Prior to the development of tracheal surgery, detailed description of the arterial blood supply of the trachea was unknown. Using radiographs of injected specimens of the human trachea, Miura and Grillo showed that blood supply of the cervical trachea originates from the inferior thyroid artery in a variable pattern (Figure 1-8).15 The blood supply enters the trachea through lateral tissue pedicles in segmental fashion throughout the trachea. Complete description of the entire tracheal blood supply was made by Salassa and colleagues (Figure 1-9).16
The upper half of the trachea is supplied in most cases by three tracheoesophageal branches of the inferior thyroid artery (see Figure 1-8A). The first branch supplies the lower cervical trachea with no or minor contributions to the esophagus. The second supplies the middle section of the cervical trachea, and the third the upper section. Both of these branches contribute to esophageal blood supply. The tracheal branches pass either anterior or posterior to the recurrent laryngeal nerves or both. The pattern varies, and there may be only one or two arteries. One or other artery may predominate (see Figure 1-8B). In 2 of 17 specimens studied, the lower cervical trachea was supplied instead by a branch originating from the sub-clavian artery (see Figures 1-8Ad,Ae). The superior thyroid artery does not give direct branches to the trachea, but it does anastomose with the inferior thyroid artery and also contributes with fine branches running from the thyroid isthmus to the adjacent tracheal wall.
The bronchial arteries provide consistent blood supply to the carina and lowermost trachea (see Figure 1-9).16 An anterior branch of the superior bronchial artery originates from the right side of the aorta posteriorly. This branch usually travels over to the proximal left main bronchus to the anterior carina. The principal and posterior branches of this vessel pass behind the esophagus to the right main bronchus. One of these branches may arise from a supreme intercostal artery. The middle bronchial artery courses around the medial aspect of the left bronchus and anastomoses at the carina with the superior bronchial artery or higher tracheal vessels. The inferior bronchial artery appears to supply chiefly the left bronchial tree. The left main bronchus is most often supplied by two left-sided aortic branches. Bronchial artery patterns are very varied (Figure 1-10).17 Flow in bronchial arteries after main bronchial artery division is given detailed consideration in Chapter 44, "Airway Management in Lung Transplantation." These considerations apply in carinal resection and reconstruction, although not as critically as in lung transplantation.
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