The Ministry of Education and Science of the Kyrgyz Republic

The Ministry of Education and Science of the Russian Federation

State Educational Institution of Higher Professional Education

Kyrgyz-Russian Slavic University

Department of the anatomy, topographic anatomy and operative surgery

The systemic anatomy of the cardiovascular, lymphatic and immune systems

Textbook

Bishkek 2019

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 The systemic anatomy of the cardiovascular, lymphatic and immune systems. Textbook.

Textbook is prepared by: senior lecturer Gaivoronskaya Y.B., senior lecturer Imanalieva A.S., senior lecturer Lobzova V.V.

This textbook is elaborated to study the blood vessels of the human body. It provides detailed description of the arterial, venous, lymphatic and immune
systems.
This textbook will help the students in preparation for practical classes related to the section “vascular system” and for the examinations on human anatomy.

Introduction
The cardiovascular system – a powerful pump (the heart) connected to an extensive system of tubes (blood vessels) – brings oxygen and nutrients to all
body cells and removes wastes. A functional cardiovascular system is vital for survival because, without circulation, tissues lack a supply of oxygen and
nutrients, and wastes accumulate. Under such conditions, cells soon change irreversibly which quickly leads to death.
The heart is hollow, cone-shaped, muscular pump, located within the thoracic cavity and resting on the diaphragm.
The blood vessels form a closed circuit that carries blood from the heart to cells and back again. These vessels include arteries, arterioles, capillaries,
venules, and veins.
Arteries are strong, elastic vessels adapted for carrying blood away from the heart under high pressure. These vessels branch into progressively thinner
tubes and eventually give rise to fine branches called arterioles.
Capillaries, the smallest diameter blood vessels, connect the smallest arterioles and the smallest venules. These thin walls form the semipermeable
membranes through which substances are exchanged between the blood and the tissue fluid that surrounds body cells.
Venules are the microscopic vessels that continue from the capillaries and merge to form veins. The veins, which carry blood back to the atria, roughly
parallel the pathways of the arteries.
Like the cardiovascular system, the lymphatic system includes a network of vessels that circulates fluids. Lymphatic vessels transport excess fluid from
interstitial spaces in most tissue and return it to the bloodstream. Special lymphatic capillaries (lacteals), located in the lining of the small intestine, absorb
digested fats then transport the fat to venous circulation. The lymphatic system also helps defend the body against disease-causing agents.
The lymphatic pathways begin as lymphatic capillaries. These tiny tubes merge to form larger lymphatic vessels, which, in turn, lead to larger vessels that
unite with veins in the thorax. Fluid inside lymphatic capillaries is called lymph. The larger lymphatic vessels lead to specialized organs called lymph
nodes. After leaving the nodes, the vessels merge to form still larger lymphatic trunks.
The thymus and spleen are lymphatic organs whose functions closely relate to those of the lymph nodes.

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 HEART
The heart is a hollow muscular organ that is somewhat pyramidal in shape and lies within the pericardium in the mediastinum. It is connected at its base to
the great blood vessels but otherwise lies free within the pericardium. The heart is placed obliquely behind the body of the sternum and adjoining parte of
the costal cartilages, so that one-third of it lies to the right and two-third to the left of the median plane. The heart measures about 12 x 9 cm and weighs
about 300 g in males and 250 g in females.
The human heart has four chambers. These are the right and left atria and the right and left ventricles. The atria lie above and behind the ventricles. On the
surface of the heart they are separated from the ventricles by an atrioventricular or coronary groove. The atria are separated from each other by an
interatrial groove. The ventricles are separated from each other by an interventricular groove, which is subdivided into anterior and posterior parts.
The heart has an apex directed downwards forwards and to the left, a base (or posterior surface) directed backwards: and anterior, inferior and left
surfaces. The surfaces are demarcated by upper, lower, right and left borders.

THE RIGHT ATRIUM

The right atrium is the right upper chamber of the heart. It receives venous blood from the whole body, pumps it to the right ventricle through the right
atrioventricular or tricuspid opening.

External Features
1. The chamber is elongated vertically, receiving the superior vena cava at the upper end and the inferior vena cava at the lower end
2. The upper end is prolonged to the left to form the right auricle. The auricle covers the root of the ascending aorta and partly overlaps the
infundibulum of the right ventricle. In the auricle presents a series of transverse muscular ridges called musculi pectinati.
Tributaries, or inlets of the Right Atrium
(1) Superior vena cava, (2) inferior vena cava, (3) coronary sinus, (4) anterior cardiac veins, (5) venae cordis minimi (Thebesian veins), (6) and
sometimes the right marginal vein.
Internal Features
(1) The superior vena cava opens at the upper end. (2) The inferior vena cava opens at the lower end. The opening is guarded by a rudimentary valve of
the inferior vena cava or Eustachian valve. During embryonic life the valve guides the inferior vena caval blood to the left atrium through the foramen
ovale. (3) The coronary sinus opens between the opening of the inferior vena cava and the right atrioventricular orifice. The opening is guarded by the
valve of the coronary sinus. (4) The venae cordis minimae open into the right atrium through small foramina. (5) The intervenous tubercle of Lower is a
very small projection, scarcely visible, on the posterior wall of the atrium just below the opening of the superior vena cava. During embryonic life it
directs the superior caval blood to the right ventricle. (6) In the interatrial septum presents the fossa ovalis, a shallow saucershaped depression, in the
lower part, which is the foramen ovalis in the embryonic life.

THE RIGHT VENTRICLE

The right ventricle is a triangular chamber which receives blood from the right atrium and pumps it to the lungs through the pulmonary trunk and
pulmonary arteries. It forms the inferior border and a large part of the sternocostal surface of the heart.
Features
1. There are two parts, (i) the inflowing part is rough due to the presence of muscular ridges called trabeculae carneae. The trabeculae carneae or
muscular ridges of three types: (1) ridges or fixed elevations, (2) bridges, (3) pillars or papillary muscles with one end attached to the ventricular
wall, and the other end connected to the cusps of the tricuspid valve by chordae tendinae. There are three papillary muscles in the right ventricle,
anterior, posterior and septal. (ii) The outflowing part or infundibulum is smooth and forms the upper conical part of the right ventricle which gives
rise to the pulmonary trunk.
2. There are two orifices: (1) the right atrioventricular or tricuspid orifice, guarded by the tricuspid valve, and (2) the pulmonary orifice guarded by the
pulmonary valve.
The tricuspid valve is made up of the following components: (1) a fibrous ring to which the cusps are attached. (2) The chordae tendinae connect the
free margins and ventricular surfaces of the cusps to the apices of the papillary muscles. They prevent eversion of the free margins and limit the amount
of ballooning of the cusps towards the cavity of the atrium. The atrioventricular valves are kept competent by active contraction of the papillary
muscles, which pull on the chordae tendinae during ventricular systole.
The pulmonary valve is called semilunar valve because their cusps are semilunar in shape. Each valve has three cusps which are attached directly to
the vessel wall – anterior, right and left. The cusps form small pockets with their mouths directed away from the ventricular cavity. The free margin of
each cusp contains a central fibrous nodule from each side of which a thin smooth margin the lunule extends up to the base of the cusp. These valves
are closed during ventricular diastole when each cusp bulges towards the ventricular cavity.
The septomarginal trabecula or moderator band is a muscular ridge extending from the ventricular septum to the base of the anterior papillary muscle.
It contains the right branch of the AV bundle.
The interventricular septum is placed obliquely. It’s one surface faces forwards and to the right and the other faces backwards and to the left. The
upper part of the septum is thin membranous part and separates not only the two ventricles but also the right atrium and left ventricle. The lower part is
thick muscular part and separates the two ventricles. Its position is indicated by the anterior and posterior interventricular grooves.

THE LEFT ATRIUM

The left atrium is a quadrangular chamber situated posteriorly. Its appendage, the left auricle projects anteriorly to overlap the infundibulum of the right
ventricle. It receives oxygenated blood from the lungs through four pulmonary veins, and pumps it to the left ventricle through the left atrio-ventricular or
bicuspid or mitral orifice which is guarded by the valve of the same name.
Features
1. The anterior wall of the atrium is formed by the interatrial septum.
2. Two pulmonary veins open into the atrium on each side of the posterior wall.
3. The greater part of the interior of the atrium is smooth walled. Musculi pectinati are present only in the auricle where they form a reticulum. The
septal wall shows the fossa lunata corresponding to the fossa ovalis of the right atrium. In addition to the four pulmonary veins, the tributaries of the
atrium include a few venae cardis minimi.

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THE LEFT VENTSHCLE
The left ventricle receives oxygenated blood from the left atrium and pumps it into the aorta.

Features
1. The interior is divisible into two parts: (1) the lower rough part with or trabeculae carneae. (2) The upper smooth part or aortic vestibule gives origin
to the ascending aorta. The vestibule lies between the membranous part of the interventricular septum and the anterior or aortic cusp of the mitral valve.
2. The interior of the ventricle shows two orifices: (1) The left atrioventricular or bicuspid or mitral orifice, guarded by the bicuspid or mitral valve, and
(2) the aortic orifice, guarded by the aortic valve is called semilunar valve.
3. There are two well developed papillary muscles, anterior and posterior. Chordae tendinae from both attached to both the cusps of the mitral valve.
4. Opposite the cusps the vessel walls are slightly dilated to form the aortic sinuses. The coronary arteries arise from the right and the left aortic sinuses.

THE WALL OF THE HEART

The greater part of the wall of the heart is made up of cardiac muscle fibers and is called myocardium.
It is covered externally by the visceral layer of the serous pericardium and this, together with a thin subserous layer of the connective tissue, is the epicardium.
The chambers of the heart are lined by the endocardium, which also covers the valves and continues with the endothelium and under lying connective tissue of
the vessels entering and leaving the chambers.
The myocardium is made up of two separate, rather complex systems of spiraling and loping bundles of fibers, one for the atria one for the ventricles. A
superficial and a deep muscular layer are distinguished in the atria. The superficial layer consists of circular fibers, where as the deep layer is made up of
longitudinal fibers arising from the fibrous rings. The musculature of the ventricles has three layers. A thin superficial layer is composed of longitudinal fibers
which arise from the right fibrous ring and descend obliquely, passing also on to the left ventricle. The fibers of the middle layer (between the longitudinal
outer and inner layers) are more or less circular. They do not pass from one ventricle to the other but are independent components of each ventricle. Cardiac
muscle cells are lightly striated and have specialized partitions between the cells. These intercalated disks are actually modified cell membranes that allow for
rapid transfer electric impulses between the cells.
The skeleton of the heart consists of fibrous rings that surround the atrioventricular, pulmonary, and aortic orifices and are continuous with the
membranous upper part of the ventricular septum. The fibrous rings around the atrioventricular orifices separate the muscular walls of the atria from
those of the ventricles, but provide attachment for the muscle fibers. The fibrous rings support the bases of the valve cusps and prevent the valves from
stretching and becoming incompetent.
CONDUCTING SYSTEM
The conducting system is made up of myocardium that is specialized for initiation and conduction of the cardiac impulse. Its fibres are finer than other
myocardial fibres, and are completely cross-striated.
The conducting system has the following parts:
1. Sinuatrial Node or SA node. It is known as the pacemaker of the heart. It generates an impulse at the rate of about 70/ min and initiates the heart
beat. It is situated at the atriocaval junction between superior vena cava and right auricle. The impulse travels through the atrial wall to reach the
AV node.
2. Atrioventricular node or AV node. It is smaller than the SA node and is situated in the lower and dorsal part of the interatrial septum. Just above
the opening of the coronary sinus. It is capable of generating impulses at a rate of about 60/ min.
3. Atrioventricular bundle or AV bundle or bundle of His. It is the only muscular connection between the atrial and ventricular musculatures. It
begins as the atrioventricular (AV) node crosses AV ring and descends along the posteroinferior border of the membranous part of the
interventricular septum. At the upper border of the muscular part of the septum it divides into right and left branches.
4. The right branch of the AV bundle passes down the right side of the interventricular septum. A large part enters the moderator band to reach the
anterior wall of the right ventricle where it divides into Purkinje fibres.
5. The left branch of the AV bundle descends on the left side of the interventricular septum and is distributed to the left ventricle after dividing into
Purkinje fibres.
6. The Purkinje fibres form a subendocardial plexus. They are large pale fibres striated only at their margins. They usually possess double nuclei.

ARTERIES SUPPLYING THE HEART

The heart is supplied by two coronary arteries, arising from the ascending aorta. Both arteries run in the coronary sulcus.

Right Coronary Artery

Right coronary artery is smaller than the left coronary artery. It arises from the right aortic sinus.
Course
1. It first passes forwards and to the right to emerge on the surface of the heart between the root of the pulmonary trunk and the right auricle.
2. It then runs downwards in the right anterior coronary sulcus to the junction of the right and inferior borders of the heart.
3. It runs backwards and to the left In the right posterior coronary sulcus to reach the posterior interventricular groove.
4. It terminates by anastomosing with the left coronary artery.
Area of Distribution: right atrium, ventricles, greater part of the right ventricle, except the area adjoining the anterior interventricular groove. A small
part of the left ventricle adjoining the posterior interventricular groove. Posterior part of the interventricular septum. Whole of the conducting system of
the heart except a part of the left branch of the AV bundle. The SA node is supplied by the left coronary artery in about 40% of cases.

Left Coronary Artery

Left coronary artery is larger than the right coronary artery. It arises from the left aortic sinus.
Courae
1. The artery first runs forwards and to the left and emerges between the pulmonary trunk and the left auricle. Here it gives the anterior interventricular
branch which runs downwards in the groove of the same name. The further continuation of the left coronary artery is called the circumflex artery.
2. After giving off the anterior interventricular branch the artery rans to the left in the left anterior coronary sulcus.
3. It winds round the left border of the heart and continues in the left posterior coronary sulcus. Near the posterior interventricular groove it terminates
by anastomosing with the right coronary artery.

Area of Distribution: left atrium, ventricles, greater part of the left ventricle, except the area adjoining the posterior interventricular groove. A small part
of the right ventricle adjoining the anterior interventricular groove. Anterior part of the interventricular septum. A part of the left branch of the AV
bundle.

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 THE VEINS OF THE HEART

These are the great cardiac vein, the middle cardiac vein, the small cardiac vein, the posterior vein of the left ventricle, the oblique vein of the left atrium,
the right marginal vein, the anterior cardiac veins, and the venae cordis minimi. All veins except the last two drain into the coronary sinus which opens
into the right atrium. The anterior cardiac veins and the venae cordis minimae open directly into the right atrium.
A. Coronary sinus: The coronary sinus is the largest vein of the heart. It is situated in the left posterior coronary sulcus. It is about 3 cm long. It ends by
opening into the posterior wall of the right atrium. It receives the following tributaries.
1. The great cardiac vein lies in the anterior interventricular groove and enter the left end of the coronary sinus.
2. The middle cardiac vein lies in the posterior interventricular groove, and joins the middle part of the coronary sinus.
3. The small cardiac vein lies in the right posterior coronary sulcus and joins the right end of the coronary sinus. The right marginal vein may drain into
the small cardiac vein.
4. The posterior vein of the left ventricle runs on the diaphragmatic surface of the left ventricle and ends in the middle of the coronary sinus.
5. The oblique vein of the left atrium is a small vein running on the posterior surface of the left atrium. It terminates in the left end of the coronary
sinus.

NERVE SUPPLY OF THE HEART

Parasympathetic nerves reach the heart via the vagus. These are cardioinhibitory; on stimulation they slow down the heart rate. Sympathetic nerves are
derived from the upper two to five thoracic segments of the spinal cord. These are cardioacceleratory and on stimulation they increase the heart rate, and
also dilate the coronary arteries. Both parasympathetic and sympathetic nerves form the superficial and deep cardiac plexuses, the branches of which run
along the coronary arteries to reach the myocardium.
The superficial cardiac plexusis situated below the arch of the aorta In front of the right pulmonary artery. It is formed by: (1) the superior cervical
cardiac branch of the left sympathetic chain: and (2) the inferior cervical cardiac branch of the left vagus nerve. It gives branches to the deep cardiac
plexus the right coronary artery, and to the left anterior pulmonary plexus.
The deep cardiac plexus is situated in front of the bifurcation of the trachea, and behind the arch of the aorta. It is formed by all the cardiac branches
derived from all the cervical and upper thoracic ganglia of the sympathetic chain, and the cardiac branches of the vagus and recurrent laryngeal nerves,
except those which form the superficial plexus. The right and left halves of the plexus distribute branches to the corresponding coronary and pulmonary
plexuses. Separate branches are given to the atria.

FETAL CIRCULATION

The fetus is dependent for its entire nutrition on the mother, and this is achieved through the placenta attached to the uterus. As the lungs are not
functioning, the blood needs to bypass the pulmonary circuit. The oxygenated blood reaches the fetus through the single umbilical vein. This vein
containing oxygenated blood traverses the umbilical cord to reach the liver. The oxygenated blood bypass the liver via the ductus venosus to join inferior
vena cava. As inferior vena cava drains into the right atrium, the oxygenated blood brought by it enters the right atrium. Then it passes into the left atrium
through foramen ovale, thus bypassing the pulmonary circuit.
From the left atrium it enters the left ventricle and traverses the systemic circuit via the ascending aorta, arch of aorta and descending thoracic and
descending abdominal aorta. The last mentioned vessel divides into common iliac arteries. Each common iliac artery terminates by dividing into external
and internal iliac arteries. Arising from two internal iliac arteries are the two umbilical arteries which in turn pass through the umbilical cord to end in the
placenta.
The deoxygenated blood from the viscera, upper limbs, head and neck also enters the right atrium via superior vena cava. This venons blood gains entry
into the right atrium and then right ventricle and leaves it via the pulmonary trunk and left pulmonary artery. The left pulmonary artery is joined to left
end of arch of aorta via the ductus arteriosus. Thus the venous blood traversing through the left pulmonary artery and ductus arteriosus enters the left end
of arch of aorta. So the descending thoracic and abdominal aorta get mixed blood. At the internal iliac artery passes via the two umbilical arteries to reach
the placenta for oxygenation.

THE PERICARDIUM
The pericardium is a fibroserous sac which encloses the heart and the roots of the great vessels. It is situated in the middle mediastinum. It consists of the
fibrous pericardium and the serous pericardium. Fibrous pericardium encloses the heart and fuses with the vessels which enter/leave the heart. Heart is
situated within the fibrous and serous pericardial sacs. The parietal layer of serous pericardium gets adherer, to the inner surface of fibrous pericardium,
while the visceral layer of serous pericardium gets adherent to the outer layer of heart and forms its epicardium.
Sinuses of Pericardium
The transverse sinus is a horizontal gap between the arterial and venous ends of the heart tube. It is bounded anteriorly by the ascending aorta and
pulmonary trunk, and posteriorly by the superior vena cava and inferiorly by the left atrium: on each side it opens into the general pericardial cavity.
The oblique sinus is a narrow gap behind the heart. It is bounded anteriorly by the left atrium, inferior vena cava, pulmonary veins and posteriorly by the
parietal pericardium.

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 THE AORTA

The aorta is the great arterial trunk which receives oxygenated blood from-the left ventricle and distributes it to all pails of the body, it is studied in three
parts: (1) the ascending aorta, (2) the arch of the aorta, and (3) the descending aorta.

THE ASCENDING AORTA

Origin and Course. The ascending aorta arises from the upper end of the left ventricle. It Is about 5 cm long and is enclosed in the pericardium. It begins
behind the left half of the sternum at the level of the lower border of the third costal cartilage. It runs upwards, forwards and to the right and becomes
continuous with the arch of the aorta. At the root of the aorta there are three dilatations of the vessel wall called the aortic sinuses. The sinuses are
posterior, left and right.

Branches. The right coronary artery arises from right aortic sinus, while the left coronary emerges from the left aortic sinus.

ARCH OF THE AORTA

Arch of the aorta is the continuation of the ascending aorta. It is situated in the superior mediastinum behind the lower half of the manubrium sterni.

Course
1. It begins behind the upper border of the second right sternochondral joint.
2. It runs upwards, backwards and to the left across the left side of the bifurcation of trachea. Then it passes downwards behind the left bronchus and on
the left side of the body of the fourth thoracic vertebra. It thus arches over the root of the left lung.
3. It ends at the lower border of the body of the fourth thoracic vertebra by becoming continuous with the descending aorta.
Branches
1. Brachiocephalic trunk which divides into the right common carotid and right subclavian arteries.
2. Left common carotid artery.
3. Left subclavian artery.

COMMON CAROTID ARTERIES

The right common carotid artery is a branch of the brachiocephalic trunk. It begins in the neck behind the right sternoclavicular joint. The left common
carotid artery is a branch of the arch of the aorta. It ascends to the back of the left sternoclavicular joint and enters the neck.
In the neck, both arteries have a similar course. Each artery runs upwards within the carotid sheath, under cover of the anterior border of the cervical
transverse processes. At the level of the upper border of the thyroid cartilage the artery ends by dividing into the external and internal carotid arteries.

EXTERNAL CAROTID ARTERY

It is one of the terminal-branches of the common carotid artery. In general it lies anterior to the internal carotid artery, and is the chief artery of supply to
structures in the front of the neck and in the face.

Course and Relations

1. The external carotid artery begins in the carotid triangle at the level of the upper border of the thyroid cartilage (opposite the disc between the third and
fourth cervical vertebrae). It runs upwards and slightly backwards and laterally, and terminates behind the neck of the mandible by dividing into the
maxillary and superficial temporal arteries.
2. In the carotid triangle, the external carotid artery lies under cover of the anterior border of the sternocleidomastoid muscle.
3. Above the carotid triangle the external carotid artery lies deep in the substance of the parotid gland.
Branches
The external carotid artery gives off eight branches which may be grouped as follows.
A. Anterior: (1) superior thyroid; (2) lingual; and (3) facial.
B. Posterior: (1) occipital; and (2) posterior auricular.
C. Medial: ascending pharyngeal.
D. Terminal: (1) maxillary; and (2) superficial temporal.

The superior thyroid artery arises from the external carotid artery just below the level of the greater cornu of the hyoid bone. It passes deep to the three
long infrahyoid muscles to reach the upper pole of the lateral lobe of the thyroid gland. Apart from its terminal branches to the thyroid gland, it gives one
important branch, the superior laryngeal artery which pierces the thyrohyoid membrane. The superior thyroid artery also gives a sternomastoid branch
(to that muscle) and a cricothyroid branch.

The lingual artery arises from the external carotid artery opposite the tip of the greater cornu of the hyoid bone. Its course is divided into three parts by
the hyoglossus muscle.
The first part lies in the carotid triangle. It forms a characteristic upward loop which is crossed by the hypoglossal nerve. The lingual loop permits free
movements of the hyoid bone.
The second part lies deep to the hyoglossus along the upper border of the hyoid bone. From the second part from lingual artery begins suprahyoid artery
to the hyoid bone and sublingual artery to the sublingual salivary gland.
The third part is called the arteria profunda linguae, or the deep lingual artery. It runs upwards along the anterior border of the hyoglossus, and then
forwards on the undersurface of the tongue. In its vertical course, it lies between the genioglossus medially and the inferior longitudinal muscle of the
tongue laterally.

The facial artery arises from the external carotid just above the tip of the greater cornu of the hyoid bone. It runs upwards first in the neck (cervical part)
and then on the face (facial part).
The cervical part of the facial artery runs upwards on the pharynx (superior constrictor) deep to the posterior belly of the digastric (with the stylohyoid)
and to the ramus of the mandible. It grooves the posterior border of the submandibular salivary gland. Next the artery makes an S-bend (two loops), first
winding down over the submandibular gland, and then up over the base of the mandible and pass laterally from the lips to the medial angle of the eye.
The cervical part of the facial artery gives off the ascending palatine, tonsillar, submental, and glandular branches (for the submandibular salivary gland
and lymph nodes). The ascending palatine artery arises near the origin of the facial artery. It passes upwards between the styloglossus and the
stylopharyngeus, crosses over the upper border of the superior constrictor and supplies the tonsil and the root of the tongue. The submental branch is a
large artery which accompanies the mylohyoid nerve, and supplies the submental triangle and the sublingual salivary gland. From facial part begins
superior and inferior labial arteries and angular artery.
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The occipital artery arises from the posterior aspect of the external carotid artery, opposite the origin of the facial artery. In the carotid triangle the artery
gives two sternomastoid branches to the muscles. From occipital artery begins auricular branch to the auricle, mastoid branch to the mastoid antrum
and dura matter of the posterior cranial fossa and descending branch to the muscles of the neck. Then it passes behind posterior belly of the digastrics in
the occipital groove of the temporal bone, and emerges in subcutaneous fat tissue between sternocleidomastoid and trapezium and supply the skin of the
occipital region.

The posterior auricular artery arises from the posterior aspect of the external carotid just above the posterior belly of the digastric. It runs upwards and
backwards deep to the parotid gland, but superficial to the styolid process. It crosses the surface (base) of the mastoid process, and ascends behind the
auricle. It supplies the back of the auricle, the skin over the mastoid process, and over the back of the scalp. Its stylomastoid branch enters the
stylomastoid foramen, and supplies the middle ear, the mastoid antrum and air cells, the semicircular canals, and the facial nerve.

Ascending pharyngeal artery. This is a small branch that arises from the medial side of the external carotid artery. It arises very close to the lower end of
the external carotid artery. It runs vertically upwards between the side wall of the pharynx and the internal carotid artery, up to the base of the skull. It
supplies the side wall of the pharynx, the tonsil, the inferior tympanic artery to the tympanic cavity and the auditory tube, which pass through the petrous
fossa. It sends meningeal branches into the cranial cavity through the jugular foramen.

Superficial temporal artery, is the smaller terminal branch of the external carotid artery. It begins, behind the neck of the mandible under cover of the
parotid gland.
It runs vertically upwards, crossing the root of the zygoma (preauricular point), where its pulsations can be easily felt. About 5 cm above the zygoma it
divides into anterior (frontal) and posterior (parietal) branches which supply the temple and scalp. The frontal branch anastomoses with the supraorbital
and supratrochlear branches of the ophthalmic artery.
In addition to the branches which supply the temple, the scalp, the parotid gland, the auricle and the facial muscles, the superficial temporal artery gives
off a transverse facial artery (already studied with the face), middle temporal artery which runs on the temporal fossa deep to the temporalis muscle,
parotid branches to the parotid gland, anterior auricular branch to the auricle and external acustic meatus and zygomaticoorbital artery to the
orbicularis oculi muscle.

MAXILLARY ARTERY

This is the larger terminal branch of the external сarotid artery, given off behind the neck of the mandible. It has a wide territory of distribution, and
supplies; (a) the external and middle ears, and the auditory tube; (d) the dura mater; (c) the upper and lower jaws; (d) the muscles of the temporal and
infratemporal regions; (e) the nose and paranasal air sinuses; (f) the palate and (g) the roof of the pharynx.
Course and Relations
For descriptive purposes the artery is divided into three parts (by the lateral pterygoid).
1. The first (mandibular) part runs horizontally forwards, first between the neck of the mandible and the sphenomandibular ligament, below and then
along the lower border of the lateral pterygoid.
2. The second (pterygoid) part runs upwards and forwards either superficial or deep to the lower head of the lateral pterygoid.
3. The third (pterygopalatine) part passes between the two heads of the lateral pterygoid and through the pterygomaxillary fissure, to enter the
pterygopalatine fossa where it lies in front of the pterygopalatine ganglion.

Branches of the Maxillary Artery (First Part)

1. The deep auricular artery supplies the external acustic meatus, the tympanic membrane and the temporomandibular joint.
2. The anterior tympanic branch supplies the middle ear including the medial surface of the tympanic membrane, it pass through petrotympanic
fissure.
3. The middle meningeal artery enters the cranial cavity through the foramen spinosum and supplies the dura matter of the middle cranial fossa.
4. The inferior alveolar artery runs downwards and forwards medial to the ramus of the mandible to reach the mandibular foramen. Passing through
this foramen the artery enters the mandibular canal (within the body of the mandible) in which it runs downwards and then forwards. Before entering the
mandibular canal the artery gives off a lingual branch to the tongue: and a mylohyoid branch that descends in the mylohyoid groove (on the medial aspect
of the mandible) and runs forwards above the mylohyoid muscle. Within the mandibular canal the artery gives branches to the mandible and to the roots of
the each tooth attached to the bone. It also gives off a mental branch that passes through the mental foramen to supply the chin.

Branches of the Maxillary Artery (Second Part). These are mainly muscular.

1. The deep temporal branches (anterior and posterior) ascend on the lateral aspect of the skull deep to the temporalis muscle.

2. Branches are also given to the pterygoid muscles and to the masseter.

3. A buccal branch supplies the buccinator muscle.

4. The posterior superior alveolar artery arises just before the maxillary artery enters the pterygomaxillary fissure. It descends on the posterior surface
of the maxilla (tuber of maxilla) and gives branches that enter alveolar canals in the bone to supply the molar and premolar teeth, and the maxillary air
sinus.

Branches of the Maxillary Artery (Third Part)

1. The infraorbital artery also arises just before the maxillary artery enters the pterygomaxillary fissure. It enters the orbit through the inferior orbital
fissure. It then runs forwards in relation to the floor of the orbit, first in the infraorbital groove and then in the infraorbital canal to emerge on the face
through the infraorbital foramen. It gives off some orbital branches to structures in the orbit, and the anterior superior alveolar branches that enter
apertures in the maxilla to reach the incisor and canine teeth attached to the bone. After emerging on the face the infraorbital artery gives branches to
the lacrimal sac, the nose and the upper lip.
2. The greater(descending) palatine artery runs downwards in the greater palatine canal to emerge on the posterolateral part of the hard palate through
the greater palatine foramen. It then runs forwards near the lateral margin of the palate to reach the incisive canal (near the midline) through which
some terminal branches enter the nasal cavity. Branches of the artery supply the palate and gums. While still within the greater palatine canal it gives
off the lesser palatine arteries that emerge on the palate through the lesser palatine foramina, and run backwards into the soft palate and tonsil.
3. The artery of the pterygoid canal runs backward in the canal of the same name and helps to supply the pharynx, the auditory tube and the tympanic
cavity.
4. 4. The sphenopalatine artery passes medially through the sphenopalatine foramen to enter branches to the lateral wall of the nose and to the paranasal
sinuses; and posterior septal branches to the nasal septum.

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 INTERNAL CAROTID ARTERY
The internal carotid artery is one of the two terminal branches of the common carotid artery. It begins at the level of the upper border of the thyroid
cartilage opposite the disc between the third and fourth cervical vertebrae, and ends inside the cranial cavity by supplying the brain. This is the principal
artery of the brain and the eye. It also supplies the related bones and meninges.
For convenience of description the course of the artery is divided into four parts: (a) cervical part, in the neck; (b) petrous part, within the petrous part of
the temporal bone; (c) cavernous part, within the cavernous sinus; and (d) cerebral part in relation to the base of the brain.

CERVICAL PART

It ascends vertically in the neck from its origin to the base of the skull to reach the lower end of the carotid canal. This part is enclosed in the carotid
sheath (with the internal jugular vein and the vagus). No branches arise from the internal carotid artery in the neck.

PETROUS PART

In the carotid canal, the artery first runs upwards, and then turns forwards and medially at right angles. It emerges at the apex of the petrous part of the
temporal bone, in the posterior wall of the foramen lacerum where it turns upwards and medially. Caroticotympanic branches enter the middle ear, and
anastomose with the manterior and posterior tympanic arteries.

CAVERNOUS PART
Within the cavernous sinus, on the both sides of the sella turcica. This part of the artery gives off: (a) cavernous branches to the trigeminal ganglion;
and (b) the superior and inferior hypophyseal branches to the hypophysis cerebri.

CERBRAL PART
This part lies at the base of the brain after emerging from the cavernous sinus. It gives off the following arteries: (a) ophthalmic; (b) anterior cerebral; (c)
middle cerebral; (d) posterior communicating; and (e) anterior chorodial. Of these, the ophthalmic artery supplies structures in the orbit; while the others
supply the brain.

OPHTHALMIC ARTERY

Course and Relations

1. The artery enters the orbit through the optic canal, lying inferolateral to the optic nerve. Both the artery and nerve lie in a common dural sheath.
2. It terminates near the medial angle of the eye by dividing into the supratrochlear and dorsal nasal branches.

Branches
While still within the dural sheath the ophthalmic artery gives off the central artery of the retina. After piercing the dura matter it gives off a large lacrimal
branch that runs along the lateral wall of the orbit. The main artery runs towards the medial wall of the orbit giving off a number of branches.
1. Branches arising from the lacrimal artery: (a) Branches are given to the lacrimal gland. (b)Two zygomatic branches enter canals, in the zygomatic
bone. One branch appears on the face through the zygomaticofacial foramen. The other appears on the temporal surface of the bone through the
zygomaticotemporal foramen. (c) Lateral palpebral branches supply the eyelids. (d) Muscular branches supply the muscles of the orbit.
2. Branches arising from the main trunk: (a) The posterior ciliary arteries (long and short) supply the eyeball (chiefly the choroid and iris). (b) The
supraorbital and supratrochlear branches supply the skin of the forehead. (c) The anterior and posterior ethmoidal branches enter foramina in the
medial wall of the orbit to supply the ethmodial air sinuses and nasal cavity. They then enter the anterior cranial fossa through the cribriforme plate of
the ethmoid bone and supply dura matter. (d) The medial palpebral branches supply the eyelids. (e) The dorsal nasal branch supplies the upper part
of the nose.

Anterior Cerebral Artery

It arisen from the internal carotid artery below the anterior perforated substance, lateral to the optic chiasma. From here it runs forwards and medially
crossing above the optic nerve to reach the longitudinal fissure separating the two cerebral hemispheres. Here the arteries of the two sides lie close
together and are united to each other by the anterior communicating artery. The artery now turns sharply to reach the genu of the corpus callosum. It
winds round the front of the genu and then runs backwards just above the body of the corpus callosum, ending near its posterior part. The main artery
supplying the medial surface is the anterior cerebral – frontal, parietal, partly of the occipital lobes, also olfactory balbs and olfactory tracts, corpus
striatum. It gives rise to two sets of branches – cortical and central. The cortical branches ramify on the surface of the cerebral hemisphere and supply
the cortex. The central (or perforating) branches pass deep into the substance of the cerebral hemisphere to supply structures within it.
Middle Cerebral Artery
After its origin from the internal carotid artery the middle cerebral artery runs laterally in the depth of the stem of the lateral sulcus. It curves on to the
superolateral surface and runs backwards in the depth of the posterior ramus of the lateral sulcus. The greater part of the superolateral surface is
supplied by the middle cerebral artery. It is divided in to the cortical and central branches.
Posterior Communicating Artery
The artery runs backwards and anastomoses with the posterior cerebral artery, helping to complete the circulus arteriosus.
The Choroid Plexuses
The choroid plexuses of the lateral and third ventricles are supplied by the anterior chorodial artery (branch of internal carotid) and the posterior
choroidal artery (branch of the posterior cerebral artery).

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 SUBCLAVIAN ARTERY
This is the principal artery of the upper limb. It also supplies a considerable part of the neck and brain through its branches. On the right side it is branch
of the brachiocephalic trunk. It arises posterior to the sternoclavicular joint. On the left side it is a branch of the arch of the aorta. It ascends and enters the
neck posterior to the left sternoclavicular joint. Both arteries pursue a similar course in the neck.

Course
1. Each artery arches laterally from the sternoclavicular joint to the outer border of the first rib where it ends by becoming continuous with the axillary
artery.
2. The scalenus anterior muscle crosses the artery anteriorly and divides it into three parts. The first part is medial, the second part posterior, and the
third part lateral to the scalenus anterior.

Branches
The subclavian artery usually gives off five branches:
1. Vertebral artery.
2. Internal thoracic artery
3. Thyrocervical trunk, which divides into three branches: (a) inferior thyroid; (b) suprascapular; and (c) superficial cervical arteries.
4. Costocervical trunk, which divides into two branches: (a) superior intercostal; and (b) deep cervical arteries.
5. Transverse cervical artery

VERTEBRAL ARTERY
The vertebral artery is one of the two principal arteries which supply the brain. In addition, it also supplies the spinal cord, the meninges, and the
surrounding muscles and bones. It arises from the posterosuperior aspect of the first part of the subclavian artery.
First Part of Vertebral Artery
It extends from the origin of the artery (from the subclavian artery) to the transverse process of the sixth cervical vertebra. This part of the artery runs
upwards and backwards in the triangular space between the scalenus anterior and the longus colli muscles.

Second Part of Vertebral Artery

It runs through the foramina transversaria of the upper six cervical vertebrae. Its course is vertical up to the axis vertebra. It then runs upward, and
laterally to reach the foramen transversaria of the atlas vertebra.

Third Part of Vertebral Artery

This part lies in the suboccipital triangle. Emerging from the foramen transversarium of the atlas, the artery winds medially round the posterior aspect of
the lateral mass of the atlas. It runs medially lying on the posterior arch of this bone, and enters the vertebral canal by pierce the posterior atlanto-occipital
membrane.

Fourth Part of Vertebral Artery

1. It extends from the posterior atlanto-occipital membrane to the lower border of the pons.
2. In the vertebral canal it pierces the dura and the arachnoid, and ascends in front of the roots of the hypoglossal nerve. As it ascends it gradually
inclines medially to reach the front of the medulla. At the lower border of the pons it unites with its fellow of the opposite side to form the basilar artery.
Branches of Vertebral Artery
A. Cervical branches
1. Spinal branches enter the vertebral canal through the intervertebral foramina, and supply the spinal cord, the meninges and the vertebrae.
2. Muscular branches arise from the third part and supply the suboccipital muscles.
B. Cranial branches
1. Meningeal branches arise near the foramen magnum and supply bone and meninges of the posterior cranial fossa.
2. The posterior spinal artery is usually a branch from the posterior inferior cerebellar artery, though it may arise from the vertebral artery at the
side of the medulla. It descends on the posterolateral aspect of the spinal cord. It is reinforced at lower levels by spinal branches of other arteries.
It supplies the posterior one third of the spinal cord.
3. The anterior spinal artery arises near the termination of the vertebral artery. The arteries of the two sides unite (at the level of the lower end of
the olive) to form a single anterior spinal artery. It descends in the anterior median fissure of the spinal cord. It is reinforced at lower levels by
spinal branches of other arteries. It supplies the anterior two thirds of the spinal cord. It also supplies part of the medulla.
4. The posterior inferior cerebellar artery is the largest branch of the vertebral artery. It arises near the lower end of the olive. The artery first runs
backwards and then upwards behind the 9th and 10th cranial nerves to reach the lower border of the pons. It then runs downwards along the
inferolateral boundary of the fourth ventricle, and finally laterally into the vallecula of the cerebellum. It supplies (a) a wedge-shaped area on the
posterolateral aspect of the medulla; (b) the lower part of the pons; and (c) the cerebellum.
5. Medullary arteries are given off to the medulla.

Basilar Artery and its Branches

The basilar artery is formed by the union of the right and left vertebral arteries, at the lower border of the pons. It ascends in the midline, ventral to the
pons, and ends at its upper border by dividing into the right and left posterior cerebral arteries. It gives off the following branches:
- superior cerebellar artery to the upper part of the cerebellum
- pontine artery to the pons
- labyrinthine artery to the internal ear, it passes through the internal acustic meatus
- anterior inferior cerebellar artery to the lower part of the cerebellum
- mesencephalic artery to the midbrain

POSTERIOR CEREBRAL ARTERY

The posterior cerebral artery is formed by bifurcation of the basilar artery and goes lateral and lies above the tentotium carebelli. Then the artery passes to the lateral surface of the
temporal and occipital lobes of the brain. The central branches go to the basal nuclei, choroidal plexus of the 3 rd ventricle and penetrate into the brain through the posterior perforate
substance. The cortical branches go to the cerebral cortex.
The posterior communicating artery comes to the posterior cerebral artery in front and as a result the arterial circle of the brain placed in the subarachnoid space becomes close.
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The posterior cerebral arteries, posterior communicating arteries and the anterior cerebral arteries united by the anterior communicating artery take part in formation of this circle.
INTERNAL THORACIC ARTERY
It arises from the inferior aspect of the first part of the subclavian artery opposite the origin of the thyrocervical trunk. The origin lies near the medial
border of the scalenus anterior. The artery runs downwards and medially in front of the cervical pleura. The artery enters the thorax by passing behind
the first costal cartilage.

Course
It descends in front of the cervical pleura. Below the first costal cartilage the artery runs vertically downwards up to its termination in the 6 th intercostal
space. The artery terminates in the sixth intercostal space by dividing into, the superior epigastric and musculophrenic arteries. The artery is accompanied
by two venae comitantes which unite at the level of the third costal cartilage to form the, internal thoracic or internal mammary vein.
Branches
1. The pericardiophrenic artery arises in the root of the neck and accompanies the phrenic nerve to reach the diaphragm. It supplies the pericardium
and the pleura.
2. The mediastinal arteries are small irregular branches that supply the fat in the mediastinum.
3. The branches to the thymus.
4. The anterior intercostal arteries are given to each of the upper six intercostal spaces.
5. The perforating branches accompany the anterior cutaneous nerves. In the female, the perforating branches in the second, third and fourth spaces
are large and supply the breast.
6. The superior epigastric artery runs downwards behind the seventh costal cartilage and enters die rectus sheath by passing between the sternal and
costal slips of the diaphragm.
7. The musculophrenic artery runs downwards and laterally behind the seventh, eighth, and ninth costal cartilages. It gives two anterior intercostal
branches to each of these three spaces. It perforates the diaphragm near the 9th costal cartilage and terminates by anastomosing with their arteries
on the undersurface of the diaphragm.
Note that through its various branches the internal thoracic artery supplies the anterior thoracic and abdominal walls from the clavicle to the umbilicus.

THYROCERVICAL TRUNK
This is a short, wide vessel which arises from the front of the first part of the subclavian artery, close to the medial border of the scalenus anterior, and
between the phrenic and vagus nerves. It almost immediately divides into the inferior thyroid, suprascapular and superficial cervical arteries.

The inferior thyroid artery is described with the thyroid gland. In addition to glandular branches (to the thyroid) it gives: (a) the ascending cervical artery
which runs upwards in front of the transverse processes of cervical vertebrae; (b) the inferior laryngeal artery which accompanies the recurrent laryngeal
nerve, and enters the larynx deep to the lower border of the inferior constrictor; and (c) other branches which supply the pharynx, the trachea, the
esophagus and surrounding muscles.

The suprascapular artery runs laterally and downwards, and crosses the scalenus anterior and the phrenic nerve. It lies behind the internal jugular vein
and the sternomastoid. It then erases the trunks of the brachial plexus and runs in the posterior triangle, behind and parallel with the clavicle, to reach the
superior border of the scapula. It crosses above the suprascapular ligament and takes part in the anastomosis around the scapula. In addition to branches to
surrounding muscles, the artery also supplies the clavicle, the scapula, and the shoulder and acromioclavicular joints.

The superficial cervical artery runs laterally above the suprascapular artery. It crosses the scalenus anterior and the phrenic nerve passing behind the
internal jugular vein and the sternomastoid. It then crosses the brachial plexus and the floor of the posterior triangle, and passes deep to the trapezius.

COSTOCERVICAL TRUNK
In arises from the posterior surface of the second part of the subclavian artery. It arches backwards over the cervical pleura, and divides into the superior
intercostal and deep cervical arteries at the neck of the first rib.
The superior intercostal artery descends in front of the neck of the first rib, and divides into the first and second posterior intercostal arteries.
The deep cervical artery is analogous to the posterior branch of a posterior intercostal artery. It passes backwards between the transverse process of the
7th cervical vertebra and the neck of the first rib. It then ascends between the semipinalis capitis and cervicis up to the axis vertebra. It anastomoses with
the occipital and vertebral arteries.

TRANSVERSE CERVICAL ARTERY

It arises from the third (or sometimes the second) part of the subclavian artery. It passes laterally and backwards through the brachial plexus, crosses the
scalenus medius, passes deep to the levator scapulae, and takes part in the anastomoses around the scapula. Its divided in two branches – superficial
branch to the muscles of the neck and dorsal scapular artery to the muscles of the back.

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 INTERNAL JUGULAR VEIN
It is a direct continuation of the sigmoid sinus. It begins at the jugular foramen, and ends behind the sternal end of the clavicle by joining the subclavian
vein to form the brachiocephalic vein. The origin is marked by a dilatation, the superior bulb which lies in the jugular fossa of the temporal bone, beneath
the floor of the middle ear cavity. The termination of the vein is marked by the inferior bulb which lies beneath the lesser supraclavicular fossa.

Tributaries
(1) Inferior petrosal sinus; (2) common facial vein; (3) lingual vein; (4) pharyngeal veins; (5) superior thyroid vein; (6) middle thyroid vein; and (7)
occipital vein. In the middle of the neck the internal jugular vein may communicate with the external jugular.
The retromandibular vein passes through the parotid salivary gland in front of the auricle. It drains the superficial temporal vein and pterygoid venous
plexus, which is situated on the both side of the lateral pterygoid muscle and borders with the maxillary artery.

VENOUS SINUSES OF DURA MATER

These are venous spaces the walls of which are formed by duramater. They have an inner lining of endothelium. There is no muscle in their walls. They
have no valves.
Venous sinuses receive venous blood from the brain, the meninges, and bones of the skull. Cerebrospinal fluid is poured into some of them.
Cranial venous sinuses communicate with veins outside the skull through emissary veins. These communications help to keep the pressure of blood in the
sinuses constant.
There are about 15 venous sinuses, of which some are paired and others are unpaired.

CAVERNOUS SINUSES
Each cavernous sinus (right or left) is a large venous space situated in the middle cranial fossa, on either side of the body of the sphenoid bone.

Tributaries (incoming channels)

A. From the orbit: (a) The superior ophthalmic vein, (b) A branch of the inferior ophthalmic vein (sometimes the vein itself), (c) The central vein of the
retina may drain either into the superior ophthalmic vein or into the cavernous sinus.
B. From the Brain: (a) Superficial middle cerebral vein; and (b) inferior cerebral veins from the temporal lobe.
C. From the meninges: (c) Sphenoparietal sinus; and (b) the frontal trunk of the middle meningeal vein may drain either into the pterygoid plexus
(through the foramen ovale) or into the sphenoparietal or cavernous sinus.

SUPERIOR SAGITTAL SINUS

This sinus occupies the upper convex, attached margin of the falx cerebri. It begins anteriorly at the crista galli by the union of tiny meningeal veins. Here
it communicates with the veins of the frontal sinus, and occasionally with the the veins of the nose (through the foramen caecum). As the sinus runs
upwards and backwards, it becomes progressively larger in size. It is triangular on cross section. It ends near the internal occipital protuberance by
turning to one side, usually the right, and becomes continuous with the right transverse sinus. Sometimes the superior sagittal sinus becomes continuous
with the left transverse sinus. It generally communicates with the opposite sinus. The junction of all these sinuses is called the confluence of sinuses.

Tributaries
The superior sagittal sinus receives the following, (a) Superior cerebral veins, (b) Parietal emissary veins, (c) Venous lacunae, usually 3 on each side
which first, receive the diploic and meningeal veins, and then open into the sinus, (d) Occasionally, a vein from the nose opens.

INFERIOR SAGITTAL SINUS

This small channel lies in the posterior two-thirds of the lower, concave free margin of the falx cerebri. It ends by joining the great cerebral vein to form
the straight sinus.

STRAIGHT SINUS
It lies in the median plane within the junction of the falx cerebri and the tentorium cerebelli. It is formed anteriorly by the union of the inferior sagittal
sinus with the great cerebral vein, and ends at the internal occipital protuberance by continuing as the transverse sinus (usually left). In addition to the
veins forming it, it also receives a few of the superior cerebellar veins.

TRANSVERSE SINUSES
These are large sinuses (right sinus usually larger than the left) situated in the posterior part of the attached margin of the tentorium cerebelli. The right
transverse sinus is usually a continuation of the superior sagittal sinus, and the left sinus a continuation of the straight sinus. Each sinus extends from the
internal occipital protuberance to the posteroinferior angle of the parietal bone where it bends downwards and becomes the sigmoid sinus.
Its tributaries are: (a) the superior petrosal sinus, (b) the inferior cerebral veins, (c) the inferior cerebellar veins, (d) the diploic (posterior temporal) vein.

SIGMOID SINUSES
Each sinus (right or left) is the direct continuation of the transverse sinus. It is S-shaped: hence the name. It extends from the posteroinferior angle of the
parietal bone to the posterior part of the jugular foramen where it becomes the superior bulb of the internal jugular vein. It grooves the mastoid part of the
temporal bone, where it is separated anteriorly from the mastoid antrum and mastoid air cells by only a thin plate of bone. Its tributaries are: (a) the
mastoid and condylar emissary veins; (b) cerebellar veins; and (c) the internal auditory vein.
OTHER SINUSES
The occipital sinus is small, and lies in the attached margin of the flax cerebelli. It begins near the foramen magnum and ends in the confluence of
sinuses.
The sphenoparietal sinuses (right and left) lie along the posterior free margin of the lesser wing of the sphenoid bone, and drain into the anterior part of
the cavernous sinus. Each sinus may receive the frontal trunk of the middle meningeal vein.
The superior petrosal sinuses lie in the anterior part of the attached margin of the tentorium cerebelli along the upper border of the petrous temporal
bone. The sinus crosses the trigeminal nerve. It drains the cavernous sinus into the transverse sinus. It receives some inferior cerebral, cerebellar and
tympanic veins.
The inferior petrosal sinuses (right and left) lie in the corresponding petrooccipital fissure, and drain the cavernous sinus into the internal jugular vein
(superior bulb). They receive: (a) labyrinthine veins (through the cochlear canaliculus and the aqueduct of the vestibule): and (b) veins from the medulla,
the pons and the cerebellum.
The basilar plexus of veins lies over the clivus of the skull. It connects the two inferior petrosal sinuses and communicates with the internal vertebral
venous plexus.

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DIPLOIC VEINS
The diploic vein drains bones of the skull. The frontal diploic vein is opened into the superior sagittal sinus. The anterior temporal diploic vein falls into
the sphenoparietal sinuses, and the posterior temporal diploic vein falls into the mastoid emissary vein. The occipital diploic vein is inconstant, it is
opened into the transverse sinus.

EMISSARY VEINS
The emissary veins are connects the superficial veins of the head and the dura matter sinuses. The mastoid emissary vein is s emissary vein is situated in
the mastoid canaliculi, it connects the transverse sinus with the posterior auricular vein. The conylar emissary vein passes through the condylar canal of
the occipital bone and connects the sigmoid sinus with the occipital vein. The parietal emissary vein passes in the parietal foramen and connects the
superior sagittal sinus with the superficial temporal vein.

EXTERNAL JUGULAR VEIN

The external jugular vein originates from the two tributaries, the anterior tributary is an anastomosis with the retromandibular vein; the posterior
tributary is the posterior auricular vein. The external jugular vein goes downward, crosses the posterior margin of the sternocleidomastoid muscle,
passing deeper a little bit higher than the clavicle. Under the inferior belly of the omohyoid muscle it falls into the subclavian or internal jugular vein.

ANTERIOR JUGULAR VEIN

The anterior external jugular arises from small veins of the anterior region of the neck. It goes to the suprasternal space while forming a shunt with vein
of the same name on the opposite sides. Thus the jugular venous arch is formed. It terminates by falling into the external jugular vein or brachiocephalic
vein.

SUBCLAVIAN VEIN
It is a continuatian of the axillary vein. It begins at the outer border of the first rib, and ends at the medial border of the scalenus anterior by joining the
internal jugular vein to from the brachiocephalic vein.
It lies: (a) in front of the subclavian artery, the scalenus anterior and the right phrenic nerve: (b) behind the clavicle and the subclavius; and (c) above the
first rib and pleura.
It tributaries are:
A. (a) the external jugular vein; (b) the dorsal scapular vein (c) the thoracic duct on the left side; and (d) the right lymphatic duct on the right side.
B. Sometimes it may also receive (a) the anterior jugular vein; and (b) a small branch from the cephalic vein which crosses the clavicle to reach the
subclavian vein.

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 DESCENDING THORACIC AORTA
Descending thoracic aorta is the continuation of the arch of the aorta. It lies in the posterior mediastinum.

Course
1. It begins on the left side of the lower border of the body of the fourth thoracic vertebra.
2. It descends with an inclination to the right and terminates at the lower border of the twelfth thoracic vertebra.
3. On the left are the mediastinal pleura and the lung.
4. On the right are the esophagus in its upper part, right mediastinal pleura and the lung on its lower part.
5. In front are: (a) the root of the left lung, (b) the esophagus which was to its right opposite Th5-7 vertebrae, is in front and passing to the left side
opposite Th8-10 vertebrae, (d) the diaphragm, at the level of the Th11-12 vertebrae.

Branches
1. Nine posterior intercostal arteries on each side from the third to eleventh intercostal spaces. Each artery gives rise to a dorsal branch, extending to
the spinal cord - spinal branches, which pass through the intervertebral foramens and others branches go to the skin and muscles of the back. The
intercostal artery passes along the costal groove between external and internal intercostal muscles, and its ends form anastomoses with the anterior
intercostals arteries (from the internal thoracic artery). The posterior intercostal arteries also provide branches to the ribs, skin and muscles, in female to
the mammary gland. The lower six posterior intercostal arteries are supplied the muscles and skin of the anterior abdominal wall.
2. The subcostal artery on each side.
3. The bronchial arteries go the lungs.
4. Esophageal branches, supplying the middle one-third of the esophagus.
5. Pericardial branches, to the posterior surface of the pericardium.
6. Mediastinal branches, to lymph nodes and fat tissue of the posterior mediastinum.
7. Superior phrenic arteries to the posterior part of the superior surface of the diaphragm. Branches of these arteries anastomose with those of the
musculophrenic and pericardiophrenic arteries.

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 SUPERIOR VENA CAVA

Superior vena cava is a large venous channel which collects blood from the upper half of the body and drains it into the right atrium. It is formed by the
union of the right and left brachiocephalic or innominate veins behind the lower border of the first right costal cartilage close to the sternum. Each
brachiocephalic vein is formed behind the corresponding sternoclavicular joint by the union of the internal jugular and subclavian veins
The superior vena cava is about 7 cm long. It begins behind the lower border of the sternal end of the first right costal cartilage, pierces the pericardium
opposite the second right costal cartilage, and terminates by opening into the upper part of the right atrium behind the third right costal cartilage. It has no
valves.

Tributaries
1. The azygos vein arches over the root of the right lung and opens into the superior vena cava at the level of the second costal cartilage, just before the
latter enters the pericardium.
2. Several small mediastinal and pericardial veins drain into the vena cava.
Brachiocephalic Veins
The right brachiocephalic vein is formed at the root of the neck by the union of the right subclavian and the right internal jugular veins. The left
brachiocephalic vein has a similar origin. It passes obliquely downward and to the right behind the manubrium sterni and front of the large branches of the
aortic arch. It joins the right brachiocephalic vein to form the superior vena cava.

Tributaries
1. Inferior thyroid veins (1-3), which are drain venous blood from the impar thyroid veinous plexus.
2. Inferior laryngeal veins.
3. Vertebral veins.
4. Deep cervical veins.
5. Internal thoracic veins.
6. Thymic and pericardial veins.

THE AZYGOS VEIN

The azygos vein drains the thoracic wall and the upper lumbar region. It forms an important channel connecting the superior and inferior venae cavae.
The term 'azygos' means unpaired. The vein occupies the upper part of the posterior abdominal wall and the posterior mediastinum.

Formation
The azygos vein is formed as continuation of the right ascending lumbar veins. It lies to the right of the lumbar vertebrae. Its lower end communicates
with the lumbar veins and inferior vena cava.

Course
1. The azygos vein enters the thorax by passing through the lumbar part of the diaphragm.
2. It lies between right sympathetic trunk and thoracic duct.
3. The azygos vein then ascends up to fourth thoracic vertebra where it arches forwards over the root of the right lung and ends by joining the posterior
aspect of the superior vena cava Just before the latter pierces the pericardium.

Tributaries
1. Right superior intercostal vein formed by union of the second, third and fourth posterior intercostal veins.
2. Fifth to eleventh right posterior intercostal veins.
3. Hemiazygos vein at the level of eight thoracic vertebra T8.
4. Accessory hemiazygos vein at the level of eight thoracic vertebra.
5. Right bronchial vein, near the terminal end of the azygos vein.
6. Several esophageal, mediastinal, pericardial veins.

HEMIAZYGOS VEIN
Hemiazygos vein is formed as continuation of the left ascending lumbar vein.

Course
Hemiazygos vein pierces the left crus of the diaphragm, ascends on the left side of the vertebra overlapped by the aorta. At the level of eighth thoracic
vertebra, it turns to the right, passes behind the esophagus and the thoracic duct, and joins the azygos vein.

Tributaries
(1) Left ascending lumbar vein, (2) left subcostal vein, and (3) ninth to eleventh left posterior intercostal veins.

ACCESSORY HEMIAZYGOS VEIN

Accessory hemiazygos vein begins at the medial end of the fourth or fifth intercostal space, and descends on the left side of the vertebral column. At the
level of eighth thoracic vertebra it turns to the right, passes behind the aorta and the thoracic duct, and joins the azygos vein.
Sometimes the hemiazygos and accessory hemiazygos veins join together to form a common trunk which opens into the azygos vein.
Tributaries
(1) Fifth to eighth left posterior intercostal veins, and (2) sometimes the left bronchial veins.

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 DESCENDING ABDOMINAL AORTA
The abdominal aorta begins in the midline at the aortic opening of the diaphragm, opposite the lower border of vertebra T12. It runs downwards and
slightly to the left in front of the lumbar vertebrae, and ends in front of the lower part of the body of vertebra L4. about 1.25 cm to the left of the median
plane, by dividing into the right and left common iliac arteries.

Branches
The branches of the abdominal aorta are classified as given below.
Ventral branches, which develop from ventral splanchnic, or vitelline arteries and supply the gut.
These are as follows:
1. Coeliac trunk.
2. Superior mesenteric artery.
3. Inferior mesenteric artery.
Lateral branches, which develop from the lateral splanchnic or mesonephric arteries and supply the viscera derived from the intermediate mesoderm.
These are the right and left :
1. Inferior phrenic arteries
2. Middle suprarenal arteries
3. Renal arteries
4. Testicular or ovarian arteries
Dorsal branches, represent the somatic intersegmental arteries and are distributed to the body wall. These are the:
1. Lumbar arteries—four pairs.
2. Median sacral artery—unpaired.
Terminal branches are a pair of common iliac arteries. They supply the pelvis and lower limbs.
Inferior phrenic arteries arise from the aorta just above the coeliac trunk. Each artery runs upwards and laterally on the corresponding crus of the
diaphragm, medial to the suprarenal gland. The right artery passes behind the inferior vena cava and the left behind the oesophagus. Each artery gives off
two to three superior suprarenal arteries, and is then distributed to the diaphragm.

Middle suprarenal arteries arise at the level of the superior mesenteric artery. Each passes laterally and slightly upwards over the corresponding crus of
the diaphragm, close to the coeliac ganglion. The right artery passes behind the inferior vena cava. The left artery runs with the splenic artery above the
pancreas.
Renal arteries are large arteries which arise from the abdominal aorta just below the level of origin of the superior mesenteric artery. The right renal
artery passes laterally behind the inferior vena cava and the head of the pancreas to reach the hilum of the right kidne y. The left renal artery runs behind
the left renal vein, the splenic vein, the body of the pancreas, and often the duodenojejunal flexure. Each artery gives off the inferior suprarenal and
ureteral branches, and is then distributed to the kidney.
Gonadal arteries are small and arise from the front of the aorta a little below the origin of the renal arteries. Each artery runs downwards and slightly
laterally on the psoas major. On the right side the artery crosses in front of the inferior vena cava, the ureter and the genitofemoral nerve. It passes deep to
the ileum. On the left side the artery crosses in front of the ureter and the genitofemoral nerve and passes deep to the colon.
The testicular artery joins the spermatic cord at the deep inguinal ring, and traverses the inguinal canal. Within the spinal cord, it lies anterior to the
ductus deferens. At the upper pole of the testis, it breaks up into branches which supply the testis and the epididymis.
The ovarian artery crosses the external iliac vessels at the pelvic brim to enter the suspensory or infundibulopelvic ligament of the ovary. It thus enters
the broad ligament and runs below the uterine tube to reach the ovary through the mesovarium. The artery gives a branch which continues medially to
anastomose with the uterine artery, and supplies the ovary, the uterine tube and to the pelvic part of the ureter.
Four pairs of lumbar arteries arise from the aorta opposite the bodies of the upper four lumbar vertebrae. The lumbar arteries end in small branches
between the transversus and internal oblique muscles and supplies the skin and the muscles of the anterior abdominal wall.

Median sacral artery represents the continuation of the primitive dorsal aorta. It arises from the back of the aorta just above the bifurcation of the latter,
and runs downwards to end In front of the coccyx. It supplies the rectum, and anastomoses with the iliolumbar and lateral sacral arteries.

THE COELIAC TRUNK

The coeliac trunk is the artery of the foregut. It supplies all derivatives of the foregut that lie in the abdomen namely: (1) The lower end of the
oesophagus, the stomach and upper part of the duodenum up to the opening of the common bile duct; (2) the liver; (3) the spleen; and (4) the greater part
of the pancreas.

Origin and Length

The coeliac trunk arises from the front of the abdominal aorta just below the aortic opening of the diaphragm at the level of the disc between vertebrae
thoracic twelve and first lumbar. The trunk is only about 1.25 cm long. It ends by dividing into its three terminal branches, namely the left gastric, hepatic
and splenic arteries.

Branches
The left gastric artery is the smallest of the three branches of the coeliac trunk. It runs upwards to the left behind the lesser sac to reach the cardiac end of
the stomach where it turns forwards and enters the lesser omentum to run downwards along the lesser curvature of the stomach. It ends by anastomosing
with the right gastric artery. It gives off (a) two or three esophageal branches at the cardiac end of the stomach; and (b) numerous gastric branches along
the lesser curvature of the stomach.

The common hepatic artery runs downwards, forwards and to the right, behind the lesser sac to reach the upper border of the duodenum. Here it enters
the lesser omentum. It then run upwards in the right free margin of the lesser omentum. In front of the portal vein, and to the left of the common bile duct.
Reaching the porta hepatis it terminates by dividing into right and left hepatic branches.
Branches: (a) The gastroduodenal artery is a large branch which arises at the upper border of the first part of the duodenum. The part of the hepatic artery
till the origin of the gastroduodenal artery is called the common hepatic artery. The part distal to it is the proper hepatic artery. The gastroduodenal
artery runs downwards behind the first part of the duodenum and divides at its lower border into the right gastroepiploic and superior pancreaticoduo denal
arteries. The right gastroepiploic artery enters the greater omentum, follows the greater curvature of the stomach, and anastomoses with the left
gastroepiploic artery. The superior pancreaticoduodenal artery (often represented by two arteries anterior and posterior) runs downwards in the
pancreaticoduodenal groove, and ends by anastomosing with the inferior pancreaticoduodenal artery, a branch of the superior mesenteric, (b) The right
gastric artery is a small branch which arises from the proper hepatic artery close to the gastroduodenal artery. It runs to the left along the lesser curvature
35
and ends by anastomosing with the left gastric artery, (c) The cystic artery is usually a branch of the right hepatic artery. It passes behind the common
hepatic and cystic ducts to reach the upper surface of the neck of the gallbladder where it divides Into superficial and deep branches for the inferior and
superior surfaces of the gall bladder, respectively.

The splenic artery is the largest branch of the celiac trunk. It runs horizontally to the left along the upper border of the pancreas behind the lesser sac. It
crosses the left suprarenal gland and the upper part of the left kidney to enter the lienorenal ligament. It gives off the following branches, (a) numerous
pancreatic branches which supply the body and tail of the pancreas. Five to seven short gastric arteries arise from the terminal part of the splenic artery, run
in the gastrosplenlc ligament, and supply the fundus of the stomach, (c) The left gastroepiploic artery also arises from the terminal part of the splenic artery,
runs downwards in the greater omentum, follows the greater curvature of the stomach, and ends by anastomosing with the right gastroepiploic artery. As
the name suggests the gastroepiploic arteries supply both the stomach and greater omentum.

SUPERIOR MESENTERIC ARTERY

The superior mesenteric artery is the artery of the midgut. It supplies all derivatives of the midgut, namely (1) the lower part of the duodenum below the
opening of the bile duct. (2) the jejunum. (3) the ileum. (4) the appendix, (5) the caecum, (6) the ascending colon. (7) the right two-thirds of the transverse
colon, and (8) the lower half of the head of the pancreas.

Origin and Course

The superior mesenteric artery arises from the front of the abdominal aorta, behind the body of the pancreas, at the level of vertebra LI, one centimeter below
the coeliac trunk. It runs downwards and to the right, forming a curve with its convexity towards the left.
At its origin it lies first behind the body of the pancreas and then in front of the uncinate process. Next it crosses the third part of the duodenum, enters the
root of mesentery, and runs between its two layers. It terminates In the right iliac fossa by anastomosing with a branch of the ileocolic artery.

Branches
The superior mesenteric artery gives off five sets of branches both from its right and left sides. Those arising from its right side are (1) inferior
pancreaticoduodenal, (2) middle colic, (3) right colic, and (4) ileocolic. Those arising from its left side are 12-15 jejunal and ileal branches.

Inferior pancreaticoduodenal artery arises from the superior mesenteric artery or from its first jejunal branch at the upper border of the third part of the
duodenum. The artery soon divides into anterior and posterior branches which run in the pancreaticoduodenal groove, supply the head of the pancreas and
the duodenum, and ends by anastomosing with the superior pancreaticoduodenal artery.

Middle colic artery arises from the right side of the superior mesenteric artery just below the pancreas. It runs downwards and forwards in the transverse
mesocolon. It divides into a right branch, which anastomoses with the right colic artery, and a left branch, which anastomoses with the left colic artery.
Further branches arising from these, form arcades and supply the transverse colon.

Right colic artery arises near the middle of the concavity of the superior mesenteric artery. It passes to die right behind the peritoneum, and at the upper part
of the ascending colon it divides into a descending branch, which anastomoses with the ileocolic artery, and an ascending branch, which anastomoses
with the middle colic artery. The branches form arch, from the convexity of which smaller branches are distributed to the upper two-thirds of the
ascending colon and the right flexure of the colon.

Ileocolic artery arises from the right side of the superior mesenteric artery. It runs downwards and to the right, and divides into superior and inferior
branches. The inferior branch of the ileocolic artery gives off (a) an ascending colic branch to the ascending colon, (b) anterior and posterior caecal
branches to the caecum, (c) an appendicular branch which passes behind the ileum and reaches the appendix through its mesentery and, (d) the ileal
branch to the terminal portion of the ileum.

Jejunal and ileal branches are about 12 to 15 in number rvnd arise from the left side of the superior mesenteric artery. They run between the two layers
of the mesentery towards the gut. They anastomose with one another to form arterial arcades which give off straight branches or vasa recta to the gut.
These branches supply the jejunum and ileum, except the terminal part of the ileum which is supplied by the ileocolic artery. On passing from jejunum to
ileum, the number of arterial arcades increases from one to as many as five. The vasa recta are longer and less numerous in the jejunum than in the ileum.
These are distributed alternately to opposite surfaces of the gut, and the neighbouring vessels do not anastomose with one another.

THE INFERIOR MESENTERIC ARTERY

The inferior mesenteric artery is the artery of the hindgut. It supplies the parts of the gut that are derivatives of the hindgut and posterior part of cloaca, the
anorectal canal, namely (1) the left one-third of the transverse colon, (2) the descending colon, (3) the sigmoid colon, (4) the rectum, and (5) the upper
part of the anal canal, above the anal valves.
Origin
The inferior mesenteric artery arises from of the abdominal aorta behind the third part of the duodenum, at the level of third lumbar vertebra, and 3 to 4 cm
above the bifurcation of the aorta
Course
It runs downward and to the left, behind the peritoneum crosses the common iliac artery medial to the left ureter, and continues in the sigmoid
mesocolon as the superior rectal artery.

Branches
The inferior mesenteric artery gives off the left colic, sigmoid and superior rectal branches.
Left colic artery is the first branch of the inferior mesenteric artery. It runs upwards and to the left behind the peritoneum of the posterior wall of the left
infracolic compartment and after a variable cours divides into an ascending and a descending branch. The ascending branch enters the transverse
mesocolon and anastomoses with the middle colic artery. The descending branch anastomoses with the highest sigmoid artery. They form a part of the
marginal artery from which branches are distributed to the left one-third of the transverse colon and to the descending colon.
Sigmoid arteries are 2 to 4 in number. They pass downwards and to the left, and anastomose with each other to form the lower part of the marginal artery.
The uppermost branch anastomoses with the descending branch of the left colic artery, whereas the lowest sigmoid artery sends a branch to anastomose
with the superior rectal artery. They supply the descending colon in the iliac fossa and the sigmoid colon.
Superior rectal artery is the continuation of the inferior mesenteric artery beyond the root of the sigmoid mesocolon, i.e. over the left common iliac
vessels. It descends in the sigmoid mesocolon to reach the rectum. Opposite third sacral vertebra it divides into right and left branches which descend one
on each side of the rectum. They pierce the muscular coat of the rectum and divide into several branches, which anastomose with one another at the level
of the anal sphincter to form loops around the lower end of the rectum. These branches communicate with the middle and inferior rectal arteries in the
submucosa of the anal canal.

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INFERIOR VENA CAVA

41
The inferior vena cava is formed by the union of the right and left common iliac veins on the right side of the body of vertebra L5. It ascends in front of
the vertebral column, on the right side of the aorta, grooves the posterior surface of the liver, pierces the central tendon of the diaphragm at the level of
vertebra T8, and opens into the lower and posterior part of the right atrium. In the abdominal cavity to the right from the inferior vena cava the right ureter
and hilum of the kidney, also sympathetic trunk lie. At the level of the fourth lumbar vertebrae the inferior vena cava is crossed by a radix mesentery. In
front surface of this vein there are duodenum, pancreas, portal vein and bile duct.

Tributaries
1. The common iliac veins formed by the union of the external and internal iliac, veins unite to form the inferior vena cava.
2. The third and fourth lumbar veins run along with the corresponding arteries and open into the posterior aspect of the inferior vena cava. The
veins of the left side cross behind the aorta to reach the vena cava.
The first and second lumbar veins may end in the third lumbar vein, the ascending lumbar vein, the azygos vein on the right side, or the hemiazygos vein
on the left side. The ascending lumbar vein is an anastomotic channel which connects the lateral sacral, iliolumbar, and the subcostal veins. It lies within
the psoas muscle, in front of the roots of the transverse processes of the lumbar vertebrae. On joining the subcostal vein it forms the azygos vein on the
right side, and the hemiazygos vein on the left side.
3. The right testicular or ovarian vein, opens into the inferior vena cava just below the entrance of the renal veins. The left gonadal vein drains into
the left renal vein. The testicular veins begins from the posterior margin of the testis, forming the pampiniform plexus. It lies in the spermatic cord, in
the inguinal canal.
4. The renal veins join the inferior vena cava just below the transpylortc plane. Each renal vein lies in front of the corresponding artery. The right
vein is shorter than the left and lies behind the second part of the duodenum. The left vein crosses in front of the aorta, and lies behind the pancreas and
the splenic vein. It receives the left suprarenal and gonadal veins.
5. The right suprarenal vein is extremely short, emerges from the hilum of the gland and soon opens.

THE PORTAL VEIN

Portal vein is a large vein which collects blood from (a) the abdominal part of the alimentary tract, (b) the gall bladder, (c) the pancreas, and (d) the spleen,
and conveys it to the liver. In the liver, the portal vein breaks up into sinusoids which are drained by the hepatic veins to the inferior vena cava.
It is called the portal vein because its main tributary, the superior mesenteric vein, begins in one set of capillaries (in the gut) and the portal vein ends in
another set of capillaries in the liver.
The portal vein is about 8 cm long. It is formed by the union of the superior mesenteric and splenic veins behind the neck of the pancreas at the level of
second lumbar vertebra. It runs upwards and a little to the right, first behind the neck of the pancreas, next behind the first part of the duodenum, and
lastly in the right free margin of the lesser omentum. The portal vein can thus be divided into infraduodenal, retroduodenal and supraduodenal parts. The
vein ends at the right end of the porta hepatis by dividing into right and left branches which enter the liver.

Branches of Portal Vein

1. The right branch is shorter and wider than the left branch. After receiving the cystic vein, it enters the right lobe of the liver.
2. The left branch is longer and narrower than the right branch. It traverses the porta hepatis from its right end to the left end, and furnishes branches to
the caudate and quadrate lobes. Just before entering the left lobe of the liver. It receives, (a) the paraumbilical veins, in the ligamentum teres from anterior
abdominal wall, and (c) the ligamentum venosum (venous duct in fetus).

Intrahepatic Course
After entering the liver, each branch divides and redivides along with the hepatic artery to end ultimately in the hepatic sinusoids, where the portal venous
blood mixes with the hepatic arterial blood.

Tributaries
Portal vein receives the following veins: (1) Splenic, (2) superior mesenteric, (3) left gastric, (4) right gastric, (5) superior pancreaticoduodenal, (6) cystic,
and (7) paraumbilical veins.
The left gastric vein accompanies the corresponding artery. At the cardiac end of the stomach it receives a few esophageal veins. The right gastric vein
accompanies the corresponding artery. It receives the prepyloric vein. The paraumbilical veins are small veins that run in the falciform ligament, along
the ligamentum teres, and establish anastomoses between the veins of the anterior abdominal wall present around the umbilicus and the portal vein.

Superior mesenteric vein is a large vein which drains blood from the small intestine, the appendix, the caecum, the acsending colon and the transverse colon. It
begins in the right iliac fossa by the union of tributaries from the ileocaecal region. It accompanies the superior mesenteric artery. The vein lies on the right side
of the artery. It terminates, behind the neck of the pancreas, by Joining the splenic vein to form the portal vein. Its tributaries are as follows: (a) Veins
corresponding to the branches of the superior mesenteric artery, (b) right gastroepiploic vein, and (c) inferior pancreaticoduodenal vein.

The inferior mesenteric vein drains blood from the rectum, the anal canal, the sigmoid colon and the descending colon. It begins as the superior rectal
vein from the upper part of the internal rectal venous plexus. In the plexus it communicates with the middle and inferior rectal veins. This vein lies lateral
to the inferior mesenteric artery. The vein ascends behind the peritoneum, passes lateral to the duodenojejunal flexure and behind the body of the
pancreas. It opens into the splenic vein, or sometimes into its junction with the superior mesenteric vein. Its tributaries correspond to the branches of the
inferior mesenteric artery.

The splenic vein drain blood from the spleen, stomach and pancreas. Its tributaries correspond to the branches of the splenic artery.

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COMMON ILIAC ARTERIES

45
These are the terminal branches of the abdominal aorta, beginning in front of vertebra L4. On each side it passes downwards and laterally and ends in
front of the sacroiliac joint, at the level of the lumbosacral intervertebral disk, by dividing into the external and internal iliac arteries.

EXTERNAL ILIAC ARTERY

External iliac artery is represented by the lower two-thirds of a line drawn from the lower end of the abdominal aorta to the mid-inguinal point.
Branches
1. The inferior epigastric artery arises from the external iliac artery near its lower end just above the inguinal ligament. It runs upwards and medially
in the extraperitoneal connective tissue, passes just medial to the deep inguinal ring, pierces the fascia transversalis at the lateral border of the rectus
abdominis and enters the rectus sheath by passing in front of the arcuate line. Within the sheath it supplies the rectus muscle and ends by
anastomosing with the superior epigastric artery, branch of the internal thoracic artery. It gives off the following branches, (a) A cremasteric branch
to the spermatic cord, or the artery of the round ligament in females; (b) a pubic branch which anastomoses with the pubic branch of the obturator
artery; (c) muscular branches to the rectus abdominis; and (d) cutaneous branches to the overlying skin.
2. The deep circumflex iliac artery is the other branch of the external iliac artery, given off from its lateral side opposite the origin of the inferior
epigastric artery. It runs laterally and upwards behind the inguinal ligament, pierces the fascia transversalis, and continues along the iliac crest, up to
its middle where it pierces the transversus abdominis to enter the interval between the transversus and the internal oblique muscles.

INTERNAL ILIAC ARTERY

The internal iliac artery begins in front of the sacroiliac joint, at the level of the intervertebral disc between the fifth lumbar vertebra and the sacrum.
Here it lies medial to the psoas major muscle. The artery runs downwards and backwards, and ends near the upper margin of the greater sciatic notch, by
dividing into anterior and posterior divisions or trunks.

Branches of Anterior Division

1. Superior Vesical Artery. The proximal 2.5 cm or so of the superior vesical artery represents the persistent part of the umbilical artery. It supplies many
branches to the upper part of the urinary bladder. One of these branches gives off the artery to the ductus deferens.

2. Obturator Artery. It runs forwards and downwards on the obturator fascia below the obturator nerve and above the obturator vein. Medially, it is
crossed by the ureter and the ductus deferens, and is covered with peritoneum. It passes through the obturator foramen to leave the pelvis and enter the
thigh. In the pelvis it gives off: (a) the pubic branch to the peritoneum on the back of the pubis, which anastomoses with the pubic branch of the inferior
epigastric artery and with its fellow of the opposite side, (b) in the obturator canal it gives acetabular branch which passes through the ligamentum of the
femoral head, and supplies the head of the femur.

3. Middle Rectal Artery. The blood goes to the rectum, and that too goes only to its muscle coats, most of its blood goes to the prostate and seminal
vesicles.

4. Inferior Vesical Artery. It usually arises with the middle rectal artery and supplies the trigone of the bladder, the prostate, the seminal vesicles, and the
lower part of the ureter. Sometimes the artery to the ductus deferens arises from the inferior vesical artery.
5. Uterine Artery. It first runs medially towards the cervix in the broad ligament of the uterus, crossing the ureter above the lateral fornix of the vagina and
2 cm latterly to the cervix. Then the artery ascends along the side of the uterus, with a tortuous course. Finally, it runs laterally towards the hilus of the
ovary, and ends by anastomosing with the ovarian artery. Apart from the uterus, the artery also gives branches to: (1) The vagina; (2) the medial two-
thirds of the uterine tube; (3) the ovary.

6. Inferior Gluteal Artery. It is the largest branch of the anterior division of the internal iliac artery. It supplies chiefly the buttock and the back of the
thigh. In the pelvis, it runs downwards in front of the sacral plexus and piriformis. Next, it pierces the parietal pelvic fascia, passes below the first sacral
nerve and then between the piriformis and the coccygeus, and enters the gluteal region through the lower part of the greater sciatic foramen. It supplies the
gluteus medius and minimus.

7. Internal Pudendal Artery. It is the smaller terminal branch of the anterior division of the internal iliac artery. It supplies the perineum and external
genitalia.

Course
In the pelvis, the artery runs downwards in front of the piriformis, the sacral plexus and the inferior gluteal artery. It leaves the pelvis by piercing the
parietal pelvic fascia and passing through the greater sciatic foramen, below the piriformis, thus entering the gluteal region.
In the gluteal region, the artery crosses the dorsal aspect of the tip of the ischial spine, under cover of the gluteus maximus. It leaves the gluteal region
by passing through the lesser sciatic foramen, and thus enters the pudendal canal.
In the pudendal canal, the artery runs downwards and forwards in the lateral wall of the ischiorectal fossa, about 4 cm above the lower margin of the
ischial tuberosity. The artery gives off the inferior rectal artery in the posterior part of the canal, and the perineal artery in the anterior part. The internal
pudendal artery continues into the deep perineal space as the artery of the penis or of the clitoris.
In the deep perineal space, the artery of the penis or clitoris which is the continuation of internal pudendal artery, runs forwards close to the side of the
pubic arch, medial to the dorsal nerve of the penis or of clitoris. The artery ends a little behind the arcuate pubic ligament by dividing into the deep and
dorsal arteries of the penis or of the clitoris.

Branches of Posterior Division

1. Iliolumbar Artery. It runs upwards in front of the sacroiliac joint and the lumbosacral trunk, and behind the obturator nerve and external lilac vessels.
Behind the psoas major, It divides Into the lumbar and iliac branches. The lumbar branch supplies the psoas, the quadratus lumborum and the erector
spinae. Its spinal branch supplies the cauda equina. The iliac branch supplies the iliac fossa and the iliacus muscle.
2. Lateral Sacral Artery. It enters the four anterior sacral foramina to supply the contents of the sacral canal. The terminations pass out through the
posterior sacral foramina and supply the muscles and skin on the back of the sacrum.

3. Superior Gluteal Artery. It enters the gluteal region through the greater sciatic foramen passing above the piriformis along with the superior gluteal
nerve. In the foramen, it divides into superficial and deep branches. It supplies the gluteus maximus.

INTERNAL ILIAC VEIN

It ascends posteromedial to the internal iliac artery, and joins the external iliac vein to form the common iliac vein at the pelvic brim, In front of the lower part of the
sacroiliac joint. Its tributaries correspond with the branches of the artery.

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Veins Arising In and Outside the Pelvic Wall:
(1) Superior gluteal is the largest tributary; (2) inferior gluteal; (3) internal pudendal; (4) obturator; and (5) lateral sacral veins and (6) iliolumbar vein.

Veins arising from the plexuses of the pelvic organs:

(1) The rectal venous plexus is drained by the unpaired superior rectal vein (into inferior mesenteric vein), paired middle and inferior rectal veins (into the internal iliac vein); (2)
the prostatic venous plexus in males anastomoses with the dorsal vein of penis and deep veins of penis: (3) the vesical venous plexus is drained by the superior and inferior
vesical veins; (4) the uterine venous plexuses are drained by the uterine veins; and (5) the vaginal venous plexuses are drained by the vaginal veins.

EXTERNAL ILIAC VEIN

The external iliac vein is paired. It is a continuation of the femoral vein. On a level of the sacroiliac joint the external iliac vein is compounded with the internal iliac vein
forming the common iliac vein. The tributaries of the external iliac vein are the inferior epigastric vein and deep circumflex iliac vein.

COMMON ILIAC VEIN

The right common iliac vein is shorter than lift one; it goes behind the artery of the same name. Into the left common iliac vein median sacral vein drains. The anterior
sacral plexus is formed from anastomoses the median sacral vein with the lateral sacral veins.

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 THE LYMPHATIC SYSTEM
The lymphatic system is a part of the vascular system. It develops in close relationship w i t h the venous system and shares with it similar structural
features (the valves, the direction of the flow of lymph from the tissues to the heart).
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The lymphatic system consists of the following parts:
(1) the closed end of the lymphatic bed begins with a meshwork of lymph capillaries piercing the tissue of the organs;
(2) the lymph capillaries develop into intraorganic plexuses of small lymphatic vessels possessing valves;
(3) these vessels emerge from the organs in the form of still larger, extraorganic, abducent lymphatic vessels interrupted by lymph nodes;
(4) the large lymphatic vessels drain into collectors and, further, into main lymph trunks of the body—right and left (thoracic.) lymphatic
ducts, w h i c h , in their turn, drain into the big veins of the neck.

The thoracic duct is the largest lymphatic vessels in the body. It drains lymph from lower limbs, abdominal cavity, left side of thorax, left upper limb and
left side of head and neck. The thoracic duct extends from the upper part of abdomen to the lower part of the neck, crossing the posterior and superior part
of the mediastinum. It is about 45 cm (18 inch) long. It has a beaded appearance because of the presence of many valves in its lumen. The thoracic duct
begins as continuations of the cisterna chyli near the lower border of Th12 vertebra and enters the thorax through the aortic opening of the diaphragm. It
ascends in the posterior mediastium between the aorta and the azygos vein. Next it crosses obliquely to the left, posterior to and then along the left side of
the esophagus near Th5 vertebra. Finally it passes posterior to the left subclavian artery, enters the neck at level of the transverse process of C 7 vertebra
and ends by opening into the angle of junction between the left subclavian and left internal jugular vein.
In the thorax, the thoracic duct receives lymph vessels from the posterior mediastinal nodes and from intercostal nodes. At the root of the neck, efferent
vessels of the nodes in the neck from the left jugular trunk, and those from nodes in the axilla form the left subclavian trunk. These trunks end in the
thoracic duct. The left bronchomediastinal trunk drains lymph from the left half of the thorax and ends in the thorax duct.

On the right side there is right lymphatic duct into which right bronchomediastinal trunk, right jugular and right subclavian trunks drain. The right
lymphatic trunk ends at the junction of right subclavian and right internal jugular veins.

Lymphatics of the thorax

Thoracic lymph nodes are separated into two types: parietal lymph nodes located in the thoracic wall, and visceral lymph nodes, which are associated with
the internal organs. The parietal nodes of the thorax are the parasternal, phrenic, and intercostal. The lymph drainage of the anterior chest wall passes to
the anterior axillary lymph nodes. Lymph drainage of the posterior chest wall passes to the posterior axillary nodes. The lymph drainage of the
intercostals spaces passes forward to the parasternale lymph nodes, situated along the internal thoracic artery, posteiorly to the intercostals lymph nodes
and paraaortic nodes in the posterior mediastium. The visceral nodes drain the lungs, pleurae, and mediastinum. The nodes in the roots and hili of the
lungs are arranged in several groups: pulmonary along the large bronchi; bronchopulmonary mainly at the hilus, and tracheobronchial (right superior
and left superior, and also inferior) near the bifurcation of the trachea. The tracheobronchial nodes drain into the paratracheal nodes: which is lied along
the lateral surface of the trachea and esophagus. Anterior mediastinal nodes are from 2 to 5 numbers, they are located along the course of the
brachiocephalic vessels and aorta and receive vessels from the thymus, pericardium, and heart. The efferents of the paratracheal and anterior mediastinal
nodes forms a bronchomediastinal trunk on each side of the trachea. There are also posterior mediastinal nodes lie along azygos system of veins and
esophagus, most of which drain directly to the thoracic duct. The phrenic nodes lie on the thoracic surface of the diaphragm and drain superior surface of
the liver and diaphragm. The efferents of the phrenic nodes drain into the posterior mediastinal and lumbar nodes.

Lymphatic vessels of the heart

- receive lymph from the myocardium and epicardium;
- follow the right coronary artery to empty into the anterior mediastinal nodes and follow the left coronary artery to empty into a tracheabronchial nodes.
Lymphatic drainage of the breast
About 75% of the lymph from the breast drains into the axillary nodes, 20% into the internal mammary nodes; and 5% into the posterior intercostal
nodes. Among the axillary nodes, the lymphatics end mostly in the anterior group (closely related to the axillary tail) and partly in the posterior and apical
groups. Lymph from the anterior and posterior groups passes to the central and lateral groups and through them to the apical group. Finally, it reaches the
supraclavicular nodes. Follows the perforating vessels through the pectoralis major muscle and the thoracic wall to enter the parasternale nodes and may
connect to lymphatics draining the opposite breast.

Lymphatics of the head and neck

A. Superficial lymph nodes of the of the head.

- lymph vessels from the face, scalp and ear drain into the occipital, retromandibular, parotid, bussal (facial), submandibular, submental and superficial
cervical nodes, which in turn drain into the deep cervical nodes including the jugulodigastric and juguloomohyoid.
B. Deep lymph nodes of the head.
- the middle ear drains into the retropharyngeal and upper deep cervical nodes. The nasal cavity and paranasal sinuses into the submandibular,
retropharyngeal and upper deep cervical; the tongue into the submental, submandibular and upper and lower cervical; the larynx into the upper and lower
deep cervical; the pharynx into the retropharyngeal and upper and lower deep cervical; and the thyroid gland into the lower deep cervical, prelaryngeal,
pretracheal, and paratracheal.
C. Superficial cervical lymph nodes.
- lie along the external jugular vein in the posterior triangle and along the anterior jugular vein in the anterior triangle, and drain into the deep cervical
nodes.
D. Deep cervical nodes.
1. Superior deep cervical nodes:
- lie along the internal jugular vein in the carotid triangle of the neck;
- receive afferent lymphatics from the back of the head and neck, tongue, palate, nasal cavity; larynx, pharynx, trachea, thyroid gland, and esophagus.
- their efferent vessels joint those of the inferior deep cervical nodes to from jugular trunk, which empties into the thoracic duct on the left and into the
junction of the internal jugular and subclavian vein on the right.
2. Inferior deep cervical nodes.
- lie on the internal jugular vein near the subclavian vein;
- recive afferent lymphatics from the anterior jugular, transverse cervical and apical axillary nodes.

Lymphatics of the upper limb

A. Lymphatics of the finger

- drain into the plexus on the dorsum and palm of hand.
B. Medial group of lymphatic vessels
- accompanies the basilic vein, passes through the cubital or supratrochlear nodes, and ascends to enter the lateral axillary nodes.
C. Lateral group of lymphatic vessels
- accompanies the cephalic vein and drains into the lateral axillary nodes and also into the deltopectoral (intraclavicular) nodes. The deltopectoral nodes
drain into the apical nodes.
D. Axillary lymph nodes
1. Central nodes
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- lie near the base of the axilla between the lateral thoracic and subscapular veins; receive lymph from the lateral, pectoral, and posterior groups of nodes,
and drain into the apical nodes.
2. Lateral nodes
- lie posteromedial to the axillary veins, receive lymph from the upper limb, and drain into the central nodes.
3. Subscapular (posterior) nodes
- lie along the subscapular vein and drain lymph from the posterior thoracic wall and the posterior aspect of the shoulder to the central nodes.
4. Pectoral nodes
- lie along the inferolateral border of the pectoralis minor muscle and drain lymph from the anterior and lateral thoracic walls, including the breast.
5. Apical nodes
- lie at the apex of the axilla medial to the axillary vein above the upper border of the pectoralis minor muscle, receive lymph from all of the other axillary
nodes (and occasionally from the breast), and drain into the subclavian trunks.

Lymphatics of the abdomen

Lymphatics in the region above the umbilicus drains into the axillary lymph nodes. Lymphatics in the region below the umbilicus drain into superficial
inguinal nodes.
On the posterior abdominal wall near the abdominal aorta lie the aortic (lumbar) nodes 3 to 50 which are divided into preaortic and lateral, paraaortic
(left and right) nodes. The preaortic nodes lie directly anterior to the abdominal aorta, and are divisible into coeliac, superior mesenteric and inferior
mesenteric groups. Their efferents form the intestinal trunk which enters the cisterna chyli. The lateral aortic nodes lie on each side of the abdominal
aorta. They receive afferents from the common iliac nodes. Their efferents form a lumbar trunk (right and left), both of which terminate in the cisterna
chyli.
A. The coeliac lymph nodes receive afferents from:
1. Hepatic lymph nodes, cystic and foramina (epiploic) lymph nodes.
2. From stomach: right and left gastric, pyloric (supra, sub and retro pyloric), right and left gastroepiploic, and from nodes around cardia.
3. Splenic lymph nodes.
4. Superior and inferior pancreatic, superior and inferior pancreatoduodenal lymph nodes.
B. The superior mesenteric nodes receive afferent from:
1. In the mesentery – juxtaintestinal group from jejunum and ileum.
2. Ileocolic, appendicular, retroceacal, preceacal, right colic, middle colic from the large intestine.
C. The inferior mesenteric nodes receive afferent from left colic, sigmoid and superior rectal lymph nodes.

Lymphatics of the pelvis

The external iliac nodes 8 to 10 lie along the external iliac vessels. They receive afferents from:
1. Inguinal lymph nodes.
2. Deeper layers of the anterior abdominal wall (inferior epigastric and circumflex iliac nodes).
3. Membranous urethra.
4. Prostate.
5. Fundus and cervix of the uterus.
6. Upper part of the vagina.
The internal iliac nodes lie along the interna iliac vessels. They receive afferents from:
1. Middle and inferior rectal lymph nodes.
2. Urinary bladder.
3. Seminal vesicles.
4. Uterus.
5. Ampule of ductus deferens.
6. Middle and lateral sacral lymph nodes.
The common iliac nodes, 4 to 6 in number lie along the common iliac artery below the bifurcation of the aorta in front of L 5 vertebra. They receive
afferents from the external and internal iliac nodes, and send their efferents to the lateral aortic nodes.

Lymphatics of the lower limb

A. Superficial lymph vessels:

- are divided into a medial group, which follows the great saphenous vein, and a lateral group, which follows the small saphenous vein.
B. Deep lymph vessels:
- consist of the anterior tibial, posterior tibial and peroneal vessels, which follow the course of the corresponding blood vessels and enter the popliteal
lymph nodes.
C. Superficial inguinal lymph nodes:
- is located subcutaneously near the saphenous femoral junction and drains the superficial thigh region;
- receives lymph from the anterolateral abdominal wall below the umbilicus, gluteal region, lower parts of the vagina and anus, and external genitalia
except the glans, and drain into the external iliac nodes.
D. Deep inguinal lymph nodes:
- lies deep to the fascia lata on the medial side of the femoral vein;
- receives lymph from deep lymph vessels (i.e., efferents of the popliteal nodes) that accompany the femoral vessels and from the glans of penis and glans
of clitoris, and drains into the external iliac nodes through the femoral canal.

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ARTERIES OF THE UPPER LIMB
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AXILLARY ARTERY
Axillary artery is the continuation of the subclavian artery. It extends from the outer border of the first rib to the lower border of the pectoralis major
muscle. It continues as the brachial artery. Its direction varies with the position of the arm.
The pectoralis minor muscle crosses it and divides it into three parts:
(l) First part, superior (proximal) to the muscle.
(2) Second part, posterior (or deep) to the muscle.
(3) Third part, inferior (distal) to the muscle.
Branches of Axillary Artery
The axillary artery gives six branches. Two branches arise from the first part, one branches from the second part, and three branches from the third part.
These are as follows:
1. Superior thoracic artery is a very small branch which may not be found during dissection. It arises from the first part of the axillary artery (near the
subclavius), but may arise from the thoracoacromial artery. It runs downwards, forwards and medially, passes between the two pectoral muscles, and
ends by supplying the muscles of the first and second intercostals spaces.
2. Thoracoacromial artery emerges at the upper border of the pectoralis minor, pierces the claviopectoral fascia, and soon divides into four terminal
branches: (a) the pectoral branch pas between the pectoral muscles, and supplies these muscles as well as the breast; (b) the deltoid branch runs in the
deltopectoral groove, along the cephalic vein; (c) the acromial branch crosses the coracoid process and ends by joining the anastomosis over the
acromion; and (d) the clavicular branch runs superomedially deep to the pectoralis major, and supplies the sternoclavicular joint and subclavius.

3. Lateral thoracic artery is a branch of the second part of the axillary artery. It emerges at, and runs along, the lower border of the pectoralis minor. In
females, the artery is large and gives off the lateral mammary branches to the breast.

4. Subscapular artery is the largest branch of the axillary artery, arising from its second part. It runs along the lower border of the subscapularis, to
terminate near the inferior angle of the scapula. It supplies the latissimus dorst and the serratus anterior. It gives off a large branch, the circumflex
scapular artery, which is larger than the continuation of the main artery. This branch passes through the triangular intermuscular space, winds round the
lateral border of the scapula deep to the teres minor, and gives a branch to the subscapular fossa (infrascapular branch), and another branch thoracodorsal
artery to the latissimus dorsi muscle.

5. Anterior circumflex humeral artery is a small branch arising from the third part of the axillary artery, at the lower border of the subscapularis. It passes
laterally in front of the intertubercular sulcus of the humerus, and anastomoses with the posterior circumflex humeral artery, to form an arterial circle
round the surgical neck of the humerus. It gives off an ascending branch which runs in the intertubercular sulcus, and supplies the head of the humerus
and shoulder joint.
6. Posterior circumflex humeral artery is much larger than the anterior artery. It arises from the third part of the axillary artery at the lower border of the
subscapularis. It runs backwards, accompanied by the axillary nerve, passes through the quadrangular, intermuscular space, and ends by anastomosing
with the anterior circumflex humeral artery round the surgical neck of the humerus. It supplies the shoulder joint, the deltoid, and the muscles bounding
the quadrangular space. It gives off a descending branch which anastomoses with the ascending branch of the profunda brachii artery.
BRACHIAL ARTERY
Brachial artery is the continuation of the axillary artery. It extends from the lower border of the pectoralis major muscle to a point in front of the elbow, at
the level of the neck of the radius, just medial to the tendon of the biceps brachii. Thus the artery begins on the medial side of the upper part of the arm,
and runs downwards and slightly laterally to end in front of the elbow. At its termination it bifurcates into the radial and ulnar arteries. It runs downwards
and laterally, from the medial side of the arm near medial border of the biceps brachi muscle to the front of the elbow.
Branches
1. Unnamed muscular branches.
2. The profunda brachii artery arises just below the teres major and accompanies the radial nerve. It pass to the posterior region of the arm and is
divided in two branches: radial collateral artery and medial collateral artery.
3. The superior ulnar collateral artery arises in the upper part of the arm and accompanies the ulnar nerve.
4. A nutrient artery is given off to the humerus.
5. The inferior ulnar collateral artery arises in the lower part and takes part in the anastomosis round the elbow joint.
6. The artery ends by dividing into two terminal branches, the radial and ulnar arteries.

RADIAL ARTERY
Radial artery is the smaller terminal branch of the brachial artery in the cubital fossa. It leaves the forearm by turning posteriorly and entering the
anatomical snuff box. Anteriorly it is overlapped by the brachioradialis in its upper part, but in the lower half it is covered only by skin, superficial and
deep fascia. Medially, there are the pronator teres in the upper one-third and the tendon of the flexor carpi radialis in the lower two-thirds of its course. In
the anatomical snuffbox radial artery runs obliquely downwards, and backwards deep to the tendons of the abductor pollicis longus, the extensor pollicls
brevis and the extensor pollicis longus, and superficial to the lateral ligament of the wrist joint. Then, it passes between the two heads of the first dorsal
interosseous muscle and between the two heads of adductor pollicis to form the deep palmar arch in the palm.
Branches in the Forearm
1. The radial recurrent artery arises just below the elbow, runs upwards deep to the brachioradialis, and ends by anastomosing with the radial collateral
artery, in front of the lateral epicondyle of the humerus.
2. Muscular branches are given to the lateral muscles of the forearm.
3. The palmar carpal branch arises near the lower border of the pronator quadratus, runs medially deep to the flexor tendons, and ends by anastomosing
with the palmar carpal branch of the ulnar artery. The palmar carpal arch supplies bones and joints at the wrist
4. The superficial palmar branch arises just before the radial artery leaves the forearm (by winding backwards). The branch passes through (occasionally
over) the thenar muscles, and ends either by supplying these muscles, or by joining the terminal part of the ulnar artery to complete the superficial palmar
arch.

Branches in the hand

Dorsum of hand: On the dorsum of the hand the radial artery gives off:
(1) The dorsal carpal branch forms a network, the rete carpi dorsalis.
(2) A branch to the lateral side of the dorsum of the thumb.
(3) The first dorsal metacarpal artery. This artery arises just before the radial artery passes into the interval between the two heads of the first dorsal
interosseous muscle.

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 Palm: In the palm (deep to the oblique head of the adductor pollicis, the radial artery gives off:
(1) The princes pollicis artery which divides at the base of the proximal phalanx into two branches for the palmar surface of the thumb.
(2) The radialis indicis artery descends between the first dorsal interosseous muscle and the transverse head of the adductor pollicis. It supplies the
lateral side of the index finger.

Deep Palmar Arch

The deep palmar arch is formed mainly by the terminal part of the radial artery, and is completed medially at the base of the fifth metacarpal bone by the
deep palmar branch of the ulnar artery. The arch lies on the proximal parts of the shafts of the metacarpals and on the interossei; under cover of the
oblique head of the adductor pollicis, the flexor tendons of the fingers, and the lumbricals.

Branches
1. From its convexity, i.e. from its distal side, the arch gives off three palmar metacarpal arteries, which run distally in the 2nd, 3rd and 4th spaces,
supply the medial four metacarpals, and terminate at the finger clefts by joining the common digital branches of the superficial palmar arch.
2. Dorsally, the arch gives off three (proximal) perforating arteries which pass through the medial three interosseous spaces to anastomose with the
dorsal metacarpal arteries.

ULNAR ARTERY
Anteriorly, in its upper half, the artery is deep and is covered by the flexor digitorum superficlalis, and the flexor carpi ulnaris. The lower half of the artery
is superficial and is covered only by skin, superficial and deep fascia. Posteriorly, the origin of the artery lies on the brachlalis. In the rest of its course, the
artery lies on the flexor dlgitorum profundus. It enters the palm by passing superficial to the flexor retinaculum. It ends by dividing into the superficial
palmar branch, which is the main continuation of the artery, and the deep palmar branch. The superficial palmar arch lies deep to the palmaris brevis and
the palmar aponeurosis. It crosses the palm over the flexor digiti minimi, the flexor tendons of the fingers, the lumbricals, and the digital branches of the
median nerve.
Branches in the forearm
1. The anterior and posterior ulnar recurrent arteries anastomose around the elbow. The smaller anterior ulnar recurrent artery arises just below the
elbow, runs upwards deep to the pronator teres, and ends by anastomosing with the inferior ulnar collateral artery in front of the medial
epicondyle. The larger posterior ulnar recurrent artery arises lower than the anterior, runs backwards and upwards deep to the flexor dlgitorum
superficlalis, and between the heads of the flexor carpi ulnaris; and ends by anastomosing with the two ulnar collateral arteries behind the medial
epicondyle.
2. The common interosseous artery (about 1 cm long) arises just below the radial tuberosity. It passes backwards to reach the upper border of the
interosseous membrane, and end by dividing into the anterior and posterior interosseous arteries.
The anterior interosseous artery is the deepest artery on the front of the forearm. It descends on the surface of the interosseous membrane between the
flexor digitorum profundus and the flexor pollicis longus. It pierces the interosseous membrane at the upper border of the pronator quadratus to enter the
extensor compartment.
The artery gives muscular branches to the deep muscles of the front of the forearm, nutrient branches to the radius and ulna, a median artery which
accompanies the median nerve.
The posterior interosseous artery passes dorsally, between the oblique cord of interosseous membrane to the posterior region of the forearm. Near its
origin, the posterior interosseous artery gives off the interosseous recurrent artery which runs upwards, and ends by anastomosing with middle collateral
artery behind the lateral epicondyle. The posterior interosseous artery supply the posterior muscles and skin of the forearm.
3. Muscular branches supply the medial muscles of the forearm.
4. Palmar and dorsal carpal branches take part in the anastomosis round the wrist joint. The palmar carpal branch helps to form the rete carpi
palmaris. The rete carpi palmaris is formed medially by the dorsal carpal branch of the ulnar artery, and laterally by the dorsal carpal branch of the
radial artery. Superiorly, the rete is joined by the anterior and posterior interosseous arteries.

Branches in the hand

Superficial palmar arch gives off four common digital arteries. On a level of the metacarpal bones every one of these arteries is bifurcated on two
proper palmar digital arteries. The proper palmar artery of the little finger goes away from the ulnar artery on the lateral side of the little finger.
The deep branch of the ulnar artery arises in front of the flexor retinaculum immediately beyond the pisiform bone. Soon it passes between the flexor
and abductor digiti minimi to join and complete the deep palmar arch.

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VEINS OF THE UPPER LIMB

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Superficial veins

Superficial veins of the upper limb assume importance in medical practice because these are most commonly used for intravenous injections and for
withdrawing blood for transfusion or for testing.
General Remarks
Most of the superficial veins of the upper limb join together to form two large veins, cephalic and basilica veins. The superficial veins are best
utilised for intravenous injections.
Dorsal Venous Arch
Dorsal venous arch lies on the dorsum of the hand. Its afferents (tributaries) include: (i) three dorsal metacarpal veins, (ii) a dorsal digital veins.
Cephalic Vein
Cephalic vein begins from the lateral end of the dorsal venous arch. It runs upwards: (i) through the roof of the anatomical snuffbox, (ii) winds round
the lateral border of the distal part of the forearm, (iii) continues upwards in front of the elbow and along the lateral border of the biceps brachii muscle,
(iv) pierces the deep fascia at the lower border of the pectoralis major, (v) runs in the deltopectoral groove up to the infraclavicular fossa, where (vi) it
pierces the clavipectoral fascia and joins the axillary vein.
Basilic Vein
Basilic vein begins from the medial end of the dorsal venous arch. It runs upwards: (1) along the back of the medial border of the forearm, (ii) winds
round this border near the elbow, (ill) continues upwards in front of the elbow (medial epicondyle) and along the medial margin of the biceps brachii muscle
up to the middle of the arm where (iv) it pierces the deep fascia, and joins the brachial vein.
Median Cubital Vein
Medial cubital vein is a large communicating vein which drains blood from the cephalic to the basilica vein.
It begins from the cephalic vein 2.5 cm below the bend of the elbow, runs obliquely upward and medially, and ends in the basilic vein 2.5 cm above
the medial epicondyle. It is separated from the brachial artery by the bicipital aponeurosis.
Median Vein of the Forearm
Median vein of the forearm begins from the palmar venous network, and ends in any one of the veins in front of the elbow. Sometimes it divides into
median cephalic and median basilic veins which join the cephalic and basilic veins respectively; this pattern replaces the median cubital vein.

Deep Veins
These are the radial, ulnar, brachial, and axillary veins, and their tributaries. They accompany the arteries (near it artery lie two veins), and are
supported by powerful surrounding muscles. The valves are more numerous in deep veins than in superficial veins.

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ARTERIES OF THE LOWER LIMB

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FEMORAL ARTERY
It is the continuation of external iliac artery. It begins behind the inguinal ligament at the midinguinal point. It passes downwards and medially, first in the femoral
triangle, and then in the adductor canal between adductor magnus and vastus medialis muscles. At the lower end of the adductor canal, i.e., at the junction of
the middle and lower thirds of the thigh it passes through an opening in the adductor magnus to become continuous with the popliteal artery.

Branches in the Femoral Triangle

The femoral artery gives off three superficial and three deep branches in the femoral triangle.
The superficial branches are: (1) the external pudendal; (2) the superficial epigastric; and (3) the superficial circumflex iliac.
The deep branches are: (1) The profunda femoris; (2) muscular branches.
The external pudendal artery gives off anterior scrotal branches in males, and anterior labial branches in females.
The superficial epigastric artery goes away as a thin trunk. It penetrates the cribriform fascia. The artery goes upwards to the umbilicus.
The superficial circumflex iliac artery goes in the lateral direction under the inguinal ligament to the anterior superior iliac spine.

Profunda Femoris Artery

This is the largest branch of the femoral artery. It is the chief artery of supply to all the three compartments of the thigh. It arises from the lateral side of
the femoral artery about 4 cm below the inguinal ligament. The origin lies in front of the iliacus. As artery descends, it passes posterior to the femoral
vessels. It leaves the femoral triangle by passing deep to the adductor longus. Continuing downwards, It passes first between the adductor longus and the
adductor brevis, and then between the adductor longus and the adductor magnus. Its terminal part pierces the adductor magnus to anastomose with upper
muscular branches of the popliteal artery.
The profunda femoris artery gives off the medial and lateral circumflex femoral arteries, and three perforating arteries.
The medial circumflex femoral artery leaves the femoral triangle by passing posteriorly, between the pectineus and the psoas major muscles. It continues
backwards between the obturator externus and adductor brevis, and ends in the gluteal region between the quadratus femoris and adductor magnus by
dividing into ascending, transverse and acetabular branches. The acetabular branch sends a twig to the head of the femur along the round ligament.
The lateral circumflex femoral artery runs laterally between the anterior and posterior divisions of the femoral nerve, passes behind the sartorius and the
rectus femoris, and divides into ascending, transverse and descending branches. The ascending branch runs deep to the tensor fasciae latae, gives branches
to the hip Joint and the greater trochanter, and anastomoses with the superior gluteal artery. The transverse branch pierces the vastus lateralis and takes
part in the cruciate anastomosis on the back of the thigh just below the greater trochanter. The descending branch runs down along the anterior border of
the vastus lateralis, accompanied by the nerve to that muscle.
The perforating arteries. The profunda femoris artery gives off three perforating arteries. They arise on the front of the thigh. They then pass through the
adductor magnus and wind round the back of the femur, piercing the aponeurotic origins of other muscles attached to the linea aspera. The first
perforating artery arises just below pectineus muscle, the second immediately below the adductor brevis, and the third below adductor longus muscle. The
perforating arteries give off muscular branches. They also give off cutaneous and anastomotic branches. The second perforating artery, sometimes the first
or third gives off the nutrient artery to the femur.

Branches in the Adductor Canal

The femoral artery enter the adductor canal at the apex of the femoral triangle. Within the canal it gives off muscular branches and a descending
genicular artery, which enters the vastus medialis and reaches the knee.

POPLITEAL ARTERY
This artery is the continuation of the femoral artery, begins at the opening in the adductor magnus or hiatus adductor magnus, i.e. at the junction of the
middle one-third with the lower one-third of the thigh. It runs downwards and slightly laterally, to reach the lower border of the popliteus, where it
terminates by dividing into the anterior and posterior tibial arteries.

Branches
Genicular branches are five in number, two superior, two inferior and one middle. The middle genicular artery pierces the oblique popliteal ligament of
the knee, and supplies the cruciate ligaments and the synovial membrane of the knee joint. The medial and lateral superior genicular arteries wind round
the corresponding side of the femur immediately above the corresponding condyle, and pass deep to the semitendinosus, semimembranosus and biceps
femoris muscles. The medial and lateral inferior genicular arteries wind round the corresponding tibial condyles, and pass deep to the collateral
ligaments of the knee. All these arteries reach the front of the knee and take part in forming the anastomosis around the knee below heads of
gastrocnemius muscle.

ANTERIOR TIBIAL ARTERY

It begins on the back of the leg at the lower border of the popliteus, opposite the tibial tuberosity. It enters the anterior compartment of the leg by passing
forwards close to the fibula, through an opening in the upper part of the interosseous membrane. In the upper one-third of the leg the artery lies between
the tibialis anterior and the extensor digitorum longus; in the middle one-third between the tibialis anterior and the extensor hallucis longus; and in the
lower one-third between the extensor hallucis longus and the extensor digitorum longus.

Branches
1. Muscular branches supply adjacent muscles.
2. Anastomose branches are given to the knee and ankle. The anterior and posterior tibial recurrent branches take part in the anastomoses round the
knee joint. The posterior tibial recurrent artery begins from the anterior tibial artery on the posterior surface of the leg, under the popliteal muscle.
The anterior tibial recurrent artery begins from the anterior tibial artery immediately after passing through the interosseous membrane on the
anterior surface of the leg.
The anterior lateral malleolar artery lies just below the lateral malleolus.
The anterior medial malleolar artery lies just below the medial malleolus.

DORSALIS PEDIS ARTERY

It is a continuation of the anterior tibial artery on to the dorsum of the foot. The artery begins in front of the ankle between the two malleoli. It passes
forwards along the medial side of the dorsum of the foot to reach the proximal end of the first intermetatarsal space. Here it dips downwards between the two
heads of the first dorsal interosseous muscle, and ends in the sole by the deep plantar artery, which completing the plantar arterial arch.

Branches
1. The lateral tarsal artery is larger than the medial and arises over the navicular bone. It passes deep to the extensor digitorum brevis, supplies this
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muscle and neighbouring tarsal joints, and ends in the lateral malleolar network.
2. The medial tarsal branches are two to three small twigs which join the medial malleolar network.
3. The arcuate artery is a large branch that arises opposite the medial cuneiform bone. It runs laterally over the bases of the metatarsal bones, deep to the
tendons of the extensor digitorum longus and the extensor digitorum brevls, and ends by anastomosing with the lateral tarsal artery. It gives off the second,
third and fourth dorsal metatarsal arteries, each of which divides into dorsal digital branches for adjoining toes. The dorsal metatarsal arteries are joined by
proximal and distal perforating arteries from the sole.
4. The first dorsal metatarsal artery arises just before the dorsalls pedis artery dips into the sole. It gives a branch to the medial side of the big toe, and
divides into dorsal digital branches for adjacent sides of the first and second toes.

POSTERIOR TIBIAL ARTERY

This is the larger terminal branch of the popliteal artery. It begins at the lower border of the popliteus, between the tibia and the fibula, deep to the
gastrocnemius. It enters the back of leg by passing deep to the tendinous arch of the soleus. In the leg, it runs downwards and slightly medially, to reach
the posteromedial side of the ankle, midway between the medial malleolus and the medial tubercle of the calcaneum. It terminates deep to flexor
retinaculum by dividing, into the lateral and medial plantar arteries.

Branches
1. The peroneal artery is the largest branch of the posterior tibial artery. This is the largest branch of the posterior tibial artery. It supplies the posterior
and lateral compartments of the leg. It runs obliquely towards the fibula, and descends along the medial crest of the fibula. It passes behind the inferior
tibiofibular and ankle joints, medial to peroneal tendons, and terminates by dividing into a number of lateral calcanean branches
2. Several muscular branches are given off to muscles of the back of the leg.
3. A nutrient artery is given off to the tibia.
4. The anastomotic branches of the posterior tibial artery are as follows:
(a) The circumflex fibular branch winds round the lateral side of the neck of the fibula to reach the front of the knee where it takes part in the anastomoses
around the knee joint.
(b) A malleolar branch anastomoses with other artries over the medial malleolus.
(c) Calcaneal branches anastomose with other artries in the region.
5. Terminal branches: These are the medial and lateral plantar arteries. They will be studied in the sole.
Medial plantar artery is a terminal branch of the posterior tibial artery. It goes on the foot first under the abductor hallucis muscle, then lies between this
muscle on the medial side and the flexor digitorum brevis on the lateral side.

Lateral plantar artery is the larger terminal branch of the posterior tibial artery. It ends at the base of the fifth metatarsal bone by becoming continuous
with the plantar arch. The plantar arch goes between flexor digitorum brevis and quadrates plantae muscles. Four plantar metatarsal arteries diverge
from the plantar arch. Each of them on a level of the base of the first phalanges is divided into two plantar digital arteries, which go to the sides of the
fingers. A calcanean branch is occasionally given off to the skin of the heel.

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 VEINS OF THE LOWER LIMB

Superficial Veins
They include the great and small saphenous veins, and their tributaries. They lie in the superficial fascia, on the surface of the deep fascia. Valves are
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more numerous in the distal parts of these veins than in their proximal parts. A large proportion of their blood is drained into the deep veins through the
perforating veins.

Deep Veins
These are the anterior and posterior tibial, peroneal, popliteal, and femoral veins, and their tributaries. They accompany the arteries, and are supported by
powerful surrounding muscles. The valves are more numerous in deep veins than in superficial veins. They are more efficient channels than the
superficial veins because of the driving force of muscular contraction.

Perforating Veins
They connect the superficial with the deep veins. Their valves permit only one way flow of blood, from the superficial to the deep veins. There are
about five perforators along the great saphenous vein, and one perforator along the small saphenous vein.

Great Saphenous Vein

It can be marked by joining the following points, although it is easily visible in living subjects.
(a) First point on the dorsum of the foot at the medial end of the dorsal venous arch.
(b)Second point on the anterior surface of the medial malleolus.
(c) Third point on the medial border of the tibia at the junction of the upper two-thirds and lower one-third of the leg.
(d)Fourth point at the adductor tubercle.
(e) Fifth point just below the centre of the saphenous opening.
Its formation on the dorsum of the foot, its course along the entire length of the lower limb, and its termination into the femoral vein. It contains about 10-
20 valves. There is one valve that lies just before the vein pierces the cribriform fascia and another at its termination into the femoral vein.
Just before piercing the cribriform fascia: (1) Superficial epigastric, (2) superficial circumflex iliac and (3) superficial external pudendal.
Small Saphenous Vein
It can be marked by Joining the following points, although this vein is also easily visible in its lower part.
(a) A point on the dorsum of the foot at the lateral end of the dorsal venous arch.
(b) Second point behind the lateral malleolus.
(c) Third point Just lateral to the tendo calcaneus above the lateral malleolus.
(d) Fourth point at the centre of the popliteal fossa.
Its formation on the dorsum of the foot, course along the back of the leg, and termination into the popliteal vein.

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THE THYMUS

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The thymus is the central (primary) organ of immunogenesis. The thymus consists of two lobes asymmetric in size — the left and the right,
connected with each other in the average part or closely. The lower part of each lobe is wide and the upper part is narrow. Quite often the
upper part of the lobes is projected into the area of the neck as a plug with two teeth. The left lobe of the thymus is longer than the right
approximately in half of cases. During its maximal development (10-15 years) the weight of the thymus reaches on average 37,5 g. At birth it
is about 4-6 cm long. 2,5-5 cm wide, and 1 cm thick.

The thymus is located in the anterior part of the superior mediastinum in the upper intrapleural space, between the right and the left
mediastinal pleura. The upper part of the thymus often comes into the pretracheal intrafascial space and lies behind the sternohyoid and
sternothyroid muscles. The anterior surface of the thymus is convex, and is connected with the posterior surface of the manubrium and the
body of the sternum (up to a level of the 4th costal cartilages). Behind the thymus there is the upper part of the pericardium, covering from the
front the initial portion of the aorta and the pulmonary trunk, also an aortic arch with large vessels, left brachiocephalic vein and superior vena
cava.

The thymus controls lymphopoesis, and maintains an effective pool of circulating lymphocytes, competent to reach to antigenic stimuli. The bone marrow
produces cells called thymocytes. These thymocytes travel to the thymus. In the thymus, the hormone thymosin is used to test the immunity of thymocyte
cells. If they pass they mature into T-cells. These T-cells can then travel to our lymph nodes, where they can now fight disease, virus and infections.
The thymus is largest and most active during the neonatal and pre-adolescent periods. By the early teens, the thymus begins to atrophy and thymic stroma
is mostly replaced by adipose tissue. Loss of the thymus at an early age through genetic mutation results in severe immunodeficiency and subsequent high
susceptibilitly to infection.
Thymus is covered by a connective tissue capsule, the septa of which penetrate into the tissue and divides it into incomplete lobules. Each lobule has a
peripheral dark zone called cortex and middle lighter zone called medulla. The cortex contains a large number of small densely packed precursors of T-
lymphocytes (thymocytes). It also contains epithelial reticular cells and macrophages.
Corticomedullary junction has numerous blood vessel, little connective tissue and mature T lymphocytes. B-cells and dentritic cells are also found here.
Medulla is the central portion, where the network of reticular endothelial cells is denser and where the lymphoid cells are fewer. There are also a number
of concentric bodies know as Hassall’s corpuscles. They are flattened epithelial reticular cells concentrically arranged and filled with keratin filaments.
Most (95%) of the T-lymphocytes produced are autoallergic (act against the host or “self” antigens), short – liver (3-5 days) and never move out of the
organ. They are destroyed within the thymus by phagocytes. Their remnants are seen in Hassall’s corpuscles. The remaining 5% of the T lymphocytes are
long – lived (3 months or more), and move out of the thymus to join the circulating pool of lymphocytes where they act as immunologically competent
but uncommitted cells, i.e. they can react to any unfamiliar, new antigen.

THE SPLEEN
The spleen functions mainly as a blood filter, removing old red blood cells. It also plays a role in both cell-mediated and humoral immune responses. The
spleen is 13 cm long, 8 cm wide and 3 cm thick and weighs about 170 g (from 100 grams to 200 grams). During digestion the spleen becomes larger. The
shape of spleen is like a shoe. Two surfaces are distinguished in the spleen : diaphragmal and visceral, two ends: anterior and posterior, and two
borders: superior and inferior. The diaphragmal surface is convex and adjoins the diaphragm. On the visceral concave surface lies a longitudinal
groove hilum, which transmits the vessels and nerves enter the spleen and provides attachment to the gastrospleenic and splenorenal ligaments. The spleen is
located in the left hypochondrium and partly in the epigastrium at a level from the ninth to the eleventh rib.
The visceral surface is irregular and has impressions: gastric is for the fundus of the stomach; renal is for the left kidney; colic is for left colic flexure;
pancreatic is for the tail of pancreas. The colic impression is related to the phrenicocolic ligament.
The spleen is made up of the following four components: supporting tissue, white pulp, red pulp, vascular system. Supporting tissue is fibro elastic and
forms the capsule, trabeculas, and a fine reticulum.
The white pulp consists of lymphatic nodules, which are arranged around an arteriole called the Malpigian corpuscle. The red pulp is formed by collection
of cells in the interstices of reticulum, in between the sinusoids. The cell population includes all types of lymphocytes, blood cells, and fixed and free
macrophages.
The vascular system consists of splenic artery, which divides at the hilum into straight vessels called penicillin, ellipsoids, and arterial capillaries.

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 Literature

1. Textbook of human anatomy. M.R. Sapin., L.L. Kolesnikov., D.B. Nikitjuk. In two volumes. New Wave Publishing Agency, Moscow,
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2010.
2. Human Anatomy. B.D. Chaurasia's. Volume one, v. two, v. three. CBS Publishers & Distributors, 2004.
3. Human anatomy. M. G. Prives. Volume I, II. English translation. Mir Publishers, Moscow, 1985.
4. Clinical anatomy for medical students. Richard S. Snell. Lippincott. Williams & Wilkins, 2000.Carmine D. Clemente. Anatomy, regional
atlas of the human body. 5th edition. Lippincott. Williams & Wilkins, 2006.
5. Atlas of Human Anatomy. H. Netter ISBN 3-905298-05-8 Basel, 2003.
6. Human anatomy, Gosling, Harris, Humpherson, Whitmore. Mosby-Wolfe, 1995.

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