Anatomy - Open TEA of the left carotid bifurcation with patch angioplasty and temporary intraluminal shunt

Anatomy Perioperative management Technique Complications Evidence Total Video

Common carotid artery

Origin	left: aortic arch right: brachiocephalic trunk
Course	ascending behind the sternocleidomastoid muscle within the carotid sheath
Division	Carotid bifurcation (Bifurcatio carotidis): Division into internal carotid artery and external carotid artery
Vascular territory	1. Internal carotid artery Brain Eye Forehead Anterior nasal cavity 2. External carotid artery Extracranial structures of the head and neck

Internal carotid artery

Origin	Branch of the common carotid artery (carotid bifurcation)
Course from caudal to cranial	1. Cervical part Section between origin of the common carotid artery to the skull base entry into the cranial cavity via the carotid canal gives off no branches 2. Petrous part runs in the petrous bone small branches to the tympanic cavity and pterygoid canal 3. Cerebral part runs in the subarachnoid space passes through the dura mater Branching into anterior cerebral artery and middle cerebral artery Anterior cerebral artery communicates via the anterior communicating artery with the contralateral anterior cerebral artery

Origin

Branch of the common carotid artery (carotid bifurcation)

Course from caudal to cranial

1. Cervical part

Section between origin of the common carotid artery to the skull base
entry into the cranial cavity via the carotid canal
gives off no branches

2. Petrous part

runs in the petrous bone
small branches to the tympanic cavity and pterygoid canal

3. Cerebral part

runs in the subarachnoid space
passes through the dura mater
Branching into anterior cerebral artery and middle cerebral artery
Anterior cerebral artery communicates via the anterior communicating artery with the contralateral anterior cerebral artery

The circle of Willis is an arterial vascular ring at the base of the brain, which serves the blood supply of the brain. It is composed – from anterior to posterior - of the following vessels:

Anterior communicating artery (unpaired)
Anterior cerebral artery (left and right)
Internal carotid artery (left and right) or its direct continuation, the middle cerebral artery
Posterior communicating artery (left and right)
Posterior cerebral artery (left and right, both from the basilar artery).

However, there are numerous variants in the formation of the circle regarding the caliber of the branches and the connections (hypoplasias of individual branches or even agenesis of partial sections). This is clinically relevant for collateral supply in stenoses.

External carotid artery

The supply areas of the external carotid artery can be divided into four groups depending on location: anterior, middle and posterior group as well as terminal branches.

1. Anterior Group

Branches (cranial → caudal)	Branches	Supply
Superior thyroid artery	Infrahyoid branch Cricothyroid branch Sternocleidomastoid branch	corresponding muscles
	Superior laryngeal artery	Inner side of larynx
	Glandular branches	Thyroid gland
Lingual artery	Suprahyoid branch	Hyoid bone
	Dorsal lingual branches	Dorsum of tongue
	Sublingual artery	Sublingual gland
	Deep lingual artery	Tip of tongue
Facial artery	Ascending palatine artery	soft palate tonsils pharynx
	Submental artery	Submandibular gland suprahyoid muscles
	Inferior labial artery	Lower lip
	Superior labial artery	Upper lip
	Angular artery	medial canthus

2. Middle Group

Branches (cranial → caudal)	Branches	Supply
Ascending pharyngeal artery	Pharyngeal branches	Pharynx
	Inferior tympanic artery	Tympanic cavity
	Posterior meningeal artery	Dura mater

3. Posterior Group

Branches (cranial → caudal)	Branches	Supply
Occipital artery	Mastoid branch	Mastoid cells
	Occipital branches	Occipital region
	Meningeal branch	Dura mater
Posterior auricular artery	Auricular branch	external ear
	Occipital branch	Occipital region
	Stylomastoid artery	Facial nerve Tympanic cavity Mastoid cells
	Posterior tympanic arteries	Tympanic cavity Mastoid cells
	Pharyngeal branches	Pharynx
	Parotid branch	Parotid gland

4. Terminal branches

Branches (cranial → caudal)			Supply
Superficial temporal artery	Transverse facial artery		Face
	Zygomatico-orbital artery		lateral canthus
	Middle temporal artery		Temporal muscle
	Frontal branch		Scalp
Maxillary artery	Mandibular part	Deep auricular artery	Temporomandibular joint external auditory canal
		Anterior tympanic artery	Tympanic cavity
		Inferior alveolar artery	Teeth Mandible Mylohyoid branch: floor of mouth Mental branch: chin
		Middle meningeal artery	Meninges
	Pterygoid part	Masseteric artery	Masseter muscle
		Pterygoid branches	Pterygoid muscles
		Deep temporal arteries	Temporal muscle
		Buccal artery	Buccinator muscle
	Pterygopalatine part	Posterior superior alveolar artery	Teeth Maxilla
		Infraorbital artery	Maxilla
		Descending palatine artery	Tonsils soft palate
		Sphenopalatine artery	Nasal cavity Nasal septum
		Artery of pterygoid canal	Pharynx Tympanic cavity

Venous Systems

Superficial and deep venous systems unite in the venous angle ("venous angle") to form the V. brachiocephalica and empty into the V. cava superior.

1. Superficial Veins

V. jugularis externa

runs in the lateral neck area covered by the platysma
penetrates the superficial lamina of the cervical fascia
empties into the venous angle, possibly even earlier, into the V. jugularis interna, then into the V. cava superior

V. jugularis anterior

usually runs over the M. sternocleidomastoideus
Vv. jugulares anteriores of both sides usually unite in the suprasternal space to form the jugular venous arch
empties into the venous angle or into the V. jugularis externa

2. Deep Veins

V. jugularis interna

see below

V. subclavia

Continuation of the V. axillaris
runs in front of the M. scalenus anterior
empties together with the V. jugularis interna in the venous angle and forms the V. brachiocephalica → V. cava superior

V. jugularis interna

Origin	arises extracranially through the confluence of the sigmoid sinus and inferior petrosal sinus begins as the superior bulb of the jugular vein passes through the skull base in the jugular foramen
Course	runs parallel to the A. carotis communis within the carotid sheath meets with the A. subclavia in the venous angle → V. brachiocephalica
Tributaries (cranial → caudal)	V. ophtalmica superior V. facialis V. retromandibularis Plexus pterygoideus Vv. pharyngeales V. lingualis V. thyreoidea superior et mediae V. sternocleidomastoidea
Drainage Area	entire brain face thyroid gland

Lymphatic vessels
The lymphatic drainage of the head and neck drains into the paired jugular trunks.
Left jugular trunk
- Drainage area: left half of the head and neck
- Empties into: Thoracic duct
Right jugular trunk
- Drainage area: right half of the head and neck
- Empties into: Right lymphatic duct

Nervous System

1. Cervical Plexus - predominantly motor innervation

Nerve	Segments	Course/Special Features	motor innervation	sensory innervation
Cervical Ansa	Superior Root: C1, C2 Inferior Root: C2, C3	Superior root parallel with hypoglossal nerve	Geniohyoid muscle infrahyoid musculature	Ø
Phrenic Nerve	C3 - C5	runs on anterior scalene muscle in the mediastinum between mediastinal pleura and pericardium to the diaphragm	Diaphragm	Pericardial branch: Pericardium Mediastinal pleura Diaphragmatic pleura Phrenicoabdominal branch: Peritoneum on the underside of the diaphragm Peritoneum of the gallbladder
Sternocleidomastoid branch	C1 - C3	forms plexus with branches of the accessory nerve (XI)	Sternocleidomastoid muscle (together with XI)	Ø
Trapezius branch	C2 - C4		Trapezius muscle (together with XI)	Ø

2. Cervical Plexus - purely sensory innervation

Nerve	Segments	Course, Special Features	Innervation
Lesser Occipital Nerve	C2, C3	runs dorsal to the sternocleidomastoid muscle	lateral occiput
Great Auricular Nerve	C2, C3	crosses over the sternocleidomastoid muscle	Skin below the auricle
Transverse Cervical Nerve	C2, C3	crosses over the sternocleidomastoid muscle Superior branch: forms anastomosis with cervical branch of facial nerve	anterior neck region
Supraclavicular Nerves	C3, C4	fan-shaped course towards clavicle	Clavicle upper chest region Shoulder

3. Sympathetic Nervous System

Sympathetic Ganglion	Special Features	Nerve Branches, Innervation
Superior Cervical Ganglion	Level of C2/3 Branches run predominantly periarterially	Jugular nerve → glossopharyngeal nerve and vagus nerve Internal carotid nerve → deep petrosal nerve External carotid nerves → salivary glands Laryngopharyngeal branches → pharyngeal plexus Superior cervical cardiac nerve → cardiac plexus Fibers to the pineal gland
Middle Cervical Ganglion	variable location, not always present	Middle cervical cardiac nerve → cardiac plexus
Inferior Cervical Ganglion	often united with the first ganglion of the thoracic sympathetic trunk to form the stellate ganglion	Inferior cervical cardiac nerve → cardiac plexus Vertebral nerve → sympathetic fibers to the cranial nerves Subclavian ansa → connection between inferior cervical ganglion and middle cervical ganglion in fusion to stellate ganglion → sympathetic fibers to sweat glands and skin vessels of the upper extremity