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Anatomy Atlases: Illustrated Encyclopedia of Human Anatomic Variation: Opus II: Cardiovascular System: Arteries: Head, Neck, and Thorax: Subclavian Arteries

Illustrated Encyclopedia of Human Anatomic Variation: Opus II: Cardiovascular System: Arteries: Head, Neck, and Thorax

Subclavian Arteries

Ronald A. Bergman, PhD
Adel K. Afifi, MD, MS
Ryosuke Miyauchi, MD

Peer Review Status: Internally Peer Reviewed


Variations of the subclavian artery are also considered along with variations of the aortic arch (listed under AORTA). Irregularities in the major branches of the aortic arch have been classified by Poynter as follows: 1). Branches fewer than usual as in the occurrence of bi-innominate arteries; 2). branches more numerous than usual, as in the absence of the innominate, and consequent separate origin of both carotid and subclavian arteries; 3). branches in abnormal succession, dependent upon an irregular development of the usual aortic-arch plan. The cases reported here belong to the last (3) named group.

The right subclavian artery may arise directly from the arch of the aorta, or as the first, second, third, fourth or even the fifth branch of that vessel. When it arises as the first branch, it takes the place usually occupied by the brachiocephalic. When it arises as the distal or last branch, it may course behind the trachea (retrotrachea) or both the trachea and esophagus (retroesophageal) to reach the groove on the first rib. Hommel (1737) described the first autopsy specimen of the right subclavian artery arising as the last branch of the aortic arch. In 1789, but not reported until 1794, Bayford described the first patient and subsequent autopsy of this patient with this unusual right subclavian artery. Cairney (1925) summerized the results of eight investigators who reported 19 instances of this variation in 2291 autopsy subjects (~0.8 %). In four studies of 1783 bodies, the frequency of this variation was about 0.6%. The first case diagnosed in life by roentgenography was reported by Kommerell in 1936. The incidences reported by x-ray study is much less than the autopsy studies (20/15000 or ~0.13%). Haesemeyer and Gavant reported that in their radiologic study of 7174 patients 36 had aberrant right subclavian artery. The frequency being 0.5%.

In other cases in which the right subclavian is the last branch of the aortic arch it may pass between the trachea and the esophagus or it may follow a pretracheal course to reach the right side. Sometimes, when the subclavian artery passes between the trachea and esophagus it compresses both the artery and the esophagus, giving rise to a "disease" named "dysphagia lusoria" by Bayford (1794), from the term "lusus naturae," meaning a "sport of nature." An excerpt from Bayford's paper follows: "Jane Fordham, was born in Bassenbourn near Royston, in Hertfordshire, in the last year of the last century (auth. note, 1699). From her infancy she was observed to have some difficulty in swallowing, but it was not much attended to, till she entered into her thirteenth year, when she first experienced those symptoms which commonly precede the erruption of the menses. At this time it became so considerable as induced her to have recourse to medicine for relief; but she received no sensible benefit from anything, except repeated bleeding.... She went on in this way, with the disease gradually increasing for many years, during which time she constantly observed, that her difficulty of swallowing was increased by violent exercise, and as she expressed herself, by everything that heated her blood; so that she was frequently obliged to lose blood once or twice in the intervals of the month.... For the last twenty years of her life this poor creature could scarcely, from day to day, muster up resolution to force food down to prevent her starving, so much was the difficulty now increased.

This difficulty she described as arising from an obstruction opposite the first bone of the sternum. The food did not return when it came to that place; but seemed to make a momentary stop: and in the instant she felt an inexpressible something approaching to strangulation of suffocation, which she could only compare to what she conceived of the agonies of death..... Different kinds of foods made no sensible difference in the effects, except that solids gave her less uneasiness than fluids: for which reason she took very sparingly of the latter. As her complaints were continually aggravated, rather than diminished by time, she became at length unable to struggle; and being worn out with fatigue and famine (for it is asserted that she scarcely swallowed a single morsel for the last three weeks of her life), she sunk into her grave in the beginning of February, 1761. I felt my self interested in making an inquiry into the cause of the obstruction by an examination of the dead body. It was not thought necessary to open the head, as there was no reason to expect any mischief in that part. The cavities of the thorax and abdomen were fully examined.... At length by mere accident I discovered an extraordinary lusus naturae in the disposition of the right subclavian artery. The right subclavian arising from the posterior part of the aorta, behind on the left hand of the left subclavian. In crossing from the left to the right it... insinuated itself between the trachea and esophagus. It should seem that this peculiar origin and course of the right subclavian artery has hitherto escaped the observation of the anatomists, otherwise in all probability it would have been recorded.... It is impossible to suppose the act of deglutition performed in this case, without a certain degree of pressure upon the artery, where it passes between the trachea and esophagus. Hence must arise an interruption of the circulation, which in so large an artery, and so near the heart, could scarcely fail of exciting very disagreeable sensation.... The act of deglutition will not be accompanied with pain or soreness, but extreme anxiety and violent palpitations of the heart." This is the end of Bayfords report.

The subclavian is rarely the second or third branch of the aortic arch, but when it is, it runs behind the right common carotid.

The right subclavian arises, embryologically, as the distal or last branch of the aortic arch when the right aortic arch remains intact and the normal root of the subclavian artery has become obliterated. An arteria aberrans, arising from the right subclavian (or superior intercostal), can generally be traced to the third thoracic vertebra behind the esophagus, and in a number of such cases can be followed across the vertebral column where it anastomoses with a branch of the thoracic aorta arising below the ductus arteriosus. It is the enlargement of this anastomosis (which is the remnant of the primitive right dorsal aorta in the embryo) that gives rise to the variation. The recurrent laryngeal nerve in such cases follows a direct course to the larynx instead of winding recurrently around the subclavian artery, because the right fourth arch that forms the first part of the subclavian is obliterated.

The right subclavian may arise higher or lower in the neck than usual, depending on whether the brachiocephalic divides above or below its normal position. On occasion the subclavian arises from the thoracic aorta.

The subclavian may perforate or pass in front of the scalenus anterior; when it perforates scalenus anterior, arterial rings may be formed around muscle slips. The artery can ascend above or remain below the level of the clavicle. The third part of the artery may be covered by the trapezius or sternocleidomastoid, or by the clavicular origin of the omohyoid. The subclavian vein occasionally accompanies the artery behind scalenus anterior; the artery may also pass between scalenus medius and posterior. The right subclavian artery may receive the thoracic duct; the left subclavian may receive a patent ductus arteriosus.

The subclavian artery divides in some cases at the medial border of scalenus anterior muscle, with the two branches continuing through the axilla and down the arm to become the radial and ulnar arteries.

Anomalous right subclavian arteries occur in 0.4-1.7% of individuals (all sources). Quain reported 4 cases/1000, Holzapfel 6/1000, and Tiedemann 8 times/1000 cases. Goldbloom reported 4/225 cadavers (1.7%), Harvey (U. Cal. Medical School) found 2/237 (0.8%), Cobey reported inThomson's Collective Investigation of the Anatomical Society of Great Britain and Ireland 5/500 (1%). It is interesting that the course of the sublavian artery was retroesophageal (between the vertebra and the esophagus) most commonly (107/238 cases), retrotracheal (between the trachea and esophagus) seldom (25/238 cases), before the trachea (in-front of) most rarely (6/238 cases).

If a cervical rib is present, the artery may run above this extra, unusual rib.

In cases of right aortic arch, the left subclavian artery may be retroesophageal when it arises as the last branch of the arch. The left subclavian may be doubled and arise as the first and the fifth branch of the aortic arch. The last branch is retroesophageal.

In cases of right aortic arch, the left subclavian shows two principal variations: 1) with the left subclavian arising as the first major vessel of the right aortic arch it crosses the anterior aspect of the trachea to reach the left side and 2) with the left subclavian artery arising as the last branch of the aortic arch, it crosses the posterior aspect of the esophagus to reach the left side. The left subclavian does not arise from the aortic arch directly but from a diverticulum, a remnant of the fourth left branchial arch.

Holzapfel, who studied the course of 133 cases of the right subclavian arising as the last branch of the aortic arch found that in 107 cases (80%) the right subclavian passed behind the esophagus to reach the right side, between the trachea and esophagus in 20 cases (15%), and in front of the trachea in 6 cases (5%). Banchi reported on 165 cases; 138 cases (83.6%) behind the esophagus, 21 cases (12.7%) between trachea and esophagus, and 7 cases (4.2%) in front of the trachea. Cairney, 1925, summarized the data of eight authors and reported 19 instances of variable right subclavian artery in 2291 autopsy specimens. Others have reported an incidence from 0.4% to 2.0% in anatomic studies. The first case diagnosed of a living patients by roentgenology was reported by Kommerell in 1936, but the incidence of cases detected by X-ray is less than in autopsy series. Brombart found only 20 cases (0.13%) in about 15,000 subjects.

Alphabetical listing of authors and dates of reported cases of the unusual course of the right subclavian artery when it arises as the last branch of the aortic arch - before 1900.
From Holzapfel, 1899.

Arnold, 1847.

Brodie, 1888.

Autenrieth-Pfleiderer, 1806, 1807.

Brown, 1868.

Bankart, 1869.

Cassebohm-Böhmer, 1741.

Barkow, 1866, 1869.

Cavasse, 1856.

Barwell, 1867.

Cerutti, 1827.

Bayford, 1789.

Colles, 1811.

Blandin, 1848.

Cruveilhier, 1832.

Böhmer, 1741.

Demarquay, 1848.

Bothezat, 1891.

Demeaux, 1841.

Bradley, 1781.

v. Düben, 1876.

Brenner, 1883.

Dubrueil, 1837, 1847, 1862.

Brent, 1844.

Dubrueil-Sappey, 1847.

Brewer, 1791.

Dunn, 1890.

Erdmann, 1772.

Löseke, 1754.

Faure, 1895.

Ludwig, 1764.

Fleischmann, 1815, 1835.

Macartney-Tiedemann, 1846.

Flesch, 1879.

Mayer, 1827.

Frandsen, 1854.

Mears, 1871.

Giacomini, 1882.

Meckel, 1751, 1805, 1810, 1816, 1820.

Godman, 1824.

Mieg, 1753.

Goetz, 1896.

Monro, 1797.

Green, 1830.

Murray, 1771.

Gross-Mears, 1871.

Neubauer-Erdmann, 1772.

Harrison, 1839.

Oehl, 1859.

Hart, 1826.

Otto, 1816,1830.

Hart-Quain, 1844.

Patruban, 1844.

Herold, 1812.

Peacock, 1860.

Hesselbach, 1824.

Pfleiderer, 1806, 1807.

Hoffman-Fabricius, 1751.

Pigné, 1847.

Hommel, 1737.

Pohl, 1773.

Hopkinson, 1830.

Pye-Smith, 1871.

Hulme, 1789.

Quain, 1844.

Hunauld, 1735. (First Report)

Rau, 1890.

Hyrtl, 1841-1859.

Reid, 1846.

Isenflamm-Fleischmann, 1800, 1845.

Sandifort, 1772, 1793.

Jacques, 1895.

Sappey-Dubrueil, 1847.

Kirby, 1818.

Schleitz, 1771.

Koberwein, 1810.

Shepherd, 1889.

Krause, 1876.

Simon, 1846.

Lauth, 1830.

Smith, 1891. (Kaninchen=Rabbit)

Leboucq, 1894.

Solger, 1893.

Leidy-Mears, 1871.

Stachelroth, 1850.

Lenoir, 1832.

Stedman, 1823.

Liston, 1839.

Struthers, 1888.

Testut, 1896.

Walsham, 1880.

Thomson, 1890.

Walter, 1785.

Tiedemann, 1822, 1846.

Weber, 1829.

Turner, 1862.

Wood, 1859, 1867.

Valentin, 1791.

Zagorsky, 1810.

Wagner, 1828.

Zenker, 1878.

Image 43, Image 61, Image 311Image 509

Retroesophageal

Left

Image 190, Image 233, Image 425

Right

See Image 61, Image 88, Image 99, Image 150, Image 151, Image 152, Image 159, Image 163, Image 166, Image 167, Image 168,Image 179, Image 180, Image 181, Image 182, See Image 190, Image 230, Image 231, Image 285

Retrotracheal

See Image 43

Arteria Lusoria Dextra (Right) and Arteria Subclavia Dextra Lusoria

See Images 230, 231, 394

Arteria Lusoria Sinistra (Left)

See Image 425


References

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Variations in the Branches of the Subclavian Artery
There is considerable variation in the branching of the subclavian artery, and the branches may be arranged differently on the two sides of the body. The usual branching order on the right side is for the vertebral, thyrocervical trunk (common trunk for the inferior thyroid, transverse cervical, and suprascapular arteries, in 50% of cases), and the internal thoracic (internal mammary) to arise from the first part of the right subclavian. When the the ascending cervical is a branch of the inferior thyroid, the transverse cervical artery and costocervical trunk arise from the second part of the subclavian. The costocervical trunk may arise from the third part, on the right side in 75% of cases and on the left in 30%. There may be one or two branches from the third part (costocervical and dorsal scapular artery in about 35% of cases). When the dorsal scapular is absent the costocervical trunk arises from the transverse cervical at the angle of the scapula. The transverse cervical may arise from the dorsal scapular when the dorsal scapular arises from the third part of the subclavian.

There are three additional types of variations, 1) the vertebral, internal thoracic (internal mammary), costocervical, and the inferior thyroid arise from the first part of the subclavian, while the transverse cervical arises from the second part and the suprascapular from either the third part or from the axillary artery. 2) The inferior thyroid, suprascapular, and the transverse scapular arise from a common stem from the first part. 3) In the rarest form, the inferior thyroid and superficial cervical arteries arise from a common trunk from the first part of the subclavian, while the suprascapular artery arises from the internal thoracic (internal mammary).

The subclavian artery may give rise to the inferior thyroid (27 of 273 cases or 9.9%), ascending cervical, suprascapular, supreme intercostal, deep cervical, accessory root to the vertebral, thyroidea ima, accessory inferior thyroid, and radial and ulnar arteries (without the axillary artery intervening). It sometimes provides a stem that gives rise to the internal thoracic, inferior thyroid, suprascapular, superior esophageal, an accessory or lateral internal thoracic, a vessel to the brachial plexus, a pericardial branch, a bronchial, or a pleural cupula branch.

J.J. Long studied the formation of the thyroid axis (thyrocervical trunk) and in all, used 75 specimens. It was found that their were four primary modes in which the branches were distributed. The four variations follow: Variation 1.- This arrangement is the usual form of the trunk. The thyroid axis, arising from the first part of the subclavian artery, gave off three vessels- the inferior thyroid, transversalis colli (transverse cervical), and suprascapular arteries. This was found in 33 of the 75 specimens. Variation 2.- In this group the posterior (dorsal) scapular artery arose from the third part of the subclavian artery in addition to three thyroid axis branches, viz, inferior thyroid, suprascapular, and superficial cervical arteries. This arrangement was found in 22 of the 75 specimens studied. Variation 3.- The group includes cases in which an artery (transversalis colli) susequently divided into superficial cervical and posterior (dorsal) scapular arose from the third part of the subclavian, while the thyroid axis provided the inferior thyroid and suprascapular arteries. This was found in 21 of 75 specimens. Variation 4.- In these cases three arteries arose from the third portion of the subclavian, sometimes as a single trunk, dividing into three branches, or as two trunks, one of which then divided into two branches. The branches in either case took the distribution of the superficial cervical, posterior (dorsal) scapular and suprascapular arteries. The inferior thyroid artery in these cases was the only representative of the axis. This was found in 4 of 75 specimens.

It can be seen that the inferior thyroid arose from the axis with one exception. The posterior (dorsal) scapular, in 42 cases out of 75, arose fron the third part of the subclavian artery, in 22 instances as a separate trunk, in 20 being conjoined with the superficial cervical, forming the transverse cervical. The suprascapular artery was also found to be a very constant branch of the thyroid axis, there being only 4 exceptions, vide Group 4 variations. The vessels arising from the third part of the subclavian varied considerably in the exact point at which they arose, sometimes coming off close to its termination, at others quite near to its origin, and in a very few cases one of the branches actually arose from the second portion of the subclavian. These variations tended to be the same on both sides of the same subject.

See also aortic arch for additional references and discussion of subclavian artery variations.


References

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Long, J.J. (1891) Formation of the thyroid axis. Transactions - Royal Academy of Medicine in Ireland 9:483-484.

Nizankowski, C., Noczynski, L. and E. Suder. (1982) Variability of the origin of ramifications of the subclavian artery in humans (studies on the Polish population). Folia Morphol., Warsaw 41:281-294.

O'Rahilly, R., Debson, H. and T.S. King (1950) Subclavian origin of bronchial arteries. Anat. Rec. 108:227-238.

Ozenne, -. (1883) Anomalie d'origine de la cartoide droite et de l'artère sous-claviere du même côté. Bulletins de la Societe Anatomique de Paris, 4th series, 8:108.

Papadatos, D. (1976) Trois observations anatomiques sur l'origine de l'arteria subclavia dextra comme denière branche de l'arcus aortae (Arteria lusoria). Anat. Anz. 140:100-117.

Poynter, C.W.M. (1916) Arterial anomalies pertaining to the aortic arches and the branches arising from them. The University Studies of the University of Nebraska, Lincoln 16:229-235.

Poynter, C.W.M. (1922) Congenital anomalies of the arteries and veins of the human body with bibliography. The University Studies of the University of Nebraska, Lincoln. 22:1-106.

Röhlich, K. (1934-35) Uber die Arteria transversa colli des Menschen. Anat. Anz. 79:37-52.

Spence, J. (1855) Case of irregularity of vessels at root of neck. Monthly Journal of Medicine, Edinburgh 20:350.

Swigart, LaV.L., Siekert, R.G., Hambly, W.C. and B.J. Anson. (1950) The esophageal arteries. An anatomic study of 150 specimens. Surg., Gynecol. Obstet. 90:234243.

vonLanz, T. and W. Wachmuth (1955) Praktische Anatomie Ein Lehr- und Hilfsbuch der Anatomischen Grundlagen Artztlichen Handelns. Springer-Verlag, Berlin, Gottingen, Heidelberg.

Walsham, W.J. (1880) The right subclavian arising from the the third part of the arch of the aorta. Anatomical variations: An account of a few of the more interesting abnormalities that have occurred in the dissecting-rooms during the past seven years; with remarks on their significance, and their bearing on the practice of surgery. St. Bartholomews Hospital Reports 16:88-89, 90.

Additional references will be found with the section on the aortic arch.

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