女性乳房手术预防乳头乳晕坏死的血供研究

目的研究女性乳头乳晕的动脉血供特点，为乳腺手术时避免乳头乳晕坏死提供解剖依据。方法对13具女性尸体26个乳房标本的乳头乳晕血管进行斛剖学观察。结果乳头乳晕动脉血供主要由胸外侧动脉分支及胸廓内动脉穿支供应：胸廓内动脉第2～4肋间血管穿支与胸外侧动脉的乳头乳晕支分别从乳晕上、内方和外上方经腺体小叶之间到达乳头乳晕基底部，然后在乳腺导管问上行供应乳头乳晕；胸廓内动脉肋间穿支和胸外侧动脉分支的浅层腺体穿支在皮下形成广泛吻合，特别是在乳晕下形成动脉网，由此网发出分支供应乳头乳晕；肋间动脉穿支与胸肩峰动脉末见有分支供应乳头乳晕。结论保留乳头的乳腺癌根治术时，为了避免乳头乳晕坏死，应注意保护乳晕下动脉网，这时的皮瓣厚度不能小于0．5cm。乳房缩小整形术时，应以乳房内上或外上象限腺体作为腺蒂，并且注意保留乳腺后方至少1．5cm厚的腺体，以保证胸廓内动脉第2～4肋间穿支或胸外侧动脉乳头乳晕支对乳头乳晕的血液供应。     

Breast Shaping by an Isolated Tissue Flap

Breast reshaping surgery for tuberous breast, breast reduction, and mastopexy procedures aim to keep the gained shape for a long time. In breast reduction, the surgeon must avoid loss of fullness in the upper pole, descent of the breast mass known as secondary dropout, and relapsed shape of the repaired tuberous breasts. As described in their clinical report, the authors use a caudally based thoracic wall flap to avoid these problems. The blood supply to the breast comes from two main sources: the mammary internal and lateral arteries. Because of vessels constantly perforating the pectoralis major muscle, it is possible to isolate a caudally based thoracic wall flap. These vessels originate from intercostal arteries as anteromedial intercostal perforators, and from the thoracoacromial artery as in the skin paddle of the pectoralis major muscle flap. This flap is long enough to reach every part of the breast where it is needed. Between January 2002 and June 2005, 64 patients underwent procedures in which the caudally based thoracic wall flap was used.     

Gross and microscopical blood supply of the trachea.

Twenty-one human tracheal specimens were perfused and dissected, 10 with conventional techniques and 11 with clearing and microdissection techniques. The lateral pedicles of the trachea and esophagus induct vessels from the inferior thyroid, subclavian, supreme intercostal, internal thoracic, innominate, and superior and middle bronchial arteries. These vessels are interconnected along the lateral surface of the trachea by an important longitudinal vascular anstomosis. From the 2 lateral longitudinal anastomoses the lateral and anterior tracheal walls receive their blood supply through transverse segmental vessels that run in the soft tissues between the cartilages. These transverse vessels interconnect the longitudinal anastomoses across the midline and feed the submucosal capillary network that arborizes richly beneath the endotracheal mucosa. The tracheal cartilages receive nourishment from the capillary bed applied to their internal surface. The esophageal arteries and their subdivisions that supply the posterior membranous wall of the trachea contribute almost nothing to the circulation of the cartilaginous walls.     

The vascularization of the os calcaneum and the clinical consequences.

This study was conducted to analyze extraosseous and intraosseous vascularization of the os calcaneum and to elucidate possible clinical manifestations. The arteries of 13 lower leg and foot specimens of human cadavers were injected with a polymer and subjected to maceration or were embedded in plastic. The examination revealed that 45% of the bone is vascularized via medial arteries and 45% via lateral arteries, whereas the remaining 10% is supplied by the sinus tarsi artery. From the medial side, two or three vessels branch off the posterior tibial artery, penetrate the calcaneus below the sustentaculum, and supply the medial part of the posterior joint. The lateral calcaneal artery normally is a branch from the posterior tibial artery. In two of 13 specimens, this lateral supply comes from the peroneal artery. The medial and lateral intraosseous arterial supply for the calcaneus is equal. Inside the bone there is a water-shed zone where the medial and lateral arterial supply meet in the midline. Only 10% of the blood flow is supplied by vessels in the sinus tarsi. Clinically, interruption of the lateral calcaneal artery during the conventional lateral surgical approach for a calcaneus fracture may result in ischemic bone necrosis. The lateral calcaneal artery could supply a local microvascular flap to cover soft tissue defects of the heel. A compartment syndrome after a calcaneus fracture may be caused by bleeding from the medial calcaneal arteries into the quadratus plantae compartment.     

山羊血管化骨髓移植的解剖学基础研究

目的通过对山羊股骨、髂骨、胸骨、肋骨4个较为常见的血管化骨髓移植供区部位相关结构的测量观察,从移植手术的角度,分析其解剖特点,为下一步建立山羊血管化骨髓移植模型提供一定的解剖依据。方法取6只（共12侧）体质量相当的山羊做活体解剖研究。观测4个供区血液供应情况,并对比4种移植物体质量、体积、骨髓干细胞密度等因素。结果髂骨可见主要滋养血管为髂内动脉及其分支,另外紧贴骨面的臀部肌肉也会有细小动脉进入骨膜,髂内血管为较理想的血管蒂;股骨的主要滋养动脉有3条：股深动脉、旋股外侧动脉及膝降动脉,取髂外血管为血管蒂;双侧胸廓内动脉及伴行静脉为胸骨的主要滋养血管,双侧胸廓内动静脉的近端可作为游离血管蒂;肋骨以第7肋为例,其肋间后动脉及其伴行静脉为主要滋养血管,可以取到一定长度的游离血管蒂。结论山羊的髂骨及股骨是较为理想的血管化骨髓移植术供区,其游离血管蒂长度及其动静脉外径均可满足异体移植术的需求。     

Anatomic basis of vascularized ulnar nerve graft by the pedicle of the superior collateral ulnar artery

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Preservation of lateral thoracic artery to improve vascular supply of distal skin without compromising pedicle length in harvesting pectoralis major myocutaneous flap.

The pectoralis major myocutaneous (PM) flap is supplied by three arterial systems. The lower chest skin of the PM flap is mainly supplied by the branches of lateral thoracic artery and internal mammary artery. The conventional harvesting technique for head and neck reconstruction utilizes single arterial supply from the pectoral branch of thoracoacromial artery. The distal skin island of PM flap is therefore compromised and requires indirect blood supply by communicating vessels. In harvesting the PM flap, the pectoralis minor muscle is divided to preserve the lateral thoracic artery and its blood supply to the lateral distal skin island of PM flap without compromising the pedicle length for head and neck reconstruction. Six PM flaps were harvested for reconstruction of head and neck defects with preservation of both the pectoral artery and lateral thoracic artery. The focal pint of swing of all six flaps was at the same point just below the mid-point of clavicle for both pectoral artery and lateral thoracic artery. The flaps can reach the oral cavity, tonsil or hypopharynx without limitation and there is no flap necrosis. In conclusion, the lateral thoracic artery can be preserved without compromising the pedicle length of PM flap. It is a recommended technique to improve the blood supply to the distal skin of PM flap.     

The vascular territories of the anterior chest wall

A series of 31 fresh cadaver injection, dissection and radiographic studies were undertaken to define the vascular architecture of the anterior chest wall and to correlate the findings of previous writers in this area. The findings confirmed that the dominant supply to this region is from the internal thoracic artery which interconnects in all layers with the posterior intercostals, the lateral thoracic, the acromio-thoracic and the transverse cervical arteries. The dominant cutaneous perforators of these vessels are concentrated around the perimeter of the pectoralis major muscle, the costal margin and over the interdigitations of the serratus anterior muscle in the mid-axillary line. The clinical significance of these findings is discussed with particular reference to the design of various breast reduction procedures and the planning of flaps in this area. Of special note is the observation that the concentration of large perforators which exists along the inframammary crease arises from the anterior intercostal vessels in the fifth and sixth intercostal spaces.     

阴囊皮肤多源性血供系统应用解剖学研究

目的探讨阴囊皮肤血供模式,明确可能的阴囊皮瓣供区。方法对10具(20侧)成年男尸阴囊皮肤进行解剖学研究。结果阴囊前动脉来自阴部外浅动脉,于阴茎根部侧方分成内、外侧支,分布于阴囊前外侧皮肤,内侧支口径为(0.54±0.34)mm和(0.69±0.09)mm;来自闭孔动脉前皮支的阴囊外侧动脉[出现率为85％,外径(0.62±0.19)mm]分布于阴囊外侧中1/3区皮肤;阴囊后动脉于阴囊后极处,分成阴囊后动脉外侧支与阴囊中隔动脉,前者[外径(0.8±0.1)mm]分布于阴囊后外侧区皮肤,后者[外径(0.9±0.2)mm]分布于阴囊中隔及阴囊中缝侧方皮肤。结论上述4组血管均在阴囊肉膜层内走行,其终末支血管相互吻合,在每一侧阴囊形成一个较为完整的动脉网络,由此提出4种类型的阴囊皮瓣切取方式,其他类型的阴囊皮瓣是上述阴囊皮瓣切取方式的变化形式。     

Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study

OBJECTIVE: To describe the extraosseous blood supply of the tibia and how the blood supply of the distal tibia is influenced by different plating techniques. DESIGN: Microdissection of cadaveric adult hip disarticulation specimens following sequential arterial injections of india ink and Ward's Blue Latex was performed. Readily identifiable arterioles measured approximately 0.5 mm in diameter. Their artery of origin was identified, and their position along the medial, lateral, and posterior aspects of the tibia was documented relative to the tibial plafond. Additionally, six matched pairs of limbs were used to assess the effects of different plating techniques on the extraosseous blood supply along the medial aspect of the distal tibia. SETTING: University anatomy laboratory. PATIENTS/PARTICIPANTS: Nine matched pairs ( = 18) of randomly obtained, adult cadaveric hip disarticulation specimens. INTERVENTION: India ink followed by Ward's Blue Latex was injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system. The skin, subcutaneous tissue, and muscles were dissected from the leg, exposing the arterial system and the extraosseous vessels of the tibia. MEAN OUTCOME MEASUREMENTS: The extraosseous blood supply of each aspect of the tibial diaphysis was determined. Each extraosseous arteriole was identified, and the locations of each documented relative to the tibial plafond. Changes in the filling of these vessels along the medial aspect of the distal tibia were documented in a separate group of specimens ( = 12), which had undergone two different plating techniques. RESULTS: The proximal metaphysis of the tibia was found to have a rich extraosseous blood supply provided primarily from vessels from the popliteal artery, the anterior tibial artery (ATA) laterally, and the posterior tibial artery (PTA) medially. In comparison, the tibial diaphysis was found to have relatively few extraosseous vessels and a considerably hypovascular region, posteriorly. Branches of the ATA were found to supply the posterior aspect of the diaphysis with these branches passing through the interosseous membrane. The diaphysis also received a variable contribution from the PTA. The lateral aspect of the diaphysis was supplied by branches of the ATA. An anastomotic network of arteries from the ATA and PTA formed the rich extraosseous blood supply of the medial distal aspect of the tibia. Open plating of the medial aspect of the distal tibia caused a statistically significant ( < 0.05) greater disruption of the extraosseous blood supply of the metaphyseal region than did percutaneously applied plates. In each specimen, open plating prevented filling of each periosteal vessel in the region as opposed to percutaneous plates, which permitted filling of the extraosseous vessels up to the edge of the plate. CONCLUSIONS: The proximal and distal metaphyseal areas of the tibia have a rich extraosseous blood supply provided primarily by branches of the ATA and the PTA. Open plating of the medial aspect of the distal tibia caused a greater disruption of this extraosseous blood supply than did percutaneously applied plates. Disruption of these extraosseous vessels following fracture and subsequent operative stabilization may slow healing and increase the risk of delayed union and nonunion. These findings support current efforts to develop less invasive methods and implants for operative stabilization of distal tibia fractures.     

A new flap in the dog containing a vascularized rib graft—The latissimus dorsi myoosteocutaneous flap

A new island flap is described in the dog which is based upon the subscapular vessels and contains latissimus dorsi muscle, overlying skin and a segment of posterior rib. The posterior rib graft is vascularized by perforating vessels which connect the overlying skin and muscle to the posterior intercostal vessels. The rib segment is supplied by the medullary branch off the posterior intercostal artery. This flap was elevated in 10 dogs. Adequate blood supply to the rib was indicated by the observation of blood flow in the posterior intercostal vessels, by bleeding from the medulla of the rib, by routine histologic examination of the rib, and by tetracycline binding to amorphous calcium phosphate. Similar perforating vessels between the latissimus dorsi muscle and the posterior intercostal vessels have been found in primates and humans. This flap may have clinical application when an island or free composite tissue transfer is needed to reconstruct a defect requiring skin, bone, and possibly muscle.     

Prevention of paraplegia secondary to operations on the aorta

Prevention of paraplegia during operations on the aorta requires knowledge of the blood supply to the spinal cord. The great radicular artery of Adamkiewicz (RAD) plays a major role in the supply to the anterior spinal artery which nourishes the anterior two-thirds of the cord. The RAD usually arises from an intercostal artery between T9-T12 but may arise higher or in 10% of patients from a lumbar artery. Temporary interruption of flow by crossclamping, hypotension, or permanent interruption of the RAD are factors in the etiology of paraplegia. In resection of descending thoracic aortic aneurysms, the thoracic aorta should not be crossclamped without an external bypass. The bypass should be nonthrombogenic to avoid necessity for anticoagulation and attendant hemorrhagic problems. Bypass flow is ideally controlled by a pump with continuous monitoring of the proximal and distal pressures to provide normal distal flow to the cord. As many intercostal and high lumbar arteries as possible should be preserved by retaining the distal posterior wall of the aneurysm. Preoperative selective catheterization of the distal thoracic intercostal or proximal lumbar vessels can delineate critical supply to the cord and should become part of the routine workup of patients being considered for surgery of the distal thoracic and thoraco-abdominal aorta. Knowledge of the location of the RAD may permit its avoidance or reinsertion into a graft. Avoidance of the RAD may be particularly applicable with infrarenal aneurysms when a large lumbar artery is seen just above or below a renal artery. Here, avoidance of all but brief suprarenal clamping and resection of the aneurysm below the feeding RAD may help to avoid paraplegia.     

Arterial supply of the femoral condyles

INTRODUCTION: The most frequent site for aseptic bone necrosis and osteochondrosis dissecans in the human knee joint is the medial femoral condyle. The aim of this study is to analyze the three-dimensional vascularization of the human knee joint and to find out if there are any differences in the blood supply of the medial and lateral femoral condyles which may explain the preponderance of aseptic bone necrosis in the medial side. MATERIAL AND METHODS: The femoral arteries of 14 unfixed lower extremities have been injected with epoxy resin. After documentation of the extraosseous course of the blood vessels the bone was macerated with 10% formic acid. The insertions of tendons and ligaments were investigated by light microscopy and immunohistochemistry. RESULTS: The arterial supply of the lateral femoral condyle originates from the upper lateral geniculate artery, the terminal ends of which penetrate the bone from lateral. Branches of the middle geniculate artery reach the bone from the medial wall of the intertubercular notch. The subchondral bone of the medial femoral condyle draws its blood supply mainly from the descending geniculate artery. Branches of the middle geniculate artery penetrate the medial femoral condyle only in the posterior part of the intercondylar fossa. These posterior vessels do not contribute to the supply of the subchondral bone. In the anterior part of the medial wall of the intercondylar fossa there is the wide femoral insertion of the posterior cruciate ligament. Injection techniques and immunohistochemical investigations show that the fibrocartilage of the chondral apophyseal insertion of the posterior cruciate ligament is avascular and acts as banier which impedes blood vessels to penetrate the bony surface in this region. The subchondral bone adjacent to the femoral insertion of the posterior cruciate ligament receives its blood supply from vessels that penetrate the bone at the medial wall of the medial femoral condyle. The blood vessels which supply the lateral parts of the medial condyle have the longest intraosseous course. The density of vessels within this region is largely reduced. CONCLUSIONS: The region adjacent to the femoral insertion of the posterior cruciate ligament is the most frequent site for osteochondrosis dissecans in the knee joint. Our results show that the arterial supply of the subchondral bone may be considered as a cofactor for the etiology of osteochondrosis dissecans.     

肝外供血动脉栓塞在巨块型肝癌治疗中的价值

目的探讨经导管肝外供血动脉栓塞在治疗巨块型肝癌中的价值。方法对35例巨块型肝癌,首次行经导管肝动脉化疗栓塞术（TACE）,第2次及其后在肝动脉TACE基础上加行经右侧胸廓内动脉、右侧肋间动脉侧支供血动脉栓塞术。结果本组35例巨块型肝癌患者,发现肝外侧支49支,对46支使用微导管进行栓塞治疗,3支行超选择灌注化疗。初次TACE治疗时肝外血供多有膈下动脉参与,治疗过程中,随着肿瘤的增大或肝动脉的闭塞,胸廓内动脉、肋间动脉、胰十二支肠动脉弓等血管有可能参与。结论对肝外侧支血管应用微导管超选择栓塞或灌注化疗均能加强TACE在巨块型肝癌治疗中的作用,提高患者带瘤生存期。     

Pectoralis major muscle: anatomical features of its arterial supply

Despite the extensive use of pectoralis major flaps in reconstructive surgery, certain pectoralis major musculocutaneous flaps may suffer from partial distal necrosis. The aim of the present study was to investigate the origin, length, and external diameter of its arterial pedicles to provide an anatomical basis for alternative techniques in reconstructive surgery. Thirty pectoral region specimens, pertaining to 14 fresh human adult cadavers and one stillbirth, were dissected, after retrograde injection of the brachial artery with red latex in pursuit of this aim. The thoracoacromial trunk (TAT) was the main nourishing vessel, arising from the first and the second parts of the axillary artery in 60% and 40%, respectively. The proximal segment was constantly supplied by the clavicular and the deltoid branches of the TAT, supplemented by its pectoral branch in 30% and the superior thoracic artery in 23.3%. The distal segment was constantly supplied by the lateral perforating branches of the anterior intercostal arteries and the perforating branches of the internal thoracic artery. The pectoral branch of both the TAT (P-TAT), and the axillary artery (PA) and the lateral thoracic artery participated in 90%, 66.7%, and 40%, respectively. Additionally, an arterial pedicle, from the arterial plexus inside the pectoralis minor muscle, was observed in 4/30 (13.3%). The clavicular and pectoral branches of the TAT are reliable pedicles for raising the proximal and distal segments of muscle flaps, respectively. The pectoral branch of axillary artery may be an alternative pedicle in the absence of P-TAT.     

Blood distribution to the anterior spinal artery from each segment of intercostal and lumbar arteries

AIM: Prevention of paraplegia, a serious complication of surgery for thoracoabdominal aortic aneurysm, has been well documented. However no assured prophylaxis against this complication has yet been found. Spinal ischemia is believed to be the major cause of paraplegia. We conducted an experimental study to define the development of paraplegia with regard to the blood supply to the spinal cord. METHODS: A porcine model was used to evaluate blood distribution to the anterior spinal artery. Colored silastic agent was selectively injected into the intercostal and lumbar arteries, and distribution to the anterior spinal artery was evaluated on 50 animals. The intercostal and lumbar arteries were ligated in the segments where the blood supply to the anterior spinal artery would be interrupted. Whether or not paraplegia developed was checked 2 days later. RESULTS: Colored silastic agent arrived at the anterior spinal artery from all segments of the 8th intercostal to 4th lumbar arteries. Two of 9 pigs (22.2%) that underwent ligation of the segments from the 9th intercostal to 2(nd) lumbar artery suffered paraplegia. In 3 non-paraplegic pigs, colored silastic agent injected into the preserved arteries was found to have covered a wider range. CONCLUSION: All the intercostal and lumbar arteries supplied blood to the anterior spinal artery. When large segments of intercostal and lumbar arteries were ligated, the blood flow from the preserved segments acquired increased dominance. The possibility exists that any intercostal and lumbar artery can supply blood to the spinal cord and become collateral circulation to the anterior spinal artery.     

Blood supply to the anterior cruciate ligament and supporting structures

The blood supply to the knee arises from a vascular plexus that surrounds the joint. The descending genicular artery, the medial and lateral inferior genicular arteries, the medial and lateral superior genicular arteries, the middle genicular artery, and the anterior and posterior tibial recurrent arteries contribute vessels that supply the various structures of the knee. The intra-articular soft tissues of the knee (the infrapatellar fat pad and synovium) mediate the blood supply to the cruciate ligaments, and preservation and utilization of these tissues should be considered when repair or reconstruction of the anterior cruciate ligament is being performed.     

Arterial blood supply to the infrahyoid muscles: An anatomical study

The arterial supply to the infrahyoid strap muscles originating from the superior thyroid artery (STA), the inferior thyroid artery (ITA), and the internal mammary artery (IMA), also called the internal thoracic artery, were investigated. Intraarterial silicone dye was injected into eight fresh cadavers followed by dissections. The blood supply to the infrahyoid muscles was found to be segmented in nature with the dividing line at the level of the cricoid ring. No axial pattern of vascularization could be demonstrated within the strap muscles. The skin overlying these muscles is supplied by tributaries arising from the above-described arteries. Application of the information gathered is discussed in consideration of local myocutaneous and myoosseous flaps for reconstructive surgery, particularly of the larynx and trachea.     

Myocardial Revascularization of the Canine Circumflex Coronary Artery Using Retrograde Internal Mammary Artery Flow Without Cardiopulmonary Bypass

A new surgical technique using perfusion of the circumflex coronary artery with retrograde blood flow of the internal mammary artery (IMA) is described. This project was undertaken because the IMA is uniquely well supplied with blood: proximally through its attachment to the subclavian artery, along the sternum by the intercostal arteries to the aorta, and distally from the iliac artery by the epigastric and musculophrenic arteries.In this experimental study, the IMA in 16 dogs was ligated and divided at the subclavian artery, then dissected free down along the sternum to obtain sufficient length. The large subclavian end was then anastomosed to the circumflex coronary artery using a metal cannula technique to perfuse the circumflex bed while the anastomosis was being done. In all 16 dogs, the retrograde flow of the IMA was adequate to maintain the circumflex bed. It is postulated that this technique may have some limited use in man.     

Thoracic aneurysm expansion secondary to collateral supplies via thyrocervical trunk and intercostal arteries in a patient after thromboexclusion.

A case of thoraco-abdominal aortic aneurysm complicated after permanent clamping of the descending aorta (thromboexclusion) is reported. Angiographic and operative findings were: (1) a pseudo-aneurysm right at the distal anastomosis of previous intrathoracic bypass for pseudo-coarctation of the aorta filled by left ninth intercostal artery, which was supplied by the left internal thoracic artery; and (2) the cervical and thoracic spinal cord were supplied by the left vertebral artery and the mediastinal branch of the left thyrocervical trunk. This rare cause of a thoraco-abdominal aortic aneurysm and the significance of the subclavian artery as a source of spinal cord blood supply are discussed.