Course and branches of the recurrent laryngeal nerve, inferior thyroid artery and inferior laryngeal artery

Length, width, and thickness of the recurrent laryngeal nerve and its extra-laryngeal twigs were estimated. Included is the course of the nerve to the suspensory ligament of the thyroid gland, to the inferior horn of the thyroid cartilage and to trachea and esophagus. The origin of the inferior thyroid artery, its width and course to the twigs of the recurrent laryngeal nerve were studied. The origin zone of the inferior laryngeal artery is also described. The different terms and opinions about the twigs of the truncus thyreocervicalis and the thyroid axis are discussed.     

The vascular territories of the superior epigastric and the deep inferior epigastric systems

The vascular territories of the superior and the deep inferior epigastric arteries were investigated by dye injection, dissection, and barium radiographic studies. By these means it was established that the deep inferior epigastric artery was more significant than the superior epigastric artery in supplying the skin of the anterior abdominal wall. Segmental branches of the deep epigastric system pass upward and outward into the neurovascular plane of the lateral abdominal wall, where they anastomose with the terminal branches of the lower six intercostal arteries and the ascending branch of the deep circumflex iliac artery. The anastomoses consist of multiple narrow "choke" vessels. Similar connections are seen between the superior and the deep inferior epigastric arteries within the rectus abdominis muscle well above the level of the umbilicus. Many perforating arteries emerge through the anterior rectus sheath, but the highest concentration of major perforators is in the paraumbilical area. These vessels are terminal branches of the deep inferior epigastric artery. They feed into a subcutaneous vascular network that radiates from the umbilicus like the spokes of a wheel. Once again, choke connections exist with adjacent territories: inferiorly with the superficial inferior epigastric artery, inferolaterally with the superficial circumflex iliac artery, and superiorly with the superficial superior epigastric artery. The dominant connections, however, are superolaterally with the lateral cutaneous branches of the intercostal arteries. For breast reconstruction, it would appear that prior ligation of the deep inferior epigastric artery would be of advantage when elevating the lower abdominal skin on a superiorly based rectus abdominis musculocutaneous flap. The vascularity of this flap would be further increased by positioning some part of the skin paddle over the dense pack of large paraumbilical perforators. Based on these anatomic studies, the relative merits of the superior and deep inferior epigastric arteries with respect to local and distant tissue transfer using various elements of the abdominal wall are discussed in detail.     

Microvasculature of the thyroid gland in the common tree shrew (Tupaia glis): microvascular corrosion cast/scanning electron microscopy study.

A thyroid vascular cast of the common tree shrew (Tupaia glis) was obtained by injection of Batson's No. 17 plastic mixture into the ascending aorta. The cast was studied under the scanning electron microscope. It was found that each half of the gland is supplied by a large superior and a rather small inferior thyroid artery. After plunging into the gland, the arteries divide into smaller branches that are the interlobular, intralobular and follicular arteries (afferent vessels). The basket-like capillaries arising from the follicular arteries and encapsulating thyroid follicles are of large diameter and are arranged in a single layer. The follicular side of the capillary casts was observed to contain numerous small and some large projecting knobs compatible with the presence of fenestrations in the endothelial cells. On the other hand, endothelial nuclear imprints were found mainly on the stromal surface of the follicular capillary casts. Transfollicular capillaries connecting the adjacent follicular capillary networks were also observed. Blood from the follicular capillaries either drains into the follicular veins (efferent vessels) or abruptly drains into the intralobular veins before proceeding to intralobular and interlobular veins, respectively. The interlobular veins are collected into a few small superior, a few larger middle and a few even larger inferior thyroid veins. These veins drain directly into the laryngeal vein lying adjacent to the deep surface of the thyroid gland before joining the jugular vein. Venous valves were identified outside the thyroid gland. In addition, the glomerular capillary island of the parathyroid gland was often seen at the cranioanterolateral and sometimes at the cranioposterolateral aspect of the thyroid gland.     

The value of preoperative Doppler sonography for planning free perforator flaps

The individual perforating vessels have a high degree of anatomical variation, therefore it is desirable to conduct a careful examination of them before undertaking a perforator flap operation. Because locating the vessels beforehand makes performing the operative procedure much easier, the aim of the present study was to assess the value of using simple acoustic Doppler sonography to plan a perforator flap operation. The vessel examinations were carried out before taking 46 free microvascular flaps from either the lower abdominal wall or the buttock for reconstructive breast surgery. The perforating vessels located were marked, and their position relative to the umbilicus or the most cranial point of the rima ani recorded using a coordinate system. In 40 patients, a perforator flap operation (deep inferior epigastric perforator flap, n = 32; superior gluteal artery perforator flap, n = 8) was actually carried out; in six of these patients, a myocutaneous flap was used because of the insufficient availability of perforating vessels. Before the operation, perforating vessels were marked for each patient, with an average of 7.3 for the deep inferior epigastric perforator flap and 6.5 for the superior gluteal artery perforator flap. Out of 286 vessels marked for later perforator flaps, 162 were identified during the operation. A preoperatively marked vessel was used in 37 of 40 patients. In the remaining patients, a vessel was used that had not been previously marked. The vertical and horizontal distance between the perforating vessels identified during the operation and the preoperative marks averaged 0.8 cm. The results show preoperative Doppler sonography to be useful for locating the position of individual perforating vessels, making it much easier to find them during the operation.     

The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system

Radiographic studies of the deep superior epigastric artery (DSEA) and its connections within the soft tissues of the abdominal wall were performed in 64 fresh cadavers. The patterns of anastomosis between the deep superior epigastric artery and the deep inferior epigastric artery (DIEA) were noted. Type I (29 percent) revealed a single deep superior epigastric artery and deep inferior epigastric artery, type II (57 percent) revealed a double-branched system of each vessel, and type III (14 percent) revealed a system of three or more major branches. In each case, the two systems were united by choke vessels in the segment of muscle above the umbilicus. The supply to the various transverse and vertical skin flaps from the deep superior epigastric artery was defined as a series of captured anatomic territories bounded by choke vessels. The upper transverse and vertical flaps had the best supply, and the TRAM flap had the most tenuous supply. Midline crossover occurs predominantly in the subdermal plexus and on the surface of the rectus sheath. Modifications of the design of the TRAM flap, the case for a delay procedure, the wisdom of including a strip of anterior rectus sheath, and the risks of splitting the muscle with respect to its nerve supply and vascular patterns are discussed on an anatomic basis.     

The vascular anatomy of the lower anterior abdominal wall: a microdissection study on the deep inferior epigastric vessels and the perforator branches

The deep inferior epigastric artery provides the main blood supply to the lower abdominal wall. Microdissection of the artery, its main branches, and the perforator vessels was undertaken in 20 cadavers. The artery was found to be associated with two veins in most of the cases (90 percent). The lateral division of the deep inferior epigastric artery and the perforator vessels it gives are more dominant (80 percent of cases) than the medial perforators (20 percent of cases). The lateral perforators were greater in number (80) and more consistent than those that arose from the medial division (28). The musculocutaneous perforators are the most important perforators supplying the anterior abdominal wall. An average of 5.4 large perforators (>0.5 mm in diameter) were dissected in each case. These perforators are mostly contained in the area lying laterally and below the umbilicus, with an average distance of 4 cm from the umbilicus. The musculocutaneous perforators may have a direct or indirect course. Larger perforators (>0.5 mm in diameter) were found to have a direct course through the subcutaneous fat to the skin. Smaller perforators do not reach the skin but terminate at the level of the deep fat layer by branching after piercing the rectus sheath. The direct perforator vessels with their associated veins (microdissection) keep a consistent diameter before dividing at the subdermal level and end by contributing to the subdermal plexus.     

The delay phenomenon: the story unfolds

Our previous studies have shown that when a flap is delayed, there is dilation of existing vessels within the flap not ingrowth of new vessels. The maximal anatomic effect on the arterial tree occurs at the level of the reduced-caliber "choke" anastomotic vessels that link adjacent vascular territories. To further investigate the sequence of anatomic changes that occurs during the delay phenomenon, a large series of 200 rabbits and 17 dogs underwent a flap delay procedure in either skin or muscle and the tissues were examined at postoperative periods between 1 hour and 1 year by using well-established fluorescein, angiographic, light microscopic, immunohistochemical, and electron microscopic techniques. These data in the rabbit skin consistently demonstrated an initial period of vasoconstriction that resolved within 3 hours postoperatively and was followed by an active and progressive dilation of choke vessels that was most dramatic between 48 and 72 hours. In vivo intravenous fluorescein dye testing revealed an interesting parallel in that there was a temporary barrier to the flow of fluorescein that occurred at the level of the choke vessels immediately after the flap was raised and that this temporary barrier-continued to impede the flow toward the flap tip in rabbits where flaps had been delayed for periods up to 72 hours. Thereafter, there was no obstruction to the flow of fluorescein along the flap. During this early delay period of 3 days, light microscopy revealed a decrease in vessel wall thickness associated with an increase in lumen diameter. Over the next 4 days, the luminal diameter continued to dilate to a lesser extent and the vessel wall thickened. Immunohistochemical analysis showed increased cell division, maximal between 24 and 72 hours, in all layers of the choke vessel wall. During this same postoperative interval, transmission electron microscopy revealed phenotypic changes in smooth muscle cells from contractile to synthetic cells. Hypertrophy of the smooth muscle cells was also observed. The vascular endothelium, which initially showed evidence of denudation, was restored to a healthy intact appearance within the first week after delay. When followed for longer periods, long-term studies of the delayed flap of up to 1 year demonstrated dramatically a permanent dilation of the choke vessel lumen and a thickening of the choke vessel wall. In canine studies, one rectus abdominis muscle was delayed by ligating the deep inferior epigastric artery. The time sequence of choke vessel dilation, studied by sequential angiograms in vivo, was comparable to that of the rabbit skin model. To ascertain the permanence and irreversibility of this dilation, the normal circulation of the delayed rectus abdominis muscle was restored by reanastomosing the deep inferior epigastric artery. Even after a recovery period of up to 3 months, the choke vessels remained dilated and tortuous instead of reverting to their original narrow diameters. From this work, it is suggested that the choke vessel dilation seen in the delay period is a permanent and irreversible event. It is an active process associated with both an increase (hyperplasia) and an enlargement (hypertrophy) of the cells in all layers of the choke artery wall and a resultant increase in caliber of these vessels. The time sequence for delay appears to be similar in different species and in different tissues, suggesting the possibility of a universal process for delay.     

Intrinsic Innervation of a Reptilian Esophagus (Podarcis hispanica)

We study the esophagus of Podarcis hispanica through different methods to clarify the structure and affinities of its wall innervation. The acetylcholinesterase method reveals cholinesterase activity in two submucosal nervous plexuses, with an increasing degree of structural complexity in the reptilian esophagus, compared with amphibians. Noradrenergic innervation, detected through fluorescence induced by formol, widely spreads its network in both the myenteric and submucosal plexuses (around the blood vessels in the external submucosal plexus, and to the glandular lamina propria in the inner submucosal plexus). Immunohistochemistry for vasoactive intestinal peptide shows a widespread innervation, with neurons clustered in ganglia and also scattered through the VIPergic network, only at the myenteric plexus. Immunohistochemistry for substance P shows a rich innervation along the entire wall of the esophagus, more concentrated in its caudal region, around the blood vessels. Electron microscopy shows the enteric neuronal ultrastructure and its relationship with the esophagus wall.     

Distribution and ontogeny of chromogranin A and tyrosine hydroxylase in the carotid body and glomus cells located in the wall of the common carotid artery and its branches in the chicken

Summary Development and distribution of chromogranin A and tyrosine hydroxylase in the carotid body and glomus cells located in and around arteries were examined in chickens at various developmental stages by an immunohistochemical staining. In 9-day-old embryos, numerous cells immunoreactive for tyrosine hydroxylase were already detected in the connective tissue surrounding the carotid body. Some of these cells also showed immunoreactivity for chromogranin A. At 10 days of incubation, a few cells immunoreactive for tyrosine hydroxylase and chromogranin A were detected within the carotid body parenchyma. At 12 days of incubation, almost all glomus cells of the carotid body were intensely immunoreactive for these substances. Furthermore, numerous tyrosine hydroxylase- and chromogranin A-immunoreactive cells were observed in the wall of the common carotid artery, along the whole length of the carotid body artery, and around the roots of the inferior thyroid artery, the ascending esophageal artery and the esophagotracheobronchial artery; the cells already exhibited adult pattern of distribution at this stage of development. Thereafter, glomus cells immunoreactive for both substances gradually increased in number and in intensity of immunoreactivity with age, although the cells located in the wall of the common carotid artery lost immunoreactivity for tyrosine hydroxylase after hatching.     

Distribution and ontogeny of chromogranin A and tyrosine hydroxylase in the carotid body and glomus cells located in the wall of the common carotid artery and its branches in the chicken

Development and distribution of chromogranin A and tyrosine hydroxylase in the carotid body and glomus cells located in and around arteries were examined in chickens at various developmental stages by an immunohistochemical staining. In 9-day-old embryos, numerous cells immunoreactive for tyrosine hydroxylase were already detected in the connective tissue surrounding the carotid body. Some of these cells also showed immunoreactivity for chromogranin A. At 10 days of incubation, a few cells immunoreactive for tyrosine hydroxylase and chromogranin A were detected within the carotid body parenchyma. At 12 days of incubation, almost all glomus cells of the carotid body were intensely immunoreactive for these substances. Furthermore, numerous tyrosine hydroxylase- and chromogranin A-immunoreactive cells were observed in the wall of the common carotid artery, along the whole length of the carotid body artery, and around the roots of the inferior thyroid artery, the ascending esophageal artery and the esophagotracheobronchial artery; the cells already exhibited adult pattern of distribution at this stage of development. Thereafter, glomus cells immunoreactive for both substances gradually increased in number and in intensity of immunoreactivity with age, although the cells located in the wall of the common carotid artery lost immunoreactivity for tyrosine hydroxylase after hatching.     

Lymph node topography and various features of the metastasis of malignant kidney tumors

Due to investigations of 102 renal preparations performed on corpses of mature persons, topographic peculiarities of the lymph nodes, getting lymph from the left and right kidneys, are revealed. Every lymph node of the left kidney gets greater amount of lymphatic vessels than every node of the right kidney. The lymph, running from the right kidney, usually gets through a less number of the subsequently arranged nodes up to the thoracic duct, as compared to the lymph, that runs from the left kidney. A typical position for the node, which the renal lymphatic vessels get into, is the fatty tissue in the area of the angle formed by the aorta edge and the inferior wall of the corresponding renal artery. The lymphatic nodes of the right kidney are arranged in the fatty tissue more compact than the left ones. These peculiarities, revealed by morphological investigations, are proved by analysis of 114 case histories of persons suffering from malignant neoplasms in the kidneys.     

The anterior tibial artery flap: anatomic study and clinical application

Satisfactory replacement of skin defects over the lower leg remains a difficult problem. Various forms of coverage, including, local rotation flaps, muscle flaps, and fascial and free flaps, have their specific indications and inherent disadvantages. In this work, a new axial skin flap based on perforating vessels in the territory of the anterior tibial artery is described. A series of 50 lower leg dissections was carried out in 25 fresh cadavers after latex injection into the femoral artery. Detailed studies of the cutaneous distribution of the anterior tibial artery showed that three main arteries perfuse the anterior lateral portion of the lower leg. The superior lateral peroneal artery and the inferior lateral peroneal artery interseptal cutaneous perforators arise at an average of 25.6 and 17.2 cm from the lateral malleolus, respectively. The superior lateral peroneal artery was present in 100 percent of the specimens, whereas the inferior lateral peroneal artery was present in 70 percent of the specimens. In their course, they give several muscular branches to the peroneus longus and brevis prior to perforating the fascia and arborizing in the subcutaneous tissues of the anterolateral portion of the leg. The average external diameter was 1.6 cm for the superior and 1.4 cm for the inferior lateral peroneal artery. The superficial peroneal nerve accessory artery is the third artery which contributes to the skin of the lower leg. It arises from the superior lateral peroneal artery in 30 percent of cases, from the inferior lateral peroneal artery in 40 percent, and from both in 30 percent. The artery runs along with the superficial peroneal nerve and gives several cutaneous perforators along its descending course. Several cutaneous axial flaps can be fashioned around this anatomy. The operative technique along with demonstrative clinical cases is presented followed by pertinent discussion.     

Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery

The key to understanding the blood supply of the anterior hemiabdomen is knowledge of the central superficial inferior epigastric artery system and the peripheral contribution of the epigastric, deep and superficial circumflex, and iliac arteries and external oblique perforators. These systems all feed into the subdermal plexus of the anterior abdominal wall. Angiographic confirmation of multiple communications between the superficial inferior epigastric artery and other major sources of abdominal wall blood supply has been obtained. Experience using the superficial inferior epigastric artery flap as a pedicled and microsurgical transfer has been described.     

Is there a caudal thyroid artery in the dog (Canis familiaris)?

Attempts have been made to establish extent of similarities as well as dissimilarities between the canine caudal thyroid and human inferior thyroid artery. On the basis of origin, course, relationship, branching pattern, major area of supply, level of anastomosis, occurrence, etc., it is proposed to rename the caudal thyroid of the dog as the tracheoesophageal artery.     

Fine structure of venules and lymphatics of the dog thyroid gland]

The endothelial cells of the venules (collecting venules) of the thyroid gland of the dog are very thin and show fenestrations. In their wall, however, more 'primitive' smooth muscle cell layers are recognizable. The endothelial cells in the lymphatic vessels are also thin, but continuous. They have all known morphological characteristics of these vessels. The fenestrae of the venules' endothelium could facilitate hormone passage from the interstitial tissue into the blood stream.     

Transport in rat vessel walls. II. Macromolecular leakage and focal spot size growth in rat arteries and veins

Transendothelial lipid transport into and spread in the subendothelial intima of large arteries, and subsequent lipid accumulation, appear to start plaque formation. We experimentally examine transendothelial horseradish peroxidase (HRP) transport in vessels that are usually, e.g., pulmonary artery (PA), or almost always, e.g., inferior vena cava (IVC), atherosclerosis resistant vs. disease prone, e.g., aorta, vessels. In these vessels, HRP traverses the endothelium at isolated, focal spots, rather than uniformly, for short circulation times. For femoral vein HRP introduction, PA spots have 30-s radii [ approximately 53.2 microm (SD 10.4); compare aorta: 54.6 microm (SD 8.75)] and grow quickly from 30 s to 1 min (40%, P<0.05) and more slowly afterward (P>0.05). This trend resembles the aorta, suggesting the PA has a similarly sparse intima. With carotid artery (CA) HRP introduction, the 30-s spot (132.86 +/- 37.32 microm) is far larger than the PAs, grows little ( approximately 28%, P<0.05) from 30 to 60 s, and is much flatter than the artery curves. Transverse electron microscopic sections after approximately 10 min HRP circulation show thin, intense staining immediately beneath both vessels' endothelia with an almost step change to diffuse staining beyond. This indicates the existence of a sparse, subendothelial intima, even when there is no internal elastic lamina (IVC). This motivates a simple model that translates growth rates into lower bounds for the flow through focal leaks. The model results and our earlier wall and medial hydraulic conductivity data explain these spot growth curves and point to differences in transport patterns that might be relevant in understanding the immunity of IVC to disease initiation.     

Angiography of the iliofemoral arteriovenous system supplying free groin flaps and free hypogastric flaps.

The circulatory anatomy of the iliofemoral region was elucidated by doing detailed angiography in 50 cases, and we classified the vessels into 4 types. In most cases, the s.c.i.a. predominated over the s.i.e.a. Therefore, it is probably better to plan free flaps supplied by this artery. This vessel usually arises approximately two or three fingerbreadths inferior to the intersection of the femoral artery and the inguinal ligament, and the skin flap should be designed in the area inferior and parallel to the inguinal ligament.     

Mechanisms of vascular adaptation to long-term orthostatic gravitational loading

Frequent symptoms and serious complaints related to orthostatic intolerance are among the important reasons for investigating the long-term control mechanisms of blood vessels especially those of veins. Previously we studied perfused and superfused saphenous vein segments from rats maintained in head-up tilt position for two weeks. It was found that passive lumen capacity and acute pressure induced myogenic response of these vessels increased substantially without measurable change in wall thickness. Sympathetic component of the smooth muscle cell membrane potential determined in vivo was also significantly enhanced in this vein, but no such change was seen in the saphenous artery and in the brachial vessels. In a separate study, rarefaction of microvessels was found in the hind limb oxydative muscles after two-week tilting, while muscular water content was unaltered. These results suggest that long-term gravitational loading may induce adaptive rearrangement of the blood vessel functions. The aim of the present study was to quantitate and compare the density of nerve fiber terminals as well as their synaptic vesicle population in the wall of saphenous vein and artery from tilted rats to those obtained from rats which were maintained in horizontal, control position. It was hypothetized that adaptation of blood vessels to long-term gravitational loading might include also a morphological restructuring of the vascular adrenergic innervation.     

Anatomy of the recurrent laryngeal nerve in normal Iraqis

A study of the anatomy of the recurrent laryngeal nerve was made on 106 post-mortem cases and fixed dissecting-room cadavers. The usual position of the nerve was in the tracheo-oesophageal groove. The nerve lay posterior to the inferior thyroid artery on the left side in most cases, while its relation was very variable on the right side. The inferior cornu of the thyroid cartilage was the best guide to the site of entry of the nerve into the larynx.     

Macroscopic and microscopic intermesenteric communications

The aim of this study was to describe all levels of the intermesenteric communications because of their importance in vascular diseases of the colon. The connections of superior and inferior mesenteric networks are very important in cases of acute or chronic obstruction to prevent ischemia and necrosis. Angiograms of mesenteric arteries were studied (40), cadaverous large intestine samples with mesentery and feeding vessels were dissected (36) or injected with India ink solution (24) or methylmetacrylate Mercox (41). In 7.9 % of cases an intermesenteric connection was described, named anastomosis intermesenterica accessoria and classified according to Pikkieff's(1) proposal. The marginal artery in the left colic flexure forms an arch called Riolan's arcade(2) or Haller's anastomosis(3) and is present in 95 % of cases. Infrequent anastomosis between straight vessels and mighty plexuses in the intestinal wall were registered. There are no regional differences when compared to the rest of colon.