Carrent issues of the aortic functional morphology
Стаття містить огляд даних, наявних в літературі, про локалізацію і морфології судинного і лімфатичного русла, рефлексогенних зон аорти і результати власного макроскопічного, мезоскопічного і мікроскопічного дослідження доповнює ці аспекти. Вперше описані регіональні клінічно значущі особливості к...
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irk-123456789-763792015-02-11T03:02:26Z Carrent issues of the aortic functional morphology Hachina, T. Оригинальные статьи Стаття містить огляд даних, наявних в літературі, про локалізацію і морфології судинного і лімфатичного русла, рефлексогенних зон аорти і результати власного макроскопічного, мезоскопічного і мікроскопічного дослідження доповнює ці аспекти. Вперше описані регіональні клінічно значущі особливості кровопостачання і лімфатичного дренажу аорти. Погоджуючись з даними інших авторів про локалізацію рефлексогенної зони в дузі аорти, автор наводить відомості про наявність аналогічної зони в адвентиції висхідної аорти. Морфологічно обгрунтовуються причини ряду постопераційних ускладнень у кардіохірургії та шляхи їх попередження. Статья содержит обзор данных имеющихся в литературе о локализации и морфологии сосудистого и лимфатического русла, рефлексогенных зон аорты и результаты собственного макроскопического, мезоскопического и микроскопического исследования дополняющего эти аспекты. Впервые описаны региональные клинически значимые особенности кровоснабжения и лимфатического дренажа аорты. Соглашаясь с данными других авторов о локализации рефлексогенной зоны в дуге аорты, автор приводит сведения о наличии аналогичной зоны в адвентиции восходящей аорты. Морфологически обосновываются причины ряда постоперационных осложнений в кардиохирургии и пути их предупреждения. 2013 Article Carrent issues of the aortic functional morphology / T. Hachina // Таврический медико-биологический вестник. — 2013. — Т. 16, № 1, ч. 2 (61). — С. 203-211. — Бібліогр.: 36 назв. — англ. 2070-8092 http://dspace.nbuv.gov.ua/handle/123456789/76379 611.132 en Таврический медико-биологический вестник Кримський науковий центр НАН України і МОН України |
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Оригинальные статьи Оригинальные статьи |
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Оригинальные статьи Оригинальные статьи Hachina, T. Carrent issues of the aortic functional morphology Таврический медико-биологический вестник |
| description |
Стаття містить огляд даних, наявних в літературі, про локалізацію і морфології судинного і лімфатичного
русла, рефлексогенних зон аорти і результати власного макроскопічного, мезоскопічного і мікроскопічного
дослідження доповнює ці аспекти. Вперше описані регіональні клінічно значущі особливості кровопостачання
і лімфатичного дренажу аорти. Погоджуючись з даними інших авторів про локалізацію рефлексогенної
зони в дузі аорти, автор наводить відомості про наявність аналогічної зони в адвентиції висхідної аорти.
Морфологічно обгрунтовуються причини ряду постопераційних ускладнень у кардіохірургії та шляхи їх
попередження. |
| format |
Article |
| author |
Hachina, T. |
| author_facet |
Hachina, T. |
| author_sort |
Hachina, T. |
| title |
Carrent issues of the aortic functional morphology |
| title_short |
Carrent issues of the aortic functional morphology |
| title_full |
Carrent issues of the aortic functional morphology |
| title_fullStr |
Carrent issues of the aortic functional morphology |
| title_full_unstemmed |
Carrent issues of the aortic functional morphology |
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carrent issues of the aortic functional morphology |
| publisher |
Кримський науковий центр НАН України і МОН України |
| publishDate |
2013 |
| topic_facet |
Оригинальные статьи |
| url |
http://dspace.nbuv.gov.ua/handle/123456789/76379 |
| citation_txt |
Carrent issues of the aortic functional morphology / T. Hachina // Таврический медико-биологический вестник. — 2013. — Т. 16, № 1, ч. 2 (61). — С. 203-211. — Бібліогр.: 36 назв. — англ. |
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Таврический медико-биологический вестник |
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AT hachinat carrentissuesoftheaorticfunctionalmorphology |
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2025-07-06T00:49:31Z |
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| fulltext |
ОРИГИНАЛЬНЫЕ СТАТЬИ
УДК 611.132
© Т. Hachina, 2013
СARRENT ISSUES OF THE AORTIC FUNCTIONAL MORPHOLOGY
Т. hachina
Kафедра Анатомии (зав. - проф. Штефанец М. И.)Кишиневского Государственного Университета Медицины
и Фармации им. «Николае Тестемицану». МД 2025 Р. Молдова, Кишинэу, ул. Н. Тестемицану 11–32. Е-mail: tamara_
hacina@rambler.ru
АКТУАЛьНі пИТАННЯ ФУНКЦіОНАЛьНОЇ мОРФОЛОГіЇ АОРТИ
Т. хачіна
РЕЗюМЕ
Стаття містить огляд даних, наявних в літературі, про локалізацію і морфології судинного і лімфатичного
русла, рефлексогенних зон аорти і результати власного макроскопічного, мезоскопічного і мікроскопічного
дослідження доповнює ці аспекти. Вперше описані регіональні клінічно значущі особливості кровопостачання
і лімфатичного дренажу аорти. Погоджуючись з даними інших авторів про локалізацію рефлексогенної
зони в дузі аорти, автор наводить відомості про наявність аналогічної зони в адвентиції висхідної аорти.
Морфологічно обгрунтовуються причини ряду постопераційних ускладнень у кардіохірургії та шляхи їх
попередження.
АКТУАЛьНЫЕ ВОпРОСЫ ФУНКЦИОНАЛьНОЙ мОРФОЛОГИИ АОРТЫ
Т. хачина
РЕЗюМЕ
Статья содержит обзор данных имеющихся в литературе о локализации и морфологии сосудистого
и лимфатического русла, рефлексогенных зон аорты и результаты собственного макроскопического,
мезоскопического и микроскопического исследования дополняющего эти аспекты. Впервые описаны
региональные клинически значимые особенности кровоснабжения и лимфатического дренажа аорты.
Соглашаясь с данными других авторов о локализации рефлексогенной зоны в дуге аорты, автор приводит
сведения о наличии аналогичной зоны в адвентиции восходящей аорты. Морфологически обосновываются
причины ряда постоперационных осложнений в кардиохирургии и пути их предупреждения.
keywords: aorta, fat pad, vasa vasorum, paraganglion, reflexogenic zone, atrial fibrillation.
The aorta is the blood vessel of the human
body that was studied from the point of view of its
macroscopic and microscopic structure, ontogenesis,
its sources of innervation and vascularization and a
lot works were written on this subject. It seemed to
us that everything is known about the aorta. Articles
on the morphology of the aorta have been published
rare for the last two decades. At the same time the
number of articles published by clinicians, especially
cardiosurgery from many countries who treat the
diseases of the heart and aorta deal with the problem
of the lack of morphological evidence that account for
a number of postoperative complications and the ways
to prevent them. The other problem that runs through
a lot of recent articles is an insufficient presentation
of interaction of the heart and aorta lymphatic and
nervous apparatuses. When the incidence of morbidity
and mortality caused by cardiovascular diseases
increases all over the world and when surgical
operations on the aorta and heart have become routine,
an urgent need for a detailed study of vasa vasorum
and nervi vasorum of the aorta as well as its lymphatic
apparatus has arisen.
A notable progress in thoracic surgery only
emphasizes the need for research into the intraorganic
and paravasal apparatus of the aorta. Clinicians state
numerous cases of postoperative blood oozing and
explain it by the administration of heparin to prevent
thrombosis in this period. However, it is not possible
to give any explanation in cases of the development
of a profuse bleeding that require resternotomy after
operations when the aorta is the access point.
Atrial fibrillation is another more frequent
postoperative complication in such surgeries. At present
the preoperative and postoperative administration of
antiarrhythmic medicines to all patients in need of
surgery on the heart does not contribute to the decrease
of the incidence of this complication. Frequent site
effects of this treatment are known.
As the ascending aorta is involved in heart
operations (it is the access poin, the point of connection
the arterial magistral of the heart-assist device, the point
of hemostat imposition and introduction of the needle
to remove a residual air) there is a need to study the
interdependence of their intraorganic lymphatic and
nervous apparatuses.
It is known that 20–40% of patients after the heart
surgery with the involvement of the aorta suffer from
irregular heartbeat, especially atrial fibrillation, 7–20%
of all postoperative patients die. In spite of all effort
of the specialists in reparative surgery of the aorta to
prevent and to stop the development of aortic aneurism,
including dissecting one, no evident and stable results
are noted.
To achieve success in the treatment and prevention
of such cases is possible only after having obtained
203
ТАвРИЧЕСкИЙ мЕДИкО-бИОЛОГИЧЕСкИЙ вЕСТНИк2013, том 16, №1, ч.2 (61)
all data on the vascular nervous apparatus, way of the
lymphatic drainage and morphological reasons.
Taking into consideration the inefficiency of
therapeutic methods to treat a number of aortic
diseases, the increasing incidence of surgeries in them
to save patients lives and impossibility to operate on
the heart without a number of manipulations on the
aorta, especially on its ascending part, the lack of
morphological and physiological reasons of developing
complications, the need to analyze the data of previous
studies again is evident. In our opinion, the main subjects
are regional specific features of vascularization, ways
of lymph drainage of the heart and aorta, as well as
localization of vascular reflexogenic zones.
Literature review. It should be noted that the
same structures are named differently by authors when
the morphology of the aorta is described, that is the
terminology is imperfect. So, the bulb of aorta is named
dilated first part of the aorta containing the aortic
semilunar valve and the aortic sinuses, in some works
(i. e. the American Heritage ® Medical Dictionary
by Houghton Mifflin, 2010), it is distal extension of
the ascending aorta before the arch, in other works
(Ruggero De Paulis, 2006, 2009). The last decade is
marked by an increasing interest in fat pads of the heart
and aorta that contain, in the opinion of some authors,
nerve conductors important for the heart activity. One
group of authors describe fat pads of the heart, the other
group describe the aortic ones [13–18], and the third
group describe the epicardial fat pads [34, 35], though
they all are located under epicardium. This confusion
in terminology inhibits the fast implementation of
morphological data into practice.
The description of fat pads on the ascending
aorta is a concrete example. Subepicardial pad of
the aorta were first described by German pathologist
Rindfleisch in 1884. In his opinion this structure is
necessary during the heart systole and it stimulates
strengthening of the aortic wall. Taking into account
the clinical significance of this accumulation of fat
and the fact that it has not been studied by clinicians
for more than a century, we present the chronology of
published articles on the issue. Gross (1921) implies
the presence of relation between the state of the blood
vessel in this zone and coronary insufficiency. Davis
(1927), Smetana (1930), Robertson (1930) describe
anastomoses of the right and left coronary arteries in
this region. Parke and Michels (1966) add data on the
sources of blood supply of the ascending aorta and
its fold. They consider subepicardial fat pad of the
ascending aorta located on the line of the contact of
the edge of the right atrium and the aorta to a shock-
absorption structure. All authors state the presence
of the ascending aorta fat pad at the level where
aneurisms often develop, though the conclusions
are drawn on the basis of a limited number of cases.
As it was the time of experimental coronary artery
bypass grafting, they attempted to interpret functional
significance of this fat collection.
At the end of the XX century the interest of
cardiosurgeons in this region increased considerably.
In 1991 Israeli researchers G. Falkowsky, I. Dzigivker,
D. Bitran [6] and in 1999 F. Unger and W. G. Rainer
raised the issue of terminology of this anatomical
structure [31, 32]. Lebona (1993) describes its
macroscopic variants and later this author describes the
presence of the paraganglion in the aortic fat fold and
its microstructure [13, 14]. However, no other works
on the subjects were published and this fact can be
explained by smoothing of this fat pad in embalming of
dead bodies. On the other hand, the conclusion suggests
a weak interaction between pathologists and clinicians
in doing research.
Nowadays when open heart and aorta surgery has
become an everyday reality all over the world and
coronary artery bypass grafting has become a frequent
and effective technique to save lives of millions of
people. Clinicians are sounding the alarm as for a high
incidence of such postoperative heart complications as
atrial fibrillation and bleeding that require resternotomy
and a detailed study of the ascending aorta has become
an urgent need. Thus, the first decade of the XXI
century has been marked by a new interest in the
ascending aorta morphology and its significance.
British researchers J. J. Morrison, M. Gospodini,
C. Campanella (2003) point out at the ascending aorta
fat folds as a surgically significant structure [23]. In a
number of articles this morphological structure is called
enigma [22,32]. In 2004–2005 the journal «Clinical
Anatomy» expands the discussion concerning the
functional significance and terminology of the aortic
fat pad with the participation of Lindsay, C. H. John
[15], J. J. Morrison with coauthors [22], F. Unger [32,
33]. So, the transversal crest, aortic crest, aortic fat
pad, ascending fold, transversal fold, semilunar fold,
fat ring of the aorta, periaortic fat pad, Rindfleisch fat
fold represent a list of names of the same ascending
aorta fat pad that, according to new data, is of great
significance in monitoring the heart activity. Recently
a lot of articles have verified the fact that on lesion of
fat pad on the anterior surface of the ascending aorta
the risk of atrial fibrillation and fatal outcome increases
[1, 4, 5, 19, 36]. However, there are some fat pads on
the ascending aorta and, if illustrative data are not
available, it is very difficult to understand which of
them is meant and, consequently, it is not possible to
implement accumulated theoretical data into practice.
So, according to Zev Davis (2000), in case the
fat pad remains intact atrial fibrillation occurs in 7%
of patients and in case of its destruction — 27% [36].
The majority of researches explain it by intraoperative
destruction of nerve conductors that provide heart
innervation at the level of the ascending aorta and,
consequently, by the loss of vagus effect on the sinus
204
ОРИГИНАЛЬНЫЕ СТАТЬИ
node. Only Lupinsky [18] in his works suggests the idea
of the impairment of the ways of heart lymph drainage
as the factor that leads to this complication.
Up to now the issue the aorta lymphatic net has not
drawn much attention of pathologists and clinicians.
Data on the intraparietal lymphatic net obtained three-
four decades ago and based on the injection methods
are contradictory and they do not depict its regional
specific features. In some articles the lymphatic nets
of the aortic wall are described, other articles affirm
their presence only in the paraaortic cellular tissue. We
have not managed to find any data on lymph drainage
from the heart and aorta based on modern methods of
investigation.
Data on the innervation of the aorta are constantly
supplemented [30, 31]. All articles on the reflexogenic
zones of blood vessels state their presence in the
region of the carotid sinus and aortic arch [11].
V. N. Chernigovsky (1944) asserts in his articles that
angioreceptors are present throughout the vascular
system, but their accumulations are located on the wall
of the aorta, pulmonary circulation vessels and in the
carotid sinus. In many articles particularly sensitive
areas of the arch are not specified, that is the whole
area of the aorta is considered as the area of marked
hemo- and baroreception. In some articles the area of
the arch in the point of origin of the subclavian artery
is specified, in other articles — the amyous areas on
the anterior surface of the arch (T. A. Grigorieva, 1948,
1954) near the point of arterial ligament attachment,
at the base of the brachiocephalic trunk and bronchial
branches.
The opinion on the depth of location of sensitive
nerve endings in the aortic wall differ [2, 3, 9, 12,
16, 20, 29]. So, A. Abraham (1950, 1953, 1961,
1963) notes the absence of baroreceptors in the aotric
media. In the same years A. V. Babaskin (1952, 1953)
and later B. M. Smolkina (1967) describe the single
nerve plexus of the middle layer of the aortic wall.
The majority of authors describe baroreceptors in the
form of compact and diffuse clusters and terminal
reticulated plates. I. Slepkov (1952, 1953) described
in the articles not only the above mentioned forms
but encapsulated nerve endings of Krause bulb type
as well he did not highlight the issue of the existence
of certain reflexogenic zones in the aortic wall. The
availability of this type of receptors in the aortic
wall is confirmed in the works of Heisman (1966).
The opinions of localization of hemoreceptors are
also diverse. The studies of pathologists Penitschka
(1931), Palme (1834), Nonidez (1935, 1937) and Boyd
(1937) showed the presence of cells identical to the
carotid glomus in the aortic arch. Penitschka describes
paraganglion aorticum and later — paraganglion
aorticum supracardiale between the aorta and the
pulmonary trunk. Iulius H. Comroe (1939) proved in
experiments on animals the presence of hemoreceptors
on the ascending aorta, pulmonary trunk and proximal
arch area adjacent to it and their blood supply through
the branches of the aorta. The author did not reveal
any hemoreceptors in adult animals and pointed out
an individual variability these receptor structures.
I. H. Comroe and Addison (1938) proved the presence
of glomus cells accumulations in the adventitia of
small aortic branches within 1 mm of their origin. The
interest of pathologists in reflexogenic areas of the
heart and aorta in the 50–60s of the XX century is clear
as it was the period of experimental and later clinical
heart transplant. N. M. Bykov (1951) described the
nodule 1–2 mm in diameter located between the aortic
arch and the point of bifurcation of the pulmonary
trunk. Small branches of the pulmonary trunk supply
the nodule with blood and those of the aorta do not
participate in its blood supply. Later E. B. Heisman
(1966) presented opposed data on vascularization
of the aortic reflexogenic area. Speaking about
hemoreception Heimans and Neil (1958) point out
aortic paraganglia. According to William J. Crause
paraganglia are located in some vascular areas: the
point of branching off of the left subclavian artery and
the corner between the right common carotid artery
and the right subclavian artery. Christopher Edwards
and Donald Heath (1960) described multiple glomus
structures around the heart and large blood vessels,
one of which, according to their data, is constant.
It is located on the dorsal surface of the point of
bifurcation of the pulmonary trunk and is supplied
with blood through its branches. The descriptions of
this glomus by other authors are very contradictory.
For instance, Becker (1966) considers it to be one of
the coronary glomuses and it is supplied through the
branches of the coronary artery. E. W. Kienecker and
H. Knoche (1978) using fluorescent method for the
determination of catecholamines demonstrated the
subendothelial location of the terminal adrenoceptive
endings in rabbits, their limited number in relation
coronary glomus cells of type I. These authors affirm
that sympathetic innervation of the ascending aorta is
weaker in comparison with the pulmonary trunk and
its own vasa vasorum.
From the 80s to the beginning of this century
the interest of researches in baro- and hemoreceptors
decreased, but successes in cardiosurgery in recent
years and increased requests for morphological data on
the heart and aorta dictate the need for further research
in this field.
Despite the great number of works on the aorta
glomus structures, there is no consensus on their
location so far. According to The American Heritage
and Stedman’s Medical Dictionary (2002) these small-
sized attach to the aortic arch being bilateral in relation
to its small branches. In one of the articles of Piskuric
et al. (2011) the presence of hemoreceptors of the aortic
arch was proved on the basis of immunofluorescent
205
ТАвРИЧЕСкИЙ мЕДИкО-бИОЛОГИЧЕСкИЙ вЕСТНИк2013, том 16, №1, ч.2 (61)
investigation of aortic glomuses in ducks. Jonathan
Balcombel et al. (2011) developed a classification of
the aortic glomuses:
1) coronary, located at the base of the arteries of
the same name;
2) pulmonary, located between the aortic arch and
pulmonary trunk;
3) subclavian, in the angle formed by the subclavian
artery and the aortic arch.
Results of the study and discussion. Numerous
studies of subjects at the macroscopic, mesoscopic and
microscopic levels and a wide range of used methods,
including immunological investigations, expand
knowledge of the morphology of the ascending aorta
and its fat pads in particular.
According to our observations on the ascending
aorta there are several subepicardial fat pads:
1) anterior, located in the anterior aortopulmonary
groove;
2) posterior, placed in the posterior aortopulmonary
groove;
3) coronary, at the base of both coronary arteries;
4) transversal, at the level of the contact of the edge
of the right atrium with the aorta.
As their form, the degree of manifestation,
localization and functional significance are diverse and
none of the terms used expresses the essence, shape, and
location, they will be called anterior, posterior, coronary
fat pads. That transversal will be termed as Rindfleisch
fat pad ((RFP), as a tribute to the first researcher of fat
fold of ascending aorta. Special interest in the latter is
due to its clinical significance.
Proximally to the pad the introduction of
aortic cannula and clamping are carried out during
heart surgery. At the level of the pad antegrade
cardioplegia and catheterization are done to perform
cardiopulmonary bypass and proximal coronary
bypass. Often the pad is removed during surgery to
facilitate access and to simplify medical manipulations
on the ascending aorta. All authors of articles on RFP
state its location on the anterior surface of ascending
aorta. It is possible to come to such a conclusion on the
basis of a limited number of observations, but having
studied over 400 subjects we made sure that it is true
in 79% of cases. Thus, in some cases RFP occupies
the anterior surface of ascending aorta, in other —
the anterior and right ones and in the third group of
cases it comprises and a part of its posterior surface.
According to our observations in 21% of cases this
fat pad is not market on the anterior surface, but it is
well developed only on its right or posterior semicircle
(Fig. 1, p.8). The fat pad can be in the form of a strip
(p.1); cylinder (p.2); crest (p.3; fold (p.4); pad (p.5
and 6); ramified and it can also be of a combined form:
strip-pad, cylinder-pad, etc.
The other authors’ typical inexactitude in the
description of RFP is the statement of its location
at the base of the aorta. The base of the aorta is
covered with the pulmonary trunk and the atrium,
but RFP is located on the base of the visible part of
Fig.1. variants of the rindfleisch fat pad (h). 1- strip; 2- cylinder; 3- crest; 4- fold; 5- oval; 6- spherical;
7- branched; 8- fat pad on the posterior surface of the aorta; 9,10- combined
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ОРИГИНАЛЬНЫЕ СТАТЬИ
the ascending aorta. According to our data, the level
of location of this structure is variable: frequently it
is placed between the proximal and middle thirds of
the ascending aorta; in 30% of cases — between its
inferior 2/5 and superior 3/5; in 12% of cases — in
its midpoint. And, finally, the lowest level is above
the proximal 1/6 of the AA. The correspondence
of RFP location and the contact point of the edge
of the right atrium and aorta remains constant. The
degree of pad accumulation does not correspond to
the general level of fat storage in the body. In some
cases we observed underdeveloped fat pads in the
III-rd grade of obesity, and vice versa, a marked fat
pad in cachexia. It will be more exactly to note the
relationship between RFP and the development of
the right atrium. The following data support the our
point of view. Fat pads are not infrequently more
marked in the prenatal period than in the postnatal
one (atria are known to be developed relatively better
in the fetuses). In case of right atrium hypertrophy
fat storage is more considerable.
It would not make sense to mention these obvious
facts if not applied clinical importance of this fat
accumulation and a close relationship between its form
and the nature of the vascular net (Fig.2). We developed
recommendations on the type of fat pad in operations
that provide direct or indirect manipulation of the
AA. The recommendations contribute to an individual
approach to select the location of place of incision.
This, in its turn, allows to prevent drug-free the most
frequent complications in cardiosurgery, such as atrial
fibrillation and bleeding. Medicines used to treat these
complications are not very effective and they often
produce side effects. Such treatment is administrated
to all patients without exception, though there is risk of
complications no more than 40% of them. In the best-
known guides for surgeons, books for medical students
and postgraduate students the phenomenon of fat pads
of the ascending aorta is not mentioned.
A number of regional specific features of the
blood supply of the AA was revealed by means of
injection of colored gelatin into the AA through the
brachiocephalic trunk. The sources of the blood supply
of the AA can be divided into two groups: ascending
and descending. According to our data the branches of
both coronary arteries refer to the first group, though
other authors affirm the participation only of one of the
two. The branches of the bronchial arteries and artery
accompanying the vagus branch to the heart are related
to the second group. This subject is described in articles
of many researches [7, 8, 24, 25, 26, 27, 28]. All above
mentioned vessels are located along the axis of the
ascending aorta. Against this background we should
note the fact that at the level of RFP all large blood
vessels and nerve trunks are transverse to the axis of
aorta. Other vessels with transversal direction that are
branches of the coronary arteries are revealed at the
base of the aorta on the line of fixation of the leaflets
of the aortic semilunar valve.
Transverse arteries of RFP, in contrast to other vasa
vasorum aortae, are the internal ones, i. e. they do not
begin outside the wall of aorta, they branch off and
ramify in the adventitia of the subepicardial AA area.
Their origin is on the concave side of the ascending
aorta, normally 1–1,5 cm above RFP and their number
ranges from 1 to 7. As a rule, one or two of them are
directed obliquely: downward and to the right and they
participate in the formation of an abundant vascular net
of the given fat pad anastomosing with other vascular
sources (Fig.3).
Fig.2. a – rindfleisch spherical fat pad; B – external layer of the ascending aorta wall coloured by
reagent schiif. 1- the anterior semicircle of the aorta; 2- the posterior semicircle of the aorta; 3- the net
of anastomoses; 4- vasa vasorum internae
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Cases of profuse postoperative bleedings in this
area are substantiated by a great abundance of blood
vessels in comparison with other areas of the aorta on
the whole, on one side, and by a high blood pressure
in these vessels, on the other side. The presence of
valve is a characteristic feature of the RFP veins. It
is, apparently, an adaptation of vessels to complex
hemodynamic conditions of the ascending aorta
required to prevent reflux.
Paraganglia are an important component of RFP.
There are a lot of data on the paraganglion of the
abdominal aorta, that is known as Zuckerkandl organ.
In a number of articles on paraganglia located in the
connective tissue between the aorta and pulmonary
trunk they are called upper and lower supracardial
paraganglia. The first description of the microscopic
structure of the paraganglion of the ascending aorta
belongs to Lebona, a researcher from Republique of
South Africa [14].
Our data show a striking similarity of the
ascending aorta paraganglion and the glomus of the
carotid reflexogenic area (Fig.4): the same two types
of cells and an abundant vascular net. As a rule, the
paraganglion is not single, it is penetrated by one of
the branches of ascending aorta vasa vasorum internae
through the center. Moreover, there are small but
numerous subepicardial accumulations of chromaffin
cells. These facts suggest the presence of hemoreceptor
area of the ascending aorta.
In RFP are numerous nerve trunks that contain
intratrunkal neurons, free and incapsulated nerve
endings with the functions of baroreception.
The trajectory of the intraparietal arterial vessels
of the aorta differs in its different parts. Numerous
vascular loops elongated a little along the axis of the
aorta are formed in the adventitia of the convex surface
of the arch. In the lower concave area of the arch there
are small branches of the bronchial arteries ascending
to the anterior and posterior semicircles of the aorta.
The presence of segmental contralateral anastomoses
is characteristic of the descending aorta and it should
be taken into account in determination of an operative
access in spondylectomy.
In availability of diverse regional specific features
of blood supply of the aorta is obviously due to
complexity of ontogenesis of the aorta (the availability
of many sources of development) and the difference of
hemodynamic conditions along the main arterial vessel
of the human body. Thus, the bulb of the aorta, that
derives from the arterial trunk, is supplied with blood
through branches of the coronary arteries; the supply
of the distal ascending aorta and a larger part of the
aortic arch that originate from the aortic sac, is provided
from the brachiocephalic trunk and vasa vasorum
internae. The concave part of the arch, formed from
the fourth aortic arch, is supplied from the branches of
the bronchial and mediastinal arteries. The descending
aorta originates from the dorsal aorta and it is supplied
from the branches of intercostal and lumbar arteries.
The arterioles of adventitia of the ascending aorta
acquire a sinusoidal trajectory with age that can be
considered as a protective mechanism in excessive
tension of the aortic wall during systole. This
characteristic becomes more marked at the age over 50.
Fig.3. Mesoscopic aspect of vascular sources of
the rindfleisch fat pad. 1- vasa vasorum internae
aortae; 2- branch of the left coronary artery; 3-
branch of the right coronary artery; 4- аnаstomosis
between both coronary arteries; Н- аnаstomoses
between descending and ascending sources of
blood-supply
Fig 4. cross-section of the paraganglion located in
the rindfleisch fat pad
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ОРИГИНАЛЬНЫЕ СТАТЬИ
The venous net of all parts of the aortic wall is
formed deeper than the location of the arteries. Venous
adventitial plexus of AA is formed 1–1,5 cm proximal
of the aortic arch. Drainage is carried out in two
longitudinal veins (one is on the anterior surface and the
other is on the posterior surface of the aorta) 140–150
µ in diameter with plenty of transverse anastomoses.
These veins flow into the tributaries of ventricular veins
of the heart located at the base of the aorta.
Intramural vessels are of great importance in
the functioning of each organ, including the aorta.
We studied the formation of the aortic blood stream.
Isolated blood vessels in the paraaortic connective
tissue were revealed in a 5-week embryo. In 1–1,5
week vessels in the adventitia of all divisions of the
aorta develop. In the following weeks the intensity
of vasa vasorum in the proximal part, i. e. on the
ascending aorta, is higher. The development of
vessels occurs later with distance from the heart.
As a result, in 7–8 weeks there are 7–8 vessels in
the AA adventitia, whereas in the abdominal part —
only 3–4 vessels. This tendency continues within the
whole intrauterine period. No vessels were revealed
in the middle layer of the aortic wall in a 9-week
embryo. Several blood vessels were revealed in the
AA media in a 10-week embryo. Blood vessels are
revealed in the thoracic aorta in a 17–25-week fetus.
The regularity of a greater provision with vessels of
the proximal areas of the aorta than of those distant
from the heart is also observed in the middle layer.
In the adventitia of a newborn there is a developed
intramural vascular net of the aorta with the branches
that grow into the outer layers of the aortic media.
According to the data of researchers vasa vasorum
of the aorta develops faster in the embryonic period
and the period of growth (Clarke J.A, 1966; Gossl M.,
2004). It should be noted that internal vasa vasorum
of the AA can be seen with the naked eye under the
epicardium of a 16-week embryo. The development of
the RFP also occurs in the later stages in comparison
with the other areas of the aorta. There are many issues
of clinical medicine on the morphology of the aorta.
Thus, the poorest vasculature is characteristic of two
areas of the aorta adjacent to the aortic arch: the distal
area of the ascending aorta and proximal area of the
descending thoracic aorta. It should be noted that these
are the areas where dissecting aneurisms of the aorta
develop (M. E. De Bakey, 2000). Is it a coincidence
or regularity?
Despite advances in the prevention of aortic
atherosclerosis the problem of affection of this vessel
remain s unsolved. Observation of more than 200 cases
with the definition of the thoracoabdominal index of the
aorta (diameter ratio of the proximal and distal areas
of the descending aorta) showed that the severity of
pathological process depends directly on its index, i. e.
a sharp narrowing of the aorta develops hemodynamic
conditions contributing to a faster development of
disease than a smooth one.
What factors does the shape of the largest blood
vessel depend on? Is it possible to influence the
morphogenesis of the aorta?
Data on the lymphatic apparatus of the aorta are
incomplete and they are not systemized. Comparative
regional data are not available. There are no reliable
sources that confirm or refute the information obtained
by researches in the last century.
On the basis of our study on the mesoscopic level
with the use of coloring reagent Schiff the trajectory of
the large lymphatic collector providing drainage from
the sinus area was described in addition to revealing of
lymphatic vessels in the aortic adventitia. In our opinion,
its lesion in surgery causes atrial fibrillation. The fact that
this complication develops in 2–3 days after the surgery
and not immediately is the proof of that. Consequently,
lymphostasis leads to this dangerous complication.
Here we can answer the question why atrial fibrillation
develops not in all patients in the impairment of fat pad
integrity. There are two reasons that:
1) individual specific characteristics of drainage
(only in 60% of persons the lymph outflow from the
right atrium occurs on a large collector, in the rest — on
the net of lymphatic vessels, which injury does not lead
to stasis in the sinus area as the lymph passes through
collaterals);
2) choice of the site of incision of the ascending
aorta in above mentioned surgical manipulations (injury
of the lymph collector, which trajectory was described
by us in other articles, should be avoided).
Our data on the presence of a large drainage trunk of
the right atrium on the anterior surface of the ascending
aorta confirm the data in the previously published work
of Golab [10]. Along with it, we were the first to reveal
the presence of subepicardial lymphatic nodules that
are regional for the sinus node area.
As for the receptor apparatus of the aorta, it is very
diverse, along with nerve endings in the form of tendril,
loose or dense bushes and incapsulated ones as well.
The latter ones were noted in RFP in all cases.
In our opinion, regularity of the presence of these
pressoreceptors in this area of the aorta is not random.
Multiple nerve nodules were revealed on the anterior
surface of the AA attached to the pulmonary trunk.
Not a few of nerve nodules are located on the posterior
surface of the aorta close to the pulmonary trunk, but
their number and size are smaller.
While studying all the areas of the thoracic portion
of the aorta we have not managed to reveal such
combination of specific characteristics of vascular,
lymphatic and nervous apparatus as in the area of RFP.
These observations suggest this anatomical structure to
be a reflexogenic area of the aorta.
Thus, a sparing approach to RFP during surgery is
one of the conditions for success.
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CONCLUSIONS
Separate parts of the vascular bloodstream and
lymphatic apparatus of the aorta not known before were
revealed for the first time.
Our data, supplementing information on the
nervous apparatus, vasa vasorum and the aortic lymph
drainage ways, allowed to reveal reasons of some
postoperative complications and ways to prevent
them.
New findings on the nervous apparatus of the aorta
promote better understanding of the mechanisms of
self-regulation of the cardiovascular system.
Obtained knowledge of regional specific
characteristics of the aorta can be implemented in
selecting a mini-access in surgery on different areas
of the aorta.
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