The Clinical Anatomy of Coronary Arteries

120 Pages·2003·6.65 MB·English

by  Prof. Dr. M. von Lüdinghausen (auth.)

Advances in Anatomy
Embryology and Cell Biology
Vol. 167
Editors
F. Beck,Melbourne B.Christ, Freiburg
W. Kriz, Heidelberg W. Kummer, GieBen
E.Marani, Leiden R. Putz, Munchen
Y. Sano, Kyoto T.H. Schiebler, Wtirzburg
G.C.Schoenwolf, Salt Lake City
K. Zilles, Dusseldorf
Springer-V erlag
Berlin Heidelberg
GmbH
M. von Liidinghausen
The Clinical Anatomy
of Coronary Arteries
With27Figures and3Tables
Springer
Prof. Dr. MICHAEL VON LUDINGHAUSEN
Institut fur Anatomie und Zellbiologie,
Universităt Wiirzburg,
Koellikerstr. 6,
97070 Wiirzburg, Germany
e-mail: [email protected]
ISSN 0301-5556
ISBN 978-3-540-43689-8
Library of Congress-Cataloging-in-Publication-Data
The Clinical Anatomy of Coronary Arteries / M. v. Liidinghausen - Berlin;
Heidelberg; New York: Springer, 2003
(Advances in anatomy, embryology, and cell biology; VoI. 167)
ISBN 978-3-540-43689-8 ISBN 978-3-642-55807-8 (eBook)
DOI 10.1007/978-3-642-55807-8
This work is subject to copyright. AlI rights are reserved, whether the whole
or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, re citation, broadcasting, reproduction on
microfilms or in any other way, and storage in data banks. Duplication of
this publication or parts thereof is permitted only under the provisions oft he
German Copyright Law of September 9, 1965, in its current version, and
permission for use must always be obtained from Springer-Verlag. Viola
tions are liable for prosecution under the German Copyright Law.
http://www.springer.de
© Springer-Verlag Berlin Heidelberg 2003
Originally published by Springer-Verlag Berlin Heidelberg New York in 2003
The use of general descriptive names, registered names, trademarks, etc. in
this publication does not imply, even in the absence of a specific statement,
that such names are exempt from the relevant protective laws and regulations
and therefore free for general use.
Product liability: The publishers cannot guarantee the accuracy of any infor
mation about dosage and application contained in this book. In every indi
vidual case the user must check such information by consulting the relevant
literature.
Production: PRO EDIT GmbH, 69126 Heidelberg, Germany
Printed on acid-free paper - SPIN: 10993798 27/3111 - 5432 1
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . .. 1
1.1 Aimsofthe Study . . . . . . . . . . . . . . . . . . . . " 2
1.2 TheCardiacVascular Systems:
TheCoronaryArteries and CardiacVeins . . . . . . .. 2
2 TheSignificanceofthe ProperVessels
oftheHumanHeartin StatisticsandDiagnostics 5
2.1 Angiography. ..... .. . . . . . . .. .. ..... . . 6
2.2 MRImaging . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.3 Ultrafast MRImaging. . . . . . . . . . . . . . . . . . " 7
2.4 CoronaryMRAngiography . . . . . . . . . . . . . . . . 7
2.5 Conventionaland Ultrafast ComputedTomography
(Cardio-CT) . . . . . . . . . . . . . . . . . . . . . . . . . 8
3 Nomenclature.. . . . . . . . . . . . . . . . . . . . . . . 9
3.1 Englishand LatinVersions 9
3.2 Abbreviations ..... . . ......... . . . . . ... 12
3.3 CommonlyUsedUnofficialorAlternative Terms
and Synonyms . . . . . . . . . . . . . . . . . . . . . . . . 13
4 ResultsandDiscussions 15
4.1 TheAnatomyofCoronaryArteries inGeneral . . . . . 15
4.1.1 TheRightCoronaryArtery 18
4.1.2 TheConus Branch 18
4.1.3 FurtherRamification
ofthe RightCoronaryArtery 19
4.1.4 ThePosteriorInterventricularArtery 20
4.1.5 SegmentationoftheRightCoronaryArtery 20
4.1.6 TheLeftCoronaryArtery 21
4.1.7 TheAnteriorInterventricularArtery 27
4.1.8 TheMedian (Intermedian) Branch 28
4.1.9 TheCircumflexArtery 28
4.2 Peculiarities oftheOriginoftheCoronaryArteries . . 29
4.2.1 TheLocationoftheRightand LeftCoronary
OrificesintheAortic Sinuses 29
4.2.2 TheLengthsand Diameters
oftheMajorCoronaryArteries 32
V
4.2.3 Three-DimensionalOrientation
onthe CoronaryStems,AnglesofOrigin
ofthe CoronaryArteries and Angle
ofDivision ofthe LCA . . . . . . . . . . . . . . . 33
4.2.4 Variable and AnomalousCoronaryOstia
and Courses . . . . . . . . . . . . . . . . . . . .. 34
4.2.5 Limited NumberofCoronaryOstia:
ASingleOstiumforaSingleCoronaryArtery
inthe Leftor RightAortic Sinus 35
4.2.6 GreaterNumberofOstiainthe Left
and RightAorticSinus . . . . . . . . . . . . . .. 38
4.2.7 Aberrantor Ectopic (Superior) Origin,
"High Take-off'ofaCoronaryArtery. . . . . . 41
4.2.8 Deep(Inferior) Origin,"LowTake-Off'
ofaCoronaryArtery . . . . . . . . . . . . . . . . 43
4.3 CoronaryDominanceorPreponderance . . . . . . . . 45
4.3.1 Balancedor IntermediateType
ofCoronaryDistribution 47
4.3.2 DominantRightCoronaryArtery 48
4.3.3 DominantLeftCoronaryArtery 48
4.4 Intramural(Intramyocardial)
and IntraluminalCourses ofthe CoronaryArteries .. 52
4.4.1 IntramuralCourses ofVentricularBranches . . 53
4.4.2 LongIntramuralCourses 53
4.4.3 Subendocardial,Intraluminal,
or IntracavitaryCourses . . . . . . . . . . . . . . 55
4.5 Atrial Branches andthe Arterial Supply
ofthe ConductionSystem . . . . . . . . . . . . . . . .. 55
4.5.1 TheArterialSupplyoftheSinuatrialNode . .. 56
4.5.2 Arterial SupplyofInteratrial
andInternodalPathways 58
4.5.3 Arterial SupplyoftheAtrioventricularNode . . 58
4.5.4 Arterial Supplyofthe CommonAVBundle
and ProximalRightand LeftBundle . . . . . . . 60
4.5.5 TheExtracardiacNoncoronaryArteries. . . .. 61
4.6 Arterial Supplyofthe InterventricularSeptum . ... 64
4.6.1 TheAnteriorInterventricular
Septal(Perforator)Branches 64
4.6.2 TheLeftSuperiorSeptalBranch
orFirstAnteriorSeptalBranch . . . . . . . . .. 69
4.6.3 ThePosteriorInterventricular
SeptalBranches . . . . . . . . . . . . . . . . . .. 69
4.6.4 TheRightSuperiorSeptalBranch 70
4.6.5 Arterial Supplyofthe RightBundle
and ModeratorBand . . . . . . . . . . . . . . . . 70
4.6.6 TheArterialSupplyofthe PapillaryMuscles . . 71
4.7 BloodSupplytothe CoronaryArteries
(VasaVasorum) 72
VI
4.8 CoronaryAnastomosesand Collaterals . . . . . . . . . 72
4.8.1 Anastomosesinthe VentricularWalls 75
4.8.2 Anastomosesinthe AtrialWalls. . . . . . . . . . 75
4.8.3 Endomural(Subendocardial)Anastomoses . . . 75
4.8.4 Intracoronary(Homocoronary)Anastomoses . 76
4.8.5 IntercoronaryAnastomosesand Collaterals . . . 76
4.8.6 NoncoronaryExtracardiacAnastomoses
toAtrial Arteries 77
4.8.7 TheSignificanceand EvaluationofAnatomically
orAngiographicallyDemonstratedAnastomoses
andCollaterals . . . . . . . . . . . . . . . . . . . . 78
4.8.8 Collaterals inPatients withOstial
and CoronarySpasm . . . . . . 80
4.9 TheCoincidenceofCoronaryArtery Anomalies
and Atherosclerosis 80
4.9.1 AnomalousCoronaryArteries
withAortic Origin . . . . . . . . . . . . . . . . . . 80
4.9.2 AnomalousCoronaryArteries
withPulmonaryTrunkOrigin . . . . . . . . . . . 81
4.10 Age-Relatedand AtheromatousCoronary
Calcifications 81
4.10.1CoronaryCalcifications 81
4.10.2Age-Related(Nonatheromatous) Calcifications
inthe CoronaryArteries . . . . . . . . . . . . . . 82
4.10.3AtheromatousCalcifications
inthe CoronaryArteries . . . . . . . . . . . . . . 82
4.10.4CoronaryCalcifications inHeartSpecimens
ofSubjectsfrom the DissectionRoom 83
4.10.5EvaluationandMeasurementofCalcifications . 83
4.10.6MultipleCoronaryAneurysmata 87
4.11 AnatomicalAspectsofSurgicalInterventions
inCoronaryAtherosclerosis . . . . . . . . . . . . . . . . 87
4.11.1 SurgicalTreatment
ofCoronaryAtherosclerosis . . . . . . . . . . . 87
4.11.2 Aorto-CoronaryBypass:
SitesofAortic Anastomoses . . . . . . . . . . . 88
4.11.3 Aorto-CoronaryBypass:
SitesofCoronaryArtery Anastomoses . . . . . 88
5 ConcludingRemarks . . . . . . . . . . . . . . . . . . . . 89
5.1 IndividualCoronaryAnatomy 89
5.1.1 CoronaryArteryDominance 89
5.1.2 RightVentricularBranches ofthe AlA . . . . . . 90
5.1.3 Atrial Branches 90
5.1.4 UnusualShortStemofthe LCA 91
5.1.5 NormallyorAnomalouslyCoursingCoronary
Arteries inValveSurgery 91
5.1.6 SingleCoronaryArtery. . . . . . . . . . . . .. 91
VII
5.1.7 Multiple Ostiain the AorticSinuses . . . . . . . 92
5.1.8 Ectopic"High"Origin . . . . . . . . . . . . . .. 92
5.1.9 Ectopic"Deep" Origin . . . . . . . . . . . . . . . 92
5.1.10MyocardialBridge and Intramyocardial
(Intramural) Course . . . . . . . .. 92
5.1.11InterventricularandCoronarySulciWithout
an EpimuralArtery . . . . . . . . . . . . . . . " 93
5.1.12Intra-,Inter-,andNoncoronaryExtracardiac
AnastomosesandCollaterals . . . . . . . . . . . 93
5.1.13CoronaryArteryCalcification. . . . . . . . . . . 94
5.1.14EvaluationandInterpretation . . . . . . . . . . . 95
6 Summary . . . . . . . . . . . . . . . . . . . . . . . . .. 97
References . . ... . . .. . .. 99
SubjectIndex . . . . ... . .. 113
VIII
1 Introduction
Considerable advanceshavebeen made in cardiologyduringthelast fewdecades.In
particular, there has been great progress in the field of coronary angiography both
when combinedwith,and without,computed tomography (CT)and magnetic reso
nance (MR)imaging.Thesetechniquesofmodernimaging allowthecardiologistand
coronarysurgeon to studyeverycardiac structure in detail,both two- and three-di
mensionallyand from either side,to analyzethe movements ofthe heartand valves,
and toobservemyocardial circulationand evenmyocardial metabolicprocesses.
However,coronary heart disease, a multifactorial illness of the coronaryvessels,
stillremainsthemost commoncauseofdeath indevelopedcountries.
In addition to the large group of patients suffering from coronaryheart disease,
there isasmaller group ofchildrenand adults whoare inneed ofopen heartsurgery
and,most frequently,valvesurgery.Averysmallnumberofindividualssufferingfrom
Wolff-Parkinson-White syndromestillawaitcompetentsurgical intervention.
These three groups ofpatientshavein common that,forthem, meticulous preop
erativediagnosticsand preparationforsurgeryareurgentlyrequired.Anyopenheart
surgeon whocarriesout proceduresinthecoronaryorinterventriculargroovesoron
theatrialwallsoftheheartmust takethenormaland anomalousorigins,courses,and
terminations ofcardiac vesselsinto consideration.Therefore,with the availabilityof
preciseanatomicaland physiologicaldata,operationtimewillbeshortened,operative
riskswilldiminish,and thesafetyoftheoperationforthepatientwillbegreater.
Morbidityand mortalityrates among our patientsoverthelast fivedecades oblige
ustoextendthefrontiers ofunderstandingwhereboth themacro-and microanatomy
and also the pathophysiology of heart diseases are concerned, and develop new
approaches for the diagnosis and treatment of myocardial dysfunction, which is
largelya consequence ofvariations in the morphologyofthe coronaryarteries and
cardiacveins.
The results of 25years of study of the intrinsic vessels of the human heart are
presented in this work; the findings have been described and evaluated from the
viewpoint of a clinically oriented anatomist, and have been compared with, and
discussed inthe light ofthe results ofother research in the fieldasmentionedinthe
internationalliterature.
1
M. von Lüdinghausen, The Clinical Anatomyof CoronaryArteries
© Springer-Verlag Berlin Heidelberg 2003
1.1
Aims oftheStudy
The main objectives of this work are to illustrate the most recent research into the
macro- and micro-anatomicalmorphologyofthecoronaryarteries,todiscusscontro
versiessurroundingthe anatomicalbasis forarterialcatheterization,and to establish
the anatomical prerequisitesnecessarybefore minimallyinvasiveand surgical inter
ventions canbecarriedout.Areaswhichmeritfurtherstudyareidentified.
Theissueofmyocardial microcirculationisnot consideredinthiswork.
1.2
TheCardiacVascularSystems:
TheCoronaryArteriesandCardiacVeins
The myocardial walls of the four-chambered heart are nourished by both the right
andleftcoronaryarteries.Thevenousdrainageisguaranteedbythecardiacveins,i.e.,
partlybytributariesoftheCSand partlybytributariesofcardiacveinsfromtheright
aorta
r...---------- I
coronar~arteries
--------
arterio- arterIioles
venous
anastomoses
r
cap,aryv/sels
lymphatics
intramyocardial--------------_
....venoujplexus"\
anterior great--atrial veno-luminal arterlo-luminal
I
cardiac cardiar veins vessels vessels
s I veno-sinusoidal arterio-slnusoidal
ver veins
vessels vessels
'------.....v.. ...------'
large small
smallestcardiacvessels
intra- intra-
Thebesianvessels
mural coronary mural
sinus sinus sinuses
ofthe ofthe
right right
atrium atrium
l
.....t.~
::::::::=-__
right atrium ..:::=......
Greatercardiacvenoussystem Smallercardiacvenous system
(GCYS) (capacity 73%) (SCYS) (capacity27%)
Fig.1.Schematicdrawingtoillustratethedistributionpatternandinterconnectionsofthetributaries
ofthegreater(GCVS) andsmallercardiacvenoussystems(SCVS)
2