Structure and features of the coronary arteries. Anatomy of the coronary arteries of the heart Right descending artery
LAD-artery having a permanent localization of the mouth, a certain direction and location in the myocardium. In most cases, it is a continuation of the LCA trunk, runs along the left edge of the pulmonary artery (at the level of the valve) and further along the anterior interventricular sulcus. Then it goes around the apex and continues to the posterior interventricular sulcus, ending in its lower third. In RCA occlusion, anastomoses can often be seen between the PLA of the RCA and the LAD.
This artery is visible in all projections. In the right oblique, it goes along the left edge of the cardiac shadow (Fig. 41): this projection is one of the most successful for assessing the middle and distal segment of the LAD. However, one or more diagonal branches are often superimposed on the proximal segment. Lesions located in the proximal LAD or the anterior divisions of the diagonal arteries may not be visible in the right oblique view. In these cases, for better dilution of the vessels, fractional administration of contrast is used and the optimal position of the tube is achieved. Sometimes a branch of the blunt edge 0B, when the mouth is located at a small distance from the bifurcation of the trunk, can overlap the proximal segment of the LAD.
In the anteroposterior projection, the LAD is represented by a branch that runs more vertically and caudally, bending around the left ventricle to the right of the observer (Fig. 42). Another feature of the LAD is in the anteroposterior or with a slight obstruction of the tube to the right (.10-15 degrees) forms an angle of more than 90 degrees, goes around the pulmonary artery and goes down the anterior interventricular sulcus. From a surgical point of view, an important point is * the departure of the first diagonal branch.
LAD in the left oblique and left lateral projection is represented by a large vessel and is directed more ventrally than other branches (Fig. 43). The septal branches are located to the left of the LAD in the left oblique view (45 degrees or more). When the LCA trunk is very short, the catheter predominantly fills one of the two large vessels (LAD in this example).
The branches of the LAD, in order from the given vessel, are: the first diagonal, the first septal, the right ventricular (rarely visible), the lesser septal, the second diagonal, and the apical. From a surgical point of view, there are three segments in the LAD: proximal, middle, and apical (Figure 44). The two additional segments are the first and second diagonal branches. The most important landmark throughout the LAD is the start of a major (usually first) septal branch. That part of the LAD, which is located between its beginning and the first septal branch, is the proximal segment.
The middle segment starts at the orifice of the first septal branch, and usually ends with the second diagonal branch. The apical segment follows distally. This segment usually reaches the apex, goes around it and passes along the posterior interventricular sulcus for a short distance.
In most cases, the first diagonal branch of the LAD is a fairly large vessel that is located approximately midway between the anterior interventricular sulcus and the blunt edge of the heart. Due to its diagonal direction on the free wall, the LV, like some others that have a similar direction, are called diagonal. "The first diagonal branch often begins near the bifurcation of the LCA trunk and sometimes departs at a separate mouth from the LCA trunk (then, the trunk has a trifurcation rather than a bifurcation ).The best projection to assess the mouths and directions of the diagonal branches is the left oblique (Fig. 39, 40, 43). In the right oblique projection, the LAD is often superimposed on the first diagonal branch (Fig. 41) and it can be quite difficult to separate these two vessels, at least their proximal segments. (Fig. 38, 45).However, in the right oblique projection, the second third of the diagonal branch is clearly visible. Here, the diagonal branch runs along the left border of the cardiac shadow, almost parallel to the shadow of the ribs. Although several small ones can depart from the LAD - diagonal" branches, one of them is considered the second diagonal branch and helps to separate the apical third of the LAD from its middle part. This vessel arises at an acute angle from the LAD and is distributed in the lateral part of the apex.
The first septal branch is the main landmark in the identification and description of LAD, both in normal and pathological conditions. The first septal branch allows you to separate the proximal from the middle third. LAD lesions are usually described in relation to segments of the artery. The first septal branch (Fig. 38), as shown in the right oblique view, arises at right angles from the LAD and runs vertically to the diaphragm in the middle of the cardiac shadow. In the left oblique projection, the first septal branch has a different direction: it appears above the LAD, then goes from right to left, from top to bottom, parallel to the LAD (Fig. 47).
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The more cranial septal branches are better seen on angiography than the inferior septal branches because they are longer and larger in diameter. Their characteristic - direct direction, slight tortuosity in comparison with other vessels, makes it easy to identify them. This may help in differentiating large diagonal rami from septal rami that are confused in the right oblique view. Another angiographic feature is a slight systolic-diastolic oscillation amplitude typical for LAD and septal branches. This is especially important when the left coronary artery is visible against the background of the OB in the right oblique view.
Occasionally, the LAD gives rise to one or more branches to the right ventricle. The higher ones are sent to the conical branch of the RCA at the level of the pulmonary valve (Fig. 48), forming a circle of Vyugence in case of occlusion, stenosis of the RCA or LCA; other branches pass along the wall of the right ventricle and anastomose with the RCA branches. These branches are rarely seen on angiograms of healthy people. However, they become visible in the case of LAD occlusion, as they acquire great importance as collaterals.
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OV departs at an acute angle from the LCA trunk and goes back along the atrioventricular sulcus to the heart cross, which reaches only in 16% (12% + 4%) of cases. In 84% of cases, OV ends distal to the obtuse margin, but does not reach the posterior interventricular sulcus. When OV not only reaches the cross of the heart, but also continues further, it gives rise to PAD (Fig. 50); in such cases, the LCA supplies blood not only to the entire interventricular septum, but also gives a branch to the AV node.
In the right oblique and anteroposterior projection, 0V is represented by the first vessel that departs from the LCA trunk (Fig. 51), forming an arc that is directed caudally, and then to the center of the heart, passing along the left atrioventricular sulcus.
In the left oblique projection, it is directed at the same time in the opposite direction from the LAD, heading caudally and posteriorly to the spine, sometimes bending around the posterior edge of the cardiac shadow (Fig. 52). In order of origin from 0V, its branches are as follows: sinus branch (41%), left atrial branch or branches, obtuse marginal branch, posterolateral branch, PMF (20%), AV node branch (12%).
From a surgical point of view, the OB is divided into 4 segments (Fig. 53). The proximal segment starts from the mouth of the OB and ends with a branch of the obtuse margin. The second segment is VTK. Usually, this is a large branch of the OV, which is located in a larger area of the obtuse margin of the heart. Segment 3 - posterolateral branch that runs along the posterolateral surface of the left ventricle. It is usually smaller in diameter than the VTK. This segment may be absent if the STTA is a branch of the VTC. The distal segment is the OV itself, located distal to the VTC and running along the posterior left pre-cardioventricular sulcus. This segment may be small in diameter. In the event that the ZLAV departs from the OB, then it is considered the last segment.
Shortly after moving away from the trunk, the OM is divided into two parallel branches of approximately the same caliber. The lower of them and the cup of larger diameter gives rise to the left ventricular branches. The one above is called the left atrial and gives rise to branches to the wall of the atrium (Fig. 54). In general, the atrial circumflex branch is relatively thin, which in the right oblique view is directed to the left of the ventricular branches towards the lower left corner of the frame.
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In the left oblique projection, the parallel course of the left atrial and left ventricular branches is very clearly visible (Fig. 55). In the case shown here, the atrial circumflex branch departs at a short distance from the orifice of the OB: The first branch of the OB is the branch of the sinus node, thin and long (which is not typical for it). Its course along the posterior wall of the left and right atrium resembles a tortuous line, then it reaches the confluence of the superior vena cava into the right atrium.
The branch of the sinus node departs from the LCA in 41% (39% + 2%) of cases. In 4 cases out of five) APU starts from the proximal segment of the OB, at a distance of several millimeters from its mouth (Fig. 56).
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The distal location of the mouth of the sinus branch is shown in the left oblique projection in Fig. 58. This branch also starts from the OB, distal to the mouth of the VTK. It goes straight up then curves to the left side of the observer towards the area of the sinus node.
The large and permanent branch or branches of the OB are the branch or branches of the obtuse margin. This vessel or vessels run along the wall of the left ventricle slightly posteriorly and towards the apex. Very often one of these vessels is represented by a large branch, which in the left oblique projection is directed along the posterior edge of the left ventricle (Fig. 59).
In the right oblique projection of the VTK. runs almost parallel to the LAD. However, in the anteroposterior projection, these main branches cross Xia with each other in the middle or distal third. In 20% of cases, other large branches also depart from 0V, but in practice, only the VTC has a larger diameter and supplies the left ventricle with blood. In these cases, the vessels located distal to the VTK are represented by several small atrial branches.
The proximal VTS, LAD, and diagonal branch may overlap if the initial segment of the VTS runs along the proximal 0B segment. With such layering of several vessels, it is difficult to recognize small (and sometimes even significant) lesions in any of these vessels in the right or left oblique projection (Fig. 61). In order to separate the vessels in such cases, it is necessary to use intermediate projections.
OV after the departure of the VTC. is directed along the posterior left atrioventricular sulcus to the cross of the heart. Since it passes in the atrioventricular sulcus (at the level of the mitral valve annulus), this section 0V fluctuates in systole and diastole (with a large amplitude) - to the apex in systole and back - in diastole. These movements are clearly visible in the right oblique projection. In 84% of cases, 0B does not reach the cross of the heart, but ends with a large branch (or two or three small branches), which are called posterolateral branches or branch. Rarely, when there is a single posterolateral branch, its diameter exceeds 2 mm. In the remaining 16%, the OV continues behind the posterolateral branch, passes along the posterior interventricular sulcus and forms the posterior interventricular artery (
Depending on whether the PMA departs from 0V or the RCA in the posterior interventricular sulcus, its course will be different. If the PMA departs from 0V, then it is better seen in the left oblique projection (Fig. 59), but the distal sections are shortened. Accordingly, for better visibility of the middle and distal segments, as well as the posterior septal artery, which arises from the PAD, it is better to use the right oblique view. The branch of the AV node (Fig. 63), which in 12% of cases departs from the final segment of the OB, is clearly visible in the left oblique projection. It is a straight thin vessel, extending from the OB at an angle of 90° in the direction opposite to the LAD.
Anatomy of the coronary circulation highly variable. Features of the coronary circulation of each person are unique, like fingerprints, therefore, each myocardial infarction is "individual". The depth and prevalence of a heart attack depend on the interweaving of many factors, in particular, on the congenital anatomical features of the coronary bed, the degree of development of collaterals, the severity of atherosclerotic lesions, the presence of "prodromes" in the form of angina, which first occurred during the days preceding the infarction (ischemic "training" of the myocardium), spontaneous or iatrogenic reperfusion, etc.
As is known, heart receives blood from two coronary (coronary) arteries: the right coronary artery and the left coronary artery [respectively a. coronaria sinistra and left coronary artery (LCA)]. These are the first branches of the aorta that depart from its right and left sinuses.
Barrel LKA[in English - left main coronary artery (LMCA)] departs from the upper part of the left aortic sinus and goes behind the pulmonary trunk. The diameter of the LCA trunk is from 3 to 6 mm, the length is up to 10 mm. Usually the trunk of the LCA is divided into two branches: the anterior interventricular branch (AMV) and the circumflex (Fig. 4.11). In 1/3 of cases, the LCA trunk is divided not into two, but into three vessels: the anterior interventricular, circumflex, and median (intermediate) branches. In this case, the median branch (ramus medianus) is located between the anterior interventricular and envelope branches of the LCA.
This vessel- analogue of the first diagonal branch (see below) and usually supplies the anterolateral sections of the left ventricle.
Anterior interventricular (descending) branch of the LCA follows the anterior interventricular sulcus (sulcus interventricularis anterior) towards the apex of the heart. In English literature, this vessel is called the left anterior descending artery: left anterior descending artery (LAD). We will adhere to the more accurate anatomically (F. H. Netter, 1987) and the term "anterior interventricular branch" accepted in the domestic literature (O. V. Fedotov et al., 1985; S. S. Mikhailov, 1987). At the same time, when describing coronarograms, it is better to use the term "anterior interventricular artery" to simplify the name of its branches.
main branches latest- septal (penetrating, septal) and diagonal. The septal branches depart from the PMA at a right angle and deepen into the thickness of the interventricular septum, where they anastomose with similar branches extending from below the posterior interventricular branch of the right coronary artery (RCA). These branches may differ in number, length, direction. Sometimes there is a large first septal branch (going either vertically or horizontally - as if parallel to the PMA), from which branches extend to the septum. Note that of all areas of the heart, the interventricular septum of the heart has the densest vascular network. The diagonal branches of the PMA run along the anterolateral surface of the heart, which they supply with blood. There are from one to three such branches.
In 3/4 cases of PMV does not end in the region of the apex, but, bending around the latter on the right, wraps itself on the diaphragmatic surface of the posterior wall of the left ventricle, supplying both the apex and partially the posterior diaphragmatic sections of the left ventricle, respectively. This explains the appearance of the Q wave on the ECG in lead aVF in a patient with extensive anterior infarction. In other cases, ending at the level or not reaching the apex of the heart, PMA does not play a significant role in its blood supply. Then the apex receives blood from the posterior interventricular branch of the RCA.
proximal area front The interventricular branch (PMV) of the LCA is called the segment from the mouth of this branch to the origin of the first septal (penetrating, septal) branch or to the origin of the first diagonal branch (less stringent criterion). Accordingly, the middle section is a segment of the PMA from the end of the proximal section to the departure of the second or third diagonal branch. Next is the distal section of the PMA. When there is only one diagonal branch, the boundaries of the middle and distal sections are approximately defined.
Educational video of the blood supply of the heart (anatomy of arteries and veins)
In case of problems with viewing, download the video from the pageThe coronary arteries are the two main channels through which blood flows to the heart and its elements.
Another common name for these vessels is coronary. They surround the contractile muscle from the outside, feeding its structures with oxygen and essential substances.
There are two coronary arteries leading to the heart. Let's take a closer look at their anatomy. Right feeds the ventricle and atrium located on its side, and also carries blood to a part of the posterior wall of the left ventricle. It departs from the anterior sinus of Vilsava and is located in the thickness of the adipose tissue on the right of the pulmonary artery. Further, the vessel goes around the myocardium along the atrioventricular groove and continues to the back wall of the organ to the longitudinal one. The right coronary artery also reaches the apex of the heart. Throughout its length, it gives one branch to the right ventricle, namely to its anterior, posterior wall and papillary muscles. Also, this vessel has branches extending to the sinoaricular node and the interventricular septum.
The supply of blood to the left and partially to the right ventricle is provided by the second coronary artery. It departs from the posterior left sinus of Valsava and heading towards the longitudinal anterior sulcus, is located between the pulmonary artery and the left atrium. Then it reaches the apex of the heart, bends over it and continues along the back surface of the organ.
This vessel is quite wide, but at the same time short. Its length is about 10 mm. Outgoing diagonal branches supply blood to the anterior and lateral surfaces of the left ventricle. There are also several small branches that extend from the vessel at an acute angle. Some of them are septal, located on the anterior surface of the left ventricle, perforating the myocardium and forming a vascular network. 
over almost the entire interventricular septum. The upper of the septal branches extends to the right ventricle, the anterior wall and to its papillary muscle.
The left coronary artery gives 3 or 4 large branches, which are important. The main one is considered anterior descending artery, which is a continuation of the left coronary. Responsible for feeding the anterior wall of the left ventricle and part of the right, as well as the apex of the myocardium. The anterior descending branch extends along the cardiac muscle and in some places plunges into it, and then passes through the thickness of the fatty tissue of the epicardium.
The second important branch is circumflex artery, which is responsible for feeding the posterior surface of the left ventricle, and the branch that separates from it carries blood to its lateral parts. This vessel departs from the left coronary artery at its very beginning at an angle, lies in the transverse groove towards the obtuse edge of the heart and, bending around it, stretches along the posterior wall of the left ventricle. Then it passes into the descending posterior artery and continues to the apex. The circumflex artery has several significant branches that carry blood to the papillary muscles, as well as the walls of the left ventricle. One of the branches also feeds the sinoaricular node.
The anatomy of the coronary arteries is quite complex. The mouths of the right and left vessels depart directly from the aorta, located behind its valve. All cardiac veins connect to coronary sinus, opening on the posterior surface of the right atrium.
Pathologies of the arteries
Due to the fact that the coronary vessels provide blood supply to the main organ of the human body, their defeat leads to the development of coronary disease, as well as myocardial infarction.
The reasons for the deterioration of blood flow through these vessels are atherosclerotic plaques and blood clots that form in the lumen and narrow it, and sometimes cause partial or complete blockage.
The left ventricle of the heart performs the main pumping function, therefore 
poor blood flow to it often leads to serious complications, disability and even death. In case of blockage of one of the coronary arteries supplying it, it is mandatory to carry out stenting or shunting aimed at restoring blood flow. Depending on which vessel feeds the left ventricle, the following types of blood supply are distinguished:
- Right. In this position, the posterior surface of the left ventricle receives blood from the right coronary artery.
- Left. With this type of blood supply, the main role is assigned to the left coronary artery.
- Balanced. The posterior wall of the left ventricle is equally supplied by both coronary arteries.
After determining the type of blood supply, the doctor can determine which of the coronary arteries or its branches is blocked and needs to be corrected promptly.
In order to prevent the development of stenosis and occlusion of the vessels supplying blood to the heart, it is necessary to regularly undergo diagnostics and promptly treat a disease such as atherosclerosis.
Rice. 50. Corrosive preparation.
Posterior view of the coronary arteries and aortic orifice.
Strictly behind is the non-coronary (non-facial) (N) sinus of the aorta. From the 1st facial sinus of the aorta (1) departs the right coronary artery (RCA), following first in front of the tricuspid valve, and then, rounding it, located posterior to it. The first major atrial branch of the PVA is the sinus node artery, which runs posterior to the aorta (shown by the white arrow). The left coronary artery (LCA) departs from the 2nd facial sinus of the aorta (2), giving rise to the circumflex and anterior interventricular branches (LAD). The black arrow shows the LAD, which supplies the apex and gives branches to the papillary muscles of both ventricles. The course of the LAD and the posterior interventricular branch (PIV) shows the divergence of the axes of the anterior and posterior interventricular septa of the heart. It can be seen that the anterior interventricular septum in the region of the cone is sharply deviated to the left.
WOK - a branch of a sharp edge.
adventitial artery
The third permanent branch of the right VA is the adventitial artery. This small artery may be a branch of the conus artery or may arise independently (see Fig. 28) from the aorta1 7 . It goes up and to the right and lies on the anterior wall of the aorta (above the sinotubular junction), heading to the left and disappearing into the fatty sheath surrounding the great vessels.
It requires coagulation during aortic cannulation and during coronary artery bypass surgery, as it can be a source of bleeding.
Having given these three branches, the right VA follows in the right atrioventricular groove and, having rounded the right edge of the heart, passes to the diaphragmatic surface. On its way through the atrioventricular sulcus, this enveloping segment of the right VA gives off several branchlets of variable size to the right atrium and right ventricle (see Fig. 40,A; 46, 50).
Acute edge artery
The acute marginal artery, or right marginal artery, is one of the largest branches of the right VA. It descends from the right VA along the sharp right edge of the heart and more often reaches the apex (and sometimes passes to the posterior surface of the heart) or reaches the middle of the right ventricle (see Fig. 46-48, 50). This is the largest collateral branch of the right VA. (D. Luzha, 1973; D. Lewin and G. Gardiner, 1988), forming the most powerful (of all branches) anastomoses with LAD. The artery is involved in the nutrition of the anterior and posterior surfaces of the sharp edge of the heart.
On the posterior surface of the right ventricle, the right VA divides into small terminal branches leading to the right atrium and right ventricle. Having given away a large branch - a branch of a sharp edge (a right ventricular branch heading towards the apex) - and having rounded the tricuspid valve, the right VA then follows the posterior surface of the heart along the atrioventricular groove to the cross of the heart. Here it forms a U-shaped bend along the inflow septum and, having given away the artery of the atrioventricular node, it goes along the posterior interventricular sulcus down to the apex (Fig. 51).
Artery of the atrioventricular node
The artery of the atrioventricular node is directed into the thickness of the myocardium through the fibrous and adipose tissue under the coronary sinus. According to most authors,
Rice. 51. Course of the right (RVA) and left (LVA) coronary arteries in the atrioventricular sulcus.
A is a drug for the heart. View from behind and from the base of the heart.
It can be seen that the right coronary artery, which originates from the aorta (A), goes around the tricuspid valve (T) and, having given up the PAD, goes further towards the left atrioventricular sulcus. It is involved in the blood supply to the posterior wall of the left ventricle. The left coronary artery goes around the mitral valve (M) only in front and does not participate in the nutrition of the posterior wall of the left ventricle.
B - scheme. |
A - aorta, LA - pulmonary artery, T and M - tricuspid and mitral valves, RV and LV - right and left ventricles, LVA - left coronary artery, ZMZhV - posterior interventricular branch (from PVA), VTK - branch of the obtuse edge.
(J) - artery of the atrioventricular node; (§) - posterolateral branch.
Here and in all subsequent figures, the code of digital designations VA, shown in fig. 70.
Rice. 52. Vascularization of the anterior interventricular septum (IVS).
Scheme. View of the IVS from the side of the right ventricle.
The right superior septal artery (1) is more often a branch of the right coronary artery (RCA), but it can also originate from the conus artery (CA). The left superior septal artery (2) is usually a branch of the anterior interventricular artery (LAD). Both arteries are involved in the vascularization of the atrioventricular node and bundle of His. Other septal branches of the LAD (shown by arrows) are defined by W. McAlpine (1975) as the anterior septal branches.
Rice. 53. Vascularization of the atrioventricular (atrioventricular) node (PZHU) and His bundle.
3 and P - posterior and right sinuses of Valsalva, a. PZhU - artery of the atrioventricular node, RV and LV - right and left ventricles, LP - left atrium, T - tricuspid valve, p - penetrating part, c - branching part of the atrioventricular node .
A - aorta, LA - pulmonary artery, ACM - anterior papillary muscle, OB - envelope branch, DV - diagonal branch, AOC - artery of the acute edge.
the artery of the atrioventricular node in 88-90% of cases is supplied with blood from the system of the right VA (see Fig. 40, 42, 43), in approximately 10% of cases - from the system of the left VA and occasionally from a mixed source (V. V. Kovanov and T. N. Anikina, 1974; K. Anderson et al., 1979; G. Gensini, 1984).
According to T. James (1958), the interventricular septum and the conducting system of the heart are vascularized at two levels. The distal part of the atrioventricular node, the bundle of His and its two legs are localized in different parts of the interventricular septum. The former are supplied with blood from the artery of the atrioventricular node, while the legs of the bundle of His and Purkinje fibers are vascularized from the septal branches of the PAD and the septal branches of the LAD. According to W. McAlpine, the area of occurrence of the atrioventricular node is partially supplied with blood by both the right and left superior septal arteries (Fig. 52, 53).
Posterior interventricular branch
PAD may also be a direct continuation of the right VA, but more often it is its branch. This is one of the largest branches of VA, which, along the course in the posterior interventricular sulcus, gives off posterior septal branches, which, firstly, anastomose with the LAD branches of the same name, and secondly, as already noted, participate in the vascularization of the terminal sections of the conduction heart systems.
Approximately a quarter of right-dominant patients have significant variation in PAD discharge. These options include double PAD, early exit PAD (before the cross of the heart), etc.
The posterolateral branch of the left ventricle
According to G. Gensini and P. Esente (1975), in about 20% of cases, the right VA forms a posterolateral branch of the left ventricle. This terminal section of the right VA V. V. Kovanov and T. N. Anikina (1974) is called the right circumflex artery. We believe that the right circumflex artery is the entire right VA in the gap between the conus artery and the last descending branch of the right VA. The right VA may in some cases extend to the obtuse marginal branch, in which case the posterolateral left ventricular branch is a branch of the right VA.
With the left type of dominance, the right VA, as a rule, does not reach the cross of the heart. With this variant of VA dystopia, the posterior interventricular branches (usually one or two) and the PLA have the beginning of the left VA. In this case, the artery of the atrioventricular node is more often also a branch of the OB of the left VA.
Left coronary artery system
The left coronary artery departs from the left (2nd facial) sinus of the aorta (see Fig. 41-43, 48, 54) immediately below the line of the sinotubular junction. The trunk of the left VA in different hearts varies markedly in length, but usually it is short and rarely exceeds 1.0 cm. The left VA, as a rule, departs in one trunk that goes around the posterior pulmonary trunk and divides into branches at the level of the nonfacial sinus of the pulmonary artery. , more often two: LAD and OB.
As noted above, in 40-45% of cases, the left VA, even before dividing into main branches, can give off the artery that feeds the sinus node. This artery may be a branch and OB of the left VA.
Anterior interventricular branch
The LAD follows down along the anterior interventricular septum and reaches the apex of the heart. Occasionally, there is a doubling of the LAD and, very rarely, an independent discharge of the LAD from the 2nd facial sinus of the aorta. Less commonly, the LAD does not reach the apex of the heart, but in about 80% of cases it reaches the apex and, rounding it, passes to the posterior surface of the heart.
Rice. 54. Corrosive preparation.
View of the coronary arteries and the aortic orifice (A) on the left. Left side projection.
The left coronary artery (LCA) arises from the 2nd facial sinus of the aorta (2) and divides into the anterior interventricular (LAD) and circumflex (OB) branches. In this projection, the LAD occupies the extreme left position along the anterior surface of the heart. OB almost immediately (this is observed very often) gives a large branch - a branch of the obtuse edge (VTK). Further, the OB goes around the mitral valve (M), which is located at an obtuse angle to the plane of the aortic base. The PMA in this heart is a branch of the right coronary artery. The terminal superficial branch of the OM is superimposed on it.
Its constant branches are the diagonal (sometimes in the amount of two or even three), septal branches and the right ventricular branch.
A. On the anterior surface of the heart, LAD gives an inconstantly pronounced artery - right ventricular branch. This artery is a remnant of the fetal circle of Viessen and is of great importance in both CHD and CAD, especially in high LAD occlusions.
B. Septal branches LADs vary greatly in size, number, and distribution. More often, a large 1st septal branch (or anterior septal branch) is detected, oriented vertically and splitting into several secondary branches that ramify the anterior interventricular septum (Fig. 55). In some cases, the 1st septal branch is located parallel to the LAD itself. Rare cases of its independent discharge are also described (W. McAlpine, 1975). This artery is also involved in the blood supply to the conduction system of the heart (Fig. 56). Therefore, in the literature there are indications of the need for its independent shunting, especially in cases where its orifice is localized between two areas of LAD stenosis.
(B. V. Shabalkin and Yu. V. Belov, 1984; J. Moran et al., 1979).
Septal ischemia resulting from occlusion of the anterior septal artery (1st septal branch of the LAD) leads to the development of ventricular tachycardia.
Rice. 55. The first septal branch (2) of the anterior interventricular branch (1) (according to R. Anderson and A. Becker, 1980).
Heart preparation (left) and angiogram (right).
Rice. 57. The first (anterior) septal branch in dogs (according to J. Twedell et al., 1989) and its role in myocardial infarction.
LVA - left coronary artery, OB - envelope branch, ASA - anterior septal artery, LAD - anterior interventricular branch.
1-5 - zones of infarction of the anterior interventricular septum on transverse sections of the heart from the base to the apex.
Rice. 56. Scheme of septal branches of the anterior interventricular branch.
View of the anterior interventricular septum (AVS) from the front, from the side of the right ventricular outflow tract (the anterior wall of the right ventricle is removed).
The first septal branch (1st CB) is most often the first branch of the LAD. It is usually larger than the other septal branches of the LAD. LAD is more often than other arteries "diving".
The envelope branch (OB) immediately after leaving the left coronary artery is “lost” in a thick layer of adipose tissue. Its intraoperative exposure is also difficult due to the overhang of the left atrial appendage (LAA) over it (clipped in the figure). The figure shows the left sinus node artery (ASA) arising from the left coronary artery. This type of blood supply to the sinus node occurs in 10-12% of cases.
LV - left ventricle, RA - right atrium, T - tricuspid valve, NG - supraventricular crest, ACM - anterior papillary muscle, LA - pulmonary artery, A - aorta, SVC - superior vena cava, PV - pulmonary veins (in the figure - left).
cardia (J. Twedell et al, 1989), which occurs, as a rule, from the side of the subendocardium and, more often, from the left ventricle (M. DeBakker et aL, 1983; L. Harris et aL, 1987; J. Twedell et aL, 1989). Therefore, adequate protection of this region of the heart during open heart surgery becomes important.
In dogs, this artery supplies the interventricular septum by 75-80% (Fig. 57). It is clear that in them the occlusion of this artery causes myocardial infarction.
W. McAlpine (1975) still distinguishes the so-called "superior septal artery", although he notes that in humans it usually has a small size or is completely absent. F. Rodriguez et al. (1961) also believe that in humans it occurs only in 12-20% of cases. This artery is very important in some animals. So, for example, in a bovine heart, it can supply blood to up to 50% of the septal area. But in humans, its allocation seems to us not entirely justified, especially since in most cases it is presented in people
V as a branch of the first septal artery.
At human, the remaining septal branches of the LAD ("anterior"), as a rule, have
smaller size (see fig. 47) (D. Lewin and G. Gardiner, 1988). These branches communicate with similar branches of the PAD (“lower”), forming a network of potential collateral vessels. And although the "effectiveness" of such collaterals has not been proven, the fact is that the interventricular septum is the most vascularized region of the heart.
In a person, the “anterior” septal branches are larger than the “lower” ones (the branches of the ZMZhV), but they can also be of equal caliber with them
The atria, part of the wall of the left ventricle (LV) and arterial vessels (at the level of the sinuses of Waltz. "you) are removed. The left coronary artery (LCA), which branches off from the aorta (A), gives off an envelope branch (OB), which follows posteriorly along the atrioventricular furrows around the mitral valve (M).
Rice. 58. Preparation of the heart.
(P.Fehn et al., 1968). And, conversely, in quails, the “lower” septal branches are larger than the “upper” ones. In them, most of the septum is supplied with blood by the "lower" septal arteries.
B. Diagonal branch(s)
LAD, following along the anterolateral surface of the left ventricle, is usually one of those branches that feed the apex (see Fig. 48, 54).
median artery
In 37% of cases, instead of a bifurcation of the left VA, there is a trifurcation (D. Lewin et al, 1982). In these cases, the "diagonal branch" is called the median artery, and it, along with the OB and LAD, departs from the trunk of the left VA. In these hearts, the median artery is the equivalent of the diagonal branch, and it vascularizes the free wall of the left ventricle. (D. Lewin and G. Gardiner, 1988).
envelope branch
OB is the next major branch of the left VA and, in some cases, may diverge from
aortic sinuses alone. It follows the left atrioventricular groove (see Fig. 43) and, having rounded the mitral valve (Fig. 54, 58) and the left (blunt) edge of the heart, passes to its diaphragmatic surface.
As already noted, more often (in 90% of cases) it is non-dominant and noticeably varies in size and length, which is mainly determined by the length of the dominant right VA. It is clear that to define such conditions as OB hypoplasia
inappropriate.
Usually, the OB gives off the left fragment of the Kugel artery (see Fig. 56), and although more often it does not reach the sinus node, in 10-12% of cases the artery of the sinus node can be formed by this branch.
OB gives 1-3 large branches of a dull edge, following downward from the atrioventricular sulcus (Fig. 59), and very often the OB system is generally represented by a large VTK and unexpressed OB.
A. Branch of the obtuse marginal artery (left
marginal branch) is the largest branch |
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view OB (see Fig. 54, 60) and can depart as |
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Rice. 59. Preparation of the heart. |
from the beginning of OV, and at the level of the obtuse margin. |
|
This is a very important branch involved in pita. |
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Atria and arterial vessels (at the level of sinu |
free wall (its anterior and posterior |
|
owls of Valsalva) have been removed. |
surface) LV along its lateral |
|
Enveloping branch (OB), having given its largest |
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the edges. In a number of OV hearts, in general, |
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branch - branch of the blunt edge (VTK) - and rounding the mit |
||
ral valve, usually gives one or more |
set by a branch of a blunt edge (Fig. 60). |
|
posterolateral left ventricular branches and with le |
OV, in addition, can give rise to le- |
|
type of blood supply to the heart ends in |
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atrial branch supplying the lateral and |
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the form of the posterior interventricular branch (PZVZhV). |
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RV and LV - right and left ventricles. |
posterior surface of the left atrium. |
Rice. 60. Anatomy of the coronary arteries supplying the lateral and posterior walls of the left ventricle (LV).
LC - pulmonary valve, SVC and IVC - superior and inferior vena cava, M - mitral valve, KS - coronary sinus, L and 3 - left and posterior sinuses of the aorta, RVA - right coronary artery, a.PZhU - arteryatrioventricular-node, PP - right atrium.
B. The terminal branch of OS is more often posterolateral (left ventricular) branch, however, the origin of this branch, as well as of the PAD and the artery of the atrioventricular node, from the OB of the left VA is determined by the dominance of the right or left VA.
With a balanced type of blood supply to the heart, PAD is vascularized from the systems of both VAs (both right and left).
Thus, the epicardial trunks of the right VA system are involved in the vascularization of the right atrium, the interatrial septum, the free wall of the right ventricle, the posterior wall of the interventricular septum, the papillary muscles of the right ventricle, and partially the posteromedial group of papillary muscles of the left ventricle.
The sinus node more often (in 55-60% of cases) is a zone of blood supply to the right VA. Atrioventricular node in predominant pain
In most cases (up to 90% of cases), it is also supplied with blood from the right VA system. The area of blood supply to the left VA includes the left atrium, the anterior, lateral, and most of the posterior wall of the left ventricle, the anterior interventricular septum, and the anterolateral group of the papillary muscles of the left ventricle. Considering the significant VA branching variability, the study of the variant
W. Grossman, 1986). In addition, the anatomy of each of the main epicardial arteries has a number of features, and the role of their branches in the blood supply to the myocardium in each particular case is ambiguous.
The present section of the work is devoted to the study of these features. We believe that with the growing interest in coronary artery bypass grafting, knowledge of these features, which are not described in domestic guidelines, would be useful.
Our understanding of the surgical anatomy of the VA will be incomplete if we do not dwell briefly on the relationship of the VA to the atrioventricular valves. Further progress in prosthetics or plastic reconstruction of atrioventricular valves is largely due to the exact knowledge of the topographic and anatomical relationships of these valves with adjacent structures of the heart and, in particular, with the vessels of the heart.
According to G.I. Zuckerman et al. (1976), the most dangerous areas are the areas of the external and internal commissures of the mitral valve, in which the circumflex branch of the left VA is as close as possible to its fibrous ring. As shown by the studies of V. I. Shumakov (1959) and L. G. Monastyrsky (1965), the projection of the fibrous ring of the mitral valve is located below the circumflex branch of the left VA on the anterior wall and below the venous sinus - on the back, but in hearts with a small size (up to 12 cm in length) on the anterior wall, this discrepancy in more than half of the cases does not exceed 1-6 mm. The intimate attachment of the mitral valve to these structures creates objective prerequisites for their iatrogenic damage (D. Miller et al., 1978), which is fraught with the development of irreversible changes in the myocardium and even the death of patients (G. I. Tsukerman et al., 1976; S. S. Sokolov, 1978). Envelope ligation
branch of the left VA is a dangerous complication and occurs in 1.2-3.1% of cases with mitral valve replacement (G. I. Tsukerman et al., 1976). A real possibility of ligation of the circumflex branch of the left VA also exists during MV annuloplasty in the case of deep suturing of the annulus fibrosus (V. A. Prelatov, 1985).
Due to the fact that with a sharp calcification of the valve and the spread of calcium to the fibrous ring (and sometimes to the wall of the atrium and ventricle), a sharp thinning of the myocardium occurs, in order to prevent damage to the circumflex branch of the left VA, G. I. Tsukerman et al. (1976) advise not to resort to complete decalcification of the valve and annulus fibrosus, strengthening (to prevent calcification) these areas with Teflon sutures from the atrium and ventricle. In addition, due to the risk of fistula formation between the coronary sinus and the cavity of the left ventricle, D. Miller et al. (1978) recommend that when reimplanting prostheses, pay attention to maintaining the integrity of the posterior wall of the left ventricle.
In this section of the work, we did not dwell on the surgical anatomy of rare variants of origin, succession, and branching of the VA. Surgical features of VA in CHD have not been described either. These materials are described in more detail in the corresponding sections.
Surgical anatomy of the atrial coronary arteries
Until recently, the description of the arterial blood supply to the atria has not been given due attention. Classical anatomy only mentions that the atrial arteries originate from the right or left coronary artery. (S. S. Mikhailov, 1987; H. Gray, 1948; W. Spatelholz, 1924). Meanwhile, all the increasing possibilities of cardiac surgery have made it possible to expand the scope of surgical interventions on the atrial complex. The safety of such interventions is largely determined by the preservation of the coronary arteries (VA), which supply the most important elements of the conduction system of the heart - the arteries of the sinoatrial node (SAN) and the atrioventricular node (AVN) (B. A. Konstantinov et al., 1981; S. Marcelletti, 1981). Due to the paucity of reports covering the variant anatomy of these VAs, we present the results of our own studies of the variant anatomy of the SPU and RV arteries in comparison with literature data.
Despite the fact that W. Spatelholz (1924) developed a regional diagram of the atrial arteries, at present the existence of the anterior, intermediate, posterior right and left atrial arteries (described by this author) has not been confirmed. Of this group, the only more or less permanent atrial coronary artery is the so-called right intermediate atrial artery. It departs from the right coronary artery (RCA) in the region of the sharp edge, goes vertically upwards and feeds the myocardium of the corresponding zone of the right atrium. It usually anastomoses with the arteries surrounding the orifice of the superior vena cava (SVC) and is therefore not fatal.
The most permanent atrial coronary arteries are those supplying the sinoatrial and atrioventricular nodes. The first move first, and the last - the last branches of the right or left (or both) BA.
The blood supply to the sinoatrial node is carried out mainly by the SPU artery (Fig. 61), damage to which, despite the abundance of additional sources of blood supply, leads to irreversible heart rhythm disturbances. According to A. A. Travin et al. (1982), there are two types of origin of the SPU artery. With the right type of blood supply to the heart, the STC artery starts from the PVA (61.4% of cases), and with the left type, from the left coronary artery (LCA) (38.6% of cases). As shown by the studies of these authors, in 47.5% of cases the artery goes around the mouth of the SVC on the right, in 37.5% - on the left, and in 15% of cases the mouth of the SVC is covered in the form of a ring. According to T. James and G. Burch (1958), the SPU artery departs from the PVA in 6-1% of cases, and from the left - in 39% of cases. Approximately the same data are given by S. Marcelletti (1981): in
Rice. 61. Options for the origin and distribution of the artery of the sinoatrial node (SPU).
A - origin of the SPU artery (1) from the right coronary artery (RVA); B - origin of the artery SPU (2) from the left coronary artery (LCA). In both cases, the SPU artery is located on the anterior surface of the atrial complex.
C, D - origin of two branches of the SPU artery from the PVA and LVA. In both cases, one SPL artery (originating from the RVA) propagates along the anterior surface of the atrial complex, while the other (which is a branch of the LVA OV) propagates along the posterior surface of the atrial complex.
D, E - SPU artery (1), which is the terminal branch of the PVA, goes around the atrial complex from behind, then passes to its anteroposterior surface (shown by a dotted line) and goes around the mouth of the SVC from behind (E).
SVC and IVC - superior and inferior vena cava, RA and LA - right and left atria, RV and LV - right and left ventricles, A - aorta, LA - pulmonary artery, M - mitral valve, KS - coronary sinus, LAD - anterior interventricular branch, DV - diagonal branch, OB - envelope branch, ZMZhV - posterior interventricular branch.
Lb% of cases, the SPL artery departs from the PVA. Regardless of the source of blood supply, the SPU artery reaches the SVC in front or behind, or (less often) surrounds its mouth.
(K. Anderson and S. Ho, 1979).
According to W. McAlpine (1975), the SPU artery in 48% of cases is a branch of the PVA, in 30% - a branch of the LVA, in 22% of cases - the posterior branch of the right or left VA. In 1968, A. Moberg noted that atrial VAs can also originate from extracardiac vessels. W. McAlpine (1975) cites in his atlas one such case described by N. Nathan et al. (1970). In it, the SPU artery is a branch of the right bronchial artery (Fig. 62).
After studying more than 500 hearts, we did not find a single such case. But in one heart with an untrue single VA, an independent discharge of the SPU artery from the aorta was found (Fig. 63). In this heart, we found a second artery that feeds the SPL and is a branch of the PVA equivalent. The rarity of our observation lies in the fact that in this heart there was a single PVA, from which the branches of the right and left VA departed. The only vessel originating from the 2nd facial sinus of the aorta was the left SPU artery. However, the presence of the second (right) artery of the STS in this rare observation confirmed our opinion that the STS is supplied, as a rule, by many branches of the right and left VA. Therefore, the allocation of arteries feeding the node is equal to
Rice. 62. Departure of the artery of the sinoatrial node (SPU) from the bronchial artery.
The designations are the same as in Fig. 61 .
Rice. 63. Departure of the SPU artery (2) by an independent mouth from the 2nd facial sinus of the aorta (A).
A, B, C - SPU artery (2) is the equivalent of a branch extending from the LVA. It spreads in front of the pulmonary artery (LA) (fragment A), passes under the left atrial appendage (U) (fragment B), and spreads along the posterior surface of the atrial complex.
The ventricular complex is supplied with blood by the untrue single VA (1), which originates from the 1st facial sinus of the aorta.
D - the second artery of the SPU is the equivalent of a branch extending from the PVA. It spreads along the anterior surface of the ventricular complex, wraps around the right atrial appendage anteriorly, and can be seen to have entered the suture (white arrow) at the cannulation site.
You can see the departure of the untrue single VA from the 1st facial sinus of the aorta.
Rice. 70. Isolated anatomical diagram of the corono-arterial tree.
1 - left coronary artery, 2 - anterior interventricular branch, 3 - envelope branch, 4 - obtuse marginal branch, Dj and D2 - 1st and 2nd diagonal arteries, 5 - right coronary artery, 6 - cone artery, 7 - artery of the sinus node, 8 - branch of the sharp edge, 9 - posterior interventricular branch, 10 - artery of the atrioventricular node.
A - aorta. Preservation of the circle of Viessen is shown by two arrows (branches of the conus artery and right ventricular branches of the anterior interventricular artery). Preservation of the primary around the atrial ring is indicated by the large arrow.
In the future, in the work (illustrations), the indicated digital code for the designations of the coronary arteries was used.
naya anatomical diagram of the structure of the corono-arterial tree. As follows from the presented data, as well as from a multi-projection study of coronary angiograms and drawings that reproduce the structure of the coronoarterial tree on corrosive preparations, in projections corresponding to those used in coronary angiography, the former do not reflect the structure of the VA in the corresponding projections. Therefore, we present a description of the anatomy of VA in accordance with the direction and determinability of VA on corrosive preparations in the corresponding projections.
Anteroposterior projection
As follows from Figures 71-74, in the anteroposterior projection, the divergence of the trunks of the right and left VA is clearly defined. This is the only projection that allows them to be visualized regardless of the level of deviation from the sinuses of Valsalva and the degree
Rice. 71. Corrosive preparation. before |
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back projection. |
Rice. 72. Corrosive preparation. before |
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1 and 2 - 1st and 2nd facial sinuses of the aorta; Dp D2 - 1st and |
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back projection. |
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2nd diagonal arteries; 5 - right coronary |
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1 and 2 - 1st and 2nd facial sinuses of the aorta. |
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contrast regurgitation. Identification of the origin of the CA and OB of the left VA in this projection is difficult.
The projection makes it possible to visualize a number of distal diagonal branches of the LAD, as well as to assess the involvement of the LAD in the blood supply to the diaphragmatic surface of the heart.
Features of all other VAs and their branches are determined only by comparing the data of a multiprojection study.
Left coronary artery
The anatomical diagram of the distribution of the main trunks of the left VA (LAD and OB) and their relationship with the departments and structures of the heart, reproduced from corrosive preparations in the 1st and 2nd anterior oblique projections, is shown in Fig. 3. 75.
1. Left anterior oblique view. In this projection, the trunk of the left VA is in an orthogonal projection, and therefore the assessment of its features is difficult. Visualization of the left VA trunk in this projection depends both on the level of its origin from the 2nd facial (left in the definitive heart) aortic sinus, and on the degree of reflux of the contrast agent into the aorta (with a sharp stenosis or occlusion of the left VA trunk, for example).
On the other hand, in this projection, the bifurcation (trifurcation) of the left VA is clearly visualized (Fig. 75, B; 76, 77 and 78). In this projection, the LAD goes along the right contour of the heart, and the OB and its large branches - along the left.
The LAD is usually recognized by the septal arteries that arise from it at a right angle. The identification of the intermediate branch of the left VA is also very important, since, if it exists, it is responsible for the blood supply to a significant basin, which includes the anterior surface of the left ventricle and the apex of the heart.
The disadvantage of the projection is the superposition of the proximal segment of the VTC with the OB.
And although in this projection the visualization of the VTC is often not difficult, the detection of constrictions
V its proximal third The 1st oblique projection is accompanied by certain difficulties.
Thus, this projection makes it possible to identify the type of branching of the left VA and structural features of the LAD, OV, and their branches. And although it does not allow assessing the state of
Rice. 75. Anatomical diagram of the distribution of the main trunks of the left coronary artery and their relationship with the departments and structures of the heart, reproduced from corrosion preparations in the 1st (B) and 2nd (A) anterior oblique projections.
Identification of the anterior interventricular branch (ALV) is easily accomplished by the presence of septal branches (SB).
In the 1st anterior oblique projection, the superposition of the envelope branch (OB) and the obtuse marginal branch (OTC) is possible, in the 2nd oblique projection in front of it, the LAD and the diagonal branch (DV) are possible.
A - aorta, LA - pulmonary artery, M - mitral valve.
Rice. 76. Corrosive preparation. 1st (left |
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anterior) oblique projection. |
Rice. 77. Corrosive preparation. 1st |
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Left coronary artery (1) and its branches. |
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(left anterior) oblique view. |
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Left coronary artery (1) and its branches, |
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i - intermediate artery (a. intermedia). |
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The rest of the designations are the same as in Fig. 70. |
the trunk of the left VA and sometimes the proximal sections of the LAD (up to the 1st septal branch) and OB, it is very informative for assessing the large left ventricular branches of the LAD (diagonal, intermediate, septal) and OB (VTK and, in part, posterolateral (ZB) left ventricular branch).
In this projection, the LAD and OB are also separated, but it is not very informative for assessing the bifurcation zone of the left VA. With absence
Rice. 78. Selective coronarogram of the left |
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coronary artery. |
Rice. 79. Corrosive preparation. 2nd |
1st (left anterior) oblique view. |
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Systems of the right (5) and left coronary arteries. |
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Septal branches of the anterior interventricular |
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branches (2) are shown by arrows, a typical ogy stroke |
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the beating branch (3) is underlined with a dotted line. |
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The rest of the designations are the same as in Fig. 70. |
Rice. 80. Corrosive preparation. 2nd |
Rice. 81. Selective coronarogram of the left |
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coronary artery. |
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(right anterior) oblique view. |
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Right (5) and left coronal arte systems |
LAD - anterior interventricular branch, DV - diagonal |
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naya branch, OB - envelope branch, VTK - branch of the obtuse edge. |
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Typical course of the envelope branch (3) and departure |
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obtuse edge branch extending from it (4) underline |
reflux of a contrast agent into the aorta, this project |
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chickpea dotted line. |
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tion is very informative for assessing the condition |
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The rest of the designations are the same as in Fig. 70. |
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proximal sections of the LAD and OB and proxies |
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small septal branches of the LAD. According to her |
but also assess the development of the right ventricular branches of the LAD. In this projection, the LAD limits the left contour of the heart, and the OB extends to the right of it (Fig. 75, A; 79-81).
The projection is also optimal for the exposure of the VTC and its departure from the OB. In this projection, the zone of divergence of the OV and VTK is located in the projection, where the indicated arterial
nye vessels are maximally diluted. Recognition of the VTC is not difficult: it is the first large branch extending from the OB, heading towards the apex.
Due to the superposition of the DW and LAD, this projection is not very informative for assessing the features of the DW.
Thus, this projection makes it possible to clearly identify the region of division of the OV and VTK, assess the state of the VTK, identify structural features of the proximal sections of the OV and LAD, and visualize the right ventricular branches of the LAD.
Right coronary artery
1. Anterior-posterior projection. This projection makes it possible to identify the origin of the right VA trunk from the 1st facial (right in the definitive heart) aortic sinus (see Fig. 71, 72), but is not very informative for assessing the origin of the conus artery.
2. Right anterior oblique view. It is optimal for assessing the origin (independent or from the right VA) and the following of the first large branches of the right VA (see Fig. 70, 79, 82) (conus, sinus node artery, adventitia). In this projection, the cone artery (CA) is directed downward, and the artery of the sinus node is directed upward from the right VA. The projection is also very informative for revealing the nature of the distribution of VA in the region of the infundibular part of the right ventricle. It allows to assess the following of the CA or the LAD deviation from the right VA, which is very important to know when planning operations for conotruncus malformations. Apparently, in this projection (as well as in the anteroposterior one), visualization is optimal from the passage of the OB from the right VA or the 1st facial sinus of the aorta.
The projection makes it possible to assess the degree of development of collaterals between the system of the right VA and the LAD (Fig. 83) and the filling of the distal channel of the latter (flows from the CA and VOC to the LAD). The same projection is the most informative for assessing the deviation of the PAD (from the right or left VA) and determining the type of dominant blood supply.
Rice. 82. Selective coronarogram of the right coronary artery (5).
2nd (right anterior) oblique view.
VOK - branch of the sharp edge, a.AVU - artery of the atrioventricular node, ZMZhV - posterior interventricular branch.
Rice. 83. X-ray from a corrosive preparation.
2nd (right anterior) oblique view.
Collaterals between the right coronary artery (RVA) and the anterior interventricular branch (LAD). Communication between the branches of the conus artery (CA) and the right ventricular branches (RV) through the cone veins (KB).
1st s, 2nd s. and 3rd p. - first, second and third septal branches, OB - circumflex branch, LVA - left coronary artery, PIA - posterior interventricular branch.
Rice. 84. Angiographic scheme of dominant circulation types (according to J. Dodge et al., 1988) (in the 2nd right anterior oblique projection): right (A), balanced (B), left (C).
A - left ventricular branches of the right coronary artery (shaded and shown by a dark arrow), B - paired (from the right and left VA) blood supply to the posterior interventricular branch (9) is darkened and shown by a curved arrow. C - blood supply to the PMA (9) from the system of the left VA is shaded and shown by a light arrow.
/ and 2 - 1st and 2nd facial sinuses of the aorta. The rest of the designations are the same as in Fig. 70.
Rice. 85. Corrosive preparation. Back view of the heart.
The right type of dominance of the blood circulation of the heart. Multiple PADs (9) (three of them) supplying the posterior septum, 2 - circumflex segment of the right coronary artery, 10 - artery of the atrioventricular node.
heart (Fig. 84). With the right type of dominance, the PFA moves away from the right VA (Fig. 85), with the left type, from the left VA (see Fig. 80, 81).
Usually, when studying coronarograms, information is obtained about the state of the coronary arteries - the nature, extent and localization of the pathological process are assessed. An integral part of this process is the assessment of the degree of development of collaterals and the distal bed of large VAs. (Yu.S. Petrosyan and L.S. Zingerman, 1974; S. Ilsley et ah, 1982). Meanwhile, when “reading” an angiogram, the interpretation of another issue is no less important: understanding the anatomy of the VA itself and the role of individual VAs.
V vascularization of the heart. A clear planning of coronary artery bypass surgery is unthinkable without an assessment of which vessel is studied on the angiogram and without identifying which parts of the heart require revascularization. In this regard, the materials presented here, we believe, may be useful to a certain extent.
V practical purposes.
Literature
1. Abdullaev F. Z., Nasedkina M. A., Mozhina A. A. et al., Characteristic features of pathological anatomy and myocardial lesions in abnormal origin of the left coronary artery from the pulmonary trunk, Arkh. Pat. - 1988. - No. 6. - S. 35-41.
2. Antipov N. V. Conduction system of the heart: detection technique, morphogenesis: Abstracts of reports. VII regional scientific conference of morphologists. - Donetsk, 1990. - S. 9-10.
3. Arutyunov V. D. Viessen-Tebezia vessels in cardiac hypertrophy and myocardial infarction: Proceedings of the 2nd Conf. Latvian pathologists. - Riga, 1962. - S. 109-111.
4. Arkhangelsky A.V. On changes in the papillary muscles of the heart in myocardial infarction. Arch. Pat. - 1959. - No. 9. - S. 48-54.
5. Aryev M. Ya., Vitushinsky V. A., Rabinerzon A. V.On collateral circulation in the heart under pathological conditions // Ter. arch. - 1935. - T. 13, issue. 3.
6. Bokeria L.A. Tachyarrhythmias. - M.: Medicine, 1989.
7. Van Praag R. Anatomy of a normal heart and a segmental approach to diagnosis // Morphology and morphometry of the heart in normal and congenital heart diseases. - M., 1990. - S. 7-31.
8. Volynsky Yu. D., Todua F. I., Mogilevsky L. S., Kokov L. S.Bronchial and systemic circulation of the lungs in surgery for congenital heart defects of the “blue” type. - 1981. - No. 3. - S. 83-84.
9. Gabain L. I., Fomin A. M. Morphological features of the bloodstream in the papillary muscles of the human heart // Systemic hemodynamics and microcirculation. - Kui byshev, 1983. - S. 23-28.
10. Dubinina R. V. On the variant anatomy of the coronary arteries with different types of blood supply to the heart // Sat. scientific works of the Arkhangelsk honey. institute. T. 1. - 1964. - S. 75-80.
11. Zinkovsky M. F., Shcherbinin V. G., Chepkaya I. L.Residual shunts after correction of atrial defects // Thoracic and heart-vessel, hir. - 1991. - No. 2. - S. 23-27.
12. Zolotova-Kostomarova M. I. Clinic and pathology of myocardial infarction: Dis. ... cand. Sciences. - M., 1951.
13. Ilyinsky, S.P., On the Vessels of Thebesia, Arch. Pat. - 1958. - T. 20, No. 5. - S. 3-11.
14. Ilyinsky S.P. Vessels of Tebezia as a variant of arteriovenous anastomoses of the heart. - L.: Lenizdat, 1962. - S. 227-233.
15. Ilyinsky S. P. Vessels of Tebezia. - L .: Medicine, 1971.
16. Ioseliani D.G. Ischemic heart disease in terms of surgical treatment: Dis. ...
Doctor of Sciences. - M., 1979.
17. Forged V. V., Anikina T. N. Surgical anatomy of human arteries. - M.: Medicine
on, 1 9 7 4 . - S. 33-37.
19. Kolesov V. I. Surgery of the coronary arteries of the heart. - L .: Medicine, 1977. - S. 26-32.
20. Konstantinov B. A. In the debate on the report of V.I. Burakovsky et al. "Basic principles of surgical treatment of Ebstein's anomaly" // Thoracic hir. - 1981. - No. 3. - S. 80-87.
21. Leporsky N. I. To the clinic of complete closure of the mouths of both coronary arteries of the heart in aortic syphilis // Ter. arch. - 1939. - T. 17, No. 4. - S. 3-16.
22. Lisitsin M. S. Types of blood supply to the heart // Vestn. hir. and border region - 1927.
- No. 9. - S. 26.
23. Puddle D. X-ray anatomy of the vascular system. - Budapest: Publishing House of the Academy of Sciences, 1973. - S. 29-33.
24. Melman E. P., Shevchuk M. G. The bloodstream of the heart and its potential reserves.
M.: Medicine, 1976.
25. Mikhailov S. S. Clinical anatomy of the heart. - M.: Medicine, 1987. - S. 184.
26. Mikhailov S. S. Ibid. - S. 190.
27. Monastyrsky L. G. Topographic and anatomical relations of the fibrous ring of the mitral valve to some anatomical formations of the heart. - 1965.
- No. 5. - S. 23-29.
28. Nagy I. [cit. according to V. V. Kovanov and T. N. Anikina (1974)].
29. Nezlin V. S. Coronary disease. - M.: Medicine, 1951.
30. Ognev B. V., Savvin V. P., Savelieva L. A. Blood vessels of the heart in normal and pathological conditions. - M., 1954.
31. Petrosyan Y. S., Abdullaev F. Z., Gharibyan V. A. Angiographic semiotics and pathophysiology of abnormal LVA discharge from the pulmonary trunk. hir. - 1990. - No. 3. - S. 8-14.
32. Petrosyan Yu. S., Zingerman L. S. Coronary angiography. - M.: Medicine, 1974. - S. 112-125. 33. Prelatov V. A. Mitral valve annuloplasty using a support ring:
Dis. ... Doctor of Sciences. - M., 1985.
34. Rabkin I. Kh., Abugova A. M "Matevosova" L. // Coronary angiography and coronary scanning: Guide to angiography / Ed. I. X. Rabkina. - M.: Medicine, 1977. - S. 67-81.
35. Rabkin I. Kh., Abugov A. M., Shabalkin B. V. Evaluation of collateral circulation according to selective coronary angiography // Kardiologiya. - 1973. - No. 11. - S. 15.
36. Rabkin I. Kh., Matevosov A. L., Khilenko A. V. Coronary scanning in the diagnosis of coronary heart disease // Ibid. - 1974. - No. 2. - S. 5-10.
37. Rabotnikov V. S., Ioseliani D. G. The state of the distal bed of the coronary arteries in patients with coronary heart disease // Ibid. - 1978. - No. 12. - S. 41-44.
38. Ryumina E. N., Berishvili I. I., Aleksi-Meskhishvili V.V. Lung scan in pain
nyh at Fallot's tetrad before and after palliative operations // Med. radiol. - 1979.
- No. 7. - S. 23-32.
39. Savelyev V. S., Petrosyan Yu. S., Zingerman L. S. et al. Angiographic diagnosis of diseases of the aorta and its branches. - M.: Medicine, 1975.
40. Samoilova SV Anatomy of the blood vessels of the heart. - "P .: Medicine, 1970.
41. Sinev A.F. Surgical anatomy of the conduction system of the heart in complex congenital heart defects: Dis. ... Doctor of Sciences. - M., 1982.
42. Smolyannikov A. V., Naddachina T. A. Pathological anatomy of coronary insufficiency. - M., 1963.
43. Sokolov S. S. Surgical anatomy of the "dangerous zones" of the heart in the correction of acquired and congenital malformations // Vestn. hir. - 1978. - No. 11. - S. 48-56.
44. Speransky L. S. Arteries of the heart // International anatomical nomenclature: Appendix 6. - M.: Medicine, 1980. - S. 207-208.
45. Travin A. A., Mikhailin S. I., Filippov B. V., Shinkarenko A. Ya. Surgical anatomy of the arteriessinoatrial And atrioventricularnodes of the heart // Thoracic hir. - 1982. - No. 1. - S. 38-42.
46. Khubutia V. I. Clinical anatomy and operative surgery of the pericardium and coronary vessels. - Ryazan, 1974. - S. 63-103.
47. Tsoy L. A., Chevagina V. N.[cit. according to V. V. Kovanov and T. N. Anikina (1974)].
48. Tsukerman G. I., Travin A. A., Georgadze O. A. On measures to prevent ligation of the circumflex branch of the left coronary artery during mitral valve replacement // Thoracic Surgery. - 1976. - No. 4. - S. 20-24.
49. Shabalkin B.V., Belov Yu.V. Aneurysms of the posterior wall of the left ventricle of the heart. Cardiology. - 1984. - No. 7. - S. 19-23.
50. Shumakov V. I. Surgical correction of mitral valve insufficiency:
Dis. ... cand. Sciences. - M., 1959.
51. Anderson K. R., Ho S. Y., Anderson R. H. Location and vascular supply of sinus node in human heart // Brit. Heart J. - 1979. - Vol. 41. - P. 28-32.
52. Anderson R. H., Becker A. E. Cardiac Anatomy. An integrated text and color atlas. - Gower Medical Publishing. - Pt. 10. - London: Churchill Livingstone, 1980.
53. Austen W. G., Edwards J. E., Frye R. L. et al. A reporting system on patients evaluated for coronary artery disease, report of the AD Hoc. Committee for Grading of Coronary Artery Disease, Council of Cardiovascular Surgery, American Heart Association (editorial) // Circulation. - 1975. - Vol. 51.-P. 7-40.
55. Baroldi G., Scomazzoni G. Coronary circulation in the normal and pathologic heart. - Armed. Forces Institute of Pathology, 1967. - P. 248-263.
56. Becker L. C. Constriction of native coronary collaterals // Cardiovasc. Res. - 2000. - Vol. 47, No. 2. -P. 217-218.
57. Bjork L. Anastomoses between the coronary and bronchial arteries // Acta Radiol. (Diag.). - Stockholm, 1966. - Vol. 4. - P. 93-96.
58. Bjork V. O., Bjork L. Coronary artery fistula // J. Thorac. Cardiovasc. Surg. - 1965.
Vol. 4 9 . -P. 921.
59. Bogers A. J. J. C. Congenital coronary artery anomalies. Clinical and embryological aspects. (Phd. Theses). - Leiden, 1989.
60. Dabizzi R. P., Caprioli G., Aiazzi L. et al. Distribution and anomalies of coronary arteries in tetralogy of Fallot // Circulation. - 1980. - Vol. 61, No. 1. - P. 95-102.
61. DeBakker M. J. T., Jause M. J., Van Capelle F. J. L, Durrer V.Endocardial mapping by simul taneous recording of endocardial electrograms during cardiac surgery for ventricular aneurysm // J. Amer. Coll. cardiol. - 1983. - Vol. 2. - P. 947-953.
62. Dodge J. T., Brown B. G., Bolson E. L., Dodge H. T.Intrathoracic spatial location of specified
coronary system on the normal human heart // Circulation. - 1988. - Vol. 78, No. 5 (Pt 1).
P.1167-1180.
63. Estes E. H. J., Dalton F. M., Entman M. L. et al. The anatomy and blood supply of the papil lary muscles of the left ventricle // Amer. Heart J. - 1966. - Vol. 71. - P. 356.
64. Favaloro R. G. Surgical treatment of coronary arteriosclerosis. - Baltimore, 1970. - P. 11.
65. Fehn P. A., Howe V. B., Pensinger R. R. Comparative anatomical stenosis of the coronary arteries of canine and parcine heart. II. Interventricular septum // Acta Anat. (Basel). - 1968.
Vol. 7 1 . -P. 223.
66. Freedom R. M., Wilson G., Trusler G. A. et al. Pulmonary atresia and intact ventricular septum // Scand. J. Thorac. Cardiovasc. Surg. - 1983. - Vol. 17. - P. 1-28.
67. Fujita M., McKown D. P., Franklin D. Opening of coronary collaterals by repeated brief coronary occlusions in conscious dogs // Angiology - J. Vase. Dis., 1988. - P. 973-980.
68. Fulton W. F. M. The coronary arteries / Ed. Ch. With Thomas. - Illinois: Springfield, 1963.
69. Geens M., Gonzalez-Lavin L., Dawbarn D., Ross D. N. The surgical anatomy of the pulmonary artery root in relation to the pulmonary valve autograft and surgery of the right ventricular outflow tract // J. Thorac. Cardiovasc. Surg. - 1971. - Vol. 6, No. 2. - P. 262-267.
70. Gensini G. G. Coronary arteriography // Heart disease - A textbook of cardiovascular medicine. 2nd ed. /Ed. E. Braunwald. - W. B. Saunders Co., 1984.
71. Gensini G. G., Buonanno C, Palacio A. Anatomy of the coronary circulation in living man - coronary arteriography // Dis. Chest. - 1967. - Vol. 52. - P. 125-140.
72. Gensini G. G., Esente P. La nomenclature angiografica internazionale della circolarione conarica umena // Giorn. ital. cardiol. - 1975. - Vol. 5, No. 2. - P. 143-198.
73. Gittenberger-de Groot A. C, Sauer U., Oppenheimer-Dekker A., Quaegebeur J. Coronary arteri al anatomy in transposition of the great arteries. A morphological study // Pediat. cardiol.
1983. - Vol. 4 (Suppl. 1.). - P. 15-24.
74. Gray H. Anatomy of the human body, Ed. 25, edited by Charles M. Goss. - Philadelphia: Lea and Febiger, 1948.
75. Gross L. The blood supply to the heart in its anatomical and clinical aspects. - New York: P.B. Hoeber, 1921.
76. Grossman W. G. Anatomy of the coronary arteries // Cardiac catheterization and angiogra phy / Ed. W. G. Grossman, Led and Febinger. - Philadelphia, 1986.
77. Hadziselimovic H., Dilberovic F., |
Blood vessels of the human heart: |
|
Coronarography and dissection // |
1980. - Vol. 106, No. 4. - P. 443-449. |
78. Harris L., Downar E., Michleborough L. et al. Activation sequence of ventricular tachycardia: Endocardial mapping studies in the human ventricle // J. Amer. Coll. cardiol. - 1987.
Vol. 5 . -P. 1040-1047.
79. Haworth S. G., Macartney F. J. The intrapulmonary arterial circulation in pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries // Amer. J. Cardiol. (abstr.). - 1979. - Vol. 43. - P. 364.
Stockley H., Clitsakis D., Layton C. Normal coronary |
|||||
test? // Brit. Heart J. - 1982. - Vol. 48. - P. 580-583. |
|||||
Marchegiani With Le fistole coronariche congenite // |
Ann. ital. Chir. |
||||
Vol. 4 1 . -P. 977.
82. James T. N. Anatomy of the coronary arteries. - New York: P. B. Hoeber, 1961.
83. James |
T. N. Blood supply of the human interventricular septum // Circulation. - 1958. |
1 7 . -P. 391. |
84.James |
T. N. Burch G. E. The atrial coronary arteries in man // Ibid. - 1958. - Vol. 17. |
85. Kiechel F., Blumenthal S., Griffiths S. P. The syndrome of papillary muscle infarction and dysfunction in infants // Congenital cardiac defects - recent advances / Ed. D. Bergsma.
Baltimore, 1972. - Vol. 8, No. 1. - P. 44-50.
86. Kirklin J. W., Bargeron L. M., Pacifico A. D. et al. Management of the tetralogy of Fallot with large aorto-pulmonary collateral arteries // Proceedings of the Fourth Joint Symposium on Congenital Heart disease. - Moscow: Mir, 1981. - P. 24-25.
87. K u gel M. A. Anatomical studies on the coronary arteries and their branches. I. Arteries anastomotica auricularis magna // Amer. Heart J. - 1927. - Vol. 3. - P. 260-270.
88. Kyriakidis M. K., Kourouklis S. V., Papaioannoi J. T. et al. Sinus node coronary arteries stu dies with angiography // Amer. J. Cardiol. - 1983. - Vol. 51. - P. 749.
89. La Porta A., Suy-Verburg R. et al. The spectrum of clinical manifestations of anomalous ori gin of the left coronary artery and surgical management // J. Pediat. Surg. - 1979. - Vol. 14, No. 3. - P. 225-227.
90. Levin D. C. Pathways and functional significance of the coronary collateral circulation // Circulation. - 1974. - Vol. 50.-P. 831-837.
91. Levin D. C, Beckman C F., Garnic J. D. et al. Frequency and clinical significance of failure to visualize the conus artery during coronary arteriography // Ibid. - 1981. - Vol. 63.-P. 833.
92. Levin D. C, Gardiner G. A. Coronary arteriography. In heart disease. - Third edition / Ed. E. Braunwald. - W. B. Saunders Co, Philadelphia, 1988. - P. 268-310.
93. Levin D. C, Harrington D. P., Bettmann M. H. et al. Anatomic variations of the coronary arteries supplying the anterolateral aspect of the left ventricle. Possible explanation for the “unexplained” anterior aneurysm // Invest. Radiol. - 1982. - Vol. 17. - P. 458.
94. Lower R. Tractatus de Corde. - Amsterdam: Elsevier, 1669.
95. MacAlpin R. N., Abbasi A. S., Grollman J. H., Eber L. Human coronary artery size during life. A cinearteriographic study // Radiology. - 1973. - Vol. 108, No. 3. - P. 567-576.
96. Mansaray M., Hynd J. W., Vergroesen J. et al. Measurment of coronary collateral flow and resistance in the presence of an open critical stenoses, and the response to intra-arterial thrombosis // Cardiovasc. Res. - 2000. - Vol. 47, No. 2. - P. 359-366.
Marcelletti C. Surgery and coronary arteries at |
risk // Pediatric Cardiology. 3./eds |
|
A. E. Becker, T. G. Losekoof, C Marcelletti, |
R. H. Anderson. - Edinburgh: Churchill |
|
Livingstone, 1981. - P. 290-297. |
||
May A. M. Surgical anatomy of the coronary arteries // Dis. Chest. - 1960. - Vol. 38. |
||
P. 645-657.
99. M with Alpine W. A. Heart and coronary arteries. An anatomical atlas for clinical diagnosis, radiological investigation, and surgical treatment. - Berlin: Heidelberg; New York: Springer-Verlag, 1975.
100. McAlpine W. A. In Heart and coronary arteries. Section II: The normal heart. - Berlin: Heidelberg; New York: Springer, 1975. - P. 20-24.
101. McGoon D. C, Baird D. K., Davis G. D. Surgical management of large bronchial collateral arteries with pulmonary stenosis or atresia // Circulation. - 1975. - Vol. 52. - P. 109.
102. Miller D. C, Schapira J. N., Stinson E. B., Shumway N. E. Left ventricular-coronary sinus fis tula following repeated mitral valve replacement // J. Thorac. Cardiovasc. Surg. - 1978.
Vol. 76, No. 1. - P. 43-45.
103. Moberg A. Anastomoses between extracardiac vessel and the coronary arteries // Acta Med. Scand. - 1968. - Vol. 485 (Suppl.). - P. 5-25.
104. Moran J. M., Michaelis L. L., Sanders J. H., Robert A. J. Separate origin of the first septal branch of left anterior descending coronary artery // J. Cardiovasc. Surg. - 1979. - Vol. 20, No. 6. -P. 621.
105 Nathan H., Orda R., Barkay M. The right bronchial artery. Anatomical considerations and surgical approach. - 1970.
106. Neiman J., Ethevenot G., Guilliere M., Cherrier F. Variations de distribution des arteres coronaries (a propos de 3000 coronarographies) // Bull. Ass. Anat. - 1976. - Vol. 60, no. 176.
P. 769-778.
107. Parker D. L., Pope D. L, Van Bree R. E., Marshall H. Three-dimensional reconstruction of moving arterial beds from digital subtraction angiography // Comput. Biomed. Res. - 1987.
Vol. 20. - P. 166-185.
