DIP Episode 91 - USMLE Anatomy Series 3 (Vascular Anatomy)

Okay folks welcome my name is divine and PGY1 transitional year resident that's going into radiology.

This will be the 91st episode of the Divine Intervention Podcasts and in this episode I'm going to continue a USM Lian madame series right so we've had like one we've had one we've had a series one and two this will be series three and really into this series this is basically an off-the-coff lecture but this will be a vascular anatomy lecture this is a floridly high-yield lecture for the USML is step one exam okay I am going to try to discuss basically like high-yield vascular anatomy in the brain high-yield vascular anatomy in the GI tract and high-yield vascular anatomy in the chest okay that'll be my focus low extremities I guess I could talk about that later at some later time or today who knows let's see how long this goes this is off-the-coff this is not really planned but I just have certain like general ideas I want to get through but again I promise you this will be a super super super super high-yield lecture for your exam if you're taking step one you need to make sure you know everything in this podcast and I'll encourage you as I give this lecture pause frequently make diagrams okay rejure these things many times go very multiple times it's kind of info dense but again I'll try to introduce like high-yield integrations as we go along so let's start with the brain okay so the brain right obviously the big big big vessel you want to know about is the I guess system of blood vessels and really today I will really be spending time talking about arteries I guess I could have a electron veins down the line but I will say some venous stuff as well so first I will guess I'll talk about the circle of willets right circle of willets you need to know for your test there are many different ways this can be tested on exams right so remember the circle of willets right so if we sort of start with the vertebral arteries right remember the vertebral arteries is a branch

of the subclavian artery and basically right so the vertebral arteries they sort of pair up together and from the basal artery right so prior to pairing up together right don't forget that those vertebral arteries both give off paica right so the posterior inferior cerebellar artery and then those vertebral arteries also together give off the anterior spinal artery remember the anterior spinal artery supplies the anterior to thirds of the spinal cord right so basically a person can have an anterior spinal artery syndrome where they basically knock out every tract in the brain with the exception of the dorsal columns in the back right in the dorsal part of the spinal cord so that's why that's kind of high you to know and I guess while I'm mentioning that we can give you this question on the US Emily's that sort of released to a person getting like a triple ear repair right so like an abdominal aortic aneurysm repair remember that the abdominal aorta in some circumstances gives rise to something known as the artery of a dangoids and the artery of a dangoids supplies some parts of the anterior part of the spinal cord so if you basically get a question about a patient that is paralyzed like has like a paralysis after getting a after getting a triple ear repair you want to think about an infarction of the artery of a dangoids that's actually very high you to know for the US Emily step one example and then if you continue on with the circle of willis right so we have the anterior spinal artery you have pica right so the posterior inferior cerebellar artery remember the posterior inferior cerebellar arteries supplies the lateral middala right so I believe this is potentially what's known as Wallenberg syndrome so if you have a pica infarct you have symptoms that look alive so the lateral middala right so for example the person will have issues with like crinion nerve 9 crini

on nerve 10 crinion nerve 11 crinion 12 right so like your glysofarin germ nerve your vegas nerve your your spinal accessory nerve right on your hypoglycer nerve so they'll have like tongue issues they will have issues with like shrugging their shoulders because their sternoclydo mastol is all screwed up they'll have issues with swallowing right because they have vegas and glysofarin germ nerve is all screwed up right and remember that in addition to that right remember the things that run in the lateral brain stem like the like the hypothalamus spinal tracts that basically deals with like your sympathetic nervous system they'll have like an itsylateral hunger syndrome right so because remember I remember from the neuro early neuro podcast I said that I guess the more recent your podcast I talked about how your autonomic nervous system and effects that's in the hypothalamus right and that path we actually kind of runs in the lateral brain stem so you can have a unilateral hunger syndrome with that that'll be an example of a central hunger syndrome and then these patients will have a contra lateral pain and temperature loss thing going on right because remember your spinal phalamic tract right sort of start runs in the lateral brain stem okay so that's how you can sort of localize a pica infact right there and then don't forget after those two vertebral arteries excuse me they come together from the bazzlar artery right the bazzlar artery and the bazzlar artery one of its main branches is aica right so the anterior inferior cerebellar artery so the anterior inferior cerebellar artery basically supplies the lateral ponds right so you have like a lateral pontein syndrome right so basically their cranial seven will be all screwed up right so they'll have like a like a belt's palsy right cranial eight would also be screwed up they can have like problems with like hearing i

mbalance they'll also have issues with like cranial five right cranial five remember cranial five um those many things right so like pain and temperature loss from the face and your lacrimal glands don't work right at least uh sorry yeah they'll have problems with the face yeah your lacrimal your not your lacrimal gland sorry your reflexes right so your conial reflex um remember the offering part of that reflex is cranial five the efferin part is cranial seven so those people have like a lot of like eye problems right so that's kind of like and they will have also have like loss of sensation in a in a trigeminal distribution right so remember trigeminal its first branch I believe is the is the ophthalmic nerve right so that will like your forehead will lose sensation also the maxillary and endybulin nerves right so sort of like those distributions and I'll talk about those cranial nerves in a lot more when I uh continue the neuro podcast and then don't forget right your bazzle artery if you have an infact of your bazzle artery you're like really screwed right because your bazzle artery right basically supplies the entire ponds right so you basically knock out the entire corticospinal tract you knock out many cranial nerves it's just a bad bad bad situation right so a bazzle artery infact can basically present like like locked actually it's it will be a vascular cause of the of the locked in syndrome right where the basic person just has like total quadriperesis as a bad situation you really do not want to have an infact of your bazzle artery and then remember right and that thing that can also cause the locked in syndrome is if you're correct hypoinitrami over zillously right so like um remember from low to high the ponds will die right so like uh central pointy myelinolysis although these these some people call it osmotic dimylination syndrome okay that can also be a

n an example of the locked in syndrome there'll be a neurogenic cause of the locked in syndrome versus a bazzle artery infact that will be an example there'll be a vascular cause of a locked in syndrome right that's what i'm talking about in a vascular anatomy lecture and they remember that coming off of the coming off of the what is it called the the bazzle artery we have the superior cerebellartery and then the terminal branch we have the posterior cerebellartery um cannot hide you to know that your superior cerebellartery is in your posterior cerebellartery um cranial three runs between those okay cranial three runs between those so your clomuron nerve right so basically if you have an aneurysm of your superior cerebellartery or your posterior cerebellartery or your posterior communicating artery um so p-com you can actually have a lot of issues with cranial three right and the thing is it is the parasympathetic functions of cranial three that would go first because if you actually look at a cross section through cranial nerve three fibers the parasympathetic function is on the outside right so any like extrinsic compression for example an aneurysm of any of those three arteries will basically make you lose like your parasympathetic function first right so you lose like your accommodation you lose like those acillary muscles they won't work as well anymore you have like the bluen pupil right so your meiosis will not work so well anymore right because your pupillary constrictors no longer work right but if you have like really bad bad bad compression after losing the parasympathetic function you then lose the motor functions of of cranial three right because remember cranial three also does a lot of high muscles right so like inferior bleak um medial rectus um inferior rectus and stuff like that right so that's where you can then progress to having like the down and

out eye right also don't forget right if you have an uncle herniation that can also cause a relatively similar symptoms but a parasympathetic fibers of cranial three run on the outside of the nerve and then the the motor fibers run on the inside right so if you have an extrinsic compression you lose parasympathetic function first before motor function and then if you have like vascular disease right so like diabetes right so like after a sclerosis or any of that crap you lose the motor function first because that's more of like because remember the blood vessels tend to like sort of run like on the inside of the nerve um at least side by side right so remember nerves have like perinorum and all that crap uh but basically if you have like a more vascular not extrinsic compression but more like ischemic you lose the motor function first before the parasympathetic function okay so kind of how you to know that for tests um and then right so remember a circle of willis you have like the posterior cerebral artery connected by the posterior communicative artery to the middle cerebral right and then the middle cerebral you then have the anterior cerebral arteries and then the anterior communicative artery right don't forget your anterior communicative artery that's the most common region of aneurysm formation in the circle of willis and remember that if you have like an anterior communicative artery aneurysm right those can actually compress um cranial nerve two fibers right so if you compress those cranial nerve two fibers you can have like uh you can have like a monocular uh like vijon loss or something like that right because remember the anterior communicative artery sort of runs in the same general vicinity as your optic nerve and remember your optic nerve is not derived from neurocress cells or like the other cranial nerves the optic nerve is actually an outgrowth of t

he diencephalon so it's actually derived from neuro tube that's also high you to know for your tests and then remember that the internal corroded artery right it gives off a lot of branches right so it gives off like the ophthalmic arteries right the ophthalmic arteries remember if you infect your thalmic arteries you can also get vijon loss because you don't you won't have much in the way of like good blood supply to like the optic nerve um also don't forget right your middle cerebral artery right also comes from your internal your middle cerebral artery remember that it gives off many high yield branches right but if you're thinking about it in terms of the homonculus if you infect your middle cerebral artery you basically have like problems with your face and problems with your upper extremities right and depending on the side of your middle cerebral artery that's all screwed up you will also have like you could have potentially like a brookas ephysia right because remember that your brookas area is in middle cerebral artery territory and then it's also kind of high to know that the middle cerebral artery actually gives off somewhat high yield artery at least some of it like the lenticular stride arteries remember the lenticular stride arteries supply like some high yield bizoganglia structures the one that's probably the highest yield to know for the usmeli exam is the posterior limb of the internal capsule if you scrub the posterior limb of the internal capsule guess what that is one of those like very small vascular issues that can cause profound deficits right so that is you'll have like contralateral like total hemiparises because remember your corticospinal tract fibers they sort of all squeezed through the posterior limb of the internal capsule on their way down to the midbrain right to like the cerebral pedoncotes so it's one of those high yield things you

want to know for tests and then don't forget right then if you're also if you have an infact of your anterior cerebral artery right that's like the leg area of your homonculus right so those people have like leg weakness and lot nut and then also don't forget that I guess some other if you're sort of being a little more nitpicky some other like high yield arteries in the brain right so don't forget like your what is it called your middle meningel artery it's actually one of the terminal branches I believe of the external crowded artery right if you screw that up right let's say you have like a temporal bone fracture you last rate your middle meningel artery you can have an epidural hematoma with that right so that's a nice way we can sort of test that and then don't forget right your brigen veins if you screw those up right say you an alcoholic and you have a tiny brain because remember alcoholism causes a cerebral atrophy or you're an old person remembers you get older you bring sort of shrinks and you sort of like have too much talking or pulling on those brigen veins that can cause that can cause a subdural hematoma right and then remember right if a person has a stroke right the biggest risk factor for stroke you definitely want to know that for exams is hypertension hypertension is the biggest risk factor for stroke remember hypertension is also the biggest risk factor for for eiotic dissection right versus cigarette smoking that's the biggest risk factor for for coronary artery disease I mean you may say a divine why do you why you're repeating this and repeating this because actually how you to know for these exams so I'll sort of keep those at the back of your mind if you may so I'm just trying to think is there any other how you think I want to discuss in the brain I think that's it let's go to chest so chest chest chest chest chest so the chest right so obvi

ously right we know that the order is important super high your order and the order right we have the ascending order and then we have the eiotic arch and then we have the descending order right the descending order um I guess you can sort of say like the ascending order eiotic arch and descending order all part of the thoracic order and then once you go below the level of the diaphragm you then have the um you then have the abdominal eiotic and I'll talk about that when we get to the GI vascular part of this presentation so remember that the order right so we have the ascending order remember the ascending order can um have some issues right so syphilis um remember syphilis can cause issues like an eiotitis and cause like aneurysms remember that syphilis loves to torch the ascending order and then more fans and earless downloads those disorders remember as downloads probably the one we care the most about for the USM list one exam is the type 4 um and as downloads remember that's the one where you have like type 3 collagen issues um or as downloads loves to cause aneurysms of the ascending order um and also don't forget right marfans remember marfans is i believe a chromosome 15 or a zomod dominant fibrolinging defect that can also cause any ascending eorica aneurysm in fact the oric dissection right is actually one of the most common causes very high you to know that if it's one of the most common causes if not the most common cause of death in patients with a marfans syndrome especially marfans syndrome that is untreated right so those are high you things that sort of torch your ascending order right and then and one thing i want to sort of like let you know right remember that if you're looking at aortic dissection there's multiple types of eiotic dissection uh but the most common classification scheme that most people use is the stanford classification right so s

tanford aortic dissection is one that just involves the ascending order a stanford b dissection is one that does not involve the ascending order and it so happens that if you have a stanford a dissection you're going to surgery surgery is the only fix if you're gonna die a stanford b dissection is something that you treat more medically okay you don't necessarily have to go to surgery right that's why that uh classification scheme is kind of high yield to know for the usml step 1 now one other thing you want to know is that if a person has an aortic dissection right your first step in management is to give them a bit of blocker okay so give them a bit of blocker that's kind of high yield to know is something related to like pulse therapy or whatever but that's all i'm gonna say the other high yield stuff is more for the step 2ck exam so we've talked about the ascending order right then actually one last thing i'll say about the ascending order is if you have an aortic dissection remember an aortic dissection can track anti-grade or you can track retrograde you can track anti-grade going to the arch going to the descending order but you can track retrograde and sort of go down towards the coronary like sinuses right the thing is it's actually high yield to know this is one of those like you remember it it's one of those questions that basically everyone will get wrong on the usml is but if you have like a retrograde tracking of an ascending aortic like dissection right so basically a Stanford a dissection the most commonly screwed up artery is the is the right coronary artery right so right coronary arteries tend to be involved more often right if you have like an ascending aortic dissection that's sort of tracking retrograde down like towards the left ventricle down for some reason right coronary artery is more commonly involved right so obviously you see like ST elev

ations in two three and AVF and remember those people you don't want to give them like a a vinyl dilator like a nitro like nitro like nitroglycerin right because those people are preload dependent right so those are kind of high yield things to know okay and one thing that just came to mind the middle cerebral artery right it's actually the most common vessel in the brain that's involved by like embolic phenomena right so like let's say you have a fib you make this nice clot in your left e-trauma you send it off to the brain the middle cerebral artery is like the most commonly involved vessel in like embolic strokes right so like an ischemic stroke to the brain okay now let's go to the arch right so remember the arch has three main branches right so we have the brachyosophonic artery that gives off the right common carotid and the rights of clavian right and then we then have the we then have the the left common carotid that on its own comes off the arch and then we have the left subclavian right we have the left subclavian now kind of high yield to know for example that um I guess a few key things right so I say that the brachyosophonic artery gives off the right common carotid and the rights of clavian right so the rights of clavian remember that if you um if you go beyond the how do I want put this um below the lateral border of the first rib the subclavian artery changes is busy seeing this so but it changes into the axillary artery right and then if you go below the inferior border of the teris major muscle you then change the axillary artery to become the brachial artery and then obviously that divides into like the radial and owner arteries and then like some interacios arteries and whatnot but that's kind of like not part of our discussion today right but again it's one of those are weird or high yield things you sort of kind of want to know for exams right an

d then you want to remember right that right remember you can have like um there's this condition that occasionally shows up on the usmls it's called like paget fruiter disease it's basically like a stenosis of the subclavian artery it usually arises classically on exams in like like ripped guys right so like guys that work out a ton so like they have like impressive like upper extremity muscles um that's when we they can show up on tests right so if you see a person that is like a ripped guy works out a ton and then like after it works out or does like stuff with his hands um his hands begin to hurt a lot and then they tell you that oh they see clot and whatever it's called like paget fruiter disease that's just again one weird high yield thing you want to know for tests and you definitely want to know that oh first border of uh like where subclavian becomes axillary right so like lateral border of first strip or where axillary becomes brachial artery right that's like the um um the inferior border of the teris major muscle those are classic things that show up on the usmls step one exam okay now don't forget right that the subclavian artery right can also be involved in something called the subclavian steel syndrome um I discussed the mechanism behind that in one of my neuro like shelf so that's I guess more third year podcasts but I have a diagram I'll encourage just go look at like my thing is neuro seven on your eight one of those and I have like this really nice diagram that explains the subclavian steel syndrome where it's sort of going to the hemodynamic consequences and all that crap and then don't forget right if you have like uh remember your axillary artery right it's it's kind of high uh high yield artery right because um if you have an aneurysm of your axillary artery guess what can happen you can compress the brachial plexus and you can get you can see

how that's like open to many many many many nice usmeli um exam questions right so again just one of those weird things you want to keep at the back of your mind and then one weird thing but I guess this is sort of going into the territory of veins that you can test on your usml step one exam don't forget that your veins right so your um there are certain high yield veins in the arm right so we have like the bacillig vein right we have the bacillig vein we have the the bacillig vein is medial we have the cephalic vein that is more lateral right it's more lateral and then we also have the brachial veins right so a classic question they can put on the usml step one example sort of mess with your head is oh if a person is getting like peripherally inserted like catheter for like access right like a peckline um you tend to put those more often in the break in the sorry not break it that'd be a bad idea you do that in the bacillig vein the bacillig vein is your first option if that's not working out so well for you you can try out the cephalic vein the only thing is the cephalic vein has an extra keng so it just kind of introduces a few more problems the bacillig vein is a lot better okay because it's like a straight shot to the upper extremity um you're almost like straight shot to like the subclavian vein and then IVC kind of deal right so I mean SVC kind of deal oops sorry so I remember again this is enough to cough lecture but I promise you I'm almost certain I'm pretty certain most of what I'm saying is accurate because I know my vascular anatomy pretty well thankful so back to the back to our discussion right so the thing is um the bacillig vein is your first option cephalic vein is your second option you essentially never want to use the brachial vein the reason you don't want to use the brachial vein is the median nerve runs superficial to the brachial vein so that

can be a huge problem right I mean probably it's a bad idea to compress your median nerve that's usually not like a good thing to do right you're getting to a lot of trouble of doing that okay now um so let's go back to the let's go back to the yodic archer so I sort of talked about that brachial cephalic and its branches now we then have the left common carotid right and then we have the left subclavian right um and again just weird things you sort of want to keep at the back of your mind remember that like giant cellaritis remember that um what is the name of this other closely related condition um takayasu takayasu disease right that's like Asian females less than 50 um those love to affect those like the yodic arch and it's like branches that's kind of how you to know for example and I guess one thing um I don't know if you'll like there's something in my mind relating to the arch and like a nerve yes yes yes yes yes that's the recurrent laranjoon nerve I've made a made mention of this in many many of my podcasts but this always good to repeat something like this right so remember your right recurrent laranjoon nerve remember that's obviously a vagus nerve cranial 10 branch I remember that you're right recurrent laranjoon nerve right um sort of loops around the right subclavian artery okay then it travels upwards right contrast that with your left recurrent laranjoon nerve that loops around the yodic arch okay I promise you that is a floridly high-yield factory you want to know for your for your USMLE exams and then I think that is where I'm gonna stop with respect to chest um I'm just literally going by body cavity I guess we can I guess jump to abdomen and I don't want this podcast to be super long so I probably stop at abdomen after this um let's see so what do I want to talk about with abdomen right so obviously you want to know like the big three arteries in

your abdomen and you sort of want to be able to say oh this is where they come off this is um so like this is where they come off this is um approximately like what vertebral level they come off and you want to know like their key branches and you definitely want to know your high yield and astomo seeds right so for example so the abdominal aorta has like three super high yield branches and I will argue for one more that's kind of important right so let's sort of go from top to bottom right so obviously we have the cilia cardry uh basically it arises at the level of the t12 of vertebral body right um and then like your sma right so like your superior mecentary cardry so it arises at the t12 to l1 like area like around like the t12 to l1 like disc spaces and whatnot your renal arteries they're like l1l2 I would definitely know that if I read you and then your iami your fear mesenteric arteries like the l2l3 disc space level okay now your superior mesenteric artery because I feel like I'll forget these so I'm just gonna go ahead and talk about it uh right now but there are two conditions that people tend to sort of mix and match on their usml right so don't mess this up on your example basically there's something known as um superior mesenteric artery syndrome that's basically where you like the third part of the doodham you compress it between the abdominal aorta and the superior mesenteric artery because the thing is the superior mesenteric artery when it's coming off of the abdominal aorta it actually comes off anteriorly so imagine the doodham sort of trapped between those two that can cause a lot of problems right because you basically have like a small bowel obstruction sort of deal going on there now the close causing condition that you should not screw this up with is not cracker syndrome basically this is this essentially happens when you like compress like th

e left renal vein between the aorta and again the superior mesenteric artery okay so I would encourage you to not screw those up on exempt right that can probably show upon exempt is like a varico seal and all that crap right and then one of the high ophthalmology the superior mesenteric artery is that if a person has an embolism right that's causing like acute mesenteric ischemia so let's say they have e-fit and then they have a sodium onset like abdominal pain out of proportion to the physical exam right the SMA is the most commonly occluded vessel under those circumstances by embellic phenomena is the most commonly occluded like mesenteric vessel okay now please um don't forget right the yocelia carry basically does everything up until like the ligament of trites right so like like medbhuadnam and then from that part of the bhuadnam to like the splenic fracture right so the splenic fracture is basically like the it's like in your left upper quadrant that's applied by the superior mesenteric artery and then everything from there to the upper rectum is done by the inferior mesenteric artery and the thing is because that splenic fracture sort of represents uh you know kind of like uh uh watershed region right between like the SMA and the IMA if a person has like systemic hypotension right those watershed areas can get screwed up real fast right so they can infart pretty quickly right because they have watershed areas they are like the last places to get enough um perfusion if you're going into the ear of the brain the regions between the middle cerebral artery and the anterior cerebral artery those are also high-yield watershed regions you want to keep in mind for your USMLE exams so now let's talk about the cilia carry right so the cilia carry you know has a lot of high-yield branches but let's just talk about the big ones and again you may see divine you're going a

little too detailed here and that's true but the thing is all these things I've mentioned it I have basically seen uh tested on exams believe it or not so it's just one of those things I will strongly strongly strongly encourage you this is where the lecture gets a little you know a little like messy right but I will try my best to make repetitions and again give you some nice integrations as we as we go along right so the cilia carry right has three big branches right so we have like the left gastric artery we have the splenic artery and then we have the common hepatic artery right now the left gastric artery is kind of important because um if you have like a malaria-wise tear the bleeding in the setting of a malaria-wise tear can actually arise from the left gastric artery because the left gastric artery actually supplies like some portions of the distal esophagus right and remember the cilia carry is the artery of the foregut right versus sma that's made god i'm in the time gut so the other branch is the splenic artery right so the thing is the splenic artery right obviously supplies the spleen right and the thing is the splenic artery actually gives off one high your artery known as the left gastroepiploic artery another term for the left gastropiploic artery is the left gastro-mental artery the left gastro-mental or gastropiploic arteries courses along the greater curvature of the stomach it and as the most is with another artery i'll talk about shortly okay and then we the third branch of the cilia carry is the common hepatic artery right the common hepatic artery um gives off actually a few high-yield arteries right so the thing is we have the common hepatic artery one of its first like big big high-yield branches you kind of want to know for tests is the gastro-dwardenal artery in fact after the gastro-dwardenal artery comes off of the common hepatic artery th

e name of the common hepatic artery changes it actually changes from the common hepatic artery to the proper hepatic artery okay so we have the common hepatic artery as one of the main branches of the cilia carry once it gives off the gastro-dwardenal artery also called the gda um that also the name changes to the proper hepatic artery the proper hepatic artery is what gives off the right hepatic artery and the left hepatic artery okay the left hepatic artery supplies like some left sides of the liver right hepatic arteries supplies like some right sides of the liver it's actually kind of high yield to know that the right hepatic artery gives off something known as the cystic artery that's the blood supply to the to the to the gallbladder okay and then that proper hepatic artery in like 50 52% of patients of people um it actually gives off the right gastric artery right so this marks I guess another region where I'll talk about a high-yield anastomosis so the right gastric artery that usually comes at least on USML East from the proper hepatic artery anastomosis along the lesser curvature of the stomach with the left gastric artery right so right gastric artery from the proper hepatic artery anastomosis with the left gastric artery which is one of the main branches of the cilia carry and it runs along the lesser curvature of the stomach right and then if we go to the gastro-dwardenal artery the gastro-dwardenal artery is actually high yield for two purposes on the USML East exams right so the thing is the gastro-dwardenal artery right we said it's basically a branch of the common hepatic artery before the common hepatic artery changes into the proper hepatic artery the gastro-dwardenal artery gives off two high-yield branches you want to keep in mind for your USML exams right so the first one is the right gastroepiploic artery also again called the right gastro-umenta

l artery that right gastropiploic artery anastomosis with the left gastropiploic artery and those run along the greater curvature so you can see how making these integrations like lesser coverage of the stomach greater coverage of the stomach because they love to test that crap on the USML East step one right so the right gastropiploic artery is a branch of the gastro-dwardenal artery the left gastropiploic artery is a branch of the splenic artery remember the splenic artery is a branch of the cilia carry it's one of the three main branches of the cilia carry so the left gastropiploic from the splenic the right gastropiploic from the from the gastro-dwardenal artery deform an anastomosis along the greater curvature of the stomach now another high yield branch of the gastro-dwardenal artery is the superior pancreatic oedwardenal artery okay it's the superior pancreatic oedwardenal artery the superior pancreatic oedwardenal artery actually anastomosis with a branch of the of the superior mesenteric artery that branch is if there is a superior pancreatic oedwardenal artery it should make sense that it should be an inferior pancreatic oedwardenal artery right so the superior and inferior pancreatic oedwardenal arteries have an anastomosis the superior pancreatic oedwardenal artery is a branch of the gastro-dwardenal artery which is a branch of the common hepatic artery which is one of the main branches of the cilia trunk versus the inferior pancreatic oedwardenal artery that is a it's actually the first branch of the superior mesenteric artery okay and the superior mesenteric artery to be honest um they actually i guess is there really any other thing i want to see with the cilia trunk yes there is actually there's one more thing i forgot is again classic thing that shows up on the usml right so if you get a question about a boy that was like cyclone or bichen right then

has like a handle by injury that can obviously scrub your pancreas that's one of like those weird rare causes of pancreatitis that you never really seen the real world where you see a lot of on exams in kids so you see pancreatitis and a kid a handle by injury kind of works together but another thing is if a person has like a handle by injury and they injure the doodham especially like more like the posterior doodham right they can actually get really bad bleeds from the gastro-dwardenal artery okay like a person has like an ulcer in the posterior doodham and the ulcer sort of like like like a like a peptic ulcer and you ulcerate ulcerate ulcerate ulcerate and then ulcerate the lining of the stomach and then you reach the level of the gastro-dwardenal artery you can have a pretty profound GI bleed from that that's one of those weird high yield things that shows up on the usml step one the usml step two ck and the surgery shelf exam those are like the three high yield areas that this factoid shows up on tests so let's jump to the superior mesenteric artery right so the superior mesenteric artery have already talked about one high yield branch that's the inferior pancreatic oedwardenal artery that are mastomosis with the superior pancreatic oedwardenal artery that is a branch of the gastro-dwardenal artery right now another branch of the superior mesenteric artery is the the right colic artery right so the right colic artery basically supplies like your ascending colon right that right colic artery actually many people actually gives off the what is it called it gives off the iliocolic artery that supplies the terminal ilium and the appendix okay so it's just one of those weird things you want to keep at the back of your mind for tests and then another branch of the sma is the middle colic artery that supplies the transverse colon okay and really I think that's all I'm

going to see with with the superior mesenteric artery and I've talked about again the high yield and astomosis of the superior mesenteric artery there's actually one more anastomosis of the superior mesenteric artery but I'll discuss it when I finish talking about the inferior mesenteric artery okay so those are the branches of the sma now I remember the sma is blood supply stops at the splinic flexure also called the left flexure whatever it's in the left upper quadrant now another high yield thing you want to keep in mind for exams is the inferior mesenteric artery right that's like the last big big bad boy branch of the of the abdominal iliote right so remember that the inferior mesenteric artery it gives off actually the left colic artery the left colic artery obviously supplies the descending colon it then also gives off the command divine think the sigmoidal arteries that supply the sigmoid colon and then it also gives off the superior rectal artery the superior rectal artery is a branch of the inferior mesenteric artery that basically supplies the upper rectum okay supplies the upper rectum now what are some high yield things you want to know here right so remember I talked about I said that oh the superior mesenteric artery has another high yield and asthmosis you want to keep in mind for your tests yeah so here's where I talk about it right so the thing is the superior mesenteric artery actually gives off the so okay you know what let me talk about it this way probably help so the thing is there's this big arterial and asthmosis for the colon that at your anasthmosis is known as the marginal artery of drumand okay the marginal artery of drumand the thing is the marginal artery of drumand is like an arterial archaed that supplies the colon and there are many arteries that contribute to the marginal artery of drumand right so you're right colic artery that's a

branch of the sma contributes your middle colic artery that's a branch of the sma contributes your left colic artery that's a branch of the iami also contributes okay so that's a high yield and asthmosis between the iami and the sma now just like I said for the sma there is actually um and iami anasthmosis that I've not mentioned yet but I'll discuss it when I get to some arteries that are a little lower in the abdomen and this is where I'm beginning to wind down this discussion so the thing is right so the abdominal ear gives off those three awesome arteries and then it comes down and divisor into two arteries right the common iliac arteries the common iliac arteries give rise to the external iliac artery obviously and the internal iliac artery right so external iliac artery internal iliac artery I'll probably talk about the external iliac artery and like it's supply of the foot and the leg low extremities in a different podcast because I feel like this podcast is a lid get a little out of hand and again I apologize I don't mean to dump all this information on you but this I promise you this is all high yield information the reason I know this well is because I remember seeing an exam sign the past okay so the external iliac artery I guess one big thing I guess I can see about the external iliac artery is that it gives off your inferior epigastric artery memory you're inferior epigastric artery is actually a very nice anastomosis between your thoracic ear order and your abdominal ear right so your thoracic ear order right has like the superior epigastric artery the superior epigastric artery like basically like through the internal memory and all that stuff so the internal memory we have like the superior epigastric the superior epigastric that's sort of coming off of your thoracic ear order actually anastomosis where you inferior epigastric which is a branch of the

external iliac which is a branch of the common iliac artery so it's kind of high yield to know that now your internal iliac artery has some I guess high yield branches you sort of want to keep at the back of your mind right and I'll just discuss those in the context of the anastomosis right so the thing is your internal iliac artery has two branches it has an anterior division and posterior division right the thing is one of the high yield anterior division branches of your internal iliac artery is something known as the inferior rectal artery the thing is the inferior rectal artery anastomosis with the superior rectal artery they already discussed as being a branch of the inferior mesenteric artery okay so your IMA gives rise to the superior rectal artery the anterior division of the internal iliac artery gives of the inferior rectal artery that anastomosis with that IMA superior rectal artery branch and then one of the branch I guess I should sort of mention this but this is kind of this is kind of like low yield it probably won't show up on you example if it did you will probably be the only percent that will get it right basically one of the posterior division arteries of your internal iliac artery is another known as the iliolomba artery that iliolomba artery actually an astomosis with a branch of the external iliac artery that's known as the deep circumflex iliac artery so the external iliac gives of the deep circumflex iliac artery that an astomosis with a branch of the posterior division of the internal iliac artery which is known as your iliolomba artery okay so I think that's kind of where I'm gonna stop for today I want to keep this under like 15 minutes but I think I can almost hear someone listening to this podcast begging me to just kind of like real quick run through the anastomosis again okay so I'll do that real quick at least let me see how many I ca

n remember right so the thing is remember that first off your left and your right gastric arteries you run along the lesser curvature of the stomach the right gastric artery usually comes from the proper hepatic artery and then the left gastric artery is one of the main branches of the cilia artery and then another anastomosis but this is along the greater curvature of the stomach are your gastroelemental also known as your gastropiploic arteries right so we have the right gastropiploic artery which is a branch of the gastroedward artery which is one of the branches of the common hepatic artery okay and then we have the left gastropiploic artery that is a branch of the splinic artery the splinic artery is actually one of the main branches of the cilia artery and then if you're looking at anastomosis between the SMA and the cilia artery remember that the gastroedward artery also gives off the superior pancreatic adornal artery in fact some people call it the anterior superior pancreatic adornal artery that anastomosis with the inferior pancreatic adornal artery that is a branch of the SMA in fact that is the first branch of the superior mesenteric artery so the inferior pancreatic adornal artery from the SMA and asthmosis with the superior pancreatic adornal artery which is a branch of the gastroedward artery okay which is a branch of the common hepatic artery which is a branch of the cilia artery okay now if you're looking at an asthmosis between the SMA and the IMA I talked about the marginal artery of drummond I said that the marginal artery of drummond is like an arcade that supplies a lot of the colon and actually some parts of the small bowel and basically the marginal artery of drummond receives like contributions from three main arteries we have the middle colic artery that is a branch of the SMA we have the right colic artery that is also a branch of the SMA a

nd then we have the left colic artery that is a branch of the IMA and then I said that the IMA can have an asthmosis with the iliac arteries right is more specifically the internal iliac artery most specifically one of the branches of the anterior division of the internal iliac artery and that is between the superior rectal artery which is a branch of the IMA and the inferior rectal artery which is one of the branches of the anterior division of the in fear of the internal iliac artery okay so internal iliac artery remember I said it has an anterior division and a posterior division one of the branches of the anterior division of the internal iliac artery is the inferior rectal artery sometimes you also see like the middle rectal artery but inferior rectal artery and asthmosis with the superior rectal artery the superior rectal artery is a branch of the inferior misinterior rectal artery and then I also said that the external iliac artery has an anasthmosis right with your thoracic order right so remember your external iliac artery gives rise to your inferior gastric vessels right inferior gastric artery and asthmosis with your superior gastric artery we sort of comes through from the internal mammary artery if I'm not mistaken I believe the internal mammary artery is also known as the internal thoracic artery but I'm not a hundred percent on that and then I also said that your external iliac can anasthmosis with your internal iliac because your external iliac gives rise to an artery known as the dip circumflex iliac artery that anasthmosis with an artery that is a branch of the posterior division of the internal iliac artery which in this case is the ilyo lombar artery okay and don't forget your inferior gastric artery right it's kind of important for many high-ealthins right it's important for like those um hernias right so like the early remember like some hernias

that define as being like lateral to the inferior gastric vessels which I think and then there are those that are medial so the inferior gastric vessels right so like you're directing when our hernias a medial or remember like MD's lie that's the mnemonic MD's don't lie but that's the mnemonic it's interesting so your direct in when our hernias right the arise medial to the inferior gastric artery and then your vessels and then you're in directing when our hernias arise lateral to the inferior gastric vessels remember your inferior gastric artery is a branch of the internal iliac artery okay is a branch of the external iliac artery okay so um I'm gonna go ahead and stop here I really hope that you find this podcast to be helpful and high-eared I can almost promise you that there'll be a few questions you'll get right on your USML step one exam without question by just knowing the contents of this podcast um there's many other vascular things I'll talk about but I even didn't and we say that this will go this long because again this is an off the cuff lecture I love giving off the cuff lectures because I don't know I feel like you get better at integrating if you if you can give off the cuff lectures but basically um that's where I'm gonna stop I'll probably talk about the low extremities and like veins and because there's actually a few high-eal things with veins but I'll discuss that in a future in a future lecture so as I always end with every lecture I do offer private 101 tutoring for the USML step one two CK two CS and step three exams and also like pre-clinical exams 30-ish-elf exams the ABIM internal medicine board exams and the medicine training exam of a tutor for all those tests and also for like college physics and college OEM and college Gen Chem I do offer tutoring for those and then I do application advising if you are a med student applying for residenc

y like ER As applications or your college student applying to med school those are like um AMCA's applications I offer advising for those are like writing personal statements mock interviews preparing applications have done these things for tons and tons and tons of people so if anyone that needs any of those services please feel free to uh refer them to me I'll be more than happy to uh point them in the right direction and I hope you have a wonderful day and um I am supporting the Milwaukee box to win the the MBA this year but we'll see what happens we'll see if they can go through the good institute warriors I feel like by saying this I've probably acquired a few uh enemies uh that live in California right of the bat but anyhow so I wish all the best I hope you enjoy this podcast I'll see you next time God bless thank you

Anterior cerebral artery (ACA), Middle cerebral artery (MCA), and Posterior cerebral artery (PCA).

PICA infarct (Posterior Inferior Cerebellar Artery).

The anterior communicating artery (ACC) and the posterior communicating artery (PCOM).

Blood pressure control/reduction (using beta-blockers or vasodilators).

The lateral border of the first rib.

Middle cerebral artery (MCA).

Celiac artery, Superior Mesenteric Artery (SMA), and Inferior Mesenteric Artery (IMA).

Wallenberg syndrome (involving CN IX, X, XI, XII, ataxia, and contralateral sensory loss).

Cranial Nerve III (Oculomotor) - specifically leading to a dilated pupil.

Right colic artery (from SMA), Middle colic artery (from SMA), and Left colic artery (from IMA).

T12 to L1.

The superior rectal artery (from IMA) anastomoses with the inferior rectal artery (from internal iliac/anterior division).

Common hepatic artery $\rightarrow$ Proper hepatic artery. The right hepatic artery gives off the cystic artery.

Deep circumflex iliac artery (from external iliac) anastomoses with the iliolumbar artery (from posterior division of internal iliac).

Wallenberg syndrome (involving CN IX, X, XI, XII, ataxia, and contralateral sensory loss).

Cranial Nerve III (Oculomotor) - specifically leading to a dilated pupil.

Right colic artery (from SMA), Middle colic artery (from SMA), and Left colic artery (from IMA).

T12 to L1.

The superior rectal artery (from IMA) anastomoses with the inferior rectal artery (from internal iliac/anterior division).

Common hepatic artery $\rightarrow$ Proper hepatic artery. The right hepatic artery gives off the cystic artery.

Deep circumflex iliac artery (from external iliac) anastomoses with the iliolumbar artery (from posterior division of internal iliac).