Anatomy_Gray

Anatomy_Gray. The left margin of the heart descends laterally from the second intercostal space to the apex located near the midclavicular line in the fifth intercostal space. The lower margin of the heart extends from the sternal end of the right sixth costal cartilage to the apex in the fifth intercostal space near the midclavicular line. Where to listen for heart sounds To listen for valve sounds, position the stethoscope downstream from the flow of blood through the valves (Fig. 3.110). The tricuspid valve is heard just to the left of the lower part of the sternum near the fifth intercostal space. The mitral valve is heard over the apex of the heart in the left fifth intercostal space at the midclavicular line. The pulmonary valve is heard over the medial end of the left second intercostal space. The aortic valve is heard over the medial end of the right second intercostal space. Visualizing the pleural cavities and lungs, pleural recesses, and lung lobes and fissures


Anatomy_Gray

Anatomy_Gray. The aortic valve is heard over the medial end of the right second intercostal space. Visualizing the pleural cavities and lungs, pleural recesses, and lung lobes and fissures Palpable surface landmarks can be used to visualize the normal outlines of the pleural cavities and the lungs and to determine the positions of the pulmonary lobes and fissures. Superiorly, the parietal pleura projects above the first costal cartilage. Anteriorly, the costal pleura approaches the midline posterior to the upper portion of the sternum. Posterior to the lower portion of the sternum, the left parietal pleura does not come as close to the midline as it does on the right side. This is because the heart bulges onto the left side (Fig. 3.111A). Inferiorly, the pleura reflects onto the diaphragm above the costal margin and courses around the thoracic wall following an VIII, X, XII contour (i.e., rib VIII in the midclavicular line, rib X in the midaxillary line, and vertebra TXII posteriorly).


Anatomy_Gray

Anatomy_Gray. The lungs do not completely fill the area surrounded by the pleural cavities, particularly anteriorly and inferiorly. Costomediastinal recesses occur anteriorly, particularly on the left side in relationship to the heart bulge. Costodiaphragmatic recesses occur inferiorly between the lower lung margin and the lower margin of the pleural cavity. In quiet respiration, the inferior margin of the lungs travels around the thoracic wall following a VI, VIII, X contour (i.e., rib VI in the midclavicular line, rib VIII in the midaxillary line, and vertebra TX posteriorly). In the posterior view, the oblique fissure on both sides is located in the midline near the spine of vertebra TIV (Figs. 3.111B and 3.112A). It moves laterally in a downward direction, crossing the fourth and fifth intercostal spaces and reaches rib VI laterally.


Anatomy_Gray

Anatomy_Gray. In the anterior view, the horizontal fissure on the right side follows the contour of rib IV and its costal cartilage and the oblique fissures on both sides follow the contour of rib VI and its costal cartilage (Fig. 3.112B). Where to listen for lung sounds The stethoscope placements for listening for lung sounds are shown in Fig. 3.113. Fig. 3.1 Thoracic wall and cavity. Left pleural cavitySternal angleManubrium of sternumXiphoid processInferior thoracic apertureSuperior thoracic apertureBody of sternumRight pleural cavityDiaphragmVertebral columnRib IRibsMediastinum Fig. 3.2 Joints between ribs and vertebrae. Fig. 3.3 Superior thoracic aperture. Manubriumof sternumEsophagusCommon carotid arteryInternal jugular veinRib ISuperior thoracicapertureApex of right lungSubclavianarteryand veinTracheaVertebra TIRib IITracheaPleauralcavity (lung)VeinsNervesArteriesEsophagus Fig. 3.4 A. Inferior thoracic aperture. B. Diaphragm.


Anatomy_Gray

Anatomy_Gray. Fig. 3.4 A. Inferior thoracic aperture. B. Diaphragm. Rib XIDistal cartilaginousends of ribs VII to X;costal marginsCentraltendonLeft domeRight domeAortichiatusEsophagealhiatusInferior thoracicapertureXiphoid processRib XIIVertebra TXIIAB Fig. 3.5 Subdivisions of the mediastinum. Fig. 3.6 Pleural cavities. TracheaLeft pleural cavitysurrounding left lungApex of right lungMediastinumRight main bronchusRight pleural cavityParietal pleuraVisceral pleuraCostodiaphragmaticrecessDiaphragm Fig. 3.7 Superior thoracic aperture and axillary inlet. Fig. 3.8 Major structures passing between abdomen and thorax. Fig. 3.9 Right breast. Fourth thoracicintercostal nerveMammary glandsLactiferousductsLactiferoussinusesPectoralis majorDeep (pectoral) fasciaAxillary processAxillarylymph nodesSecond, third, and fourth anteriorperforating branches of internalthoracic arteryInternalthoracic arteryParasternallymph nodesLymphatic vessel Fig. 3.10 Vertebral level TIV/V.


Anatomy_Gray

Anatomy_Gray. Fig. 3.10 Vertebral level TIV/V. Fig. 3.11 Left-to-right venous shunts. Fig. 3.12 A. Segmental neurovascular supply of thoracic wall. B. Anterior view of thoracic dermatomes associated with thoracic spinal nerves. C. Lateral view of dermatomes associated with thoracic spinal nerves. Left common carotid arteryInternal thoracic arteriesRight subclavian arteryArch of aortaAnteriorcutaneous branchAnteriorintercostal arteryAPosteriorintercostal arteryLateralcutaneous branchIntercostal nerve Fig. 3.13 Sympathetic trunks. Fig. 3.14 Flexible thoracic wall and inferior thoracic aperture. Sternum moves forwardin inspiration because ofrib elevationElevation of lateral aspectof ribs in inspirationDiaphragm descends toincrease thoracic capacityin inspiration Fig. 3.15 Innervation of the diaphragm. Fig. 3.16 Breasts.


Anatomy_Gray

Anatomy_Gray. Fig. 3.15 Innervation of the diaphragm. Fig. 3.16 Breasts. Parasternal nodesSuspensory ligamentsLactiferous sinusesLactiferous ductsRetromammary spaceSecretory lobulesPectoralis major muscleMammary branches ofinternal thoracic arteryAxillary processLateral thoracic arteryLateral axillary nodesCentral axillary nodesApical axillary nodesPectoral branch ofthoracoacromial arteryInternal thoracic arteryAreolaSecretorylobulesLymphatic and venous drainagepasses from lateral and superiorpart of the breast into axillaLymphatic and venousdrainage passes from medial partof the breast parasternallySome lymphatic and venous drainagemay pass from inferior part of thebreast into the abdomenPectoral axillary nodes Fig. 3.17 Muscles and fascia of the pectoral region. Fig. 3.18 Typical thoracic vertebra.


Anatomy_Gray

Anatomy_Gray. Fig. 3.17 Muscles and fascia of the pectoral region. Fig. 3.18 Typical thoracic vertebra. LaminaSpinous processTransverse processPedicleVertebral bodyPosteriorAnteriorVertebral foramenSuperior demifacetFacet for articulation with tubercle of ribSuperiorPosteriorInferiorAnteriorFacet for articulationwith tubercle of ribDemifacets for articulation with head of ribsSuperior articular processInferior articular processSuperior viewSuperolateral view Fig. 3.19 Atypical thoracic vertebrae. Vertebra TIVertebra TXVertebra TXISuperior costal facet for head of rib ISingle complete costal facet for head of rib XNo costal facet on transverse process Fig. 3.20 Ribs. Fig. 3.21 A typical rib. A. Anterior view. B. Posterior view of proximal end of rib. Fig. 3.22 Atypical ribs. Fig. 3.23 Sternum. Fig. 3.24 Costovertebral joints.


Anatomy_Gray

Anatomy_Gray. Fig. 3.20 Ribs. Fig. 3.21 A typical rib. A. Anterior view. B. Posterior view of proximal end of rib. Fig. 3.22 Atypical ribs. Fig. 3.23 Sternum. Fig. 3.24 Costovertebral joints. Joint capsuleVertebraVertebraDiscRibJoint cavitiesCostotransverse jointCostotransverse ligamentSuperior costotransverse ligamentLateral costotransverseligamentJoint with vertebral bodyIntra-articular ligamentSuperolateral viewSuperior view Fig. 3.25 Sternocostal joints. Fig. 3.26 Intercostal space. A. Anterolateral view. B. Details of an intercostal space and relationships. Intercostal space. C. Transverse section.


Anatomy_Gray

Anatomy_Gray. Fig. 3.25 Sternocostal joints. Fig. 3.26 Intercostal space. A. Anterolateral view. B. Details of an intercostal space and relationships. Intercostal space. C. Transverse section. Posterior ramus of spinal nerveLateral branches ofintercostal nerveand vesselsAnterior cutaneousbranch ofintercostal nerve Anterior perforatingbranches ofintercostal vessels Intercostal nerveCostal grooveAortaInternal thoracic arteryand veinPosterior intercostal artery and veinAnterior intercostal artery and veinCollateral branches ofintercostal nerve and vesselsIntercostal veinIntercostal arteryVisceral pleuraParietal pleuraEndothoracic fasciaPleural cavityLungIntercostal nerveCollateral branchesInternal intercostal muscleExternal intercostal muscleSerratus anterior muscleInnermost intercostal muscleSuperficial fasciaSkinAB Fig. 3.27 Intercostal muscles. Fig. 3.28 A. Subcostal muscles. B. Transversus thoracis muscles. Fig. 3.29 Arteries of the thoracic wall.


Anatomy_Gray

Anatomy_Gray. Fig. 3.27 Intercostal muscles. Fig. 3.28 A. Subcostal muscles. B. Transversus thoracis muscles. Fig. 3.29 Arteries of the thoracic wall. Superior epigastric arteryInternal thoracic arteryAortaAnterior perforatingbranchesAnterior intercostal arteryCollateral branch of posteriorintercostal arterySupreme intercostal arteryPosterior intercostal arteryMusculophrenic arterySubclavian arteryCostocervical trunk Fig. 3.30 Veins of the thoracic wall. Fig. 3.31 Major lymphatic vessels and nodes of the thoracic wall. Fig. 3.32 Intercostal nerves. Fig. 3.33 Right thoracotomy for esophageal cancer with intrathoracic large-bore drain. In this case, a neo-esophagus has been fashioned from the stomach. Fig. 3.34 Diaphragm. Fig. 3.35 Movement of thoracic wall during breathing. A. Pump handle movement of ribs and sternum. B. Bucket handle movement of ribs. BuckethandlemovementElevation of lateralshaft of ribSuperior and anteriormovement of sternumBAPump handle


Anatomy_Gray

Anatomy_Gray. BuckethandlemovementElevation of lateralshaft of ribSuperior and anteriormovement of sternumBAPump handle Fig. 3.36 Chest radiograph showing an elevated right hemidiaphragm in a patient with right-sided diaphragmatic paralysis. Fig. 3.37 Pleural cavities. Fig. 3.38 Parietal pleura. Costal partPulmonary ligamentMediastinal partPleura surroundingstructures in root of lungCervical pleuraSuprapleural membraneDiaphragmatic part Fig. 3.39 Pleural reflections. Fig. 3.40 Parietal pleural reflections and recesses. Fig. 3.41 CT image of left pleural effusion. AortaLeft lungRight lungLeft empyema with air-fluid level Fig. 3.42 Pneumothorax in a patient with extensive subcutaneous emphysema. Fig. 3.43 Lungs. Fig. 3.44 Roots and hila of the lungs. Fig. 3.45 A. Right lung. B. Major structures related to the right lung.


Anatomy_Gray

Anatomy_Gray. Fig. 3.43 Lungs. Fig. 3.44 Roots and hila of the lungs. Fig. 3.45 A. Right lung. B. Major structures related to the right lung. DiaphragmBronchusBronchus to superior lobePulmonary arteryPulmonary veinsRib ISubclavian arterySubclavian veinEsophagusPosteriorAnteriorInferior vena cavaAzygos veinLeft brachiocephalic veinRight brachiocephalic veinHeartInferior lobeSuperior lobeMiddle lobeSuperior vena cavaOblique fissureHorizontal fissureAB Fig. 3.46 A. Left lung. B. Major structures related to the left lung. Fig. 3.47 A. Bronchial tree. B. Bronchopulmonary segments. TracheaLeft main bronchusCarinaRight main bronchusLobar bronchiLobar bronchiSegmental bronchiof middle lobeBranch of pulmonary arteryMedial bronchopulmonary segmentof middle lobe of right lungLateral bronchopulmonary segmentof middle lobe of right lungAB Fig. 3.48 Bronchopulmonary segments. A. Right lung. B. Left lung. (Bronchopulmonary segments are numbered and named.)


Anatomy_Gray

Anatomy_Gray. Fig. 3.48 Bronchopulmonary segments. A. Right lung. B. Left lung. (Bronchopulmonary segments are numbered and named.) Fig. 3.49 Pulmonary vessels. A. Diagram of an anterior view. B. Axial computed tomography image showing the left pulmonary artery branching from the pulmonary trunk. C. Axial computed tomography image (just inferior to the image in B) showing the right pulmonary artery branching from the pulmonary trunk. Fig. 3.50 Pulmonary innervation. Fig. 3.51 Lymphatic drainage of lungs. Fig. 3.52 HRCT of patient with emphysema. Fig. 3.53 Bronchoscopic evaluation. A. Of the lower end of the trachea and its main branches. B. Of tracheal bifurcation showing a tumor at the carina.


Anatomy_Gray

Anatomy_Gray. Fig. 3.52 HRCT of patient with emphysema. Fig. 3.53 Bronchoscopic evaluation. A. Of the lower end of the trachea and its main branches. B. Of tracheal bifurcation showing a tumor at the carina. Fig. 3.54 Imaging of the lungs. A. Standard posteroanterior view of the chest showing tumor in upper right lung. B. Axial CT image of lungs showing tumor in right lung. C. Coronal CT image of lungs showing tumor in left lung extending into mediastinum. D. Radionuclide study using FDG PET showing a tumor in the right lung. Fig. 3.55 Cross-section of the thorax showing the position of the mediastinum. Fig. 3.56 Lateral view of the mediastinum. Fig. 3.57 Subdivisions of the mediastinum. Fig. 3.58 Thymus. Fig. 3.59 Sagittal section of the pericardium. FibrouspericardiumParietal layerof serouspericardiumVisceral layerof serouspericardium(epicardium)PericardialcavityJunction between fibrous pericardium and adventitia of great vessels Fig. 3.60 Phrenic nerves and pericardiacophrenic vessels.


Anatomy_Gray

Anatomy_Gray. Fig. 3.60 Phrenic nerves and pericardiacophrenic vessels. Fig. 3.61 Posterior portion of pericardial sac showing reflections of serous pericardium. Arch of aortaSuperior vena cavaInferior vena cavaBranch of rightpulmonary arteryAscending aortaThoracic aortaCut edge of pericardiumRight pulmonary veinsLeft pulmonary arteryLeft pulmonary veinsOblique pericardial sinus(formed by reflection onto thepulmonary veins of heart)Transverse pericardial sinus(separates arteries from veins) Fig. 3.62 Coronal CT showing pericardial effusion. Fig. 3.63 Schematic illustration of the heart showing orientation, surfaces, and margins. Fig. 3.64 Base of the heart. Arch of aortaSuperior vena cavaInferior vena cavaRight pulmonary arterySulcus terminalisRight pulmonary veinsRight atriumRight ventricleApexLeft atriumLeft inferior pulmonary veinLeft superior pulmonary veinLeft ventricleCoronary sinusLeft pulmonary artery Fig. 3.65 Anterior surface of the heart.


Anatomy_Gray

Anatomy_Gray. Fig. 3.65 Anterior surface of the heart. RALABicuspidvalveTricuspid valveAortic valvePulmonary trunkPulmonary valveAortaRVLVArch of aortaSuperior vena cavaInferior vena cavaRight coronaryarteryRight atriumRight ventricleAscending aortaInferior marginApexSmall cardiac veinPulmonary trunkLeft auricleLeft ventricleObtuse marginAnterior interventricular grooveGreat cardiac veinAnterior interventricular branch of left coronary artery Fig. 3.66 Diaphragmatic surface of the heart. Arch of aortaSuperior vena cavaInferior vena cavaRight pulmonary arteryRight pulmonary veinsRight atriumRight ventricleMiddle cardiac veinMarginal branch ofright coronary arteryApexLeft atriumLeft pulmonary veinsLeft ventricleCoronary sinusLeft pulmonary arteryPosterior interventricular groovePosterior interventricularbranch of right coronaryartery Fig. 3.67 Chest radiographs. A. Standard posteroanterior view of the chest. B. Standard lateral view of the heart.


Anatomy_Gray

Anatomy_Gray. Fig. 3.67 Chest radiographs. A. Standard posteroanterior view of the chest. B. Standard lateral view of the heart. Right ventricleLeft atrium Right atriumArch of aortaInferior vena cavaABPulmonary trunkLeft auricleLeft ventricle Superior vena cava Apex of heart Fig. 3.68 Sulci of the heart. A. Anterior surface of the heart. B. Diaphragmatic surface and base of the heart. Fig. 3.69 A. The heart has two pumps. B. Magnetic resonance image of midthorax showing all four chambers and septa. Fig. 3.70 Internal view of right atrium. Arch of aortaSuperior vena cavaInferior vena cavaLimbus of fossa ovalisCrista terminalisMusculi pectinatiRight ventricleFossa ovalisValve of coronary sinusOpening of coronary sinusRight auricleValve of inferior vena cava Fig. 3.71 Internal view of the right ventricle.


Anatomy_Gray

Anatomy_Gray. Fig. 3.71 Internal view of the right ventricle. Arch of aortaSuperior vena cavaTricuspidvalveRight auricleRight atriumAnterior cuspSeptal cuspPosterior cuspPosterior papillary muscleTrabeculae carneaeAnterior papillary muscleChordae tendineaePulmonary trunkPulmonaryvalveLeft auricleSeptal papillary muscleSeptomarginal trabeculaAnterior semilunar cuspRight semilunar cuspLeft semilunar cuspConus arteriosus Fig. 3.72 Posterior view of the pulmonary valve. Fig. 3.73 Left atrium. A. Internal view. B. Axial computed tomography image showing the pulmonary veins entering the left atrium. Arch of aortaMitral valveLeft auricleABPulmonary arteriesPulmonary veinsValve of foramen ovaleLeft ventricleLeft atriumAscending aortaRight ventricleRight pulmonary veinLeft atriumEsophagusThoracic aortaLeft pulmonary vein Fig. 3.74 Internal view of the left ventricle.


Anatomy_Gray

Anatomy_Gray. Fig. 3.74 Internal view of the left ventricle. Arch of aortaCoronary sinusMitral valve posterior cuspPulmonary arteriesPulmonary veinsAnterior papillarymuscleMitral valve anterior cuspPosterior papillarymuscleChordae tendineaeTrabeculae carneaeLeft atrium Fig. 3.75 Anterior view of the aortic valve. Fig. 3.76 Cardiac skeleton (atria removed). Right fibrous trigoneLeft fibrous trigoneLeft atrioventricular ringFibrous ring of pulmonary valveAtrioventricular bundleRight atrioventricular ringFibrous ring of aortic valveAntAntAntRtRtPostPostPostPosteriorAnteriorLeftRightSeptalLtLt Fig. 3.77 Cardiac vasculature. A. Anterior view. B. Superior view (atria removed). Fig. 3.78 A. Anterior view of coronary arterial system. Right dominant coronary artery. B. Left anterior oblique view of right coronary artery. C. Right anterior oblique view of left coronary artery.


Anatomy_Gray

Anatomy_Gray. C. Right anterior oblique view of left coronary artery. Right marginal branch Posterior interventricular branchRight coronary artery Left marginal branch Circumflex branchAnterior interventricular branchRight marginal branchof right coronary artery Right coronary arteryRight atriumRight ventricleSinu-atrial nodal branchof right coronary arteryABCPosterior interventricularbranch of right coronary artery Anterior interventricularbranch of leftcoronary artery Left coronary arteryCircumflex branchof left coronary arteryLeft marginal branchof circumflex branchDiagonal branch ofanterior interventricular branchLeft auricleLeft ventricle Fig. 3.79 Left dominant coronary artery.


Anatomy_Gray

Anatomy_Gray. Fig. 3.79 Left dominant coronary artery. Right marginal branchof right coronary arteryRight coronary arteryPosterior interventricular branch ofcircumflex branch of left coronary arterySinu-atrial nodal branchof left coronary arteryAnterior interventricularbranch of left coronary artery Left coronary arteryCircumflex branchof left coronary arteryLeft marginal branchof circumflex branchDiagonal branch ofanterior interventricular branch Fig. 3.80 A and B. Axial maximum intensity projection (MIP) CT image through the heart. A. Normal anterior interventricular (left anterior descending) artery. B. Stenotic (calcified) anterior interventricular (left anterior descending) artery. C and D. Vertical long axis multiplanar reformation (MRP) CT image through the heart. C. Normal anterior interventricular (left anterior descending) artery. D. Stenotic (calcified) anterior interventricular (left anterior descending) artery.


Anatomy_Gray

Anatomy_Gray. Fig. 3.81 Heart sounds and how they relate to valve closure, the electrocardiogram (ECG), and ventricular pressure. RPQST1st2nd1stSYSTOLESYSTOLEDIASTOLEVentricularpressureECGHeartsoundsAtrial contractionClosure of mitraland tricuspid valvesClosure of aortic andpulmonary valves"lub""lub""dub" Fig. 3.82 Major cardiac veins. A. Anterior view of major cardiac veins. B. Posteroinferior view of major cardiac veins. Fig. 3.83 Conduction system of the heart. A. Right chambers. B. Left chambers. Fig. 3.84 Cardiac plexus. A. Superficial. B. Deep. Left vagus nerveRight vagus nerveVagal cardiac branchesVagal cardiac branchesCardiac nerves fromsympathetic trunkSuperior vena cavaArch of aortaSuperficial cardiac plexusPulmonary trunkLeft recurrent laryngeal nerveRight recurrent laryngeal nerveLeft vagus nerveRight vagus nerveCardiac nerves from sympathetic trunkDeep cardiac plexusVagal cardiac branchesVagal cardiac branchesAB


Anatomy_Gray

Anatomy_Gray. Fig. 3.85 Major vessels within the middle mediastinum. A. Anterior view. B. Posterior view. Ascending aortaPulmonary trunkSuperiorvena cavaSuperior vena cavaInferior vena cavaOblique pericardial sinusRight pulmonaryarteryRight pulmonaryveinsRight atriumLeft pulmonaryveinsLeft pulmonaryarteryArch of aortaAB Fig. 3.86 Structures in the superior mediastinum. Right internal jugular veinRight common carotid arteryLeft common carotid arteryLeft subclavian arteryRight subclavian arteryRight pulmonary arteryLeft pulmonary arteryPulmonary trunkLeft subclavian veinLeft brachiocephalic veinRight brachiocephalic veinRight subclavian veinLeft internal jugular veinTracheaEsophagusEsophagusArch of aortaAscending aortaThoracic aortaLeft main bronchusRight main bronchusSuperior vena cava Fig. 3.87 Cross section through the superior mediastinum at the level of vertebra TIII. A. Diagram. B. Axial computed tomography image.


Anatomy_Gray

Anatomy_Gray. Fig. 3.87 Cross section through the superior mediastinum at the level of vertebra TIII. A. Diagram. B. Axial computed tomography image. ThymusManubrium of sternumLeft brachiocephalic veinRight brachiocephalic veinBrachiocephalic trunkLeft phrenic nerveRight phrenic nerveLeft vagus nerveLeft recurrent laryngeal nerveRight vagus nerveLeft common carotid arteryLeft subclavian arteryThoracic ductEsophagusTIIITracheaABLeft common carotid arteryEsophagusLeft subclavian arteryTracheaLeft brachiocephalic veinBrachiocephalic trunkRight brachiocephalic vein Fig. 3.88 Superior mediastinum with thymus removed. Fig. 3.89 Left superior intercostal vein. Fig. 3.90 Superior mediastinum with thymus and venous channels removed. Fig. 3.91 Axial CT showing aortic dissection. Fig. 3.92 Cross section through the superior mediastinum at the level of vertebra TIV. A. Diagram. B. Axial computed tomography image.


Anatomy_Gray

Anatomy_Gray. Fig. 3.91 Axial CT showing aortic dissection. Fig. 3.92 Cross section through the superior mediastinum at the level of vertebra TIV. A. Diagram. B. Axial computed tomography image. Manubrium of sternumThymusLeft phrenic nerveRight phrenicnerveArch of aortaLeft vagus nerveRight vagusnerveLeft recurrent laryngeal nerveThoracic ductTIVSuperior vena cavaTracheaArch ofazygos veinArch ofazygos veinEsophagusBAEsophagusTracheaArch of aortaSuperior vena cava Fig. 3.93 Trachea in the superior mediastinum. TracheaLeft brachiocephalicveinBrachiocephalictrunkLeft mainbronchusRight main bronchusPulmonary trunkSuperior venacavaArch of aortaTIV/V vertebrallevel Fig. 3.94 Right vagus nerve passing through the superior mediastinum. Fig. 3.95 Left vagus nerve passing through the superior mediastinum. Fig. 3.96 Left recurrent laryngeal nerve passing through the superior mediastinum.


Anatomy_Gray

Anatomy_Gray. Fig. 3.95 Left vagus nerve passing through the superior mediastinum. Fig. 3.96 Left recurrent laryngeal nerve passing through the superior mediastinum. Left recurrent laryngeal nerveLeft vagus nerveRight mainbronchusTIV/VvertebrallevelLeft main bronchusLigamentum arteriosumLeft pulmonary arteryLeft subclavian arteryPulmonary trunkEsophagusEsophagusTracheaThoracic aortaArch of aorta Fig. 3.97 Esophagus. Right main bronchusLeft main bronchusLeft subclavian arteryLeft common carotid arteryEsophagusEsophagusTracheaThoracic aortaArch of aortaBrachiocephalic trunkDiaphragm Fig. 3.98 Sites of normal esophageal constrictions. EsophagusTracheaPharynxDiaphragmJunction of esophagus with pharynxWhere esophagus iscrossed by arch ofaortaWhere esophagus is compressed by left main bronchusAt the esophageal hiatusPosition ofesophagusposterior toleft atrium Fig. 3.99 Esophageal plexus. Fig. 3.100 Axial CT showing esophageal cancer. Fig. 3.101 Thoracic aorta and branches.


Anatomy_Gray

Anatomy_Gray. Fig. 3.99 Esophageal plexus. Fig. 3.100 Axial CT showing esophageal cancer. Fig. 3.101 Thoracic aorta and branches. Left subclavian arterySupremeintercostal arterySuperior leftbronchialarteryRightbronchialarteryEsophagusEsophagusTracheaArch of aortaPosteriorintercostalarteriesMediastinalbranchesEsophageal branches Fig. 3.102 Azygos system of veins. Left superior intercostal veinRight superior intercostal veinAccessory hemiazygos veinHemiazygos veinAzygos veinOpening of azygos veininto superior vena cavaPosterior intercostal veinRight subcostal veinAscending lumbar veinRight ascending lumbar veinInferior vena cava Fig. 3.103 Thoracic duct. Fig. 3.104 Thoracic portion of sympathetic trunks.


Anatomy_Gray

Anatomy_Gray. Fig. 3.103 Thoracic duct. Fig. 3.104 Thoracic portion of sympathetic trunks. Fig. 3.105 Anterior view of chest wall with the locations of skeletal structures shown. A. In women. The location of the nipple relative to a specific intercostal space varies depending on the size of the breasts, which may not be symmetrical. B. In men. Note the location of the nipple in the fourth intercostal space. ClavicleCostal cartilageCoracoid processCostal marginJugular notchSternoclavicular jointManubrium of sternumRib IRib XXiphoid processASternal angleIIIIIIVVVIVIIVIIIIXBody of sternum ClavicleCostal cartilageCoracoid processSternal angleCostal marginJugular notchSternoclavicular jointManubrium of sternumRib IRib XBody of sternumXiphoid processBIIIIIIVVVIVIIVIIIIX Fig. 3.106 A. Close-up view of nipple and surrounding areola of the breast. B. Lateral view of the chest wall of a woman showing the axillary process of the breast.


Anatomy_Gray

Anatomy_Gray. Fig. 3.106 A. Close-up view of nipple and surrounding areola of the breast. B. Lateral view of the chest wall of a woman showing the axillary process of the breast. Fig. 3.107 Anterior view of the chest wall of a man showing the locations of various structures related to the TIV/V level. Fig. 3.108 Anterior view of the chest wall of a man showing the locations of different structures in the superior mediastinum as they relate to the skeleton. Right internal jugular veinRight common carotid arteryLeft common carotid arteryLeft subclavian arteryRight subclavian arteryRight pulmonaryarteryLeft pulmonaryarteryPulmonary trunkLeft subclavian veinLeft brachiocephalicveinRight brachiocephalic veinRight subclavian veinLeft internal jugular veinTracheaEsophagusEsophagusArch of aortaAscending aortaThoracic aortaLeft main bronchusRight mainbronchusSuperiorvena cava Fig. 3.109 Anterior view of the chest wall of a man showing skeletal structures and the surface projection of the heart.


Anatomy_Gray

Anatomy_Gray. Fig. 3.109 Anterior view of the chest wall of a man showing skeletal structures and the surface projection of the heart. Fig. 3.110 Anterior view of the chest wall of a man showing skeletal structures, heart, location of the heart valves, and auscultation points. Fig. 3.111 Views of the chest wall showing the surface projections of the lobes and the fissures of the lungs. A. Anterior view in a woman. On the right side, the superior, middle, and inferior lobes are illustrated. On the left side, the superior and inferior lobes are illustrated. B. Posterior view in a woman. On both sides, the superior and inferior lobes are illustrated. The middle lobe on the right side is not visible in this view.


Anatomy_Gray

Anatomy_Gray. Fig. 3.112 Views of the chest wall. A. Posterior view in a woman with arms abducted and hands positioned behind her head. On both sides, the superior and inferior lobes of the lungs are illustrated. When the scapula is rotated into this position, the medial border of the scapula parallels the position of the oblique fissure and can be used as a guide for determining the surface projection of the superior and inferior lobes of the lungs. B. Lateral view in a man with his right arm abducted. The superior, middle, and inferior lobes of the right lung are illustrated. The oblique fissure begins posteriorly at the level of the spine of vertebra TIV, passes inferiorly crossing rib IV, the fourth intercostal space, and rib V. It crosses the fifth intercostal space at the midaxillary line and continues anteriorly along the contour of rib VI. The horizontal fissure crosses rib V in the midaxillary space and continues anteriorly, crossing the fourth intercostal space and following the contour


Anatomy_Gray

Anatomy_Gray. anteriorly along the contour of rib VI. The horizontal fissure crosses rib V in the midaxillary space and continues anteriorly, crossing the fourth intercostal space and following the contour of rib IV and its costal cartilage to the sternum.


Anatomy_Gray

Anatomy_Gray. Fig. 3.113 Views of the chest wall of a man with stethoscope placements for listening to the lobes of the lungs. A. Anterior views. B. Posterior views. Apex of right lungApex of left lungSuperior lobe of right lungSuperior lobe of left lungMiddle lobe of right lungInferior lobe of right lungInferior lobe of left lungABIIIIIIIVVVIVIIVIIIIXXXIXIIIIIIIIIVVVIVIIVIIIIXX Fig. 3.114 A. Normal left coronary artery angiogram. B. Left coronary artery angiogram showing decreased flow due to blockages. C. Mechanism for perceiving heart pain in T1–4 dermatomes. Fig. 3.115 Axial maximum intensity projection (MIP) CT image through the heart. A. Normal anterior interventricular (left anterior descending) artery. B. Stenotic (calcified) anterior interventricular (left anterior descending) artery. eFig. 3.116 Cervical ribs. A. Neck radiograph demonstrating bilateral cervical ribs. B. Coronal computed tomography image showing cervical ribs.


Anatomy_Gray

Anatomy_Gray. eFig. 3.116 Cervical ribs. A. Neck radiograph demonstrating bilateral cervical ribs. B. Coronal computed tomography image showing cervical ribs. eFig. 3.117 Chest radiograph demonstrating an air/fluid level in the pleural cavity. eFig. 3.118 Chest radiograph of an individual with a pacemaker. The pacemaker wires (2) can be seen traveling through the venous system to the heart where one ends in the right atrium and the other ends in the right ventricle. eFig. 3.119 Chest radiograph demonstrating translucent notches along the inferior border of ribs III to VI. eFig. 3.120 A. CT image of aortic dissection. B. Normal aorta (left) and an aortic dissection (right). The line in the right figure indicates the plane of the CT scan shown in A. The true lumen surroundedby the collapsed intima and mediaCollapsed intima and mediaABThe false lumenThe false lumenAscendingaortaThoracic aortaThe true lumenEntrypointReturnpoint eFig. 3.121 Chest radiograph showing left upper lobe infection.


Anatomy_Gray

Anatomy_Gray. Table 3.1 Muscles of the pectoral region Table 3.2 Muscles of the thoracic wall Table 3.3 Branches of the thoracic aorta In the clinic Axillary tail of breast It is important for clinicians to remember when evaluating the breast for pathology that the upper lateral region of the breast can project around the lateral margin of the pectoralis major muscle and into the axilla. This axillary process (axillary tail) may perforate deep fascia and extend as far superiorly as the apex of the axilla. In the clinic Breast cancer is one of the most common malignancies in women. It develops in the cells of the acini, lactiferous ducts, and lobules of the breast. Tumor growth and spread depends on the exact cellular site of origin of the cancer. These factors affect the response to surgery, chemotherapy, and radiotherapy. Breast tumors spread via the lymphatics and veins, or by direct invasion.


Anatomy_Gray

Anatomy_Gray. When a patient has a lump in the breast, a diagnosis of breast cancer is confirmed by a biopsy and histological evaluation. Once confirmed, the clinician must attempt to stage the tumor. Staging the tumor means defining the: size of the primary tumor, exact site of the primary tumor, number and sites of lymph node spread, and organs to which the tumor may have spread. Computed tomography (CT) scanning of the body may be carried out to look for any spread to the lungs (pulmonary metastases), liver (hepatic metastases), or bone (bony metastases). Further imaging may include bone scanning using radioactive isotopes, which are avidly taken up by the tumor metastases in bone, and PET-CT, which can visualize active foci of the metastatic disease in the body.


Anatomy_Gray

Anatomy_Gray. Lymph drainage of the breast is complex. Lymph vessels pass to axillary, supraclavicular, and parasternal nodes and may even pass to abdominal lymph nodes, as well as to the opposite breast. Containment of nodal metastatic breast cancer is therefore potentially difficult because it can spread through many lymph node groups. Subcutaneous lymphatic obstruction and tumor growth pull on connective tissue ligaments in the breast, resulting in the appearance of an orange peel texture (peau d’orange) on the surface of the breast. Further subcutaneous spread can induce a rare manifestation of breast cancer that produces a hard, woody texture to the skin (cancer en cuirasse).


Anatomy_Gray

Anatomy_Gray. A mastectomy (surgical removal of the breast) involves excision of breast tissue. Within the axilla the breast tissue must be removed from the medial axillary wall. Closely applied to the medial axillary wall is the long thoracic nerve. Damage to this nerve can result in paralysis of the serratus anterior muscle, producing a characteristic “winged” scapula. It is also possible to damage the nerve to the latissimus dorsi muscle, and this may affect extension, medial rotation, and adduction of the humerus. In the clinic Cervical ribs are present in approximately 1% of the population. A cervical rib is an accessory rib articulating with vertebra CVII; the anterior end attaches to the superior border of the anterior aspect of rib I. Plain radiographs may demonstrate cervical ribs as small horn-like structures (see Fig. 3.106).


Anatomy_Gray

Anatomy_Gray. Plain radiographs may demonstrate cervical ribs as small horn-like structures (see Fig. 3.106). It is often not appreciated by clinicians that a fibrous band commonly extends from the anterior tip of the small cervical ribs to rib I, producing a “cervical band” that is not visualized on radiography. In patients with cervical ribs and cervical bands, structures that normally pass over rib I (see Fig. 3.7) are elevated by, and pass over, the cervical rib and band.


Anatomy_Gray

Anatomy_Gray. Clinically, “thoracic outlet syndrome” is used to describe symptoms resulting from abnormal compression of the brachial plexus of nerves as it passes over the first rib and through the axillary inlet into the upper limb. The anterior ramus of T1 passes superiorly out of the superior thoracic aperture to join and become part of the brachial plexus. The cervical band from a cervical rib is one cause of thoracic outlet syndrome by putting upward stresses on the lower parts of the brachial plexus as they pass over the cervical band and related cervical rib. In the clinic Collection of sternal bone marrow The subcutaneous position of the sternum makes it possible to place a needle through the hard outer cortex into the internal (or medullary) cavity containing bone marrow. Once the needle is in this position, bone marrow can be aspirated. Evaluation of this material under the microscope helps clinicians diagnose certain blood diseases such as leukemia. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic Single rib fractures are of little consequence, though extremely painful. After severe trauma, ribs may be broken in two or more places. If enough ribs are broken, a loose segment of chest wall, a flail segment (flail chest), is produced. When the patient takes a deep inspiration, the flail segment moves in the opposite direction to the chest wall, preventing full lung expansion and creating a paradoxically moving segment. If a large enough segment of chest wall is affected, ventilation may be impaired and assisted ventilation may be required until the ribs have healed. In the clinic Surgical access to the chest A surgical access is potentially more challenging in the chest given the rigid nature of the thoracic cage. Moreover, access is also dependent upon the organ that is operated upon and its relationships to subdiaphragmatic structures and structures in the neck. The most common approaches are a median sternotomy and a lateral thoracotomy.


Anatomy_Gray

Anatomy_Gray. A median sternotomy involves making a vertical incision in the sternum from just below the sternal notch to the distal end of the xiphoid process. Care must be taken not to cause injury to the vessels, in particular to the brachiocephalic veins. Bleeding from the branches of the internal thoracic artery can occur and needs to be controlled. Opening the sternum causes traction on the upper ribs and may lead to rib fractures. Sometimes partial sternotomy is performed with the incision involving only the upper part of the sternum and ending at the level of manubriosternal junction or just below. A median sternotomy allows access to the heart, including coronary arteries and valves, pericardium, great vessels, anterior mediastinum, and thymus, as well as to the lower trachea. It can also be used for removal of retrosternal goiter or during esophagectomy. The incision can be extended laterally into the supraclavicular region, giving access to the subclavian and carotid arteries.


Anatomy_Gray

Anatomy_Gray. A lateral thoracotomy gives access to the ipsilateral hemithorax and its contents including the lung, mediastinum, esophagus, and heart (left lateral thoracotomy) (Fig. 3.33). However, it involves division of muscles of the thoracic wall which leads to significant postoperative pain that needs to be well controlled to avoid restricted lung function. The incision starts at the anterior axillary line and then passes below the tip of the scapula and is extended superiorly between the posterior midline and medial border of the scapula. The pleural cavity is entered through an intercostal space. In older patients and those with osteoporosis, a short segment of rib is often resected to minimize the risk of a rib fracture.


Anatomy_Gray

Anatomy_Gray. Minimally invasive thoracic surgery (video-assisted thoracic surgery [VATS]) involves making small (1-cm) incisions in the intercostal spaces, placing a small camera on a telescope, and manipulating other instruments through additional small incisions. A number of procedures can be performed in this manner, including lobectomy, lung biopsy, and esophagectomy. In the clinic Insertion of a chest tube is a commonly performed procedure and is indicated to relieve air or fluid trapped in the thorax between the lung and the chest wall (pleural cavity). This procedure is done for pneumothorax, hemothorax, hemopneumothorax, malignant pleural effusion empyema, hydrothorax, and chylothorax, and also after thoracic surgery.


Anatomy_Gray

Anatomy_Gray. The position of the thoracostomy tube is usually between the anterior axillary and midaxillary anatomical lines from anterior to posterior and in either the fourth or fifth intercostal space. The position of the ribs in this region should be clearly marked. Anesthetic should be applied to the superior border of the rib and the inferior aspect of the intercostal space, including one rib and space above and one rib and space below. The neurovascular bundle runs in the neurovascular plane, which lies in the superior aspect of the intercostal space (just below the rib); hence, the reason for positioning the tube on the superior border of a rib (i.e., at the lowest position in the intercostal space).


Anatomy_Gray

Anatomy_Gray. Chest tube insertion is now commonly done with direct ultrasound guidance. This approach allows the physician both to assess whether the pleural effusion is simple or complex and loculated, and to select the safest site for entering the pleural space. In some cases of pneumothorax, a chest drain can be inserted under computed tomography-guidance, especially in patients with underlying lung disease where it is difficult to differentiate a large bulla from free air in the pleural space. In the clinic Local anesthesia of intercostal nerves produces excellent analgesia in patients with chest trauma and in those patients requiring anesthesia for a thoracotomy, mastectomy, or upper abdominal surgical procedures. The intercostal nerves are situated inferior to the rib borders in the neurovascular bundle. Each neurovascular bundle is situated deep to the external and internal intercostal muscle groups.


Anatomy_Gray

Anatomy_Gray. The intercostal nerves are situated inferior to the rib borders in the neurovascular bundle. Each neurovascular bundle is situated deep to the external and internal intercostal muscle groups. The nerve block may be undertaken using a “blind” technique or under direct imaging guidance. The patient is placed in the appropriate position to access the rib. Typically, under ultrasound guidance, a needle may be advanced into the region of the subcostal groove, followed by an injection with a local anesthetic. Depending on the type of anesthetic used, analgesia may be shortor long-acting. Given the position of the neurovascular bundle and the subcostal groove, complications may include puncture of the parietal pleura and an ensuing pneumothorax. Bleeding may also occur if the artery or vein is damaged during the procedure. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic In cases of phrenic nerve palsy, diaphragmatic paralysis ensues, which is manifested by the elevation of the diaphragm muscle on the affected side (Fig. 3.36). The most important cause of the phrenic nerve palsy that should never be overlooked is malignant infiltration of the nerve by lung cancer. Other causes include postviral neuropathy (in particular, related to varicella zoster virus), trauma, iatrogenic injury during thoracic surgery, and degenerative changes in the cervical spine with compression of the C3–C5 nerve roots. Most patients with unilateral diaphragmatic paralysis are asymptomatic and require no treatment. Some may report shortness of breath, particularly on exertion. Bilateral paralysis of the diaphragm is rare but can cause significant respiratory distress.


Anatomy_Gray

Anatomy_Gray. Surgical plication of the diaphragm can be performed in cases with respiratory compromise and is often done laparoscopically. The surgeon creates folds in the paralyzed diaphragm and sutures them in place, reducing the mobility of the diaphragmatic muscle. There is usually good improvement in lung function, exercise tolerance, and shortness of breath after the procedure. In the clinic A pleural effusion occurs when excess fluid accumulates within the pleural space. As the fluid accumulates within the pleural space the underlying lung is compromised and may collapse as the volume of fluid increases. Once a pleural effusion has been diagnosed, fluid often will be aspirated to determine the cause, which can include infection, malignancy, cardiac failure, hepatic disease, and pulmonary embolism. A large pleural effusion needs to be drained to allow the collapsed part of the lung to reexpand and improve breathing (Fig. 3.41). In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic A pneumothorax is a collection of gas or air within the pleural cavity (Fig. 3.42). When air enters the pleural cavity the tissue elasticity of the parenchyma causes the lung to collapse within the chest, impairing the lung function. Occasionally, the gas within the pleural cavity may accumulate to such an extent that the mediastinum is “pushed” to the opposite side, compromising the other lung. This is termed a tension pneumothorax and requires urgent treatment. Most pneumothoraces are spontaneous (i.e., they occur in the absence of no known pathology and no known lung disease). In addition, pneumothoraces may occur as a result of trauma, inflammation, smoking, and other underlying pulmonary diseases. Certain pulmonary metastases, such as in patients with osteosarcoma, may cause spontaneous pneumothorax especially after chemotherapy. The occurrence of pneumothorax interferes with cancer treatment and increases mortality.


Anatomy_Gray

Anatomy_Gray. The symptoms of pneumothorax are often determined by the degree of air leak and the rate at which the accumulation of gas occurs and the ensuing lung collapses. They include pain, shortness of breath, and cardiorespiratory collapse, if severe. In the clinic Imaging the lungs Medical imaging of the lungs is important because they are one of the commonest sites for disease in the body. While the body is at rest, the lungs exchange up to 5 L of air per minute, and this may contain pathogens and other potentially harmful elements (e.g., allergens). Techniques to visualize the lung range from plain chest radiographs to high-resolution computed tomography (CT), which enables precise localization of a lesion within the lung. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic High-resolution computed tomography (HRCT) is a diagnostic method for assessing the lungs but more specifically the interstitium of the lungs. The technique involves obtaining narrow cross-sectional slices of 1 to 2 mm. These scans enable the physician and radiologist to view the patterns of disease and their distribution. Diseases that may be easily demonstrated using this procedure include emphysema (Fig. 3.52), pneumoconiosis (coal worker’s pneumoconiosis), and asbestosis. HRCT is also useful in regular follow-ups of patients with interstitial disease to monitor disease progression. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic Patients who have an endobronchial lesion (i.e., a lesion within a bronchus) may undergo bronchoscopic evaluation of the trachea and its main branches (Fig. 3.53). The bronchoscope is passed through the nose into the oropharynx and is then directed by a control system past the vocal cords into the trachea. The bronchi are inspected and, if necessary, small biopsies are obtained. Bronchoscopy can also be used in combination with ultrasound (a technique known as EBUS, endobronchial ultrasound). An ultrasound probe is inserted through a working channel of the bronchoscope to visualize the airway walls and adjacent structures. EBUS allows an accurate localization of the lesion and therefore provides a higher diagnostic yield. It can be used for sampling of mediastinal and hilar lymph nodes or to assist in transbronchial biopsy of pulmonary nodules. In the clinic It is important to stage lung cancer because the treatment depends on its stage.


Anatomy_Gray

Anatomy_Gray. In the clinic It is important to stage lung cancer because the treatment depends on its stage. If a small malignant nodule is found within the lung, it can sometimes be excised and the prognosis is excellent. Unfortunately, many patients present with a tumor mass that has invaded structures in the mediastinum or the pleurae or has metastasized. The tumor may then be inoperable and is treated with radiotherapy and chemotherapy. Spread of the tumor is by lymphatics to lymph nodes within the hila, mediastinum, and root of the neck. A key factor affecting the prognosis and ability to cure the disease is the distant spread of metastases. Imaging methods to assess spread include plain radiography (Fig. 3.54A), computed tomography (CT; Fig. 3.54B,C), and magnetic resonance imaging (MRI). Increasingly, radionuclide studies using fluorodeoxyglucose positron emission tomography (FDG PET; Fig. 3.54D) are being used.


Anatomy_Gray

Anatomy_Gray. In FDG PET a gamma radiation emitter is attached to a glucose molecule. In areas of high metabolic activity (i.e., the tumor), excessive uptake occurs and is recorded by a gamma camera. In the clinic Pericarditis is an inflammatory condition of the pericardium. Common causes are viral and bacterial infections, systemic illnesses (e.g., chronic renal failure), and after myocardial infarction.


Anatomy_Gray

Anatomy_Gray. Pericarditis is an inflammatory condition of the pericardium. Common causes are viral and bacterial infections, systemic illnesses (e.g., chronic renal failure), and after myocardial infarction. Pericarditis must be distinguished from myocardial infarction because the treatment and prognosis are quite different. As in patients with myocardial infarction, patients with pericarditis complain of continuous central chest pain that may radiate to one or both arms. Unlike myocardial infarction, however, the pain from pericarditis may be relieved by sitting forward. An electrocardiogram (ECG) is used to help differentiate between the two conditions. It usually shows diffuse ST elevation. Echocardiography can also be performed if there is clinical or radiographic suspicion of pericardial effusion. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic Normally, only a tiny amount of fluid is present between the visceral and parietal layers of the serous pericardium. In certain situations, this space can be filled with excess fluid (pericardial effusion) (Fig. 3.62). Because the fibrous pericardium is a “relatively fixed” structure that cannot expand easily, a rapid accumulation of excess fluid within the pericardial sac compresses the heart (cardiac tamponade), resulting in biventricular failure. Removing the fluid with a needle inserted into the pericardial sac can relieve the symptoms. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic Abnormal thickening of the pericardial sac (constrictive pericarditis), which usually involves only the parietal pericardium, but can also less frequently involve the visceral layer, can compress the heart, impairing heart function and resulting in heart failure. It can present acutely but often results in a chronic condition when thickened pericardium with fibrin deposits causes pericardial inflammation, leading to chronic scarring and pericardial calcification. As a result, normal filling during the diastolic phase of the cardiac cycle is severely restricted. The diagnosis is made by inspecting the jugular venous pulse in the neck. In normal individuals, the jugular venous pulse drops on inspiration. In patients with constrictive pericarditis, the reverse happens and this is called Kussmaul’s sign. Treatment often involves surgical opening of the pericardial sac. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic Valve problems consist of two basic types: incompetence (insufficiency), which results from poorly functioning valves; and stenosis, a narrowing of the orifice, caused by the valve’s inability to open fully. Mitral valve disease is usually a mixed pattern of stenosis and incompetence, one of which usually predominates. Both stenosis and incompetence lead to a poorly functioning valve and subsequent heart changes, which include: left ventricular hypertrophy (this is appreciably less marked in patients with mitral stenosis); increased pulmonary venous pressure; pulmonary edema; and enlargement (dilation) and hypertrophy of the left atrium. Mitral valve stenosis can be congenital or acquired; in the latter, the most common cause is rheumatic fever. Stenosis usually occurs decades after an acute episode of rheumatic endocarditis.


Anatomy_Gray

Anatomy_Gray. Mitral valve stenosis can be congenital or acquired; in the latter, the most common cause is rheumatic fever. Stenosis usually occurs decades after an acute episode of rheumatic endocarditis. Aortic valve disease, both aortic stenosis and aortic regurgitation (backflow), can produce marked heart failure. Aortic valve stenosis is the most common type of cardiac valve disease and results from atherosclerosis causing calcification of the valve leaflets. It can also be caused by postinflammatory or postrheumatic conditions. These may lead to aortic regurgitation such as infective endocarditis, degenerative valve disease, rheumatic fever, or trauma.


Anatomy_Gray

Anatomy_Gray. Valve disease in the right side of the heart (affecting the tricuspid or pulmonary valve) is most likely caused by infection. Intravenous drug use, alcoholism, indwelling catheters, and extensive burns predispose to infection of the valves, particularly the tricuspid valve. The resulting valve dysfunction produces abnormal pressure changes in the right atrium and right ventricle, and these can induce cardiac failure. In the clinic In practice, physicians use alternative names for the coronary vessels. The short left coronary artery is referred to as the left main stem vessel. One of its primary branches, the anterior interventricular artery, is termed the left anterior descending artery (LAD). Similarly, the terminal branch of the right coronary artery, the posterior interventricular artery, is termed the posterior descending artery (PDA). In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic A heart attack occurs when the perfusion to the myocardium is insufficient to meet the metabolic needs of the tissue, leading to irreversible tissue damage. The most common cause is a total occlusion of a major coronary artery. Occlusion of a major coronary artery, usually due to atherosclerosis, leads to inadequate oxygenation of an area of myocardium and cell death (Fig. 3.80). The severity of the problem will be related to the size and location of the artery involved, whether or not the blockage is complete, and whether there are collateral vessels to provide perfusion to the territory from other vessels. Depending on the severity, patients can develop pain (angina) or a myocardial infarction (MI).


Anatomy_Gray

Anatomy_Gray. This is a technique in which a long fine tube (a catheter) is inserted into the femoral artery in the thigh and passed through the external and common iliac arteries and into the abdominal aorta. It continues to be moved upward through the thoracic aorta to the origins of the coronary arteries. The coronaries may also be approached via the radial or brachial arteries. A fine wire is then passed into the coronary artery and is used to cross the stenosis. A fine balloon is then passed over the wire and may be inflated at the level of the obstruction, thus widening it; this is termed angioplasty. More commonly, this is augmented by placement of a fine wire mesh (a stent) inside the obstruction to hold it open. Other percutaneous interventions are suction extraction of a coronary thrombus and rotary ablation of a plaque.


Anatomy_Gray

Anatomy_Gray. If coronary artery disease is too extensive to be treated by percutaneous intervention, surgical coronary artery bypass grafting may be necessary. The great saphenous vein, in the lower limb, is harvested and used as a graft. It is divided into several pieces, each of which is used to bypass blocked sections of the coronary arteries. The internal thoracic and radial arteries can also be used. In the clinic The most common abnormalities that occur during development are those produced by a defect in the atrial and ventricular septa.


Anatomy_Gray

Anatomy_Gray. A defect in the interatrial septum allows blood to pass from one side of the heart to the other from the chamber with the higher pressure to the chamber with the lower pressure; this is clinically referred to as a shunt. An atrial septal defect (ASD) allows oxygenated blood to flow from the left atrium (higher pressure) across the ASD into the right atrium (lower pressure), resulting in a left to right shunt and volume overload in the right-sided circulation. Many patients with ASD are asymptomatic, but in some cases the ASD may cause symptoms and needs to be closed surgically or by endovascular devices. Occasionally, increased blood flow into the right atrium over many years leads to right atrial and right ventricular hypertrophy and enlargement of the pulmonary trunk, resulting in pulmonary arterial hypertension. In such cases, the patients can present with shortness of breath, increasing tiredness, palpitations, fainting episodes and heart failure. In ASD, the left ventricle is not


Anatomy_Gray

Anatomy_Gray. arterial hypertension. In such cases, the patients can present with shortness of breath, increasing tiredness, palpitations, fainting episodes and heart failure. In ASD, the left ventricle is not enlarged as it is not affected by increased returning blood volume.


Anatomy_Gray

Anatomy_Gray. The most common of all congenital heart defects are those that occur in the ventricular septum—ventriculoseptal defect (VSD). These lesions are most frequent in the membranous portion of the septum and they allow blood to flow from the left ventricle (higher pressure) to the right ventricle (lower pressure), leading to an abnormal communication between the systemic and pulmonary circulation. This leads to right ventricular hypertrophy, increased pulmonary blood flow, elevated arterial pulmonary pressure, and increased blood volume returning to the left ventricle, causing its dilation. Increased pulmonary pressure in most severe cases may cause pulmonary edema. If large enough and left untreated, VSDs can produce marked clinical problems that might require surgery. VSD may be an isolated abnormality or part of a syndromic constellation, such as the tetralogy of Fallot.


Anatomy_Gray

Anatomy_Gray. The tetralogy of Fallot, the most common cyanotic congenital heart disorder diagnosed soon after birth, classically consists of four abnormalities: pulmonary stenosis, VSD, overriding aorta (originating to a varying degree from the right ventricle), and right ventricular hypertrophy. The underdevelopment of the right ventricle and pulmonary stenosis reduce blood flow to the lungs, leading to reduced volume of oxygenated blood returning to the heart. The defect in the interventricular septum causes mixing of oxygenated and nonoxygenated blood. The mixed blood is then delivered by the aorta to the major organs, resulting in poor oxygenation and cyanosis. Infants can present with cyanosis at birth or develop episodes of cyanosis while feeding or crying (tet spells). Most affected infants require surgical intervention. The advent of cardiopulmonary bypass was crucial in delivering highly satisfactory surgical results.


Anatomy_Gray

Anatomy_Gray. Occasionally, the ductus arteriosus, which connects the left branch of the pulmonary artery to the inferior aspect of the aortic arch, fails to close at birth. This is termed a patent or persistent ductus arteriosus (PDA). When this occurs, the oxygenated blood in the aortic arch (higher pressure) passes into the left branch of the pulmonary artery (lower pressure) and produces pulmonary hypertension and left atrial and ventricular enlargement. The prognosis in patients with isolated PDA is extremely good, as most do not have any major sequelae after surgical closure. All of these defects produce a left-to-right shunt, indicating that oxygenated blood from the left side of the heart is being mixed with deoxygenated blood from the right side of the heart before being recirculated into the pulmonary circulation. These shunts are normally compatible with life, but surgery or endovascular treatment may be necessary.


Anatomy_Gray

Anatomy_Gray. Rarely, a shunt is right-to-left. In isolation, this is fatal; however, this type of shunt is often associated with other anomalies, so some deoxygenated blood is returned to the lungs and the systemic circulation. In the clinic Auscultation of the heart reveals the normal audible cardiac cycle, which allows the clinician to assess heart rate, rhythm, and regularity. Furthermore, cardiac murmurs that have characteristic sounds within the phases of the cardiac cycle can be demonstrated (Fig. 3.81). In the clinic Classic symptoms of heart attack


Anatomy_Gray

Anatomy_Gray. In the clinic Classic symptoms of heart attack The typical symptoms are chest heaviness or pressure, which can be severe, lasting more than 20 minutes, and often associated with sweating. The pain in the chest (which may be described as an “elephant sitting on my chest” or by using a clenched fist to describe the pain [Levine sign]) often radiates to the arms (left more common than the right), and can be associated with nausea. The severity of ischemia and infarction depends on the rate at which the occlusion or stenosis has occurred and whether or not collateral channels have had a chance to develop. In the clinic Are heart attack symptoms the same in men and women?


Anatomy_Gray

Anatomy_Gray. In the clinic Are heart attack symptoms the same in men and women? Although men and women can experience the typical symptoms of severe chest pain, cold sweats, and pain in the left arm, women are more likely than men to have subtler, less recognizable symptoms. These may include abdominal pain, achiness in the jaw or back, nausea, shortness of breath, or simply fatigue. The mechanism of this difference is not understood, but it is important to consider cardiac ischemia for a wide range of symptoms. In the clinic The cardiac conduction system can be affected by coronary artery disease. The normal rhythm may be disturbed if the blood supply to the coronary conduction system is disrupted. If a dysrhythmia affects the heart rate or the order in which the chambers contract, heart failure and death may ensue. In the clinic Ectopic parathyroid glands in the thymus


Anatomy_Gray

Anatomy_Gray. In the clinic Ectopic parathyroid glands in the thymus The parathyroid glands develop from the third pharyngeal pouch, which also forms the thymus. The thymus is therefore a common site for ectopic parathyroid glands and, potentially, ectopic parathyroid hormone production. In the clinic Large systemic veins are used to establish central venous access for administering large amounts of fluid, drugs, and blood. Most of these lines (small-bore tubes) are introduced through venous puncture into the axillary, subclavian, or internal jugular veins. The lines are then passed through the main veins of the superior mediastinum, with the tips of the lines usually residing in the distal portion of the superior vena cava or in the right atrium. Similar devices, such as dialysis lines, are inserted into patients who have renal failure, so that a large volume of blood can be aspirated through one channel and reinfused through a second channel. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic Using the superior vena cava to access the inferior vena cava Because the superior and inferior venae cavae are oriented along the same vertical axis, a guidewire, catheter, or line can be passed from the superior vena cava through the right atrium and into the inferior vena cava. This is a common route of access for such procedures as: transjugular liver biopsy, transjugular intrahepatic portosystemic shunts (TIPS), and insertion of an inferior vena cava filter to catch emboli dislodged from veins in the lower limb and pelvis (i.e., patients with deep vein thrombosis [DVT]). In the clinic Coarctation of the aorta


Anatomy_Gray

Anatomy_Gray. In the clinic Coarctation of the aorta Coarctation of the aorta is a congenital abnormality in which the aortic lumen is constricted just distal to the origin of the left subclavian artery. At this point, the aorta becomes significantly narrowed and the blood supply to the lower limbs and abdomen is diminished. Over time, collateral vessels develop around the chest wall and abdomen to supply the lower body. Dilated and tortuous intercostal vessels, which form a bypass to supply the descending thoracic aorta, may lead to erosions of the inferior margins of the ribs. This can be appreciated on chest radiographs as inferior rib notching and is usually seen in long standing cases. The coarctation also affects the heart, which has to pump the blood at higher pressure to maintain peripheral perfusion. This in turn may produce cardiac failure. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic Diffuse atherosclerosis of the thoracic aorta may occur in patients with vascular disease, but this rarely produces symptoms. There are, however, two clinical situations in which aortic pathology can produce life-threatening situations. The aorta has three fixed points of attachment: the aortic valve, the ligamentum arteriosum, and the point of passing behind the median arcuate ligament of the diaphragm to enter the abdomen. The rest of the aorta is relatively free from attachment to other structures of the mediastinum. A serious deceleration injury (e.g., in a road traffic accident) is most likely to cause aortic trauma at these fixed points.


Anatomy_Gray

Anatomy_Gray. In certain conditions, such as in severe arteriovascular disease, the wall of the aorta can split longitudinally, creating a false channel, which may or may not rejoin into the true lumen distally (Fig. 3.91). This aortic dissection occurs between the intima and media anywhere along its length. If it occurs in the ascending aorta or arch of the aorta, blood flow in the coronary and cerebral arteries may be disrupted, resulting in myocardial infarction or stroke. In the abdomen the visceral vessels may be disrupted, producing ischemia to the gut or kidneys. In the clinic


Anatomy_Gray

Anatomy_Gray. In the clinic The normal aortic arch courses to the left of the trachea and passes over the left main bronchus. A right-sided aortic arch occurs when the vessel courses to the right of the trachea and passes over the right main bronchus. A right-sided arch of aorta is rare and may be asymptomatic. It can be associated with dextrocardia (right-sided heart) and, in some instances, with complete situs inversus (left-to-right inversion of the body’s organs). It can also be associated with abnormal branching of the great vessels, particularly with an aberrant left subclavian artery. In the clinic Abnormal origin of great vessels


Anatomy_Gray

Anatomy_Gray. In the clinic Abnormal origin of great vessels Great vessels occasionally have an abnormal origin, including: a common origin of the brachiocephalic trunk and the left common carotid artery, the left vertebral artery originating from the aortic arch, and the right subclavian artery originating from the distal portion of the aortic arch and passing behind the esophagus to supply the right arm—as a result, the great vessels form a vascular ring around the trachea and the esophagus, which can potentially produce difficulty swallowing. This configuration is one of the most common aortic arch abnormalities. In the clinic The vagus nerves, recurrent laryngeal nerves,


Anatomy_Gray

Anatomy_Gray. In the clinic The vagus nerves, recurrent laryngeal nerves, The left recurrent laryngeal nerve is a branch of the left vagus nerve. It passes between the pulmonary artery and the aorta, a region known clinically as the aortopulmonary window, and may be compressed in any patient with a pathological mass in this region. This compression results in left vocal cord paralysis and hoarseness of the voice. Lymph node enlargement, often associated with the spread of lung cancer, is a common condition that may produce compression. Chest radiography is therefore usually carried out for all patients whose symptoms include a hoarse voice.


Anatomy_Gray

Anatomy_Gray. More superiorly, in the root of the neck, the right vagus nerve gives off the right recurrent laryngeal nerve, which “hooks” around the right subclavian artery as it passes over the cervical pleura. If a patient has a hoarse voice and a right vocal cord palsy is demonstrated at laryngoscopy, chest radiography with an apical lordotic view should be obtained to assess for cancer in the right lung apex (Pancoast’s tumor). In the clinic When patients present with esophageal cancer, it is important to note which portion of the esophagus contains the tumor because tumor location determines the sites to which the disease will spread (Fig. 3.100). Esophageal cancer spreads quickly to lymphatics, draining to lymph nodes in the neck and around the celiac artery. Endoscopy or barium swallow is used to assess the site. CT and MRI may be necessary to stage the disease. Once the extent of the disease has been assessed, treatment can be planned. In the clinic


Anatomy_Gray

Anatomy_Gray. Once the extent of the disease has been assessed, treatment can be planned. In the clinic The first case of esophageal rupture was described by Herman Boerhaave in 1724. This case was fatal, but early diagnosis has increased the survival rate up to 65%. If the disease is left untreated, mortality is 100%. Typically, the rupture occurs in the lower third of the esophagus with a sudden rise in intraluminal esophageal pressure produced by vomiting secondary to an uncoordination and failure of the cricopharyngeus muscle to relax. Because the tears typically occur on the left, they are often associated with a large left pleural effusion that contains the gastric contents. In some patients, subcutaneous emphysema may be demonstrated. Treatment is optimal with urgent surgical repair. A 65-year-old man was admitted to the emergency room with severe central chest pain that radiated to the neck and predominantly to the left arm. He was overweight and a known heavy smoker.


Anatomy_Gray

Anatomy_Gray. A 65-year-old man was admitted to the emergency room with severe central chest pain that radiated to the neck and predominantly to the left arm. He was overweight and a known heavy smoker. On examination he appeared gray and sweaty. His blood pressure was 74/40 mm Hg (normal range 120/80 mm Hg). An electrocardiogram (ECG) was performed and demonstrated anterior myocardial infarction. An urgent echocardiograph demonstrated poor left ventricular function. The cardiac angiogram revealed an occluded vessel (Fig. 3.114A,B). Another approach to evaluating coronary arteries in patients is to perform maximum intensity projection (MIP) CT studies (Fig. 3.115A,B). This patient underwent an emergency coronary artery bypass graft and made an excellent recovery. He has now lost weight, stopped smoking, and exercises regularly.


Anatomy_Gray

Anatomy_Gray. When cardiac cells die during a myocardial infarction, pain fibers (visceral afferents) are stimulated. These visceral sensory fibers follow the course of sympathetic fibers that innervate the heart and enter the spinal cord between the TI and TIV levels. At this level, somatic afferent nerves from spinal nerves T1 to T4 also enter the spinal cord via the posterior roots. Both types of afferents (visceral and somatic) synapse with interneurons, which then synapse with second neurons whose fibers pass across the cord and then ascend to the somatosensory areas of the brain that represent the T1 to T4 levels. The brain is unable to distinguish clearly between the visceral sensory distribution and the somatic sensory distribution and therefore the pain is interpreted as arising from the somatic regions rather than the visceral organ (i.e., the heart; Fig. 3.114C). The patient was breathless because his left ventricular function was poor.


Anatomy_Gray

Anatomy_Gray. The patient was breathless because his left ventricular function was poor. When the left ventricle fails, it produces two effects. First, the contractile force is reduced. This reduces the pressure of the ejected blood and lowers the blood pressure. The left atrium has to work harder to fill the failing left ventricle. This extra work increases left atrial pressure, which is reflected in an increased pressure in the pulmonary veins, and this subsequently creates a higher pulmonary venular pressure. This rise in pressure will cause fluid to leak from the capillaries into the pulmonary interstitium and then into the alveoli. Such fluid is called pulmonary edema and it markedly restricts gas exchange. This results in shortness of breath. This man had a blocked left coronary artery, as shown in Fig. 3.114B. It is important to know which coronary artery is blocked.


Anatomy_Gray

Anatomy_Gray. This man had a blocked left coronary artery, as shown in Fig. 3.114B. It is important to know which coronary artery is blocked. The left coronary artery supplies the majority of the left side of the heart. The left main stem vessel is approximately 2 cm long and divides into the circumflex artery, which lies between the atrium and the ventricle in the coronary sulcus, and the anterior interventricular artery, which is often referred to as the left anterior descending artery (LAD). When the right coronary artery is involved with arterial disease and occludes, associated disorders of cardiac rhythm often result because the sinu-atrial and the atrioventricular nodes derive their blood supplies predominantly from the right coronary artery. When this patient sought medical care, his myocardial function was assessed using ECG, echocardiography, and angiography. During a patient’s initial examination, the physician will usually assess myocardial function.


Anatomy_Gray

Anatomy_Gray. During a patient’s initial examination, the physician will usually assess myocardial function. After obtaining a clinical history and carrying out a physical examination, a differential diagnosis for the cause of the malfunctioning heart is made. Objective assessment of myocardial and valve function is obtained in the following ways:


Anatomy_Gray

Anatomy_Gray. ECG/EKG (electrocardiography)—a series of electrical traces taken around the long and short axes of the heart that reveal heart rate and rhythm and conduction defects. In addition, it demonstrates the overall function of the right and left sides of the heart and points of dysfunction. Specific changes in the ECG relate to the areas of the heart that have been involved in a myocardial infarction. For example, a right coronary artery occlusion produces infarction in the area of myocardium it supplies, which is predominantly the inferior aspect; the infarct is therefore called an inferior myocardial infarction. The ECG changes are demonstrated in the leads that visualize the inferior aspect of the myocardium (namely, leads II, III, and aVF).


Anatomy_Gray

Anatomy_Gray. Chest radiography—reveals the size of the heart and chamber enlargement. Careful observation of the lungs will demonstrate excess fluid (pulmonary edema), which builds up when the left ventricle fails and can produce marked respiratory compromise and death unless promptly treated. Blood tests—the heart releases enzymes during myocardial infarction, namely lactate dehydrogenase (LDH), creatine kinase (CK), and aspartate transaminase (AST). These plasma enzymes are easily measured in the hospital laboratory and used to determine the diagnosis at an early stage. Further specific enzymes termed isoenzymes can also be determined (creatine kinase MB isoenzyme [CKMB]). Newer tests include an assessment for troponin (a specific component of the myocardium), which is released when cardiac cells die during myocardial infarction.


Anatomy_Gray

Anatomy_Gray. Exercise testing—patients are connected to an ECG monitor and exercised on a treadmill. Areas of ischemia, or poor blood flow, can be demonstrated, so localizing the vascular abnormality. Nuclear medicine—thallium (a radioactive X-ray emitter) and its derivatives are potassium analogs. They are used to determine areas of coronary ischemia. If no areas of myocardial uptake are demonstrated when these substances are administered to a patient the myocardium is dead. Coronary angiography—small arterial catheters are maneuvered from a femoral artery puncture site through the femoral artery and aorta and up to the origins of the coronary vessels. X-ray contrast medium is then injected to demonstrate the coronary vessels and their important branches. If there is any narrowing (stenosis), angioplasty may be carried out. In angioplasty tiny balloons are passed across the narrowed areas and inflated to refashion the vessel and so prevent further coronary ischemia and myocardial infarction.


Anatomy_Gray

Anatomy_Gray. A 53-year-old man presented to the emergency department with a 5-hour history of sharp pleuritic chest pain and shortness of breath. The day before he was on a long haul flight, returning from his holidays. He was usually fit and well and was a keen mountain climber. He had no previous significant medical history. On physical examination his lungs were clear, he was tachypneic at 24/min, and his saturation was reduced to 92% on room air. Pulmonary embolism was suspected and the patient was referred for a CT pulmonary angiogram. The study demonstrated clots within the right and left main pulmonary arteries. There was no pleural effusion, lung collapse, or consolidation. He was immediately started on subcutaneous enoxaparin and converted to oral anticoagulation over the course of a couple of days. The whole treatment lasted 6 months as no other risk factors (except immobilization during a long haul flight) were identified. There were no permanent sequelae.


Anatomy_Gray

Anatomy_Gray. The embolic material usually originates in the peripheral deep veins of the lower limbs and less commonly in the pelvic, renal, or upper limb deep veins. The material gets detached from the main thrombus in the deep veins and travels into the pulmonary circulation, where it can lodge either in the pulmonary trunk and main pulmonary arteries, giving rise to central pulmonary embolism or in the lobar, segmental, or subsegmental branches, giving rise to peripheral embolism. The gravity of symptoms is partly dependent on the thrombus load and on which part of the pulmonary arterial tree is affected. Large pulmonary embolisms can lead to severe hemodynamic and respiratory compromise and death (e.g., a saddle thrombus lodged in the pulmonary trunk and in both main pulmonary arteries). Common risk factors include immobilization, surgery, trauma, malignancy, pregnancy, oral contraceptives, and hereditary factors.


Anatomy_Gray

Anatomy_Gray. Common risk factors include immobilization, surgery, trauma, malignancy, pregnancy, oral contraceptives, and hereditary factors. A young man has black areas of skin on the tips of his fingers of his left hand. A clinical diagnosis of platelet emboli was made and a source of the emboli sought. Emboli can arise from many sources. They are clots and plugs of tissue, usually platelets, that are carried from a source to eventually reside in small vessels which they may occlude. Arterial emboli may arise in the heart or in the arteries that supply the region affected. In cases of infected emboli, bacteria grow on the valve and are showered off into the peripheral circulation. A neck radiograph and coronal CT image of the neck demonstrates a cervical rib (eFig. 3.116). Cervical ribs may produce three distinct disease entities:


Anatomy_Gray

Anatomy_Gray. A neck radiograph and coronal CT image of the neck demonstrates a cervical rib (eFig. 3.116). Cervical ribs may produce three distinct disease entities: Arterial compression and embolization—the cervical rib (or band) on the undersurface of the distal portion of the subclavian artery reduces the diameter of the vessel and allows eddy currents to form. Platelets aggregate and atheroma may develop in this region. This debris can be dislodged and flow distally within the upper limb vessels to block off blood flow to the fingers and the hand, a condition called distal embolization. Tension on the T1 nerve—the T1 nerve, which normally passes over rib I, is also elevated by the presence of a cervical rib; thus the patient may experience a sensory disturbance over the medial aspect of the forearm, and develop wasting of the intrinsic muscles of the hand. Compression of the subclavian vein—this may induce axillary vein thrombosis.


Anatomy_Gray

Anatomy_Gray. Compression of the subclavian vein—this may induce axillary vein thrombosis. A Doppler ultrasound scan revealed marked stenosis of the subclavian artery at the outer border of the rib with abnormal flow distal to the narrowing. Within this region of abnormal flow there was evidence of thrombus adherent to the vessel wall. This patient underwent surgical excision of the cervical rib and had no further symptoms. A 52-year-old man presented with headaches and shortness of breath. He also complained of coughing up small volumes of blood. Clinical examination revealed multiple dilated veins around the neck. A chest radiograph demonstrated an elevated diaphragm on the right and a tumor mass, which was believed to be a primary bronchogenic carcinoma. By observing the clinical findings and applying anatomical knowledge, the site of the tumor can be inferred.


Anatomy_Gray

Anatomy_Gray. By observing the clinical findings and applying anatomical knowledge, the site of the tumor can be inferred. The multiple dilated veins around the neck are indicative of venous obstruction. The veins are dilated on both sides of the neck, implying that the obstruction must be within a common vessel, the superior vena cava. Anterior to the superior vena cava in the right side of the chest is the phrenic nerve, which supplies the diaphragm. Because the diaphragm is elevated, suggesting paralysis, it is clear that the phrenic nerve has been involved with the tumor. A 35-year-old man was shot during an armed robbery. The bullet entry wound was in the right fourth intercostal space, above the nipple. A chest radiograph obtained on admission to the emergency room demonstrated complete collapse of the lung. A further chest radiograph performed 20 minutes later demonstrated an air/fluid level in the pleural cavity (eFig. 3.117).


Anatomy_Gray

Anatomy_Gray. A further chest radiograph performed 20 minutes later demonstrated an air/fluid level in the pleural cavity (eFig. 3.117). Three common pathological processes may occur in the pleural cavity. If air is introduced into the pleural cavity, a pneumothorax develops and the lung collapses because of its own elastic recoil. The pleural space fills with air, which may further compress the lung. Most patients with a collapsed lung are unlikely to have respiratory impairment. Under certain conditions, air may enter the pleural cavity at such a rate that it shifts and pushes the mediastinum to the opposite side of the chest. This is called tension pneumothorax and is potentially lethal, requiring urgent treatment by insertion of an intercostal tube to remove the air. The commonest causes of pneumothorax are rib fractures and positive pressure ventilation lung damage.


Anatomy_Gray

Anatomy_Gray. The pleural cavity may fill with fluid (a pleural effusion) and this can be associated with many diseases (e.g., lung infection, cancer, abdominal sepsis). It is important to aspirate fluid from these patients to relieve any respiratory impairment and to carry out laboratory tests on the fluid to determine its nature. Severe chest trauma can lead to development of hemopneumothorax. A tube must be inserted to remove the blood and air that has entered the pleural space and prevent respiratory impairment. This man needs treatment to drain either the air or fluid or both. The pleural space can be accessed by passing a needle between the ribs into the pleural cavity. In a normal healthy adult, the pleural space is virtually nonexistent; therefore, any attempt to introduce a needle into this space is unlikely to succeed and the procedure may damage the underlying lung.


Anatomy_Gray

Anatomy_Gray. Before any form of chest tube is inserted, the rib must be well anesthetized by infiltration because its periosteum is extremely sensitive. The intercostal drain should pass directly on top of the rib. Insertion adjacent to the lower part of the rib may damage the artery, vein, and nerve, which lie within the neurovascular bundle. Appropriate sites for insertion of a chest drain are either in the fourth or fifth intercostal space between the anterior axillary and midaxillary anatomical lines. This position is determined by palpating the sternal angle, which is the point of articulation of rib II. Counting inferiorly will determine the rib number and simple observation will determine the positions of the anterior axillary and midaxillary lines. Insertion of any tube or needle below the fifth interspace runs an appreciable risk of crossing the pleural recesses and placing the needle or the drain into either the liver or the spleen, depending upon which side the needle is inserted.


Anatomy_Gray

Anatomy_Gray. An elderly woman was admitted to the emergency room with severe cardiac failure. She had a left-sided pacemaker box, which had been inserted for a cardiac rhythm disorder (fast atrial fibrillation) many years previously. An ECG demonstrated fast atrial fibrillation. A chest radiograph showed that the wire from the pacemaker had broken under the clavicle. Anatomical knowledge of this region of the chest explains why the wire broke.


Anatomy_Gray

Anatomy_Gray. Anatomical knowledge of this region of the chest explains why the wire broke. Many patients have cardiac pacemakers. A wire arises from the pacemaker, which lies within the subcutaneous tissue over the pectoralis major muscle and travels from the pacemaker under the skin to pierce the axillary vein just beneath the clavicle, lateral to the subclavius muscle. The wire then passes through the subclavian vein, the brachiocephalic vein, the superior vena cava, and the right atrium, and lies on the wall of the right ventricle (where it can stimulate the heart to contract) (eFig. 3.118). If the wire pierces the axillary vein directly adjacent to the subclavius muscle, it is possible that after many years of shoulder movement the subclavius muscle stresses and breaks the wire, causing the pacemaker to fail. Every effort is made to place the insertion point of the wire as far laterally as feasible within the first part of the axillary vein.


Anatomy_Gray

Anatomy_Gray. A 20-year-old man visited his family doctor because he had a cough. A chest radiograph demonstrated translucent notches along the inferior border of ribs III to VI (eFig. 3.119). He was referred to a cardiologist and a diagnosis of coarctation of the aorta was made. The rib notching was caused by dilated collateral intercostal arteries. Coarctation of the aorta is a narrowing of the aorta distal to the left subclavian artery. This narrowing can markedly reduce blood flow to the lower body. Many of the vessels above the narrowing therefore enlarge due to the increased pressure so that blood can reach the aorta below the level of the narrowing. Commonly, the internal thoracic, superior epigastric, and musculophrenic arteries enlarge anteriorly. These arteries supply the anterior intercostal arteries, which anastomose with the posterior intercostal arteries that allow blood to flow retrogradely into the aorta. Enlargement of the intertcostal vessels results in notching of the ribs.


Anatomy_Gray

Anatomy_Gray. The first and second posterior intercostal vessels are supplied from the costocervical trunk, which arises from the subclavian artery proximal to the coarctation, so do not enlarge and do not induce rib notching. A 62-year-old man was admitted to the emergency room with severe interscapular pain. His past medical history indicated that he was otherwise fit and well; however, it was noted he was 6’ 9” and had undergone previous eye surgery for dislocating lenses. On examination the man was pale, clammy, and hypotensive. The pulse in his right groin was weak. An ECG demonstrated an inferior myocardial infarction. Serum blood tests revealed poor kidney function and marked acidosis. The patient was transferred to the CT scanner and a diagnosis of aortic dissection was made.


Anatomy_Gray

Anatomy_Gray. The patient was transferred to the CT scanner and a diagnosis of aortic dissection was made. Aortic dissection is an uncommon disorder in which a small tear occurs within the aortic wall (eFig. 3.120). The aortic wall contains three layers, an intima, a media, and an adventitia. A tear in the intima extends into the media and peels it away, forming a channel within the wall of the vessel. Usually the blood reenters the main vessel wall distal to its point of entry. The myocardial infarction Aortic dissection may extend retrogradely to involve the coronary sinus of the right coronary artery. Unfortunately, in this patient’s case the right coronary artery became occluded as the dissection passed into the origin. In normal individuals the right coronary artery supplies the anterior inferior aspect of the myocardium, and this is evident as an anterior myocardial infarct on an ECG. The ischemic left leg


Anatomy_Gray

Anatomy_Gray. The ischemic left leg The two channels within the aorta have extended throughout the length of the aorta into the right iliac system and to the level of the right femoral artery. Although blood flows through these structures it often causes reduced blood flow. Hence the reduced blood flow into the left lower limb renders it ischemic. The patient became acidotic.


Anatomy_Gray

Anatomy_Gray. The patient became acidotic. All cells in the body produce acid, which is excreted in the urine or converted into water with the production of carbon dioxide, which is removed with ventilation. Unfortunately, when organs become extremely ischemic they release significant amounts of hydrogen ions. Typically, this occurs when the gut becomes ischemic. With the pattern of dissection, (1) the celiac trunk, superior mesenteric artery, and inferior mesenteric artery can be effectively removed from the circulation or (2) the blood flow within these vessels can be significantly impeded, rendering the gut ischemic and hence accounting for the relatively high hydrogen ion levels. Similarly the dissection can impair blood flow to the kidneys, which decreases their ability to function.


Anatomy_Gray

Anatomy_Gray. Similarly the dissection can impair blood flow to the kidneys, which decreases their ability to function. The patient underwent emergency surgery and survived. Interestingly, the height of the patient and the previous lens surgery would suggest a diagnosis of Marfan syndrome, and a series of blood tests and review of the family history revealed this was so. A 35-year-old male patient presented to his family practitioner because of recent weight loss (14 lb over the previous 2 months). He also complained of a cough with streaks of blood in the sputum (hemoptysis) and left-sided chest pain. Recently, he noticed significant sweating, especially at night, which necessitated changing his sheets.


Anatomy_Gray

Anatomy_Gray. On examination the patient had a low-grade temperature and was tachypneic (breathing fast). There was reduced expansion of the left side of the chest. When the chest was percussed it was noted that the anterior aspect of the left chest was dull, compared to the resonant percussion note of the remainder of the chest. Auscultation (listening with a stethoscope) revealed decreased breath sounds, which were hoarse in nature (bronchial breathing). A diagnosis of chest infection was made. Chest infection is a common disease. In most patients the infection affects the large airways and bronchi. If the infection continues, exudates and transudates are produced, filling the alveoli and the secondary pulmonary lobules. The diffuse patchy nature of this type of infection is termed bronchial pneumonia. Given the patient’s specific clinical findings, bronchial pneumonia was unlikely.


Anatomy_Gray

Anatomy_Gray. Given the patient’s specific clinical findings, bronchial pneumonia was unlikely. From the clinical findings it was clear that the patient was likely to have a pneumonia confined to a lobe. Because there are only two lobes in the left lung, the likely diagnosis was a left upper lobe pneumonia. A chest radiograph was obtained (eFig. 3.121). The posteroanterior view of the chest demonstrated an area of veil-like opacification throughout the whole of the left lung. Knowing the position of the oblique fissure, any consolidation within the left upper lobe will produce this veil-like shadowing. Lateral radiographs are usually not necessary but would demonstrate opacification anteriorly and superiorly that ends abruptly at the oblique fissure. Upper lobe pneumonias are unusual because most patients develop gravity-dependent infection. Certain infections, however, are typical within the middle and upper lobes, commonly, tuberculosis (TB) and histoplasmosis.


Anatomy_Gray

Anatomy_Gray. A review of the patient’s history suggested a serious and chronic illness and the patient was admitted to hospital. After admission a bronchoscopy was carried out and sputum was aspirated from the left upper lobe bronchus. This was cultured in the laboratory and also viewed under the microscope and tuberculous bacilli (TB) were identified. A 68-year-old man came to his family physician complaining of discomfort when swallowing (dysphagia). The physician examined the patient and noted since his last visit he had lost approximately 18 lb over 6 months. Routine blood tests revealed the patient was anemic and he was referred to the gastroenterology unit. A diagnosis of esophageal cancer was made and the patient underwent a resection, which involved a chest and abdominal incision. After 4 years the patient remains well though still subject to follow-up.


Anatomy_Gray

Anatomy_Gray. The patient underwent a flexible endoscopic examination of the esophagus in which a tube is placed through the mouth and into the esophagus and a camera is placed on the end of the tube. It is also possible to use biopsy forceps to obtain small portions of tissue for adequate diagnosis. The diagnosis of esophageal carcinoma was made (squamous cell type) and the patient underwent a staging procedure. Staging of any malignancy is important because it determines the extent of treatment and allows the physician to determine the patient’s prognosis. In this case our patient underwent a CT scan of the chest and abdomen, which revealed no significant lymph nodes around the lower third esophageal tumor. The abdominal scan revealed no evidence of spread to the nodes around the celiac trunk and no evidence of spread to the liver. Bleeding was the cause of the anemia.


Anatomy_Gray

Anatomy_Gray. The abdominal scan revealed no evidence of spread to the nodes around the celiac trunk and no evidence of spread to the liver. Bleeding was the cause of the anemia. Many tumors of the gastrointestinal system are remarkably friable, and with the passage of digested material across the tumor, low-grade chronic bleeding occurs. Over a period of time the patient is rendered anemic, which in the first instance is asymptomatic; however, it can be diagnosed on routine blood tests. Complex surgery is planned.


Anatomy_Gray

Anatomy_Gray. Complex surgery is planned. The length of the esophagus is approximately 22 cm. Tumor spread can occur through the submucosal route and also through locoregional lymph nodes. The lymph nodes drain along the arterial supply to the esophagus, which is predominantly supplied by the inferior thyroid artery, esophageal branches from the thoracic aorta, and branches from the left gastric artery. The transthoracic esophagectomy procedure involves placing the patient supine. A laparotomy is performed to assess for any evidence of disease in the abdominal cavity. The stomach is mobilized, with preservation of the right gastric and right gastro-omental arteries. The short gastric vessels and left gastric vessels are divided, and a pyloromyotomy is also performed.


Anatomy_Gray

Anatomy_Gray. The abdominal wound is then closed and the patient is placed in the left lateral position. A right posterolateral thoracotomy is performed through the fifth intercostal space, and the azygos vein is divided to provide full access to the whole length of the esophagus. The stomach is delivered through the diaphragmatic hiatus. The esophagus is resected and the stomach is anastomosed to the cervical esophagus. The patient made an uneventful recovery. Most esophageal cancers are diagnosed relatively late and often have lymph node metastatic spread. A number of patients will also have a spread of tumor to the liver. The overall prognosis for esophageal cancer is poor, with approximately a 25%, 5-year survival rate. Diagnosing esophageal cancer in its early stages before lymph node spread is ideal and can produce a curative procedure. Our patient went on to have chemotherapy and enjoys a good quality of life 4 years after his operation.


Anatomy_Gray

Anatomy_Gray. Our patient went on to have chemotherapy and enjoys a good quality of life 4 years after his operation. A 45-year-old woman, with a history of breast cancer in the left breast, returned to her physician. Unfortunately the disease had spread to the axillary lymph nodes and bones (bony metastatic disease). A surgeon duly resected the primary breast tumor with a wide local excision and then performed an axillary nodal clearance. The patient was then referred to an oncologist for chemotherapy. Chemotherapy was delivered through a portacath, which is a subcutaneous reservoir from which a small catheter passes under the skin into the internal jugular vein. The patient duly underwent a portacath insertion without complication, completed her course of chemotherapy, and is currently doing well 5 years later.


Anatomy_Gray

Anatomy_Gray. The portacath was placed on the patient’s right anterior chest wall and the line was placed into the right internal jugular vein. The left internal jugular vein and subcutaneous tissues were not used. The reason for not using this site was that the patient had previously undergone an axillary dissection on the left, and the lymph nodes and lymphatics were removed. Placement of a portacath in this region may produce an inflammatory response and may even get infected. Unfortunately, because there are no lymphatics to drain away infected material and to remove bacteria, severe sepsis and life-threatening infection may ensue. How was it placed?


Anatomy_Gray

Anatomy_Gray. How was it placed? The ultrasound shows an axial image across the root of the neck on the right demonstrating the right common carotid artery and the right internal jugular vein. The internal jugular vein is the larger of the two structures and generally demonstrates normal respiratory variation, compressibility, and a size dependence upon the patient’s position (when the patient is placed in the head-down position, the vein fills and makes puncture easy). The risks of the procedure As with all procedures and operations there is always a small risk of complication. These risks are always balanced against the potential benefits of the procedure. Placing the needle into the internal jugular vein can be performed under ultrasound guidance, which reduces the risk of puncturing the common carotid artery. Furthermore, by puncturing under direct vision it is less likely that the operator will hit the lung apex and pierce the superior pleural fascia, which may produce a pneumothorax.