’s, Ehlers-Danlos, etc)
‫‏‬
Lower Risk
– Aneurysm <5 cm/stable/ well followed
– Aneurysm repaired/stable

48
Thoracic Aorta
Summary
‫‏‬
Thoracic aortic dilation/aneurysm fairly common with age
‫‏‬
Risk factors are traditional cardiovascular risk factors
‫‏‬
Most are asymptomatic
‫‏‬
Thoracic aortic rupture rare
‫‏‬
Thoracic dissection rare
‫‏‬
Ascending aorta most common site of aneurysm formation
‫‏‬
Low risk for aneurysms less than 4 cm
In the end, it’s not what you call it………it’s size that matters!
REMEMBER

superior vena cava (SVC, also known as the
cava or cva)
‫‏‬ The superior vena cava (SVC, also known as the cava or cva) is a short,
but large diameter vein located in the anterior right
superior mediastinum. Its latin name is related to its large pipe
appearance in cadavers, 'cava' meaning 'hollow'.
49
Thoracic Aorta

‫‏‬ The superior vena cava is very important for the function of
the cardiovascular system, since it largely contributes to the input of
blood to the right atrium. Any hypertensive process in the right half of the
heart or in the pulmonary circulation retrogradely affects both superior
and inferior venae cavae. This is important since the veins are not
adjusted to high pressures, which can result with forming an aneurysm
or even rupture of the wall of the SVC.
‫‏‬ This article will discuss the anatomy and function of the superior vena
cava.
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Thoracic Aorta
Key facts about the superior vena cavaTable quiz
Source Brachiocephalic vein, azygos vein
Draining area Upper half of the body (above the diaphragm)
Drains to Right atrium of heart

‫‏‬ Contents
‫‏‬ Anatomy
‫‏‬ Function
‫‏‬ Clinical notes
– Superior vena cava obstruction (SVCO)
– Superior vena cava syndrome (SVCS)
– Superior vena cava thrombosis
– Superior vena cava aneurysm
– Persistent left superior vena cava (PLSVC)
‫‏‬ Sources
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Thoracic Aorta

‫‏‬ Anatomy
‫‏‬ Left brachiocephalic vein
‫‏‬ Vena brachiocephalica sinistra
‫‏‬ 1/3
‫‏‬ Synonyms: Left innominate vein, Vena anonyma sinistra
‫‏‬ 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.
‫‏‬ There is no valve that divides the SVC from the right atrium, which
conducts blood from right atrial and right ventricular contractions
upwards into the internal jugular vein (seen as the jugular venous
pressure) and sternocleidomastoid muscle.
52
Thoracic Aorta

‫‏‬ Positionally, the SVC begins behind the lower border of the 1st right
costal cartilage and descends vertically behind the 2nd and 3rd
intercostal spaces to drain into the right atrium at the level of the 3rd
costal cartilage. Its lower half is covered by a fibrous pericardium, which
is pierced by the SVC at the level of the 2nd costal cartilage.
53
Thoracic Aorta
Function
Superior vena cava coursing towards the right atrium of the
heart, returning deoxygenated blood from the body.
The SVC is one of the 2 large veins by which blood is returned from the body to the right side
of the heart. After circulating through the body systemically, deoxygenated blood returns to
the right atrium of the heart through either the SVC, which drains the upper body, or
the inferior vena cava (IVC) that drains everything below the diaphragm.

‫‏‬ Clinical notes
‫‏‬ Superior vena cava obstruction (SVCO)
‫‏‬ This usually refers to a partial or complete obstruction of the SVC,
often in the context of cancer (lung cancer, metastatic cancer, or
lymphoma). Clinically this obstruction can lead to enlarged veins in
the head and neck, and cause shortness of breath, cough, chest
pain, and difficulty swallowing).
‫‏‬ A clinical test known as Pemberton’s sign can be performed to
identify this condition. A positive Pemberton's sign is marked by
facial congestion and cyanosis (and/or respiratory distress) after 1
minute of having the patient elevate both arms until they touch the
sides of the face. This sign is indicative of superior vena
cava syndrome, commonly the result of a mass in the mediastinum.
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Thoracic Aorta

‫‏‬ Superior vena cava syndrome (SVCS)
‫‏‬ This syndrome refers to a group of symptoms caused by the
obstruction of the SVC. More than 90% of the cases of SVC
obstruction are caused by cancer, most commonly bronchogenic
carcinoma, which includes small cell and non-small cell lung
carcinoma, Burkitt’s lymphoma, lymphoblastic lymphomas, pre-T-
cell lineage acute lymphoblastic leukemia, and other acute
leukemias.
‫‏‬ Characteristic symptoms are edema of the arms and face,
development of swollen collateral veins on the front of the chest
wall, shortness of breath, difficulty swallowing, stridor, cough, and
neurological symptoms (reduced alertness, etc. from edema in
the brain or airway compromise). Again, Pemberton’s sign can be
used to identify an SVCO.
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Thoracic Aorta

‫‏‬ Superior vena cava thrombosis
‫‏‬ The thrombosis often occurs from a thrombus around a long-
term central venous catheter (CVC), especially in cancer patients with
permanent indwelling CVCs. CVC-related thrombosis is as high as
30% in adults. However, patients can be treated with thrombolytics
or anticoagulants, or by removal of the catheter.
‫‏‬ Superior vena cava aneurysm
‫‏‬ Venous aneurysms arising from the mediastinal systemic veins are
extremely rare, with the majority being fusiform (“spindle-shaped”)
aneurysms that arise from the SVC.
‫‏‬ Persistent left superior vena cava (PLSVC)
‫‏‬ A PLSVC is an embryologic remnant that is the most common
variation of the thoracic venous system, resulting from a failure to
involute during embryologic development.
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Thoracic Aorta

The inferior vena cava (IVC) is the largest vein
of the human body. It is located at
the posterior abdominal wall on the right side of
the aorta. The IVC’s function is to carry
the venous blood from the lower
limbs and abdominopelvic region to the heart.
The inferior vena cava anatomy is essential
due to the vein’s great drainage area, which
also makes it a hot topic for anatomy exams.
For that reason, this page will cover the IVC
anatomy in a way that’s easy to read and
understand.
57
Thoracic Aorta

Key facts
Table quiz
Definition and functionThe vein that collects
deoxygenated blood from the abdomen,
pelvis and lower limbs and carries it to the
right atrium of the heartSourceCommon iliac
veins (L5)TributariesInferior Phrenic,
right Suprarenal, Renal, right Testicular
(gonadal), Lumbar, common Iliac
and Hepatic veins
Mnemonic: Portal System Returns To Liver
In Humans
Clinical relationsInferior vena cava
thrombosis 60
Thoracic Aorta

Anatomy
Inferior vena cava
Vena cava inferior
1/4
Synonyms: IVC
The inferior vena cava arises from the confluence
of the common iliac veins at the level of L5
vertebra, just inferior to the bifurcation of the
abdominal aorta. It then ascends the posterior
abdominal wall, to the right side of the aorta and
the bodies of the L3-L5 vertebrae. After passing
through its fossa on the posterior liver surface, the
IVC enters the thorax by traversing the inferior
vena caval foramen of the diaphragm.
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Thoracic Aorta

‫‏‬ The tributaries of the IVC correspond to the branches of the abdominal
aorta. Note that some professors will want you to know at which
vertebral level the IVC gets its direct tributaries, so they are as follows:
‫‏‬ The direct tributaries are the inferior phrenic veins (T8), right suprarenal
(L1), renal (L1), right testicular (gonadal) (L2), lumbar (L1-L5),
common iliac (L5) and hepatic (T8). If you want an easy way to
remember them just memorise the mnemonic
' Portal System Returns To Liver In Humans'.
‫‏‬ Left gonadal and left suprarenal renal veins drain first into the left renal
vein
‫‏‬ The veins of the stomach, spleen, pancreas, small and large
intestines first empty into the hepatic portal vein. The hepatic portal vein
carries this blood to the liver to be processed and detoxified. Then, the
blood reaches the IVC through the hepatic veins.
‫‏‬ The inferior vena cava communicates with the superior vena
cava through the collateral vessels, which include the azygos
vein, lumbar veins, and vertebral venous plexuses.
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Thoracic Aorta

‫‏‬ Function
‫‏‬ The IVC’s function is to convey the blood from the abdomen, pelvis,
and lower limbs to the right atrium of the heart. Additional IVC functions
are noticeable during some health disturbances, such as hepatic portal
vein obstruction or the obstruction of the IVC itself.
‫‏‬ Specialized vessels called
the portocaval (portosystemic) anastomoses open if the hepatic portal
vein is obstructed. The intestinal blood then bypasses the liver and
empties into the IVC directly. In cases where the IVC is occluded,
the collateral vessels to the superior vena cava open.
‫‏‬ Learn more about portocaval anastomoses with our article, then take this
specially designed quiz to consolidate everything you’ve learned about
the IVC and its tributaries.
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Thoracic Aorta

‫‏‬ Inferior vena cava thrombosis
‫‏‬ Thrombosis of the inferior vena cava (IVCT) is a condition in which a
blood clot (thrombus) impedes the blood flow through the IVC. The
thrombus can be formed within the IVC itself, which is rare, or, more
commonly, travel from the deep veins of the legs in a condition called
deep venous thrombosis (DVT).
‫‏‬ IVC thrombosis may be caused by all the conditions that lead to venous
stasis. These include congenital abnormalities of the IVC,
immobilization, obesity, pregnancy, sedentary lifestyle, and tumors of
surrounding organs. IVCT presents with symptoms of venous
obstruction, such as pain and swelling of lower limbs and scrotum. IVCT
is diagnosed by ultrasound, CT,and MRI.
‫‏‬ Depending on the severity of the condition, the IVCT can be treated by
surgical removal of the thrombus, thrombolytic therapy, and
anticoagulant therapy. The treatment is necessary to prevent
disseminating of the thrombus into the pulmonary circulation (pulmonary
thromboembolism), which is an urgent medical condition.
‫‏‬ Sources
66
Thoracic Aorta

Azygos vein
and
Hemiazygos
vein
67
Thoracic Aorta

Veins of the thoracic wall
‫‏‬ The thoracic wall is drained anteriorly by the internal thoracic vein
and posteriorly by the azygos system of veins
69

‫‏‬ The azygos system of veins serves as an important anastomotic
pathway capable of returning venous blood from the lower part of
the body to the heart if the inferior vena cava is blocked.
70

‫‏‬ The major veins in the system are:
‫‏‬ Azygos vein, on the right
‫‏‬ Hemiazygos vein and the accessory hemiazygos vein, on the
left.
71

‫‏‬ Azygos vein
‫‏‬ The azygos vein arises opposite vertebra LI or LII
‫‏‬ It is formed by the union of the right ascending lumbar vein , the
right subcostal vein and lumber azygos veins .
72

‫‏‬ In addition to the posterior intercostal veins, the azygos vein
communicates with the vertebral venous plexuses.
74

‫‏‬ The azygos vein enters the thorax through the aortic hiatus of the
diaphragm, or it enters through or posterior to the right crus of the
diaphragm.
76

‫‏‬ It ascends through the posterior mediastinum, usually to the right
of the thoracic duct.
77

‫‏‬ At approximately vertebral level TIV, it arches anteriorly, over the
root of the right lung, to join the superior vena cava.
78

‫‏‬ Tributaries of the azygos vein
‫‏‬ Right superior intercostal vein
‫‏‬ 5th – 11th right posterior ICV
‫‏‬ Hemiazygos vein;
‫‏‬ Accessory hemiazygos vein
‫‏‬ Esophageal veins
‫‏‬ Mediastinal veins
‫‏‬ Pericardial veins
‫‏‬ Right bronchial veins
80

Hemiazygos vein
‫‏‬ The hemiazygos vein (inferior hemiazygos vein) usually arises at
the junction between the left ascending lumbar vein and the left
subcostal vein .
81

‫‏‬ The hemiazygos vein usually enters the thorax through the left crus
of the diaphragm, but may enter through the aortic hiatus.
83

‫‏‬ It ascends through the posterior mediastinum, on the left side, to
approximately vertebral level TIX.
‫‏‬ At this point, it crosses the vertebral column, posterior to the
thoracic aorta, esophagus, and thoracic duct, to enters the azygos
vein.
‫‏‬ The hemiazygos vein receives the inferior three intercostal veins, the
inferior oesophageal veins, and several small mediastinal branches.
84

‫‏‬ Accessory hemiazygos vein
‫‏‬ The accessory hemiazygos vein descends on the left side of upper thoracic vertebrae up to the
vertebral level TVIII . At this point, it crosses the vertebral column to join the azygos vein, or
ends in the hemiazygos vein, or has a connection to both veins. Usually, it also has a connection
superiorly to the left superior intercostal vein. Vessels that drain into the accessory hemiazygos
vein include: the fourth to eighth left posterior intercostal veins
86

Thoracic Part of
Sympathetic Chain

Sympathetic trunks
‫‏‬ The sympathetic trunks (sympathetic chain, gangliated cord) are a
paired bundle of nerve fibers that run from the base of the skull to
the coccyx.

Paravertebral sympathetic ganglia
Sympathetic trunks

‫‏‬ The sympathetic trunks are two parallel nerve cords extending on
either side of the vertebral column from the base of the skull to the
coccyx

‫‏‬ The ganglia and trunks are connected to adjacent spinal nerves by
gray rami communicantes throughout the length of the sympathetic
trunk and by white rami communicantes in the thoracic and upper
lumbar parts of the trunk (T1 to L2).

‫‏‬ The whiter rami are afferent fibers to the ganglion and found only
from T1 to L2 segments. These contain the preganglionic and
afferent sensory fibers.
‫‏‬ The gray rami communicans are present in all segments. They are
efferent fibers of the sympathetic ganglia. These contain the
postganglionic fibers.

‫‏‬ Parts of sympathetic chain
‫‏‬ Cervical part
‫‏‬ Thoracic part
‫‏‬ lumber Part
‫‏‬ Sacral part

Thoracic part
of
Sympathetic
chain
Cervical part
of sympathetic
chain
Medial arcuate
lig. of
diaphragm
Abdominal part
of sympathetic
chain
Neck of 1st
rib

Sympathetic
chain
Medial arcuate
ligament

Branches
- Rami communicants to
corresponding intercostal
nerves.
- To autonomic plexuses in
thorax.
- To aorta.
- To abdominal organs through

Applied Anatomy
1- Spinal anesthesia at high level
may lead to temporary drop of
blood pressure.
2- In case of essential
hypertension, cutting of
sympathetic chain between T2 &
T5 will lead to drop of blood
pressure.

Autonomic Plexes
1- Pulmonary
Plexuses.
2-Oesophageal
plexuses.
3- Cardiac plexuses
(superficial and deep).

1- Pulmonary Plexus
(Posterior & Anterior)

2- Oesophageal Plexus
(Anterior & Posterior)

3- Cardiac Plexus
(Superficial & Deep)

Thoracic Lymph
Drainage
A- From Chest wall.
B- From thoracic contents.

A- From Chest Wall
1- Superficial lymph vessels:
- From front of chest to
pectoral lymph nodes,
parasternal or lower deep
cervical lymph nodes.
- From back of chest to
subscapular nodes.

2- Deep lymph vessels:
A- From anterior chest wall to
parasternal nodes.
B- Posterior part of chest wall to
intercostal lymph nodes (opposite
neck of ribs).
C- Four diaphragmatic nodes
(anterior, posterior and 2 lateral)
which drain diaphragm and liver.

B- from Thoracic
Contents
1- Anterior mediastinal
nodes.
2- Posterior mediastinal
nodes.
3- Nodes of lungs, bronchi
and trachea.

• Lymph vessels from:
-Anterior mediastinal nodes.
-Tracheal lymph nodes.
-Parasternal lymph nodes.
Will unit together to form broncho-
medistinal lymph vessels which joins
thoracic duct on left side and right
lymphatic duct in right side.

Deep lymph nodes of chest wall

AORTA SVC IVC AZV HAZV TTHRCSMPTHC 2022.ppt

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