Arteries of the forearm. Arterial collaterals of the elbow region

When ligating large vessels

Collateral blood flow

When ligating the common carotid artery

Roundabout circulation in the region supplied by the ligated artery is carried out:

Through the branches of the external carotid artery on the healthy side, anastomosing with the branches of the external carotid artery on the operated side;

Along the branches of the subclavian artery (the sito-cervical trunk - the lower thyroid artery) from the operated side, anastomosing with the branches of the external carotid artery (superior thyroid artery) also from the operated side;

Through the anterior and posterior communicating arteries of the internal carotid artery. To assess the possibility of a roundabout blood flow through these vessels, it is advisable to determine the cranial index
(CI), because in dolichocephals (CI less than or equal to 74.9) more often,
than brachycephalic (CI equal to or greater than 80.0) one or both
communicating arteries are absent:

CHI \u003d Wx100 / L

where W is the distance between the parietal tubercles, D is the distance between the glabella and the external occipital protrusion.

Through the branches of the ophthalmic artery of the operated side with the terminal branches of the external carotid artery (maxillary and superficial temporal arteries).

External carotid artery

The ways of development of collateral blood flow are the same as in the case of ligation of the common carotid artery, except for the branches of the subclavian artery from the side of the operation. To prevent thrombosis of the internal carotid artery, if possible, it is desirable to ligate the external carotid artery in the interval between the origin of the superior thyroid and lingual arteries.

2.2.3. Collateral blood flow during ligation
subclavian and axillary artery

There are practically no ways for the development of a roundabout blood flow during ligation of the subclavian artery in its 1st segment (before entering the interstitial space) before the discharge of the transverse artery of the scapula and the internal mammary artery. The only possible way of blood supply is anastomoses between the intercostal arteries and the thoracic branches of the axillary artery (the artery surrounding the scapula and the dorsal artery of the chest). Ligation in the 2nd segment of the subclavian artery (in the interstitial space) allows you to participate in the roundabout blood circulation along the above-described path of the transverse artery of the scapula and the internal mammary artery. Ligation of the subclavian artery

in the 3rd segment (to the edge of the 1st rib) or ligation of the axillary artery in the 1st or 2nd segments (respectively, to the pectoralis minor muscle or under it) adds the last source to the roundabout blood flow - a deep branch of the transverse artery of the neck. Ligation of the axillary artery in the 3rd segment (from the lower edge of the pectoralis minor to the lower edge of the pectoralis major muscle) below the origin of the subscapular artery does not leave any paths for roundabout blood flow.

Collateral blood flow during ligation

Brachial artery

Ligation of the brachial artery above the origin of the deep artery of the shoulder is unacceptable due to the lack of opportunities for the development of bypass circulation.

When ligating the brachial artery below the origin of the deep artery of the shoulder and the superior communicating ulnar artery, up to its division into the ulnar and brachial arteries, the blood circulation distal to the ligation site is carried out in two main ways:

1. Deep artery of the shoulder → middle collateral artery →
network of the elbow joint → radial recurrent artery → radial
artery;

2. Brachial artery (depending on the level of ligation) →
superior or inferior collateral ulnar artery →
network of the elbow joint → anterior and posterior ulnar recurrent
artery -» ulnar artery.

Collateral blood flow during ligation

Ulnar and radial arteries

Restoration of blood flow during ligation of the radial or ulnar arteries is carried out due to the superficial and deep palmar arches, as well as a large number of muscle branches.

The ligation of the brachial artery is carried out below the origin of the deep artery of the shoulder (a. profunda brachii), which is the main collateral route.

The patient's arm is retracted in the same way as when ligating the axillary artery. A typical site for arterial ligation is the middle third of the arm.

Ligation of the brachial artery in the middle third of the shoulder.

To expose the brachial artery, an incision is made along the medial edge of the biceps brachii muscle. The skin, subcutaneous tissue, superficial fascia and own fascia of the shoulder are dissected. The biceps muscle of the shoulder (m.biceps brachii) is pulled outward, the artery is isolated from the adjacent nerves, veins and tied up (Fig. 11).

Collateral circulation is well restored with the help of anastomoses of the deep artery of the shoulder with a. recurrens radialis; a.a. collaterales ulnares sup. and inf., c a. recurrens ulnaris and branches of intramuscular vessels.

Fig.11. Exposure of the brachial artery in the shoulder area. 1- biceps muscle of the shoulder; 2- median nerve; 3- brachial artery; 4- ulnar nerve; 5- brachial vein; 6 - medial cutaneous nerve of the forearm.

Ligation of the brachial artery in the cubital fossa.

The hand is taken away from the body and set in a position of strong supination. The tendon of the biceps brachii is felt. An incision is made along the ulnar edge of this tendon. The median vein of the elbow (v. mediana cubiti) enters the incision in the subcutaneous tissue, which is crossed between two ligatures.

Carefully dissecting a thin plate of fascia, the tendon of the biceps muscle is exposed; then becomes visible lacertus fibrosus, going obliquely from top to bottom. This tendon stretch is carefully cut in the direction of the skin incision.

Directly below it lies an artery accompanied by a vein. When looking for an artery, you need to remember that the vessel is quite close under the skin, and therefore you should go slowly, carefully and strictly in layers.

Ligation of the brachial artery in the antecubital fossa is safe, since a roundabout circulation can develop through several anastomotic pathways that make up the arterial network of the elbow (rete cubiti): aa. collateralis radialis, collateralis ulnaris superior et inferior, aa. recurrens radialis, recurrens ulnaris, recurrens interossea. In this case, the collateral arteries anastomose with the corresponding recurrent ones.

Ligation of the radial and ulnar arteries (a. Radialis, a. Ulnaris)

Ligation of the ulnar and radial arteries is performed at different levels of the forearm.

Ligation of the radial artery in the muscular region.

Putting the hand in the supination position, an incision is made along the medial edge of the brachioradialis muscle at the border of the upper and middle thirds of the forearm; dissect the dense fascia of the forearm. The brachioradialis muscle is pulled to the radial side, while at the same time moving the flexor group (m. flexor carpi radialis and, in depth, m. flexor digitorum superficialis) to the ulnar side. Here, under a very thin fascial sheet, an artery is easily found, accompanied by its veins.

With the radial artery, a thin superficial branch of the radial nerve (ramus superficialis n. Radialis) passes here, but not directly next to the vessels, but somewhat further to the radial side, being hidden under the brachioradialis muscle (Fig. 12).

Ligation of the axillary artery
The projection line of the artery runs on the border between the anterior and middle third of the width of the armpit or along the anterior border of hair growth (according to N.I. Pirogov) or is a continuation upward of the medial groove of the shoulder (according to Langenbeck). The hand is in the abduction position. A skin incision 8-10 cm long is carried out above the coracobrachialis muscle, 1-2 cm away from the projection line. Dissect the subcutaneous tissue, superficial fascia.

Own fascia is cut along the grooved probe. The beak-shoulder muscle is moved outward with a hook and the medial wall of the fascial sheath of the muscle is dissected along the probe. The artery lies behind the median nerve or in a fork formed by the medial and lateral crura of the nerve. Outside is n. musculocutaneus, medially - n. ulnaris, cutaneus antebrachii medialis, cutaneus brachii medialis, behind - n. radialis. The axillary vein, the wound of which is dangerous due to the possibility of an air embolism, should remain medially from the surgical wound. The artery is ligated.

Collateral circulation after ligation of the axillary artery is carried out by branches of the subclavian artery (aa. transversa colli, suprascapularis) and the axillary artery (aa. thoracodorsalis, circumflexa scapulae).

Ligation of the brachial artery
The projection line of the artery corresponds to the medial groove of the shoulder, but it is recommended to use a roundabout approach to approach the vessel in order to exclude injury or involvement of the median nerve in the scar. The hand is in the abduction position. An incision 5-6 cm long is made along the medial edge of the biceps brachii muscle, 1-1.5 cm outward and anterior to the projection line. The skin, subcutaneous tissue, superficial and own fascia are dissected in layers. The biceps muscle that appears in the wound is retracted outwards with a hook. After dissection of the posterior wall of the sheath of the biceps muscle located above the artery, the median nerve is pushed inward with a blunt hook, the brachial artery is isolated from the accompanying veins and ligated.

Collateral circulation is carried out by branches of the deep artery of the shoulder with recurrent branches of the ulnar and radial arteries.

Ligation of the radial artery
The projection line of the radial artery connects the middle of the elbow bend with the pulse point. The hand is in supination position. A skin incision 6-8 cm long is carried out along the projection of the vessel. Own fascia is opened along a grooved probe and the radial artery with its accompanying veins is found. In the upper half of the forearm, it passes between m. brachioradialis (outside) and m. pronator teres (inside) accompanied by the superficial branch of the radial nerve, in the lower half of the forearm - in the groove between rn. brachioradialis and rn. flexor carpi radialis. A ligature is applied to the selected artery.

Ligation of the ulnar artery
The projection line goes from the internal condyle of the shoulder to the pisiform bone. This line corresponds to the course of the ulnar artery only in the middle and lower third of the forearm. In the upper third of the forearm, the location of the ulnar artery corresponds to the line connecting the middle of the elbow bend with a point located on the border of the upper and middle thirds of the medial edge of the forearm. Hand in supination position.

A skin incision 7-8 cm long is carried out along the projection line. After dissection of the own fascia of the forearm, the ulnar flexor of the hand is pulled inwards with a hook and enters the gap between this muscle and the superficial flexor of the fingers. The artery lies behind the deep leaf of the own fascia of the forearm. It is accompanied by two veins, outside of the artery is the ulnar nerve. The artery is isolated and ligated.

Ligation of the femoral artery
The projection line, with an outwardly rotated, slightly bent limb at the knee and hip joints, runs from the middle of the inguinal ligament to the medial femoral condyle. Ligation of the artery can be performed under the inguinal ligament, in the femoral triangle and the femoral-popliteal canal.

Ligation of the femoral artery in the femoral triangle. The skin, subcutaneous tissue, superficial and broad fascia of the thigh are dissected in layers along the projection line with an incision 8-9 cm long. At the top of the triangle, the tailor's muscle is retracted outward with a blunt hook. Cutting the back wall of the sheath of the sartorius muscle along the grooved probe, the femoral vessels are exposed. With a ligature needle, a thread is brought under the artery, which lies on top of the femoral vein, and the vessel is tied up. Collateral circulation during ligation of the femoral artery below the origin of the deep femoral artery from it is carried out by the branches of the latter.

Popliteal artery ligation
The position of the patient is on the stomach. The projection line is drawn through the middle of the popliteal fossa. An incision 8-10 cm long is used to dissect the skin, subcutaneous tissue, superficial and intrinsic fascia. Under the fascia in the fiber passes n. tibialis, which is carefully taken outward with a blunt hook. Under it, a popliteal vein is found, and even deeper and somewhat medially in the fiber near the femur, the popliteal artery is isolated and ligated. Collateral circulation is carried out by branches of the arterial network of the knee joint.

Ligation of the anterior tibial artery
The projection line of the artery connects the middle of the distance between the head of the fibula and tuberositas tibiae with the middle of the distance between the ankles. A skin incision 7-8 cm long is carried out along the projection line. After dissection of the subcutaneous tissue, superficial and own fascia, hooks are removed medially m. tibialis anterior and laterally - m. extensor digitorum longus. In the lower third of the lower leg, you need to penetrate between m. tibialis anterior and m. extensor hallucis longus. The artery with accompanying veins is located on the interosseous membrane. Outside of it lies the deep peroneal nerve. The isolated artery is ligated.

Ligation of the posterior tibial artery
The projection line of the artery runs from a point 1 cm posterior to the medial edge of the tibia (above) to midway between the medial malleolus and the Achilles tendon (below).

Ligation of the posterior tibial artery in the middle third of the leg. A skin incision 7-8 cm long is carried out along the projection line. The subcutaneous tissue, superficial and proper fascia of the lower leg are dissected in layers. The medial edge of the gastrocnemius muscle is retracted posteriorly with a hook. The soleus muscle is cut along the fibers, departing 2-3 cm from the line of its attachment to the bone, and the edge of the muscle is retracted posteriorly with a hook. The artery is found behind a deep sheet of the own fascia of the lower leg, which is dissected along a grooved probe. The artery is separated from the veins accompanying it and the tibial nerve passing outward and bandaged according to the general rules.

Projection of the axillary artery: along the line on the border between the anterior and middle third of the width of the armpit or along the anterior border of hair growth in the armpit (according to Pirogov).

Technique of exposure and ligation of the axillary artery:

1. The position of the patient: on the back, the upper limb is laid aside at a right angle and laid on a side table

2. An incision of the skin, subcutaneous adipose tissue, superficial fascia, 8-10 cm long, somewhat anterior to the projection line, respectively, of the bulge of the abdomen of the coracobrachialis muscle

3. We dissect the anterior wall of the sheath of the coracobrachialis muscle along the grooved probe.

4. We retract the muscle outwards and, carefully, so as not to damage the axillary vein associated with the fascia, dissect the posterior wall of the sheath of the coracobrachialis muscle (which is also the anterior wall of the vascular sheath)

5. We stretch the edges of the wound, select the elements of the neurovascular bundle: in front, the axillary artery (3) is covered by the median nerves (1), laterally - by the musculocutaneous nerve (2), medially - by the cutaneous medial nerves of the shoulder and forearm (6), by the ulnar nerve , behind - the radial and axillary nerve. The axillary vein (5) and the cutaneous nerves of the shoulder and forearm are displaced medially, the median nerve is displaced laterally and the axillary artery is isolated.

6. The artery is tied with two ligatures (two for the central section, one for the peripheral section) BELOW THE OUTPUT tr. thyrocervicalis ABOVE THE DISCHARGE of the subscapular artery (a.subscapularis). Collateral circulation develops due to anastomoses between the suprascapular artery (from the thyroid cervical trunk of the subclavian artery) and the artery that goes around the scapula (from the subscapular artery - a branch of the axillary artery), as well as between the transverse artery of the neck (a branch of the subclavian artery) and the thoracic artery (from the subscapular artery - branches of the axillary artery).