Vascular & lymphatic system

CV1.7 To understand the organization of the vascular and

lymphatic systems and their clinical correlates

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Required textbook:
Agur, A. M. R., Dalley, A. F., & Moore, K. L. (2019). Moore’s Essential Clinical Anatomy(6thed.).
Philadelphia: Wolters Kluwer.
TEXTONLIN:URL:http://auamed.idm.oclc.org/login?url=http://meded.lwwhealthlibrary.com/boo
k.aspx?bookid=2610
• Chapter 1: Overview and Basic Concepts: Cardiovascular System , • Lymphoid System.
• Chapter 4: Thorax: Thoracic aorta & its branches , Superior vena cava & Inferior vena cava,
Thoracic duct, Right lymphatic duct
• Chapter 5: Abdomen: Abdominal aorta & its branches , Portal vein, Lumbar, celiac, superior
mesenteric, splenic, pancreaticoduodenal, hepatic node
• Chapter 6: Pelvis and Perineum: External iliac & internal iliac artery and its branches ,
Common, external, internal iliac lymph node
• Chapter 3: Upper limb: Axillary artery, Brachial artery and its branches, Veins of upper limb:
Axillary, brachial, cubital, cephalic, median cubital, basilica vein, Axillary lymph node,
Superficial & deep cervical, submental, submanibular parotid, jugulo group
Chapter 7: Lower limb: Femoral artery, Popliteal artery & anterior, posterior tibial artery,
Most of the Images in this PPT are from
Femoral, popliteal, great saphenous, small saphenous vein this textbook (Keith L. Moore)
• Chapter 9: Neck: External carotid artery & its branches , External jugular, internal jugular vein
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Learning objectives:
Given a clinical scenario/image, the student should be able to:
CV1.7.1: Identify the major arteries supplying the head, neck, trunk, and extremities.
CV1.7.2: Identify the surface projection of palpation of major arteries in the body.
MS 1.4.3. Describe the venous drainage of the upper limb
MS 1.10.4. Describe the venous drainage of the lower limb
CV1.7.3: Recognize the major superficial and deep veins of the head, neck, trunk,
and extremities.
GI1.20.6. Describe the functional anatomy of the hepatic portal venous system and
the four sites of portocaval anastomosis.
CV1.7.4: Recognize the formation and function of the portal venous system.
FO1.7.5. Describe the functional components of the lymphatic system with emphasis
on the drainage of the right lymphatic and thoracic ducts.
MS 1.4.4. Describe the lymphatic drainage of the upper limb
MS 1.10.5. Describe the lymphatic drainage of the lower limb.
CV1.7.5: Recognize the major lymphatic channels in the body.
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Given a clinical scenario/image, the student should be able to:
CVI.7.1: Identify the major arteries supplying the head, neck, trunk, and
extremities
Integrated Learning objectives from Semester 1 (Foundation, MSK, GIT & Neuro systems):
• NB1.10.1. Recognize the blood supply of the CNS from the carotid and vertebral arteries.
• MS 1.15.4. Describe the blood vessels and lymphatics of the head and neck region
• GI1.12.1. Differentiate the position, parts, (cardia, fundus, body, pylorus), curvatures, relations, blood supply, innervation, and lymphatic drainage of the
stomach.
• GI1.17.2. Describe the location, parts, relations, and blood supply of the duodenum.
• GI1.17.4. Identify the features, relations, blood supply, and lymphatic drainage of the large intestine.
• GI1.17.5. Describe the position, relations, blood supply, nerve supply, lymphatic drainage of the appendix.
• GI1.17.6. Describe the structure of the rectum and anal canal with emphasis on sphincters,
• nerve supply, blood supply, lymphatic drainage, and the role of the pectinate line.
• MS 1.4.14. Identify the branches of subclavian, axillary, and brachial artery with an emphasis on scapular anastomosis.
• MS 1.5.9. Identify the course and branches of the brachial, radial, and ulnar arteries and the anastomosis around the elbow joint
• MS 1.10.11. Describe the course and branches of the femoral artery.
• MS 1.11.9. Describe the course and branches of the popliteal, anterior and posterior tibial arteries.

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Overview-Vascular system

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Arteries
Heart -oxygenated blood
Under high pressure
Blood vessels
Veins
Deoxygenated blood
Right atrium of the heart
have valves-unidirectional flow
Capillaries
Microscopic vessels form network between arterioles to the venules
Sinusoids

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 Anastomoses & collateral circulation Clinical correlates
Terminal (end) arteries:
Ex: occlusion of artery of retina –blindness
Functional terminal arteries (arteries with ineffectual anastomoses):
segments of brain, liver, kidney, spleen & intestines
Varicose veins
Arteriosclerosis:
hardening of arteries
Build of fat in the arterial walls
Ischemia
Infarction
Consequences of a thrombus
are myocardial infarction
(heart attack), stroke,
and gangrene
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Case Study:
Source: Keith L Moore
During a lengthy trip in the car, a 38-year-old woman experienced substernal discomfort, pain in the right side of her
thorax, and breathlessness. She said that she felt sick to her stomach (nausea) and that she was going to faint
(syncope). Believing she may have been experiencing a heart attack, her husband drove her to a hospital.
• Physical Examination: The physician observed evidence of shock and rapid breathing (tachypnea). He also noted
swollen, tender veins (varicose veins), particularly in her right thigh and calf (signs and symptoms of
thrombophlebitis). On questioning, he learned that she had had painful varicose veins in her lower limbs for some
time and that they became extremely painful during her recent long car ride. He also learned that she had been
taking birth control pills for approximately 9 years. Examination of her lungs revealed a few small, moist
atelectatic rales (transitory, light crackling sounds) in the right side of her chest. Auscultation also revealed a
pleural rub on the right side. Cardiac examination detected tachycardia (rapid beating of the heart) and
arrhythmia (irregularity of the heartbeat). An ECG suggested some right heart strain. Radiographs of her
thorax, pulmonary angiograms, photoscans, and fluoroscopy were requested.
Case Study Contd.,
• Radiology Report: The radiographs show some increase in radiolucency of the right lung. Fluoroscopy of her lungs
revealed poor or absent pulsations in the descending branch of the right pulmonary artery and relative anemia of
the right lung that is consistent with pulmonary thromboembolism (PTE). The photoscans (scintigrams) obtained
after intravenous injection of radioactive iodinated (131I) human albumin microparticles showed practically no
pulmonary blood flow to the right lung.
• Diagnosis: PTE resulting from the release of a thrombus from a varicose vein in the lower limb.

Questions:
1. What are the main factors involved in pulmonary thromboembolism and thrombogenesis?

2. How do you think the radiologist injected the contrast material into the
patient’s right ventricle during pulmonary angiography?

3. What was the probable cause of the patient’s severe substernal

discomfort and shoulder pain?
Aorta: Arteries of Thorax
Ascending aorta: Right coronary artery & Left coronary artery
Arch of Aorta
Brachiocephalic trunk; Right common carotid artery & right subclavian artery
Left common carotid artery
Left subclavian artery
Descending thoracic aorta: Begins on the left side of the inferior border of the body of the T4 vertebra and descends in the
posterior mediastinum on the left sides of the T5–T12 vertebrae.
It continues as abdominal aorta at the level T12 vertebra
Branches:
Posterior intercostal
Subcostal
Bronchial
Mediastinal
Esophageal
Superior phrenic
Pair of Internal Thoracic arteries :Branch of the subclavian artery (1ST part). Arises in the root of the neck:
Upper 6 anterior intercostal arteries
Musculophrenic arteries
Superior epigastric arteries
Clinical correlates
Aneurysm of Ascending Aorta
The distal part of the ascending aorta receives a strong
thrust of blood when the left ventricle contracts. Because
its wall is not yet reinforced by fibrous pericardium, an
aneurysm (localized dilation) may develop.
An aortic aneurysm is evident on a chest film
(radiograph of the thorax) or an MR angiogram as an
enlarged area of the ascending aorta silhouette.
Individuals with an aneurysm usually complain of chest
pain that radiates to the back.
The aneurysm may exert pressure on the trachea,
esophagus, and recurrent laryngeal nerve, causing
difficulty in breathing and swallowing. [email protected] 14
 Clinical correlates
Coarctation of Aorta
The arch of the aorta or thoracic aorta has an abnormal narrowing
(stenosis) that diminishes the caliber of the aortic lumen, producing an
obstruction to blood flow to the inferior part of the body.
The most common site for a coarctation is near the ligamentum
arteriosum.
When the coarctation is inferior to this site (postductal coarctation), a
good collateral circulation usually develops between the proximal and
distal parts of the aorta through the intercostal and internal thoracic
arteries.
This type of coarctation is compatible with many years of life because the
collateral circulation carries blood to the thoracic aorta inferior to the
stenosis.
The collateral vessels may become so large that they cause notable
pulsation in the intercostal spaces and erode the adjacent surfaces of the
ribs, which is visible in radiographs of the thorax.

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 Arteries of abdomen
Arteries of Anterolateral abdominal
wall (refer GIT)

Branches of abdominal aorta –to the

abdominal viscera (refer GIT)

Arteries of pelvis
 Arteries of Pelvis
4 main arteries in females and 3 main arteries in males:
1.Unpaired median sacral artery
2. Paired superior rectal artery
3.Paired internal iliac artery
4. Paired ovarian arteries (FEMALES)

Branches internal iliac artery

Anterior division:
Superior vesical artery(patent part of umbilical artery) (part of it
obliterated umbilical artery-medial umbilical ligament)
Obturator artery
Uterine artery (in females) also gives
vaginal artery
Middle rectal artery
Inferior gluteal artery
Internal pudendal artery
Inferior vesical artery (in males)
Posterior division:
Iliolumbar
Superior gluteal
Lateral sacral
 Arteries of Head & neck
Pair of Common carotid arteries
Pair of Internal carotid arteries
Pair of External carotid arteries
Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Posterior auricular
Superficial temporal
Maxillary
Arteries of Upper limb
Subclavian artery (neck/clavicle)
Axillary artery (arm pit)
Brachial artery (arm)
Radial artery (forearm)
Ulnar artery (forearm)
Superficial palmar arch (palm)
Common digital arteries
Proper palmar digital arteries
Arteries of Lower limb
External iliac (from common
iliac in pelvis)
Femoral (thigh)
Popliteal (knee)
Anterior tibial (leg, ankle and
dorsal foot)
Posterior tibial (leg, ankle and
sole)
Fibular (leg and ankle)
Medial and lateral plantar aa.
(foot)
Common plantar digital aa.
Plantar digital
Learning objectives:
Given a clinical scenario/image, the student should be able to:
CV1.7.1: Identify the major arteries supplying the head, neck, trunk, and extremities.
CV1.7.2: Identify the surface projection of palpation of major arteries in the body.
MS 1.4.3. Describe the venous drainage of the upper limb
MS 1.10.4. Describe the venous drainage of the lower limb
CV1.7.3: Recognize the major superficial and deep veins of the head, neck, trunk,
and extremities.
GI1.20.6. Describe the functional anatomy of the hepatic portal venous system and
the four sites of portocaval anastomosis.
CV1.7.4: Recognize the formation and function of the portal venous system.
FO1.7.5. Describe the functional components of the lymphatic system with emphasis
on the drainage of the right lymphatic and thoracic ducts.
MS 1.4.4. Describe the lymphatic drainage of the upper limb
MS 1.10.5. Describe the lymphatic drainage of the lower limb.
CV1.7.5: Recognize the major lymphatic channels in the body.
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Peripheral Pulses
Learning objectives:
Given a clinical scenario/image, the student should be able to:
CV1.7.1: Identify the major arteries supplying the head, neck, trunk, and extremities.
CV1.7.2: Identify the surface projection of palpation of major arteries in the body.
MS 1.4.3. Describe the venous drainage of the upper limb
MS 1.10.4. Describe the venous drainage of the lower limb
CV1.7.3: Recognize the major superficial and deep veins of the head, neck, trunk,
and extremities.
GI1.20.6. Describe the functional anatomy of the hepatic portal venous system and
the four sites of portocaval anastomosis.
CV1.7.4: Recognize the formation and function of the portal venous system.
FO1.7.5. Describe the functional components of the lymphatic system with emphasis
on the drainage of the right lymphatic and thoracic ducts.
MS 1.4.4. Describe the lymphatic drainage of the upper limb
MS 1.10.5. Describe the lymphatic drainage of the lower limb.
CV1.7.5: Recognize the major lymphatic channels in the body.
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 Veins of Thorax

Spinal and vertebral veins

Accessory hemiazygos (variable)
Hemiazygos vein
Azygos vein
Superior vena cava
 Veins of Abdomen
Internal iliac vein (pelvis, gluteal,
perineum)
External iliac vein (drains lower
limb)
Common iliac
Inferior vena cava (receives venous
drainage from pelvis, lower limb,
gonads, kidney, liver, adrenals,
lumbar veins, and inferior phrenic
veins)
Then drains into the right atrium of
heart
 Veins of head & neck
Pair of Brachiocephalic veins
Pair of External jugular veins
Pair of Internal jugular veins
 Veins of upper limb
Deep veins start in deep venous arches of
hand and foot and drain via veins (venae
comitantes) that are parallel to the arteries
and bear the same names.
Superficial veins: includes the cephalic and
basilic veins that drain the upper limb into
axillary vein).

These veins all contain valves to aid in

venous return to the heart
 Veins of Lower limb
Deep veins start in deep venous
arches of the foot and drain via
veins (venae comitantes) that are
parallel to the arteries and bear
the same names.
Superficial veins: include the
great and small saphenous veins
that drain the lower limb into the
femoral and popliteal veins,
respectively.

These veins all contain valves to

aid in venous return to the heart
Learning objectives:
Given a clinical scenario/image, the student should be able to:
CV1.7.1: Identify the major arteries supplying the head, neck, trunk, and extremities.
CV1.7.2: Identify the surface projection of palpation of major arteries in the body.
MS 1.4.3. Describe the venous drainage of the upper limb
MS 1.10.4. Describe the venous drainage of the lower limb
CV1.7.3: Recognize the major superficial and deep veins of the head, neck, trunk,
and extremities.
GI1.20.6. Describe the functional anatomy of the hepatic portal venous system and
the four sites of portocaval anastomosis.
CV1.7.4: Recognize the formation and function of the portal venous system.
FO1.7.5. Describe the functional components of the lymphatic system with emphasis
on the drainage of the right lymphatic and thoracic ducts.
MS 1.4.4. Describe the lymphatic drainage of the upper limb
MS 1.10.5. Describe the lymphatic drainage of the lower limb.
CV1.7.5: Recognize the major lymphatic channels in the body.
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 Concept of a Portal System
Arterial blood passes into a
capillary system, then enters the
venous system (portal vein), then
enters another capillary
(sinusoidal) system in the liver, and
then enters another venous
system (hepatic veins and IVC).

(e.g., hepatic portal system and

hypophyseal portal system)
Portal vein and its Inferior vena cava and its
tributaries. tributaries.

Two Venous systems in the abdomen

1. Portal venous system
2. Systemic (Caval) venous system
Anastomoses (communication) between these systems provide collateral
circulation in case of obstruction in portal
S D'Costavein
Clinical correlates

Courtesy: John T. Hansen

Clinical correlates

Courtesy: John T. Hansen

Clinical correlates

Courtesy: John T. Hansen

Learning objectives:
Given a clinical scenario/image, the student should be able to:
CV1.7.1: Identify the major arteries supplying the head, neck, trunk, and extremities.
CV1.7.2: Identify the surface projection of palpation of major arteries in the body.
MS 1.4.3. Describe the venous drainage of the upper limb
MS 1.10.4. Describe the venous drainage of the lower limb
CV1.7.3: Recognize the major superficial and deep veins of the head, neck, trunk,
and extremities.
GI1.20.6. Describe the functional anatomy of the hepatic portal venous system and
the four sites of portocaval anastomosis.
CV1.7.4: Recognize the formation and function of the portal venous system.
FO1.7.5. Describe the functional components of the lymphatic system with emphasis
on the drainage of the right lymphatic and thoracic ducts.
MS 1.4.4. Describe the lymphatic drainage of the upper limb
MS 1.10.5. Describe the lymphatic drainage of the lower limb.
CV1.7.5: Recognize the major lymphatic channels in the body.
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 Overview-Lymphatic system
❖Lymph: watery fluid that resembles plasma
❖Lymphatic tissues
❖Lymphocytes:T and B cells

❖Lymphoid organs: Thymus, spleen, lymph

node
❖Immunologic defense of the body
❖Lymphatic vessels:
❖network of vessels and capillaries that
transport lymph

❖Removal of tissue fluid

❖Absent in CNS, teeth, bone & bone
marrow
❖Large lymph vessels
❖Right lymphatic duct
❖Thoracic duct
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 Lymphatic system
Function:
❖Protect body against infection---
activation of the immune system.
❖Collect fluids, solutes, hormones,
and plasma proteins and return
them to the venous system.
❖Absorb fat (chylomicrons) from the
small intestine and return to venous
system (subclavian veins in lower
neck).
Lymphatic drainage:
❖Lymphatic system is essential for
returning ECF, solutes, and protein
back to the bloodstream.

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Thoracic duct
The thoracic duct conveys most
lymph of the body to the
venous system: that from the:
Lower limbs
Pelvic cavity
Abdominal cavity
Left upper limb
and left side of the thorax,
head, and neck
The lymph from the right
superior quadrant is by right
lymphatic duct
 Lymph nodes
Palpable Nodes
Deep cervical nodes (high
neck region)
Axillary nodes (arm pit---
axilla)
Inguinal nodes (groin
region---inguinal)
Deep Nodes
Mediastinal nodes
(bronchomediastinal)
Para-aortic (lumbar) nodes
(abdomen)
Iliac nodes (pelvis)
 Lymph node -Breast
75% of the lymph from the
breast drains into the axillary
lymph nodes.
The remainder of the lymph
drains into:
Infraclavicular nodes
Pectoral nodes
Parasternal nodes (Intercostal
and infra-mammary nodes)
Clinical correlates
Lymphatic system is involved in the metastasis
(spread) of cancer
Lymphangitis :
Secondary inflammation of lymphatic vessels
Lymphadenitis:
Secondary inflammation of lymph nodes
Lymphedema:
Accumulation of interstitial fluid

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REVIEW Case Study:
Source: Keith L Moore
During a lengthy trip in the car, a 38-year-old woman experienced substernal discomfort, pain in the right side of her
thorax, and breathlessness. She said that she felt sick to her stomach (nausea) and that she was going to faint
(syncope). Believing she may have been experiencing a heart attack, her husband drove her to a hospital.
• Physical Examination: The physician observed evidence of shock and rapid breathing (tachypnea). He also noted
swollen, tender veins (varicose veins), particularly in her right thigh and calf (signs and symptoms of
thrombophlebitis). On questioning, he learned that she had had painful varicose veins in her lower limbs for some
time and that they became extremely painful during her recent long car ride. He also learned that she had been
taking birth control pills for approximately 9 years. Examination of her lungs revealed a few small, moist
atelectatic rales (transitory, light crackling sounds) in the right side of her chest. Auscultation also revealed a
pleural rub on the right side. Cardiac examination detected tachycardia (rapid beating of the heart) and
arrhythmia (irregularity of the heartbeat). An ECG suggested some right heart strain. Radiographs of her
thorax, pulmonary angiograms, photoscans, and fluoroscopy were requested.
Case Study Contd.,
• Radiology Report: The radiographs show some increase in radiolucency of the right lung. Fluoroscopy of her lungs
revealed poor or absent pulsations in the descending branch of the right pulmonary artery and relative anemia of the
right lung that is consistent with pulmonary thromboembolism (PTE). The photoscans (scintigrams) obtained after
intravenous injection of radioactive iodinated (131I) human albumin microparticles showed practically no pulmonary
blood flow to the right lung.
• Diagnosis: PTE resulting from the release of a thrombus from a varicose vein in the lower limb.

Questions:
1. What are the main factors involved in pulmonary thromboembolism and thrombogenesis?

2. How do you think the radiologist injected the contrast material into the
patient’s right ventricle during pulmonary angiography?

3. What was the probable cause of the patient’s severe substernal

discomfort and shoulder pain?