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INTRODUCTION

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In contemporary practice, catheter-based interventions have become an increasingly important therapeutic modality for the treatment of nearly all areas of the peripheral arterial and venous system, including the head, neck, and great vessels, as well as the upper and lower extremities. A thorough understanding of the peripheral arterial and venous anatomy is the foundation for any successful peripheral vascular interventional procedure. This chapter describes the arterial and venous anatomy above and below the diaphragm, with emphasis on the pertinent anatomic variants and radiographic examinations in the catheterization laboratory.

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AORTIC ARCH AND UPPER EXTREMITIES

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The vascular anatomy of the aortic arch and upper extremities begins at the level of the sinus of Valsalva. From the sinotubular ridge, the ascending aorta travels anteriorly and superiorly, passing over the main pulmonary artery and left mainstem bronchus. At this level, the mean diameter of the ascending thoracic aorta in the normal adult human is 3.5 cm.

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The brachiocephalic or right innominate artery is the first major branch off the aortic arch. The next major vessel that arises from the aortic arch is the left carotid artery. The left subclavian artery is the last great artery that arises directly off the aortic arch. After the left subclavian artery arises, the aortic arch ends. This anatomic region, called the isthmus, is found between the last great vessel and the attachment of the ductus arteriosus, after which the descending aorta begins and continues down to the level of the iliac bifurcation.

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In 30% of patients, the normal relationship described above is not seen. The most common variants are a shared ostium of the brachiocephalic artery and the left carotid artery (15%), or the so called “bovine arch,” where the left carotid artery arises from the proximal aspect of the brachiocephalic trunk (10%). Other common variants include the right subclavian arising from the arch distal to the left subclavian artery and the left vertebral artery arising directly from the aortic arch (5%) between the left carotid and left subclavian arteries.1,2 In healthy individuals, the great vessels arise from the horizontal portion of the aortic arch, but with increasing age, the vessels tend to shift counterclockwise toward the ascending aorta.

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The right innominate or brachiocephalic artery gives rise to the right subclavian artery and right common carotid artery. After the bifurcation of the subclavian and carotid arteries on the right, the next vessels that arise off the right subclavian include the right vertebral artery and the right internal mammary artery. The right subclavian artery then gives rise to the thyrocervical trunk and the costocervical trunk. At this location, the subclavian artery becomes the axillary artery after it crosses the lateral margin of the first rib. On the left, the subclavian artery gives rise to the left vertebral artery and the left internal mammary artery. Anatomically, its course is similar to the ...

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