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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| Опубліковано в: : | Таврический медико-биологический вестник |
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| Дата: | 2013 |
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Кримський науковий центр НАН України і МОН України
2013
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| Назва журналу: | Digital Library of Periodicals of National Academy of Sciences of Ukraine |
| Цитувати: | 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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Digital Library of Periodicals of National Academy of Sciences of Ukraine| _version_ | 1859481126636093440 |
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| author | Hachina, T. |
| author_facet | Hachina, T. |
| 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. |
| collection | DSpace DC |
| container_title | 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.
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.
|
| first_indexed | 2025-11-24T14:12:43Z |
| format | Article |
| 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
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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
206
|
| id | nasplib_isofts_kiev_ua-123456789-76379 |
| institution | Digital Library of Periodicals of National Academy of Sciences of Ukraine |
| issn | 2070-8092 |
| language | English |
| last_indexed | 2025-11-24T14:12:43Z |
| publishDate | 2013 |
| publisher | Кримський науковий центр НАН України і МОН України |
| record_format | dspace |
| spelling | Hachina, T. 2015-02-10T06:29:49Z 2015-02-10T06:29:49Z 2013 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 https://nasplib.isofts.kiev.ua/handle/123456789/76379 611.132 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. en Кримський науковий центр НАН України і МОН України Таврический медико-биологический вестник Оригинальные статьи Carrent issues of the aortic functional morphology Актуальні питання функціональної морфології аорти Актуальные вопросы функционал ьной морфологии аорты Article published earlier |
| spellingShingle | Carrent issues of the aortic functional morphology Hachina, T. Оригинальные статьи |
| title | Carrent issues of the aortic functional morphology |
| title_alt | Актуальні питання функціональної морфології аорти Актуальные вопросы функционал ьной морфологии аорты |
| 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 |
| title_short | Carrent issues of the aortic functional morphology |
| title_sort | carrent issues of the aortic functional morphology |
| topic | Оригинальные статьи |
| topic_facet | Оригинальные статьи |
| url | https://nasplib.isofts.kiev.ua/handle/123456789/76379 |
| work_keys_str_mv | AT hachinat carrentissuesoftheaorticfunctionalmorphology AT hachinat aktualʹnípitannâfunkcíonalʹnoímorfologííaorti AT hachinat aktualʹnyevoprosyfunkcionalʹnoimorfologiiaorty |