Ebook Atlas on X-ray and angiographic anatomy: Part 2

(BQ) Part 2 book “Atlas on X-ray and angiographic anatomy” has contents: Angiograms, productin of x-rays, digital subtractin angiography, computed and digital radiography, picture archiving and communicatins system, computed tomography contrast media.

CEREBRAL CIRCULATION

Normal Intracranial Arterial System

Branches of the aortic arch: Brachiocephalic

artery, the left common carotid artery, and left

subclavian artery (Flow chart 7.1)

The extracranial carotid arteries: The right

common carotid artery usually arises from the

bifurcation of the brachiocephalic artery The

left common carotid artery arises from the aortic

arch distal to the origin of brachiocephalic artery

Both the right and left common carotid arteries

bifurcate into the external and internal carotid

arteries on either side at C4- C5 level

Branches of the external carotid artery: Superior

thy roidal artery, ascending pharyngeal artery,

lingual artery, occipital artery, facial artery,

posterior auri cular artery, internal maxillary

artery and superficial temporal artery

The internal maxillary artery branches are

super ficial temporal artery, middle meningeal

artery, accessory meningeal artery and anterior

deep tem poral artery

The superior thyroid artery supplies the thyroid

and larynx The ascending pharyngeal artery

supplies the nasopharynx and tympanic cavity The

lingual artery supplies the tongue, floor of the mouth

and submandibular gland The occipital artery

supplies the scalp and upper cervical musculature

Facial artery branches supply the palate, pharynx, orbit, face and important anastomosis with other external carotid artery branches

The superficial temporal artery and posterior auricular arteries supply the scalp, buccal region and ear structures The internal maxillary artery gives vascular supply to temporalis muscles, meninges, paranasal sinuses and mandible While traversing the foramen spinosum, the middle meningeal artery may supply a branch, through the petrous bone, to the facial nerve

Internal carotid artery: The intracranial portions

are petrous and cavernous portions

Petrous portion of internal carotid artery: The ICA

while passing through the carotid canal, gives of the Vidian artery which anastomoses with the basilar artery of posterior circulation

Cavernous portion of internal carotid artery: It gives off the following branches—

Meningohypophyseal trunk, inferolateral trunk, ophthalmic artery, posterior communicating artery, anterior choroidal artery, anterior and middle cerebral arteries

The ophthalmic artery is the first branch of the supraclinoid portion of the ICA and thus serves as

a demarcation between the intracavernous and subarachnoid segments of the ICA

The posterior communicating artery (PCOM) connects the ICA with vertebrobasilar circulation

Flow chart 7.1: Cerebral circulation

(P1 segment of ipsilateral posterior cerebral

artery) The posterior communicating artery

supplies the thalamus, hypothalamus and optic

chiasm

The anterior choroidal artery originates

from ICA, it supplies the choroid plexus of

lateral ventricle and anastomoses with lateral

posterior choroidal artery The occlusion of

anterior choroidal artery can cause hemiplegia,

Flow chart 7.2: Internal carotid artery branches

hemiparesis, homonymous hemianopia as its minute perforators supply the internal capsule, thalamus, basal ganglia (Flow chart 7.2)

Circle of Willis: It is an important collateral

system at the base of the brain surrounding the optic chiasm and pituitary stalk It comprises of—the basilar artery bifurcation (basilar tip), P1 segments of posterior cerebral artery proximal

Willis include branches to the thalamus, limbic

system, reticular activating system, cerebral

peduncles, posterior limb of internal capsule

and oculomotor nerve nucleus The recurrent

artery of Heubner originates from the A1 segment

to supply the anterior limb of internal capsule,

portion of the globus pallidus and head of the

caudate nucleus

The anterior cerebral artery: The most proximal

segment is the A1 segment, its origin at the

terminal ICA to the anterior communicating

artery (ACOM) A2 segment is the portion distal

Fig 7.1: Circle of Willis

Abbreviations: ACA: Anterior cerebral artery; ACom: Anterior

communicating artery; MCA: Middle cerebral artery; ICA:

Internal carotid artery; PCom: Posterior communicating

artery; PCA: Posterior cerebral artery; SCA: Superior- internal

carotid artery; Basilar: Basilar artery; AICA: Anterior cerebral

artery; VA: Vertebral artery; ASA: Anterior spinal artery

arteries The ACA bifurcates into the pericallosal and callosomarginal arteries (Figs 7.2 to 7.6)

The middle cerebral artery: The most proximal

segment is M1 segment It extends from ICA bifurcation to the insular cortex (island of Reil) M2 segment is the course of the artery in the insular cortex and sylvian fissure and it bifurcates into anterior and posterior cortical branches The branches of the anterior cortical M2 segment are lateral orbitofrontal, operculofrontal and central sulcus arteries The central sulcus arteries are called precentral (prerolandic) and central (rolandic) bran ches which supply motor and sensory cortical strips The branches of posterior cortical M2 segment are the anterior and posterior parietal, angular and posterior temporal arteries (Figs 7.2 to 7.6)

The Vertebrobasilar Circulation

Vertebral arteries: The vertebral arteries originate

from the subclavian arteries One of the vertebral arteries may be dominant in size as compared to the other Each vertebral artery passes through the transverse foramen of C6 and passes superiorly through the transverse foramina of C5 to C1, then

it courses posteriorly around the atlanto-occipital joint and ascends through the foramen magnum, penetrating the atlanto-occipital membrane and dura It gives off the posterior-inferior cerebellar artery and the anterior spinal arteries It then travels superiorly around the lateral aspect of medulla to join with the contralateral vertebral artery to form the basilar artery at pontomedullary junction

The posterior inferior cerebellar artery (PICA) provides branches to the medulla, the occlusion of which can cause the lateral medullary syndrome

or pyramidal tract ischemia Lateral medullary

Fig 7.2: Angiogram of right anterior cerebral circulation arterial phase—AP view

Fig 7.3: Angiogram of right anterior cerebral circulation arterial phase—Lateral view

Fig 7.4: Angiogram of right anterior cerebral circulation arterial phase—Lateral view

Fig 7.5: Angiogram right anterior cerebral circulation capillary phase—AP view

Fig 7.6: Angiogram of right anterior cerebral circulation capillary phase—Lateral view

Fig 7.7: Angiogram of right anterior cerebral circulation venous phase—AP view

syndrome consists of ipsilateral Horner’s

syndrome, facial sensory loss, pharyngeal/

laryngeal paralysis, contralateral pain and

temperature sensory loss in the limbs and trunk

Anterior spinal arteries: It originates from the

vertebral arteries distal to the posteroinferior

cerebellar artery origin, they course inferomedially

to join with their contralateral artery along the

anterior cord

Basilar artery: The two vertebral arteries

join together to form the basilar artery at the

pontomedullary junction The basilar artery

courses anterosuperiorly over the ventral pons It

gives off small pontine perforating branches which

supply the pyramidal tracts, medial lemnisci, red

nuclei, respiratory centers and nuclei for cranial

nerves (III, VI, XII) The basilar artery gives off the

anterior inferior cerebellar artery and the superior

cerebellar artery The labyrinthine artery is a

branch of the anterior inferior cerebellar artery

Superior cerebellar artery provides vascular supply to the cerebellar peduncles, vermis, dentate nucleus, lateral pontine structures, spinothalamic tracts and sympathetic

Posterior cerebral arteries: Arise from the basilar

artery at the level of pontomesencephalic tion, superior to the oculomotor nerve and tentorium The proximal PCA is divided into P1 and P2 segments at the junction of the PCA with the posterior communicating artery A filling defect is frequently seen at the transition between P1 and P2 during frontal vertebral artery angiograms due to the inflow of unopacified blood from the ipsilateral posterior communicating artery The proximal P2 segment gives rise to the posterior thalamoperforating and thalamogeniculate arteries which supply the posterior portions

junc-of the thalamus, geniculate bodies, choroid plexus of third and lateral ventricles, posterior limb of internal capsule, optic tract and small

Fig 7.8: Angiogram of right anterior cerebral circulation venous phase—Lateral view

Fig 7.9: Angiogram of posterior cerebral circulation arterial phase—AP view

branches to the cerebral peduncles The other

branches of posterior cerebral artery are the

splenial artery, anterior and posterior temporal

branches, parietooccipital artery The distal PCA

courses posteriorly around the brainstem in the

ambient cistern, travelling more medially in the

quadrigeminal plate cistern The distal calcarine

cortical branches converge towards the midline

but are separated by falx, on Townes projection

vertebral angiogram (Figs 7.9 to 7.12)

NORMAL INTRACRANIAL

VENOUS SYSTEM

Cerebral cortical veins: Multiple cortical veins

drain towards the superior sagittal sinus The

superficial middle cerebral vein which lies

in the sylvian fissure may have anastomotic

communication with the deep cerebral venous

system, the facial veins and the extracranial

pterygoid venous plexus Posteriorly the

superficial middle cerebral vein communicates

with the veins of Trolard and Labbe towards the

ipsilateral transverse sinus The veins of Trolard

and Labbe cross the subdural space to enter the dural sinuses

Deep cerebral veins: These are the paired septal

veins which run close to midline beside septum pellucidum The paired thalamostriate veins pass along the floor of the lateral ventricles between the body of caudate nucleus and thalamus The internal cerebral veins run posteriorly in the roof of third ventricle The paired basal veins of Rosenthal are formed by the confluence of deep middle and anterior cerebral veins on the ventral surface of brain The basal veins then coalese posteriorly with the internal cerebral veins to form the vein of Galen (Figs 7.7 and 7.8) This vein

of Galen travels in the midline for about 1–2 cm under the splenium of corpus callosum, it then joins the inferior sagittal sinus in the posterior fossa to form the straight sinus at the junction of falx and tentorial incisura (Flow chart 7.3)

The posterior fossa veins: These are the anterior

pontomesencephalic veins, the precentral veins, superior and inferior vermian veins The anterior

Fig 7.10: Angiogram of posterior cerebral circulation arterial phase—Lateral view

Fig 7.11: Angiogram of posterior cerebral circulation capillary phase—AP view

Fig 7.12: Angiogram of posterior cerebral circulation capillary phase—Lateral view

pontomesencephalic vein runs along the ventral

surface of pons, it drains either into the basal

vein of Rosenthal or posterior mesencephalic

vein (Figs 7.13 and 7.14) The precentral veins run

along the posteriorly in the roof of fourth ventricle

and drains into the vein of Galen (Flow chart 7.4)

Dural sinuses: The dura mater which envelops the

central nervous system has two layers that form

the reflections like the falx cerebri, tentorium and

falx cerebelli The layers of dura separate to form

venous drainage channels or dural sinuses for the

brain Some of them anastomose with the veins of

scalp through the emissary veins The main dural

sinuses found are the superior sagittal sinus,

inferior sagittal sinus, occipital sinuses, paired

transverse sinuses and paired cavernous sinuses

(Figs 7.7 and 7.8)

The superior sagittal sinus travels along the

superior margin of falx cerebri, it continues

posteriorly and inferiorly in a cresenteric course to the junction point between the falx and tentorium containing the confluence of sinuses—The torcular Herophili near the occipital protuberance

The inferior sagittal sinus is found within the lower edge of falx between the cerebral hemispheres It drains posteriorly to join with the vein of Galen forming the straight sinus The straight sinus drains posteriorly in midline into the torcular herophili

The occipital sinuses are of variable size, are seen to course superomedially within the dura of the posterior fossa, just lateral to foramen magnum and drains towards the torcular herophili

The paired transverse sinus follows a cresenteric course within the periphery of the tentorium, laterally and anteriorly from the torcula The transverse sinuses receive drainage from the inferior cerebral veins and vein of Labbe,

it communicates with the cavernous sinuses via

Fig 7.13: Angiogram of posterior cerebral circulation venous phase—AP view

Fig 7.14: Angiogram of posterior cerebral circulation venous phase—Lateral view

the superior petrosal sinuses, which run along the

petrous bone and as it nears the tentorium it is

called the sigmoid sinus which later empties into the internal jugular vein (Flow chart 7.5)

Flow chart 7.3: Normal venous anatomy of the brain

Flow chart 7.4: Posterior fossa veins and jugular bulb

The ascending aorta arises at the aortic root,

from the left ventricle Immediately above the

aortic root, the ascending aorta bulges to form

the aortic sinuses, the aortic sinuses give rise

to right and left coronary arteries to supply the

heart The ascending aorta the courses upwards

and continues as the aortic arch The main

branches of the aortic arch (arch of aorta) are

the brachiocephalic trunk, left common carotid

artery and the left subclavian artery (Figs 7.15

and 7.16) Sometimes the thyroidea ima artery may arise from the aortic arch These branches

of aortic arch supply the head, neck, brain and upper limbs (Flow chart 7.6)

The aortic arch on plain chest X-ray appears behind the mediastinal structures in midline The aortic knuckle or arch at the level of sternal angle (angle of Louis) Sometimes age-related calcification may be noted at this site The arch

of aorta passes above the left bronchus and to

THE THORACIC AORTA

The paired cavernous sinuses receive venous

drainage from the orbits through the superior

and inferior ophthalmic veins The jugular bulbs

communicate with the cavernous sinuses by

means of the paired inferior petrosal sinuses The inferior petrosal sinuses also interconnect with those on the opposite side through a clival venous plexus

Fig 7.15: Outline of the thoracic aorta on chest X-ray—PA view (A) Ascending thoracic aorta curves upwards and at the level

of sternal angle continues as arch of aorta; (B) Arch of aorta curves above the left main bronchus and descends into posterior mediastinum It gives off the: 1 Brachiocephalic trunk; 2 Left common carotid artery; 3 Left subclavian artery; (C) At the level

of 4th thoracic vertebra, the arch of aorta becomes the descending thoracic aorta; (D) Descending thoracic aorta in posterior mediastinum enters the abdominal cavity through the aortic hiatus (12th dorsal vertebra level)

Fig 7.16: Angiogram showing the thoracic aorta

ABDOMINAL AORTA

The abdominal aorta is the continuation of the

thoracic aorta below the diaphragm at T12 vertebral

level In the abdomen aorta is retroperitoneal in its

course and travels downwards to its bifurcation

at the level of L4 vertebral body The abdominal

aorta supplies the viscera, peritoneum, gonads

and spine during its course Its anterior branches

are the celiac arterial trunk, superior mesenteric

artery, inferior mesenteric artery (Fig 7.17)

Its lateral branches are inferior phrenic artery,

suprarenal arteries, gonadal arteries, lumbar

arteries Its terminal branches at L4 vertebral level

are the common iliac arteries and the median

sacral artery (Flow chart 7.7)

CELIAC TRUNK

The celiac trunk is the main vascular supply

of the foregut supplying the lower part of the

esophagus to the duodenum; it also supplies the

liver, pancreas and spleen The celiac trunk arises

at the level of T12 vertebra from the abdominal

aorta and courses forwards until the upper border

of pancreas and terminates into: the left gastric artery, splenic artery, common hepatic artery (Fig 7.18) The left gastric artery gives off esophageal branches, then courses to the right along the lesser curvature of stomach and gives of branches to the stomach The splenic artery courses to the left, is tortuous and runs in the splenorenal ligament to the hilum of the spleen Before giving off terminal splenic branches it gives off 6-7 short gastric arteries which course in gastrosplenic ligament and the left gastroepiploic artery (which supplies the stomach and omentum).The splenic artery also gives off the posterior gastric artery during its course to splenic hilum The common hepatic artery courses over the upper border of the pancreas, the main branches are: right gastric artery, gastroduodenal artery, small supraduodenal arteries and terminal branch—The hepatic artery The right gastric artery runs forwards in the lesser omentum and to the left in lesser curvature of stomach to anastomose with the left gastric artery The gastroduodenal artery passes behind the 1st part of duodenum

ABDOMINAL ANGIOGRAPHY

the left of trachea and esophagus At the level of

4th thoracic vertebra the arch of aorta courses

downwards as the descending thoracic aorta in

the posterior mediastinum

The descending thoracic aorta gives off

post-erior intercostal arteries, 9 in number on either

side These intercostal arteries pass laterally into the intercostal spaces At the level of the aortic hiatus in diaphragm (at 12th thoracic vertebra), the descending aorta passes into the abdominal cavity and continues in the abdomen as the abdominal aorta

and at the lower border of duodenum divides

into the right gastroepiploic artery and superior

pancreaticoduodenal arteries The supraduodenal

arteries are smaller branches arise from the

common hepatic artery The common hepatic artery at the porta hepatis divides into the right and left hepatic arteries to supply the liver (Flow chart 7.8)

Fig 7.17: Angiogram of abdominal aorta

Flow chart 7.7: Abdominal aorta branches

Fig 7.18: Angiogram of celiac arterial trunk

Flow chart 7.8: Celiac arterial trunk (artery of foregut)

SUPERIOR MESENTERIC ARTERY

The superior mesenteric artery is the artery of

mid- gut and supplies the gut from the bile duct

entrance to the splenic flexure of colon This

artery arises from the abdominal aorta at the level

of lower border of L1 vertebra It courses behind the body of pancreas, later it lies anterior to the left renal vein, uncinate process of pancreas and third part of duodenum Its main branches are

the inferior pancreaticoduodenal artery, jejunal

and ileal branches, ileocolic artery, right colic

artery, middle colic artery (Fig 7.19) The inferior

pancreaticoduodenal artery is the first branch of

superior mesenteric artery It further divides into

anterior and posterior branches to supply the

head of pancreas and adjacent duodenum The

jejunal and ileal branches pass between the two

layers of the mesentery and create a network of

arteries along the jejunum and ileum to supply

the same The ileocolic artery courses down to

the base of mesentery into the right iliac fossa

and divides into superior and inferior branches

The superior branch courses along the ascending

colon to anastomose with the right colic artery

The inferior branch courses down to the ileocolic

junction and gives off the anterior and posterior

cecal arteries, an appendicular artery and an

ileal artery that anastomoses with the terminal

branches of superior mesenteric artery The

right colic artery course downwards into the

right infracolic compartment and divides into

the ascending and descending branches The ascending branch courses along the ascending colon upwards to anastomose with a branch from middle colic artery at hepatic flexure of colon The descending branch courses downwards along the ascending colon to anastomose with a branch from the ileocolic artery The middle colic artery arises from the superior mesenteric artery at the lower border of neck of pancreas It courses into the transverse mesocolon and on the right side

of transverse colon divides into two branches – The right and left branches The right branch anastomoses with the ascending branch of right colic artery The left branch anastomoses with a branch of the left colic artery (Flow chart 7.9)

INFERIOR MESENTERIC ARTERY

It is also called as the artery of hindgut It arises as

an anterior branch of abdominal aorta at the level

of L3 vertebra and courses downwards in lower abdomen Its branches are the left colic artery,

Fig 7.19: Angiogram of superior mesenteric artery

Fig 7.20: Angiogram of right renal artery early arterial phase

Fig 7.22: Angiogram of right renal artery nephrogram phase Fig 7.21: Angiogram of right renal artery late arterial phase

Fig 7.23: Angiogram of renal arteries in pyeloureterogram phase

Flow chart 7.10: Renal artery angiogram

ARTERIAL SYSTEM

The axillary artery is the main artery supplying the

upper extremity It is a continuation of the third part

of the subclavian artery The axillary artery begins

at the outer border of the first rib and continues

until the lower border of teres major muscle (Fig

7.24) Beyond the teres major muscle the axillary

artery continues into the arm as the brachial

artery (Flow chart 7.11 and 7.12) The axillary

artery for description purposes is subdivided into

three parts by the pectoralis minor muscle which

crosses middle 1/3rd the axillary artery The 1st

part of axillary is proximal to pectoralis muscle; it

gives off the superior thoracic artery The 2nd part

of axillary artery is beneath the pectoralis minor

muscle, it gives off the lateral thoracic artery and

the thoracoacromial artery The 3rd part of axillary

artery is distal to the pectoralis minor muscle; it

gives off the subscapular artery, anterior humeral

circumflex artery and the posterior circumflex

artery

The brachial artery is continuation of axillary

artery in arm The artery is superficial in its

course and lies beneath the deep fascia in the

anteromedial aspect of arm Its branches are: the

profunda brachii artery, middle collateral artery, radial collateral artery, superior ulnar collateral artery, inferior ulnar collateral artery, muscular branches to flexor muscles and nutrient artery to humerus (Figs 7.25 and 7.26)

The radial artery originates as a terminal branch of the brachial artery at the cubital fossa

It runs deep to the brachioradialis muscle on the lateral aspect of forearm and at the wrist joint it courses in the anatomical snuff box and forms the deep palmar arch The radial artery gives small muscular branches in forearm, the radial recurrent artery and a superficial branch near the radiocarpal joint (Flow chart 7.13) The princeps pollicis artery is a branch of radial artery in hand,

it divides into two smaller branches that run laterally along the thumb (Figs 7.27 and 7.28).The ulnar artery arises as a terminal branch of the brachial artery at cubital fossa It courses on the medial aspect of forearm deep to the flexor muscles The ulnar artery gives off the anterior and posterior ulnar recurrent arteries in proximal forearm and also a few muscular branches along its course in forearm The ulnar artery passes superficial to the flexor retinaculum at the wrist joint and continues as the superficial palmar arch

UPPER LIMB ANGIOGRAPHY

artery of Drummond is crucial to maintain the

vascular supply of large bowel

RENAL ARTERY

Both the renal arteries arise at right angles to the

abdominal aorta at the level of L2 vertebra The left

artery is shorter than the right Each renal artery gives

off small suprarenal and ureteric branches The renal

arteries course behind the pancreas and the renal vein

to reach the hilum of the kidney on either side (Figs

7.20 to 7.23) At the hilum the renal artery branches

into anterior and posterior divisions Each kidney is

subdivided into five segments based on arterial supply The anterior arterial division supplies the apical, upper, middle and lower segments while the posterior arterial division supplies the posterior segment (Flow chart 7.10) There is no collateral circulation between these segmental arteries The segmental arteries are accompanied by their corres ponding veins Each segmental artery divides into lobar artery, interlobar artery, arcuate artery and finally into interlobular arteries The segmental veins communicate with each other and at the hilum they join to form the renal vein

At the hilum of each kidney the structures from front

to back are vein, artery and ureter

Fig 7.24: Angiogram showing subclavian artery and axillary artery

Fig 7.25: Angiogram showing brachial artery

Fig 7.26: Angiogram showing radial and ulnar arteries

Fig 7.27: Angiogram showing ulnar artery and anterior interosseous artery

Fig 7.28: Angiogram showing superficial palmar arch

branches distal to the radial tubercle and supplies

the muscles of the forearm (Figs 7.27 and 7.28)

The superficial palmar arch is a direct

conti-nuation of the ulnar artery in the hand, it is joined

on its lateral side by the superficial branch of

radial artery to complete the superficial palmar

arch

The deep palmar arch is a direct continuation

of the radial artery, it is joined on its medial side

by the deep branch of ulnar artery to complete the

deep palmar arch (Fig 7.29)

The dorsal carpal arch is formed by both the

radial and ulnar arteries within the fascia on

Fig 7.29: Angiogram showing deep palmar arch

the dorsal digital veins by oblique intercapitular

veins These volar digital veins drain into a venous

plexus which is situated across the front of the

wrist The dorsal digital veins from the adjacent

sides of the fingers unite to form three dorsal

metacarpal veins They have an ulnar and radial

network of veins on either side The radial part of

the venous network is continued into the forearm

as the cephalic vein The ulnar part of the network

is continued into forearm as the basilic vein

The cephalic vein continues from the radial

part of the dorsal venous network It runs along

the radial border of the forearm The cephalic vein

then ascends in front of the elbow in the groove

between the brachioradialis and the biceps

brachii muscles In the upper third of the arm it

passes between the pectoralis major muscle and

deltoid muscle It pierces the coracoclavicular

fascia and joins the axillary vein just below the

clavicle

The basilic vein is formed from the ulnar part

of the dorsal venous network It travels along the ulnar side of the forearm and in the arm it lies along the medial border of the biceps brachii muscle It perforates the deep fascia in the middle

of the arm and continues on the medial side of the brachial artery to the lower border of the teres major muscle, it then courses in the axilla as the axillary vein

The median antibrachial vein drains the venous plexus on the volar surface of the hand It travels on the ulnar side of the front of the forearm and joins with the basilic vein

Deep Veins

The deep veins of the hand are the common volar digital veins, volar metacarpal veins, dorsal meta carpal veins They unite in the hand to join the radial veins and the superficial veins at the dorsum of the wrist (Flow chart 7.14)

Flow chart 7.12: Brachial artery

The venae comitantes of the radial and ulnar

are the deep veins of the forearm, they unite in

front of the elbow to form the brachial veins

The brachial veins are placed one on either

side of the brachial artery, receiving tributaries

corresponding with the branches given off from that

vessel; near the lower margin of the subscapularis

muscle, they join the axillary vein The deep veins

have numerous anastomoses, not only with each

other, but also with the superficial veins

The axillary vein it begins at the lower border

of the teres major muscle, as the continuation of

the basilic vein and ends at the outer border of the first rib as the subclavian vein At the lower border of the subscapularis muscle it receives the brachial veins The cephalic vein joins the axillary vein close to its termination

The subclavian vein is the continuation of the axillary vein, extends from the outer border

of the first rib to the sternal end of the clavicle, where it unites with the internal jugular to form the innominate vein It usually has a pair of valves, which are situated around 2.5 cm from its termination

Flow chart 7.13: Radial artery and ulnar artery

Flow chart 7.14: Upper limb venous system

lumbar vertebra The common iliac arteries then

divide into inter nal iliac and external iliac arteries

(Fig 7.30) The external iliac artery descends along

the medial bor der of psoas major muscle and at

the midinguinal point enters the thigh region The

midinguinal point is a point midway between the

anterior superior iliac spine and the symphysis

pubis (Flow chart 7.15)

The common femoral artery is the direct

conti nuation of the external iliac artery in the

profunda femoris artery which is the major artery

of the thigh The other small branches of common femoral artery are the superficial circumflex iliac artery, superficial epigas tric artery, superficial external pudendal artery (Flow chart 7.16) and the deep external pudendal artery (Fig 7.31).The profunda femoris artery gives off the medial circumflex femoral artery, lateral femoral circumflex femoral artery and four small perforating branches to muscles The medial

Fig 7.30: Angiography of lower limb (abdominal aorta at its bifurcation)

Flow chart 7.15: Lower limb arterial system

Flow chart 7.16: Superficial femoral artery and profunda femoris artery

circumflex artery gives off the ascending and descending branches and a horizontal branch The lateral circumflex femoral artery gives off the ascending and descending branches and a transverse branch (Fig 7.32)

The superficial femoral artery is a direct nuation of the common femoral artery in the mid and lower thigh region and accompanies the superficial femoral vein The superficial femoral artery descends on the medial side of thigh and enters the adductor canal (Fig 7.33)

conti-The popliteal artery is the continuation

of superficial femoral artery after exiting the adductor hiatus in popliteal fossa It gives off the muscular branches – two sural branches and five genicular branches The genicular branches are superior and inferior lateral branches, superior and inferior medial branches and single

Fig 7.31: Angiography of lower limb (external iliac and common iliac artery)

Flow chart 7.17: Popliteal artery

middle branch These genicular branches form

anastomoses around the knee joint (Flow chart

7.17) The popliteal artery divides into a smaller

branch—the anterior tibial artery and the larger

branch is the posterior tibial artery (Fig 7.34)

The anterior tibial artery is a branch of

popliteal artery In the leg the anterior tibial artery

enters the extensor compartment near the upper

border of interosseous membrane and courses

downwards towards the ankle At the ankle, the

anterior tibial artery continues as the dorsalis

pedis artery of the foot (Figs 7.34 to 7.37)

The posterior tibial artery is considered as a

direct continuation of the popliteal artery and

it enters the posterior compartment of leg and

courses downwards Behind the medial malleolus

the post erior tibial artery divides into medial and

lateral plantar arteries

The dorsalis pedis artery runs forwards to the

base of first intermetatarsal space and passes

down into the sole, where it joins the lateral plantar artery to complete the plantar arch The first dorsal metatarsal artery is a branch of the dorsalis pedis artery before it enters the sole

VENOUS ANATOMY

The veins are classified into three systems—The deep veins, superficial veins and perforator veins The superficial veins are the great saphenous vein, short saphenous vein.The deep veins are femoral vein, popliteal vein, anterior tibial vein, posterior tibial veins and peroneal vein The perforator veins are the veins connecting the superficial veins with deep veins and contain valves in their walls to prevent backflow of blood and assist in maintaining the superficial-to-deep direction of the blood flow

The great saphenous vein is a large superficial vein of the lower extremity It originates from the dorsal venous arch of the foot It courses

Fig 7.32: Angiography of lower limb (external iliac and common iliac artery)

Fig 7.33: Angiography of lower limb (superficial femoral artery)

upwards anterior to the medial malleolus and

continues on the medial side of leg At the knee,

the great saphenous vein lies over the posterior

border of medial epicondyle of femur The great

saphenous vein travels medially in lower thigh

and then courses anteriorly in upper thigh to

pierce the fascia lata; this opening is called the

saphenous opening The great saphenous vein

joins the femoral vein, this junction is called

the saphenofemoral junction The tributaries

of the great saphenous vein are many, at the

ankle it receives the medial marginal vein, it also

communicates with the small saphenous vein,

the femoral vein, anterior and posterior tibial

veins In the upper thigh the great saphenous vein receives the tributaries from superficial epigastric, superficial iliac circumflex and superficial external pudendal vein (Flow chart 7.18)

The small saphenous vein is a superficial vein

in posterior leg It originates from the lateral end

of dorsal venous arch It courses posterior to the lateral malleolus and continues upwards on the lateral aspect of leg It passes between the heads

of gastrocnemius muscle and drains into the popliteal vein at the knee

The superficial femoral vein is a part of the deep venous system of lower extremity As the popliteal vein exits the adductor canal and enters the thigh

Fig 7.34: Angiography of lower limb (popliteal artery)

Fig 7.35: Angiography of lower limb (popliteal artery at bifurcation)

Fig 7.36: Angiography of lower limb (tibial and peroneal arteries)

Fig 7.37: Angiography of lower limb (capillary phase in leg)

Flow chart 7.18: Lower limb venous system

region it becomes the superficial femoral vein

The superficial femoral vein receives profunda

femoris vein in upper thigh region and becomes

the common femoral vein At the saphenofemoral

junction, the common femoral vein receives the

great saphenous vein

The popliteal vein lies alongside the popliteal

artery in popliteal fossa It originates by the

unification of the anterior and posterior tibial

veins in popliteal fossa Its tributaries in the

popliteal fossa are the peroneal vein and short

saphenous vein The popliteal vein enters into the

adductor canal and enters into the thigh as the

superficial femoral vein

The anterior tibial vein drains the anterior

compartment of leg and dorsum of foot The

anterior tibial vein courses upwards alongside the anterior tibial artery and pierces the interosseous membrane to enter the popliteal fossa and unites with the posterior tibial veins to form the popliteal vein

The posterior tibial vein drains the posterior compartment of leg and plantar surface of foot

It courses upwards to enter the popliteal fossa and unites with the anterior tibial veins to form the popliteal vein The posterior tibial veins are accompanied by the posterior tibial arteries along its course in leg

The peroneal veins, also known as venae comitantes, are the accompanying veins of the peroneal artery of leg The peroneal veins course upwards and join the popliteal vein

The esophagus is a hollow muscular tube; it is 25 cm

in length The esophagus begins at the lower border

of cricoid cartilage at the level of C6 vertebra For

descriptive purposes the esophagus has a cervical

segment, thoracic segment and intrabdominal

seg ment The cervical segment of esophagus is

in the midline posterior to the trachea, it courses

to the left as it enters the thoracic cavity The

thoracic segment of esophagus courses to midline

between the 5th to 7th thoracic vertebral level,

further down in the thoracic cavity the esophagus

lies to the left of midline The esophageal opening

in the left hemidiaphragm is at the level of 10th

thoracic vertebra The intraabdominal segment

of esophagus is short in length, around 1-2

cm and enters the stomach In passive state

the esophagus is collapsed, it distends when a

bolus of food or water passes through its lumen

During barium swallow exa minations observe

the peristaltic waves on fluoro scopy propagating

the barium bolus into the stomach below At the

distal end of esophagus is the lower esophageal

sphincter, it helps to maintain the tone of the

esophagus preventing gastric reflux and at the

same time provides support to the esophagus

by acting as a support sling to the diaphragm If

there is failure of the lower esophageal sphincter

to relax the esophagus dilates and food contents

may be visible on X-ray films as air-fluid levels One must keep in mind the normal anatomical narrowing of the esophagus at the following sites: (i) The cricopharyngeal sphincter in cervical segment, at origin of esophagus, around 15 cm from incisor teeth (ii) At the level of aortic arch, around 22 cm from incisor teeth (iii) The left bronchus crosses in front of esophagus, around 27

cm from incisor teeth (iv) the esophageal opening

in diaphragm, around 38 cm from the incisor teeth

It is a upper gastrointestinal (GI) radiological study using high density barium contrast media (250%) Two to three table spoon scoops are given orally and the upper GI is visualized

on fluoroscopy A control film is necessary if perforation is suspected; water-soluble contrast such as gastrograffin is given orally instead of barium In routine studies, no special patient preparation is required, after the patient swallows the barium contrast in erect position and spot films are taken under fluoroscopic guidance The column of barium contrast is followed

on fluoroscopy as the barium passes in the oropharynx into the esophagus and finally into the stomach Normally the spot films of upper cervical region with esophagus is covered in posteroanterior (PA), lateral and right antero-roblique (RAO) views The spot films of lower

BARIUM SWALLOW

esophagus with gastroesophageal junction are

covered in posteroanterior (PA), lateral and

right antero-oblique (RAO) views Special views

in Trendelendburg position may be needed to demonstrate hiatus hernia No special aftercare is required for this procedure (Figs 8.1 to 8.3)

Fig 8.1: Barium swallow study (upper gastrointestinal tract—lateral view)

Fig 8.2A

A

Fig 8.3: Barium swallow study (upper gastrointestinal tract—right antero-oblique view)

Fig 8.4B Figs 8.2A and B: Barium swallow study (upper gastrointestinal tract posteroanterior view)

B

The stomach is a muscular structure that distends

when filled with barium contrast on barium

meal follow-through study At its proximal end

is the gastroesophageal junction, to the left of

midline The main parts of stomach are the

cardia, fundus, body and pyloric portion (Fig

8.4) The cardia refers to the portion of stomach at

the gastroesophageal junction, it is located to the

left of midline, at 10 thoracic vertebral level, it is

around 40 cm from the incisor teeth The fundus

is the portion of stomach which lies above the

level of cardia and usually filled with air, as seen

on plain X-ray abdomen The body of stomach

has two curvatures—The greater curvature and

the lesser curvature There is a small notch in the

lower part of lesser curvature; this notch is called incisura angularis The pylorus of stomach is the portion which lies beyond the incisura angularis,

it has two subportions—The proximal portion is called the pyloric antrum and the distal portion

is called the pyloric canal The pyloric canal lies anterior to the head and neck of pancreas The gastroduodenal junction lies to the right of midline at L1 vertebral level, the pyloric sphincter

is a thickened section of the pyloric canal at the gastroduodenal junction (Fig 8.5)

The duodenum is a loop of bowel that connects the stomach to the jejunum The duodenum begins at L1 vertebral level to the right of midline

at the gastroduodenal junction The curved loop

BARIUM MEAL FOLLOW-THROUGH (BMFT)

Fig 8.4: BMFT study erect posteroanterior (PA) view of stomach with duodenal cap