Parts of the subclavian artery along the course. Subclavian artery: structure. The importance of the subclavian artery

Subclavian artery, a. subclavia, steam room; subclavian arteries begin in the anterior mediastinum: right - from the brachiocephalic trunk, truncus brachio-cephalicus; left - directly from the aortic arch. Therefore, the left subclavian artery is longer than the right one: its intrathoracic part lies behind the left brachiocephalic vein, v. brachio-cephalica sinistra. The subclavian artery goes upward and laterally to the apertura thoracis superior, forming a slightly convex arc that goes around the dome of the pleura and the apex of the lung, leaving a slight depression on the latter (sulcus arteriae subclaviae). Having reached the 1st rib, the subclavian artery enters the interstitial space (spatium interscalenum), formed by the adjacent edges of the anterior and middle scalene muscles. In this interval, the artery lies on the 1st rib. Above it in the indicated interval is the brachial plexus. On the upper surface of the 1st rib, at the location of the artery, a groove is formed - a groove of the subclavian artery, sulcus a. subclaviae. Having rounded the 1st rib in the interstitial space, the subclavian artery lies under the clavicle and enters the axillary fossa, where it receives the name of the axillary artery, a. axillaris. Three sections are topographically distinguished in the subclavian artery: the first section is from the place of origin to the interstitial space, the second section is in the interstitial space, and the third is from the interstitial space to the upper opening of the axillary cavity, apertura superior cavi axillaris. Branches of the first division of the subclavian artery. In the first section from a. subclavia depart the following branches: vertebral artery, a. vertebralis, internal thoracic artery, a. thoracica interna, and the thyroid trunk, truncus thyrocervicalis.

1. Vertebral artery, a. vertebralis, departs from the subclavian artery immediately after it leaves the chest cavity. Starting from the upper medial wall of the subclavian artery, the vertebral artery goes upward and somewhat backward, located behind the common carotid artery along the outer edge of m. longus colli in the scala-vertebral triangle. Then it enters the transverse opening of the VI cervical vertebra and rises vertically upward through the openings of the same name in all cervical vertebrae. Having left the transverse opening of the II cervical vertebra, the vertebral artery turns outward and, approaching the transverse opening of the atlas, goes up and passes through it. Then it follows medially along sulcus a. vertebralis on the upper surface of the atlas, turns upward and, perforating the membrana atlantoocipitalis posterior and the dura mater, enters through the large occipital foramen into the cranial cavity into the subarachnoid space, cavum subarachnoideale. Heading into the cranial cavity to the clivus upwards and somewhat anteriorly, the left and right vertebral arteries converge, following the surface of the medulla oblongata, and at the posterior edge of the pons of the brain are connected to each other, forming one unpaired vessel - the basilar artery, a. basilaris. The latter, continuing its path along the clivus, is adjacent to the basilar groove, sulcus basilaris, the lower surface of the bridge and, at its anterior edge, is divided into two - right and left - posterior cerebral arteries. The posterior cerebral arteries, aa .. cerebri posteriores, first go outward, located above the cerebellum tenon, which separates them from the upper cerebellar arteries located below. Then they wrap back and up, go around the outer periphery of the legs of the brain and branch out on the basal and partly upper-lateral surface of the occipital and temporal lobes of the cerebral hemispheres. Further, they give branches to the indicated parts of the brain, as well as to the posterior perforated substance to the nodes of the large brain, the legs of the brain and the choroid plexus of the lateral ventricles: cortical branches, rr. corticales, temporal branches, rr. temporales, occipital branches, rr. occipitales, parietal-occipital branch, r. pa-rietooccipitalis, central branches, rr. centrales, and a villous branch, g. chorioideus (rami chorioidei post.).

The following branches depart from the vertebral artery:

a) Muscular branches to the prevertebral muscles of the neck.

b) Spinal branches, rr. spinales, depart from that part of the vertebral artery that passes through the foramina transversaria. They pass through the intervertebral foramens of the cervical vertebrae into the spinal canal, where they supply the spinal cord and its membranes with blood.

c) Posterior spinal artery, a. spinalis posterior (steam room), departs on each side of the vertebral artery in the cranial cavity, slightly above the foramen magnum. The artery goes down, enters the spinal canal and along the posterior surface of the spinal cord, along the line of entry of the posterior roots into it, reaches the region of the cauda equina, supplying the spinal cord and its membranes with blood. The posterior spinal arteries anastomose with each other, as well as with rr. spinales from the vertebral, intercostal and lumbar arteries.

d) Anterior spinal artery, a. spinalis anterior, starts from the vertebral artery above the anterior margin of the foramen magnum. The anterior spinal artery goes down, at the level of the decussation of the pyramids, decussatio pyramidum, connects with the artery of the same name on the opposite side, forming one unpaired vessel. The latter descends along the anterior median fissure, fissura mediana anterior, of the spinal cord and ends in the region of the filum terminale, filum terminale, supplies the spinal cord and its membranes and anastomoses with rr. spinales from the vertebral, intercostal and lumbar arteries.

e) Posterior inferior cerebellar artery, a. cerebelli inferior posterior, branches in the lower posterior part of the cerebellar hemispheres.

e) Anterior inferior cerebellar artery, a. cerebelli inferior anterior, - the last branch of the vertebral artery, can also depart from a. basilaris. It supplies blood to the anteroinferior part of the cerebellum.

The following branches depart from the basilar artery:

a) Labyrinth artery, a. labyrinthi, goes through the porus and meatus acustici interni along with the vestibulocochlear nerve, n. vestibulocochlearis, to the inner ear.

b) Bridge branches, rr. adpontem, enter the substance of the bridge.

c) Superior cerebellar artery, a. cerebelli superior, starts from the basilar artery, a. basilaris, at the anterior edge of the bridge, goes out and back around the legs of the brain and branches in the region of the upper surface of the cerebellum and in the choroid plexus of the third ventricle.

2. Internal thoracic artery, a. thoracica interim, starts from the lower surface of the subclavian artery just at the level of the origin of the vertebral artery, a. vertebralis; heading down a. thoracica intema passes behind the subclavian vein, enters through the apertura thoracis superior into the chest cavity and descends parallel to the edge of the sternum along the posterior surface of the cartilages of I-VII ribs, being covered with m. transversus thoracis and the parietal pleura. At the level of the VII rib a. thoracica interna is divided into the musculophrenic artery, a. musculophrenica, and the superior epigastric artery, a. epigastric superior.

a) Muscular-phrenic artery, a. musculophrenica, runs along the costal arch along the line of attachment of the costal part of the diaphragm to the chest. The artery gives branches to the diaphragm, abdominal muscles, as well as the anterior intercostal branches, rr. intercostales anteriores, which number 5 are sent to the lower intercostal space.

b) Superior epigastric artery, a. epigastrica superior, follows downward, pierces the posterior wall of the sheath of the rectus abdominis muscle, is located on the posterior surface of this muscle and anastomoses with the inferior epigastric artery at the level of the navel, a. epigastrica inferior (branch of the external iliac artery, a. iliaca extema). The superior epigastric artery sends branches to the rectus abdominis and its vagina, as well as the falciform ligament of the liver and the skin of the umbilical region. In addition to these two large branches, the following branches depart from the internal thoracic artery: pericardial-phrenic artery, a. pericardiocophrenica, begins at the level of the 1st rib and follows along with the phrenic nerve, n. phrenicus, to the diaphragm, sending branches along the way to the pericardium, branches of the thymus gland, rr. thy mid, - to the thymus; mediastinal branches, rr. mediastinaies, - in. anterior mediastinum, bronchial branches, rr. bronchiales, - to the terminal section of the trachea and bronchi; sternal branches, rr. sternales, - to the back of the sternum; perforating branches, rr. perforantes, which perforate 6-7 upper intercostal spaces and give branches to the pectoralis major and minor muscles, as well as to the mammary gland; anterior intercostal branches, rr. intercostales anteriores, two each go to the upper intercostal space, where they, following along the upper and lower edges of the ribs, anastomose with the posterior intercostal arteries, aa .. intercostales posteriores, from the thoracic aorta. Intercostal branches running along the lower edges of the ribs are more developed.

3. The thyroid trunk, trwcus thyrocervicaiis, departs from the anterior superior surface of the subclavian artery before it enters the interstitial space. The thyroid trunk is up to 1.5 cm long.

Moving away from the subclavian artery, it immediately divides into the following branches:

a) Inferior thyroid artery, a. thyroidea inferior, goes up and medially along the anterior surface of the anterior scalene muscle, behind the internal jugular vein and common carotid artery. Having formed an arc at the level of the VI cervical vertebra, it approaches the posterior surface of the lower part of the lateral lobe of the thyroid gland. Here the artery gives glandular branches, rr, into the substance of the gland. glandulares, and also sends tracheal branches, rr. tracheales, - to the trachea, esophageal branches, rr. esophagei, - to the esophagus and pharynx and the lower laryngeal artery, a. laryngea inferior, - to the larynx. The lower laryngeal artery enters the wall of the larynx, where it forms an anastomosis with the superior laryngeal artery, a. laryngea superior, originating from the superior thyroid artery.

b) Ascending cervical artery, a. cervicalis ascendens, follows up the anterior surface of the anterior scalene muscle and the muscle that lifts the scapula, located medially from the phrenic nerve.

The ascending cervical artery gives:

1. muscle branches to the prevertebral muscles and to the deep muscles of the occiput;
2. spinal branches, rr. spines.

c) The superficial branch (superficial cervical artery), g. superficialis (a. cervicalis super ficialfs, variant), follows in the lateral direction in front of the anterior scalene muscle, the brachial plexus and the muscle that lifts the scapula. In the outer part of the lateral triangle of the neck, the artery hides under the trapezius muscle, supplies it with blood, and also sends branches to the skin and lymph nodes of the supraclavicular region.

d) Suprascapular artery, a. suprascapularis, goes outward and somewhat downward, located behind the clavicle, in front of the anterior scalene muscle. Then the artery along the lower abdomen m. omohyoideus reaches the notch of the scapula and passes over the superior transverse ligament of the scapula into the supraspinatus fossa. Here the artery gives off branches to sh. supraspinatus, after which it goes around the neck of the scapula and enters the infraspinatus fossa, where it sends branches to the muscles lying here and anastomoses with the artery that surrounds the scapula, a. circumflexa Scapulae. Branches of the second division of the subclavian artery. In the second section, only one branch departs from the subclavian artery - the costocervical trunk, truncus costocervicalis.

Costocervical trunk, truncus costocervicalis, begins in the interstitial space from the posterior surface of the subclavian artery and, following backwards, immediately divides into the following two branches.

1. Deep cervical artery, a. cervicalis profunda, goes back and slightly upward, passes under the neck of the 1st rib, goes into the neck area and follows up to the 2nd cervical vertebra, supplying blood to the deep muscles of the back of the neck, and also sending branches to the spinal cord into the spinal canal. Its branches anastomose with branches from a. vertebralis, a. cervicalis ascendens and from a. occipitalis.
2. The superior intercostal artery, a. intercostalis suprema, goes down, crosses the anterior surface of the neck of the I, and then the II ribs and sends the posterior intercostal arteries (I and II) to the first and second intercostal spaces. aa.. intercostales posteriores I et II. The latter, following in the intercostal spaces, are connected to the anterior intercostal branches a. thoracica interna.

From the superior intercostal artery depart:

a) spinal branches, rr. spinales, and

b) posterior branches, rr. dorsales, to the muscles of the back.

Branches of the third division of the subclavian artery. In the third section, only one branch departs from the subclavian artery - the transverse artery of the neck. Transverse artery of the neck. a. transversa colli, starts from the subclavian artery, after its exit from the interstitial space. The artery goes back and outward, passes between the branches of the brachial plexus and, bypassing the middle and posterior scalene muscles, lies under the muscle that lifts the scapula.

Here, at the upper angle of the scapula, the transverse artery of the neck divides into superficial and deep branches.

a) Superficial cervical artery, a. cervicalis superficialis, goes up between the muscle that lifts the scapula and the belt muscle of the neck, supplies blood to these muscles, as well as a number of others.

b) Descending scapular artery, a. scapularis descendens, follows down under the rhomboid muscles and, located along the medial edge of the scapula between the attachment of mm. rhom-boidei and m. serratus anterior, reaches the latissimus dorsi. The artery supplies the indicated muscles, as well as the skin of this area, and anastomoses with the terminal part of the thoracic artery, a. thoracodorsalis.

SUBCLAVIAN ARTERY [arteria subclavia(PNA, JNA, BNA)] - a large vessel that supplies blood to the occipital lobes of the cerebral hemispheres, the medulla oblongata, the cerebellum, the cervical spine and spinal cord, the deep muscles of the neck, partially the organs of the neck, the shoulder girdle and the upper limb.

Anatomy

Both P. a. begin in the upper mediastinum: right P. a. - from the brachiocephalic trunk (truncus brachiocephalicus), and the left one - directly from the aortic arch; therefore, it is longer than the right one and its intrathoracic part lies behind the left brachiocephalic vein (Fig. 1). P. a. pass upward and laterally, forming a slightly convex arc, around the edges of the dome of the pleura and the apex of the lung. Having reached the 1st rib, P. a. penetrates into the interstitial space (spatium interscalenum), formed by the adjacent edges of the anterior and middle scalene muscles. In the interstitial space, the artery lies on the 1st rib. Having rounded at the exit from the interstitial space I rib, P. a. passes under the collarbone and enters the axillary fossa (see), where it passes into the axillary artery (a. axillaris).

For orientation in localization of P.'s damages and. and a choice of rational operational access to it conditional division of P. is recommended and. into three sections: 1) intrathoracic - from the beginning of the vessel to the inner edge of the anterior scalene muscle, 2) interscalene - from the inner to the outer edge of the anterior scalene muscle, 3) clavicular - from the outer edge of the anterior scalene muscle to the outer edge of the 1st rib. P.'s trunks and. are stable in position. Of practical importance are options for the variability of the position of P. a., associated with the presence of an additional cervical rib.

P.'s trunks and. in the second and third sections they have a symmetrical arrangement and are projected from both sides to the middle of the clavicle. The bifurcation of the brachiocephalic trunk is usually projected in the region of the upper edge of the right sternoclavicular joint.

According to V. V. Kovanov and T. I. Anikina (1974), the angle of departure of the left P. a. in 90% of cases it does not exceed 90°, and the right one in 88% is equal to 30-60°. It is noted that the diameter of the right P. a. more than the left - in 72% of cases it is 10-12 mm, while the left in 62% is 7-9 mm.

In the first department on the right to the anterior wall of P. a. the right venous angle is adjacent, often intimately soldered by the fascia with P. a.; here the artery is crossed by the vagus and phrenic nerves passing in front of it. The recurrent laryngeal nerve lies behind this area, and medially, the common carotid artery originates (see). Such a syntopy of vessels and nerves in this area creates significant difficulties during operations on P. a. On the left ahead of P. a. the left brachiocephalic vein and the thoracic duct are located (see). The nerves on the left do not cross P. a., but run parallel. In the first department from P. and. the following branches depart (Fig. 2): vertebral artery (a. vertebralis), internal thoracic (a. thoracica int.) and thyroid trunk (truncus thyreocervicalis). The vertebral artery departs from P. and. directly at the place of its exit from the chest cavity and goes up, located behind the common carotid artery, along the long muscle of the neck (m. longus colli), where it enters the transverse opening of the VI cervical vertebra. The internal thoracic artery (a. thoracica int.) starts from the lower surface of P. a. at the level of origin of the vertebral artery. Heading down, the internal thoracic artery passes behind the subclavian vein, enters the chest cavity and, being covered with the transverse muscle of the chest (m. transversus thoracis) and the parietal pleura, descends parallel to the edge of the sternum along the back surface of the cartilages I - VII ribs. The thyroid trunk departs from the anteroposterior surface of P. a. before its entry into the interstitial space; it has a length of 1.5 cm and is immediately divided into the following branches: the lower thyroid artery (a. thyreoidea inf.); ascending cervical artery (a. cervicalis ascendens); superficial branch (g. superficialis) or superficial cervical artery (a. cervicalis superficialis); suprascapular artery (a. suprascapularis), passing along the anterior surface of the anterior scalene muscle.

In the second section from P. a., from its posterior surface, only one branch departs - the costal-cervical trunk (truncus costocervicalis), which begins in the interstitial space of P. a. and soon divides into two branches: the deep cervical artery (a. cervicalis profunda) and the highest intercostal artery (a. intercostalis suprema).

In the third department from P. and. after its exit from the interstitial space, only one branch also departs - the transverse artery of the neck (a. transversa colli), which is divided into two branches: ascending and descending.

Research methods

Research methods at various defeats of P. and. the same as other blood vessels (see Blood vessels, research methods). A wedge is widely used, methods - determining the degree of ischemic disorders in the upper limb (discoloration and venous pattern of the skin, trophic disorders, etc.), as well as palpation and auscultation of the vessel lesion area (absence of a pulse in peripheral vessels, the appearance of systolic or continuous noise, etc. .). Evaluation of functions, the state of collateral circulation in case of damage to P. a. carried out on the basis of samples of Henle, Korotkov, etc. (see Vascular collaterals). Instrumental studies (thermoplethysmo-, oscillo-, rheovasography, flowmetry, ultrasonic dopplegraphy, etc.) make it possible to objectively study hemodynamics in the P. pool and. Contrasting rentgenol, methods allow to detect the nature of patol, changes in the vessel (partial or complete occlusion, violation of integrity, the nature of the aneurysm, the size of the aneurysmal sac, the ways of inflow and outflow of blood in it, etc.), as well as to objectively study the existing ways of collateral circulation. Rarely used radioisotope angiography (see).

Pathology

Developmental defects. Along with the angiodysplasias inherent in all blood vessels (see. Blood vessels, malformations), a significant role in disturbance of blood supply of P. and. play various anomalies. So, some anomalies of P.'s discharge and. cause a prelum of a gullet, a cut is found out radiologically in the form of a triangular defect of its filling (fig. 3). Clinically, this is manifested by a constant difficulty in passing food through the esophagus. Occasionally there is patol, tortuosity of the right P. a., accompanied by ischemic disorders in the upper limb (weakening of the pulse on the radial artery, decreased sensitivity, periodic pain in the muscles of the arm, especially during exercise). The same symptomatology is observed in the presence of additional, or so-called. cervical, ribs, with syndromes of large and small pectoral muscles, accompanied by compression of the lumen of P. a. Treatment is usually surgical. The prognosis is favorable.

Damage P. a. are the most common type of her pathology. Extremely seldom at a prelum of a thorax P.'s separation is observed and. from the aorta (usually in combination with damage to the spine, main bronchus, lung, etc.). A complete interruption of the subclavian vessels, the brachial plexus occurs when the entire upper limb is torn off along with the scapula. Such an injury, observed when: getting a hand into a rotating device, usually leads to the development of shock (see); due to a drop in ADH, the closure of the lumen of the ends of the artery: and the vein with crushed edges of their walls may not cause severe bleeding.

P.'s wounds and. in the Great Patriotic War of 1941 - 1945. accounted for 1.8% of the total number of injuries of the main arteries, and in 30.3% of cases there was also a simultaneous injury to the nerves. According to B. V. Petrovsky, with wounds P. a. damage to the lungs and pleura was observed in 77% of cases. More than Vg wounds P. a. were combined with gunshot fractures of bones - the collarbone, ribs, humerus, scapula, etc. Approx. 75% of damage to the subclavian vessels accounted for injuries only to the artery, the simultaneous injury of the subclavian artery and vein was approx. 25%; external bleeding at wound only P. and. was observed in 41.7% of cases, with a combined injury of the artery and vein in 25.8%. The resulting internal bleeding (into the pleural cavity) ended, as a rule, with a fatal outcome. Damages of various departments of P. and. have some features. So, wounds in the first section of P. a., often together with a vein, are the most life-threatening. At damages of the left P. and. sometimes there is also an injury and the thoracic duct (see); damages in the second department more often., than defeats in other departments, are followed by a trauma of a brachial texture (see). Pulsating hematoma (see) after P.'s wounds and. developed in 17.5% of cases.

In peacetime, according to the statistics of specialized clinics of the Military Medical Academy, P.'s wounds and. account for 4% of injuries of all arteries, in 50% of cases they are combined with damage to the brachial plexus. Variety of the combined damages of P. and. and other anatomical formations causes the following features of their wedge, manifestations. 1. Threatening massive primary bleeding (see), especially when the vessel is injured in the first section. 2. Frequent arrosive bleeding, the cause of which is suppuration of the wound channel, damage to the walls of the vessel by fragments of shells, bone fragments, osteomyelitis, with pulsating hematomas P. a. can lead to rapid death of the victim. 3. The constant possibility of rupture of the arterial aneurysmal sac, requiring careful monitoring of all changes in its size (the sudden increase in the sac is a reliable and objective sign of rupture) and hemodynamics. 4. Formed aneurysm P. a. manifested by classical signs (see Aneurysm): the appearance of systolic (with arterial) or continuous systolic-diastolic (with arteriovenous) noise, disappearing with compression of the proximal end; change in pulse on the radial artery; the appearance of an arteriovenous aneurysm of an expanded venous pattern on the arm, shoulder girdle, chest wall, including in the subclavian region (see); a progressive increase in autonomic disorders (impaired sweating, trophism of the skin, nails, hair growth, etc.), especially in the presence of paresis, paralysis and other phenomena of damage to the brachial plexus (see). With arteriovenous aneurysm, which has arisen due to the constant discharge of arterial blood into the venous bed, patol, blood circulation causes an increased load on the myocardium with the development of cardiac decompensation. Yu. Yu. Dzhanelidze found that in the pathogenesis and dynamics of its development, the so-called. fistulous circle, i.e., the distance between the aneurysmal sac and the cavities of the heart; the shorter it is (especially when the aneurysm is localized on P. a., carotid arteries), the faster cardiac decompensation occurs.

For all types of damage to P. a., if there is no self-stopping of bleeding or self-healing of the aneurysm, surgery is indicated.

Diseases. P.'s inflammatory process and. - arteritis (see), aortoarteritis - is clinically shown by an occlusive syndrome (see. Obliterating defeats of vessels of extremities), arises as a result of hl. arr. atherosclerosis. A diffuse lesion of the vessel is possible, but the most common variant is occlusion of the first section of P. a. At the same time, signs of ischemia of the hand develop, and with occlusion and vertebral artery - symptoms of insufficient blood supply to the brain: headache, dizziness, staggering, nystagmus (see), etc. With contrast rentgenol. the study reveals the absence of a contrast agent in the lumen of the vessel, a break in its shadow at the level of the mouth or a pronounced stenosis with a distally located post-stenotic expansion (Fig. 4). So called. scalene muscle syndrome is a consequence of cicatricial-inflammatory processes in the tissue of the interstitial space of the neck. It leads to P.'s occlusion and. in the second department with a typical wedge, a picture of an ischemia of a hand (see. Scalene muscle a syndrome). Sclerotic and mycotic (inf. of nature or embolic) aneurysms of P. and are rather rare. Unlike usual atherosclerotic occlusions, at to-rykh morfol, changes occur generally in an internal cover of a vessel, at sclerotic aneurysms the elastic framework of an artery wall collapses that promotes its saccular expansion (fig. 5).

Mycotic aneurysms of P. and. more often occur with various heart diseases (rheumatism, endocarditis, etc.), localized in the peripheral parts of the vessel. Their aneurysmal sac is filled with a thrombotic mass, from which the same microflora can be sown as from the cavities of the heart.

Acute thromboembolism P. a. usually accompanied by mitral valve stenosis complicated by left atrial thrombosis, atherosclerosis, scalene syndrome. They begin suddenly and are characterized by the rapid development of ischemia of the hand: cold and marble

pallor of the skin of the arm, muscle pain, impossibility of active movements, disappearance of the pulse on the brachial and radial arteries (see Thromboembolism).

Treatment of P.'s diseases and. conservative (see. Obliterating lesions of the vessels of the extremities, treatment) and operational.

Operations

Indications for surgery are bleeding, rupture of a pulsating hematoma or aneurysmal sac, stenosis or occlusion of P. a. with progressive ischemic and neurological disorders of the hand, and with lesions of the vertebral artery - brain disorders (see Brain, operations). As a rule, various operations are simultaneously performed on the nerves of the brachial plexus and its trunks - neurolysis (see), restorative operations, primarily the nerve suture (see).

Inflammatory processes on the skin in the area of ​​the surgical field may be a contraindication (see).

Anesthesia: usually one of the types of inhalation anesthesia (see), Neuroleptanalgesia (see), while, according to indications, controlled hypotension is used at certain stages of the intervention (see Artificial hypotension); less commonly used local anesthesia (see Local Anesthesia).

More than 20 operational accesses to P. are described and. The most common are the classical section, sections according to Lexer, Reich, Dobrovolskaya, Petrovsky, Akhutin, Dzhanelidze, and others (Fig. 6). Since the mid 70s. for access to the first department of P. and. began to widely use thoracotomy (see) in combination with sternotomy (see Mediastinotomy), for access to the second section - supra- and subclavian incisions (usually the clavicle does not intersect).

In the mid 70s. at limited stenoses of an atherosclerotic origin began to apply P.'s dilatation and. special catheters (see X-ray endovascular surgery). Outcomes of operations on P. and. depend not only on the intervention on the vessel, but no less on the nature of the operation on the brachial plexus and its trunks.

Bibliography: Vishnevsky A. A. and Galankin N. K. Congenital heart defects and large vessels, M., 1962; Vishnevsky A. A., Krakovsky N. I. and 3olotorevsky V. Ya. Obliterating diseases of the arteries of the extremities, M., 1972; Knyazev M. D., Mirza-Avakyan L. G. and Belorusov O. S. Acute thrombosis and embolism of the main arteries of the extremities, Yerevan, 1978; Kovanov V.V. and AnikinaT. I. Surgical anatomy of arteries of the person, M., 1974, bibliogr.; Lytkin M. I. and Kolomiets V. P. Acute trauma of the main blood vessels, L., 1973; Multivolume guide to surgery, ed. B. V. Petrovsky, vol. 10, p. 416, M., 1964; Experience of the Soviet medicine in the Great Patriotic War of 1941-4945, v. 19, M., 1955; Ostroverkhov G. E., Lubotsky D. N. and Bomash Yu. M. Operative surgery and topographic anatomy, p. 158, 375, Moscow, 1972; Petrovsky BV Surgical treatment of vascular wounds, M., 1949; Petrovsky B. V. and Milonov O. B. Surgery of aneurysms of peripheral vessels, M., 1970; Pokrovsky A. V. Clinical angiology, M., 1979; Guide to angiography, ed. P.I. X. Rabkina, M., 1977; Saveliev V. S. et al. Angiographic diagnosis of diseases of the aorta and its branches, M., 1975; Sinelnikov R. D. Atlas of human anatomy, t. 2, p. 286, 302, M., 1979; Emergency surgery of the heart and blood vessels, ed. M. E. De Beki and B. V. Petrovsky. Moscow, 1980. Hardy J. D. Surgery of the aorta and its branches, Philadelphia, 1960; R i with h N. M. a. Spencer F. C. Vascular trauma, Philadelphia, 1978; The surgical management of vascular diseases, ed. by H. Haimovici, Philadelphia, 1970.

G. E. Ostroverkhov (an.), M A. Korendyaeev (hir.).

Subclavian artery (a. subclavia) - a large paired vessel, is part of the subclavian neurovascular bundle of the neck, which is formed by the subclavian artery, subclavian vein and brachial plexus.

The right subclavian artery departs from the brachiocephalic trunk (truncus brachiocephalicus), the left - directly from the aortic arch (arcus aortae), so the left one is 4 cm longer than the right one. Three sections are distinguished along the course of the subclavian artery and according to its relationship with the anterior scalene muscle.

On its way, the subclavian artery passes along with the brachial plexus through the spatium interscalenum, formed by the adjacent surfaces of the anterior and middle scalene muscles, and passes along the 1st rib into sulcus a. subclaviae. Therefore, 3 sections are topographically distinguished in the subclavian artery: the first section - from the place of origin of the artery to the inner edge of the anterior scalene muscle (m. scalenus ant.) in the scale-vertebral gap (spatium scalenovertebrale), the second - limited by the limits of the interscalene gap (spatium interscalenum) and the third - from the outer edge of the anterior scalene muscle to the middle of the clavicle, where the subclavian artery passes into the axillary (a. axillaris). In the third section, the subclavian artery can be pressed against the I rib behind tuberculum m to stop bleeding. scaleni.

The 1st subclavian artery gives three important branches:

vertebral (a. vertebralis), thyroid trunk (truncus thyrocervicalis), internal thoracic artery (a. thoracica interna). As well as branches from the thyroid trunk (truncus thyreocervicalis): the lower thyroid artery (a. thyroidea inferior), and its branch - the ascending cervical artery (a. cervicalis ascendens), superficial cervical artery (a. cervicalis superficialis), suprascapular artery (a. suprascapularis). The suprascapular artery (a. suprascapularis) is involved in the formation of the scapular arterial circle.

The 2nd division of the subclavian artery gives branches: the costocervical trunk (truncus costocervicalis) and its branches: the uppermost intercostal artery (a. intercostalis suprema), and the deep cervical artery (a. cervicalis profunda), penetrating into the muscles of the back of the neck.

The third section of the subclavian artery is located in the outer triangle of the neck, here the transverse artery of the neck (a. transversa colli) departs from the artery, which perforates the plexus brachialis, supplies neighboring muscles and descends along the medial edge of the scapula to its lower angle. All elements of the subclavian neurovascular bundle are connected together to pass into the axillary fossa on the upper limb.

Shoulder plexus.

The brachial plexus, plexus brachialis, is composed of the anterior branches of the four lower cervical nerves and most of the first thoracic; often a thin branch from C111 joins. The brachial plexus exits through the gap between the anterior and middle scalene muscles into the supraclavicular fossa, located above and behind a. subclavia. Three thick nerve bundles arise from it, going into the axillary fossa and surrounding a. axillaris from three sides: from the lateral (lateral bundle), medial (medial bundle) and posterior to the artery (posterior bundle). In the plexus, the supraclavicular (pars supraclavicularis) and subclavian (pars infraclavicularis) parts are usually distinguished. Peripheral branches are divided into short and long. Short branches depart in various places of the plexus in its supraclavicular part and partly supply the muscles of the neck, as well as the muscles of the girdle of the upper limb (with the exception of m. trapezius) and the shoulder joint. Long branches originate from the above three bundles and run along the upper limb, innervating its muscles and skin. Projection of the brachial plexus: the patient's head is turned in the opposite direction from the surgeon and is taken up. The projection corresponds to the line connecting the border between the middle and lower thirds of the posterior edge of the sternocleidomastoid muscle with the middle of the upper edge of the clavicle.

Ticket 78

1. Topography of the outer triangle of the neck: boundaries, external landmarks, layers, fascia and cellular spaces, vessels and nerves. 2. Scapular-clavicular triangle. 3. Vascular - nerve bundle of the outer triangle. 4. Scapular - trapezoid triangle. 5. Vascular - nerve formations. 6. Projection on the skin of the subclavian artery, operative access to the artery according to Petrovsky.

1. Topography of the outer triangle of the neck: boundaries, external landmarks, layers, fascia and cellular spaces, vessels and nerves.

Borders: in front of the lateral (rear) edge m. sternocleidomastoideus, behind - the anterior edge of the trapezius muscle (musculus trapezius), below - the clavicle (clavicula).

By the lower abdomen, the scapular-hyoid muscle (m. omohyoideus) divides the lateral region into two triangles: the larger scapular-trapezoid triangle (trigonum omotrapezoideum) and the smaller scapular-clavicular triangle (trigonum omoclaviculare).

External landmarks that form the boundaries of the area. An important landmark is the posterior edge of the sternocleidomastoid muscle, m. sternocleidornastoideus, clearly visible, especially when turning the head in the opposite direction, as well as the anterior edge of the trapezius muscle - the back. The clavicle limits the area from below.

2. Scapular-clavicular triangle (trigonum omoclaviculare).

Borders: triangle, the lower border is the clavicle, the front is the posterior edge of the sternocleidomastoid muscle, the upper-posterior border is the projection line of the lower abdomen of the scapular-hyoid muscle (m. omohyoideus).

External landmarks: large supraclavicular fossa, fossa supraclavicularis major.

Layers and fasciae: Skin, subcutaneous fat, fascia. The skin of the scapular-clavicular triangle is thin and mobile. The superficial fascia and platysma of the scapular-clavicular triangle cover the entire triangle, as does the superficial lamina of the fascia of the neck (2nd fascia). Between the 1st and 2nd fascia in the lower part of the scapular-clavicular triangle, along the posterior edge of the sternocleidomastoid muscle, passes v. jugularis externa. It perforates the 2nd and 3rd fascia and flows into the confluence angle of the subclavian and internal jugular veins or the common trunk with the internal jugular vein into the subclavian. The adventitia of the vein is associated with the fascia that it perforates, so it gapes when injured. In this case, along with heavy bleeding, an air embolism is also possible. The pretracheal plate of the fascia of the neck (3rd fascia) is located below m. omohyoideus, behind the 2nd fascia of the neck. Together with her, she is attached to the collarbone. Behind the 3rd fascia in the scapular-clavicular triangle is an abundant layer of fatty tissue containing the supraclavicular lymph nodes. There is no 4th fascia in this scapular-clavicular triangle. The 5th fascia is prevertebral, poorly developed and forms a sheath for the neurovascular bundle.

TOTAL FASCIA IN THE BULDOCLAVIC TRIANGLE: 1, 2, 3, X, 5.

Cell gap: cellular space of the scapular-clavicular triangle (spatium omoclaviculare) .

3. Vascular - nerve bundle of the scapular - clavicular triangle

Between the 3rd and the 5th fascia lying behind it, the subclavian vein passes, heading from the middle of the clavicle to the prescalene space. In it, between the 1st rib and the clavicle, the walls of the subclavian vein are firmly fused with the fascial sheath of the subclavian muscle and the fasciae of the neck. Thanks to the fixed position, the subclavian vein is available here for punctures and percutaneous catheterization. Sometimes, with sudden movements of the arm during heavy physical exertion, the subclavian vein can be compressed between the clavicle and the subclavian muscle and the 1st rib, followed by the development of acute thrombosis of both the subclavian and axillary veins (Paget-Schretter syndrome). Clinical manifestations of the syndrome are edema and cyanosis of the limb. A pronounced pattern of veins is determined on the shoulder and anterior surface of the chest.

In the scapular-clavicular triangle, under the 5th fascia, partly above the clavicle, there are 3 arteries: a. suprascapularis, a. cervicalis superficialis and a. transversa colli, and the superficial cervical and suprascapular arteries run behind the upper edge of the clavicle anteriorly and below the trunks of the supraclavicular part of the brachial plexus plexus brachialis, and the transverse artery of the neck passes between the trunks of this plexus. The subclavian artery and the brachial plexus pass into the scapular-clavicular triangle from the interstitial space. The 5th fascia forms the sheath for the brachial plexus and artery. The subclavian artery (3rd section) lies on the 1st rib immediately outward from the scalene tubercle and descends down the anterior surface of the 1st rib, thus being located between the clavicle and the 1st rib. In the third section a. subclavia can be pressed to stop bleeding to the 1st rib behind tuberculum m. scaleni.

Projections. The subclavian artery projects to the middle of the clavicle. The subclavian vein is projected medially to the artery, the projection line of the brachial plexus runs from above from the border between the lower and middle thirds of the sternocleidomastoid muscle at an angle to the clavicle lateral to the artery.

4. Scapular - trapezoid triangle (trigonum omotrapezoideum)

Borders: from below it limits the scapular-hyoid muscle (m. omohyoideus), in front - the posterior edge of the sternocleidomastoid muscle, behind - the anterior edge of the trapezius muscle.

External landmarks: the anterior edge of the trapezius and the posterior edge of the sternocleidomastoid above the greater supraclavicular fossa.

Layers and 5. Vascular - nerve formations.

The skin is thin, mobile. In the subcutaneous tissue of the triangle there are branches of the cervical plexus - supraclavicular nerves, nn. supraclaviculares, innervating the skin of the neck and shoulder girdle.

The superficial fascia covers the entire triangle. Flatysma covers only the anteroinferior part of the triangle. The next layer, as in all other triangles, is the superficial plate of the fascia of the neck (2nd fascia). Neither the 3rd nor the 4th fascia is present in this triangle.

In the fiber between the 2nd and 5th fascia passes the accessory nerve, n. accessorius, which innervates the sternocleidomastoid and trapezius muscles.

From under the sternocleidomastoid muscle, there are also transverse superficial cervical arteries and veins. These vessels, as well as the accessory nerve, lie on the 5th fascia. In the same layer, along the accessory nerve, there are lymph nodes that collect lymph from the tissues of the lateral region of the neck.

The 5th, prevertebral, fascia covers the anterior and middle scalene muscles. Between these muscles, the cervical and brachial plexuses, plexus cervicalis and plexus brachialis, also lying under the 5th fascia, are formed.

TOTAL FASCIA IN THE SHOULDER-TRAPEZIOID TRIANGLE: 1, 2, X, X, 5.

subclavian artery,a. subcldvia, originates from the aorta (left) and brachiocephalic trunk (right). The left subclavian artery is about 4 cm longer than the right. The subclavian artery exits the chest cavity through its upper aperture, goes around the dome of the pleura, enters (together with the brachial plexus) into the interstitial space, then passes under the clavicle, bends over 1 rib (lies in its groove of the same name) and below the lateral edge of this rib penetrates into axillary cavity, where it continues as the axillary artery.

Conventionally, the subclavian artery is divided into three sections: 1) from the place of origin to the inner edge of the anterior scalene muscle, 2) in the interstitial space and 3) at the exit from the interscalene space. In the first section, three branches depart from the artery: the vertebral and internal thoracic arteries, the thyroid-cervical trunk, in the second section - the costal-cervical trunk, and in the third - sometimes the transverse artery of the neck.

1. vertebral artery,a. vertebralis, - the most significant of the branches of the subclavian artery, departs from its upper semicircle at the level of the VII cervical vertebra. The vertebral artery has 4 parts: between the anterior scalene muscle and the long muscle of the neck is its prevertebral part, pars prevertebrdlis. Next, the vertebral artery goes to the VI cervical vertebra - this is its transverse process (cervical) part, pars transversdria (cervicalis), then passes upward through the transverse openings of the VI-II cervical vertebrae. Coming out of the transverse opening of the II cervical vertebra, the vertebral artery turns laterally and the next section is the atlas part, pars atldntica. Having passed through the hole in the transverse process of the atlas, it goes around its superior articular fossa [surface] behind, pierces the posterior atlantooccipital membrane, and then the dura mater of the spinal cord (in the spinal canal) and through the large occipital foramen enters the cranial cavity - here its intracranial part begins , pars intracranidlis. Behind the pons of the brain, this artery joins with a similar artery on the opposite side, forming the basilar artery. From the second, transverse process, part of the vertebral artery depart spinal (radicular) branches,rr. spindles (radicals), penetrating through the intervertebral foramina to the spinal cord, and muscle branches,rr. muscles, to the deep muscles of the neck. All other branches are separated from the last - intracranial part: 1) anterior meningeal branch, d.meningeus an­ interior, and posterior meningeal branch, d.meningeus posterior[meningeal branches,rr. meningei]; 2) posterior spinal artery,a. spindlis posterior, goes around the outside of the medulla oblongata, and "then goes down along the posterior surface of the spinal cord, anastomosing with the artery of the same name on the opposite side; 3) anterior spinal artery,a. spindlis anteri­ or, connects with the artery of the same name of the opposite side into an unpaired vessel, heading down in the depths of the anterior fissure of the spinal cord; four) posterior inferior cerebellar artery(right and left), a. inferior posterior cerebelli, rounding the medulla oblongata, branches in the posterior inferior parts of the cerebellum.

basilar artery,a. basildris (see Fig. 47, 48), - an unpaired vessel, located in the basilar groove of the bridge. At the level of the anterior edge of the bridge, it is divided into two terminal branches - the posterior right and left cerebral arteries. From the trunk of the basilar artery depart: 1) anterior inferior cerebellar artery(right and left), a. inferior anterior cerebelli, branch on the lower surface of the cerebellum; 2) labyrinth artery(right and left), a. labyrinthi, pass near the vestibulocochlear nerve (VIII pair of cranial nerves) through the internal auditory meatus to the inner ear; 3) pontine arteries, aa.pontis (branches to the bridge); four) middle cerebral arteries, aa.mesenphdlicae (branches to midbrain); 5) superior cerebellar artery(right and left), a. superior cerebelli, branches in the upper parts of the cerebellum.

posterior cerebral artery,a. cerebri posterior, goes around the brain stem, branches on the lower surface of the temporal and occipital lobes of the cerebral hemisphere, gives off cortical and central branches. A flows into the posterior cerebral artery. cong-municans posterior (from the internal carotid artery), resulting in the formation arterial(willisian) brain circle,circulus arteriosus cerebri. The right and left posterior cerebral arteries, which close the arterial circle from behind, participate in its formation. -1 The posterior communicating artery connects the posterior cerebral artery with the internal carotid artery on each side. The anterior part of the arterial circle of the cerebrum is closed by the anterior communicating artery, located between the right and left anterior cerebral arteries, which branch off from the right and left internal carotid arteries, respectively. The arterial circle of the cerebrum is located on its base in the subnautonic space. It covers the front and sides of the optic chiasm; the posterior communicating arteries lie lateral to the hypothalamus, the posterior cerebral arteries are in front of the pons.

2. internal thoracic artery,a. thoracica interna (Fig. 49), departs from the lower semicircle of the subclavian artery opposite and somewhat lateral to the vertebral artery. The artery descends down the posterior surface of the anterior chest wall, adjoining the cartilages of the I-VIII ribs from behind. Under the lower edge of the VII rib, it splits into two terminal branches - the muscular-diaphragmatic and superior epigastric arteries. A number of branches depart from the internal mammary artery: 1) mediastinal branches,rr. mediastindles, to the mediastinal pleura and tissue of the upper and anterior mediastinum; 2) thymus branches,rr. thymici; 3) bronchial and tracheal branches,rr. bronchioles et tracheales, to the lower trachea and the main bronchus of the corresponding side; four) pericardial diaphragmatic artery,a. pericardiacophrenica, starts from the artery trunk at the level of the 1st rib and, together with the phrenic nerve, descends along the lateral surface of the pericardium (between it and the mediastinal pleura), gives branches to it and to the diaphragm, where it anastomoses with other arteries supplying the diaphragm; 5) chest branches,rr. sterndles, blood supply to the sternum and anastomosing with the same name branches of the opposite side; 6) perforating branches,rr. perfordntes, pass in the upper 5-6 intercostal spaces to the pectoralis major muscle, skin, and the 3rd, 4th and 5th perforating arteries give [medial] branches of the mammary gland, gg.mammarii [ mediates] (among women); 7) anterior intercostal branches,rr. intercostdles anteriores (I-V), depart in the upper five intercostal spaces in the lateral direction to the intercostal muscles; eight) musculophrenic artery, a.muscleophrenica, goes down and laterally to the diaphragm. Along the way, it gives intercostal branches to the muscles of the five lower intercostal spaces; 9) superior epigastric artery, a.epigastrica superior, enters the vagina of the rectus abdominis muscle, through its posterior wall, supplies blood to this muscle, located on its posterior surface. At the level of the navel, it anastomoses with the inferior epigastric artery (a branch of the external iliac artery). The musculophrenic and superior epigastric arteries are the terminal branches of the internal mammary artery.

3. thyroid trunk,truncus thyrocervicdlis, departs from the subclavian artery at the medial edge of the anterior scalene muscle. The trunk has a length of about 1.5 cm and in most cases is divided into 3 branches: the inferior thyroid, suprascapular and transverse arteries of the neck. 1) Inferior thyroid artery, a. thyroidea inferior, goes up the anterior surface of the long muscle of the neck to the thyroid gland and gives glandular branches,rr. glandular es. from the inferior thyroid artery pharyngeal and esophageal branches,rr. pharyngedles et oesophagedles; tracheal branches,rr. tracheales, and inferior laryngeal artery,a. laryngedlis inferior, which, under the plate of the thyroid cartilage, anastomoses with the superior laryngeal artery (a branch of the superior thyroid artery).

2) Suprascapular artery, a. suprascapuldris, behind the clavicle, it goes back to the notch of the scapula, through which it penetrates into the supraspinatus, and then into the infraspinatus fossa, to the muscles lying there. Anastomoses with the circumflex scapular artery (a branch of the subscapular artery) and gives acromial branch, d.acromidis, which anastomoses with the branch of the same name from the thoracoacromial artery.

3) Transverse artery of the neck, a. transversa cervicis, most often passes between the trunks of the brachial plexus posteriorly and at the level of the medial end of the spine of the scapula is divided into superficial branch,superficialis, next to the muscles of the back, and deep branch,profundus, which runs along the medial edge of the scapula down to the muscles and skin of the back. Both branches of the transverse artery of the neck anastomose with the branches of the occipital artery (from the external carotid artery), the posterior intercostal arteries (from the thoracic aorta), with the subscapular artery and the artery surrounding the scapula (from the axillary artery) (Table 2).

4. Costo-cervical trunk,truncus costocervicdlis, departs from the subclavian artery in the interstitial space, where it immediately divides into the deep cervical and highest intercostal arteries. 1) Deep cervical artery, a. cerviclidis profunda, follows posteriorly between the 1st rib and the transverse process of the 7th cervical vertebra, to the semispinous muscles of the head and neck. 2) The highest intercostal artery, a. inter- costlis suprema, goes down in front of the neck of the 1st rib and branches in the first two intercostal spaces, giving first and second posterior intercostal artery, aa.intercostdles posterio- res (I- II).

The subclavian artery (a. subclavia) is a large paired vessel that supplies blood to the occipital regions of the brain, the cerebellum, the cervical part of the spinal cord, the muscles and organs (partially) of the neck, the shoulder girdle and the upper limb.

The right subclavian artery departs from the brachiocephalic trunk (truncus brachiocephalicus), the left - directly from the aortic arch (arcus aortae). The left subclavian artery is 2-2.5 cm longer than the right one. There are three parts along the subclavian artery: the first - from the place of origin of the artery to the inner edge of the anterior scalene muscle (m. scalenus ant.), the second - limited by the limits of the interstitial space (spatium interscalenum ) and the third - from the outer edge of the anterior scalene muscle to the middle of the clavicle, where the subclavian artery passes into the axillary (a. axillaris).

Rice. 1. Topography of the right subclavian artery: 1 - a. vertebralis; 2 - truncus tliyreocervicalis (removed); 3 - m. scalenus ant. (cut off); 4-a. subclavia dext.; .5 - m. scalenus post, (deleted); 6-a. transversa colli (deleted); 7 - truncus costocervicalis.

The first part of the subclavian artery is located on the dome of the pleura and is covered in front by the anastomosis of the internal jugular vein (v. jugularis interna) and the right subclavian vein (v. subclavia) or the initial part of the brachiocephalic vein and the thoracic duct (left). The vagus nerve (n. vagus) and the thoracic-abdominal nerve (n. phrenicus) are adjacent to the anterior surface of the subclavian artery from the inside. Behind the artery is the lower cervical sympathetic node, which, connecting with the first thoracic, forms a stellate node; medially from the subclavian artery is the common carotid artery (a. carotis communis). The right subclavian artery is covered by a loop of the recurrent laryngeal nerve (n. laryngeus recurrens) - a branch of the vagus nerve. The following branches depart from the first part of the subclavian artery (Fig. 1): the vertebral artery (a. vertebralis), the internal thoracic artery (a. thoracica interna) and the thyroid-cervical trunk (truncus thyreocervicalis).

The second part of the subclavian artery is located directly on the first rib between the anterior and middle scalene muscles. In this part, the costocervical trunk (truncus costocervicalis) departs from the subclavian artery, splitting into the superior intercostal artery (a. intercostalis suprema) and the deep artery of the neck (a. cervicalis profunda), as well as the transverse artery of the neck (a. transversa colli).

The third part of the subclavian artery is located relatively superficially and is the most accessible for surgical interventions. Anterior to the artery is the subclavian vein (v. subclavia). The bundles of the brachial plexus are adjacent to it from above, in front and behind.

Damage to the subclavian artery in peacetime is relatively rare, gunshot wounds during the Great Patriotic War accounted for 1.8% of all body vascular injuries. When the subclavian artery is injured, simultaneous damage to the vein, stellate node, brachial plexus, pleura and lung, thoracic lymphatic duct is possible. Symptoms of injury to the subclavian artery: circulatory disorders of the upper limb, external bleeding (in 41.7%), pulsating hematoma. With simultaneous injury of the pleura and lung, hemothorax is observed, the thoracic duct - chylothorax, with damage to the brachial plexus - complete or partial paralysis of the upper limb. Traumatic aneurysms are relatively rare.

Rice. 2. Incisions during surgery on the subclavian artery: 1 - according to Petrovsky; 2 - according to Lexer; 3 - according to Akhutin; 4 - according to the Reich; 5 - classic; 6 - according to the type of the Dobrovolsky section.

Temporary stop of bleeding from the subclavian artery is carried out by the maximum institution of the hand behind the back and down or by finger pressure, the final one is by ligation of the artery or by the imposition of a vascular suture. After ligation of the subclavian artery, gangrene is observed in 20.5% of cases (V. I. Struchkov). Operations on the subclavian artery are performed for aneurysms (see Aneurysm), for some congenital heart defects (tetralogy of Fallot) to create anastomoses between the systemic and pulmonary circulation, with obliterating arteritis, traumatic arteriovenous fistulas. The main accesses to the subclavian artery - see fig. 2. Expanded access with resection of the clavicle is especially important for traumatic aneurysms. See also Blood vessels.