========== ANNALS Of ANATOMY ==========

A study of the deep ascending cervical artery

(new definition) and its relation to some other arteries
in the human cervical region *

Masahiro Koizumi, Shin'ichi Sekiya, Masaharu Horiguchi

and Masako Harada

Department of Anatomy, Iwate Medical University School of Medicine, 19-1 Uchimaru,

Morioka, Iwate, 020 Japan

Summary. A minute study of cervical arteries in 67 Key words: Ascending cervical artery - Transverse cer-
Japanese bodies, totalling 130 sides, revealed that a small vical artery - Dorsal intersegmental arteries - Longitudi-
twig arose from the second part of the subclavian artery nal anastomosis - Human cervical arteries - Gross
and ascended under the scalenus anterior muscle, sending anatomy
spinal branches and muscular branches to scalenus muscles
in 77 % of cases. Judging from its course and distribution,
it is reasonable to consider that this ascending twig is a Introduction
precostal anastomosis of cervical intersegmental arteries
and has the same morphological significance as the Variations in the origin of the human cervical arteries are
ascending cervical artery. The authors therefore propose numerous and have been discussed many times by anato-
the name "deep ascending cervical artery (Ca-p)" for this mists and surgeons. Especially in surgery, these arteries
twig. The Ca-p may also be the source artery of the cos- are quite important in the treatment to alleviate severe
tocervical trunk or the transverse cervical artery from the neurovascular compression at the thoracic outlet by resec-
second part of the subclavian artery. In 22 cases the deep tion of the cervical rib or the scalenus anterior muscle
cervical artery or the costocervical trunk from the first part (Adson 1947; Daseler and Anson 1959). The human sub-
had disappeared and was compensated by a branch from clavian artery is the source of the following arteries to the
the Ca-p. On the other hand, there were some cases in cervical region: the costocervical trunk, the inferior thy-
which the lateral branch to the scalenus medius muscle roid artery, the ascending cervical artery, the transverse
from the Ca-p had developed into the transverse cervical cervical artery and the suprascapular artery. Although the
artery or its deep branch. This artery arose from the sec- Nomina Anatomica (6th edition, 1989) refers to these
ond part of the subclavian artery and ran laterally under arteries, except for the costocervical trunk, as branches of
the scalenus anterior muscle, passing through the brachial the thyrocervical trunk, and the ascending cervical artery
plexus. In the remaining 23 % of cases a typical Ca-p did as a branch of the inferior thyroid artery, the transverse
not exist, but a similar branch from the costocervical trunk cervical artery and/or the suprascapular artery often arise
was found instead. Since this branch has the same course as independent arteries from the second or the third part of
and distribution as the Ca-p, we have called it the cos- the subclavian artery, and some textbooks of anatomy
tocervical type of Ca-p (Ca-pe). (Benninghoff 1952; Elze 1960) list the ascending cervical
artery and the inferior thyroid artery as parallel branches
of the thyrocervical trunk. It is well known that, according
to English textbooks, the transverse cervical artery
originates from the thyrocervical trunk and runs over the
* This study was supported by Grant from Keiryokai Research brachial plexus to reach the trapezius and rhomboid musc-
Foundation No. 25 and No. 90.
Correspondence to: Masahiro Koizumi, Department of Anatomy,
les, but in German textbooks the transverse cervical artery
Juntendo University, School of Medicine, 2-1-1 Hongo, Bunkyo- is said to arise from the subclavian artery and pass through
ku, Tokyo, 113 Japan the brachial plexus. Moreover, two terminal branches (the

~I
Ann Anat (1994) 176: 233-242
Gustav Fischer Verlag Jena
superficial and deep branches) of the transverse cervical clarify its morphological significance and relationship to
artery frequently have different origins from the subclavian some of the other cervical arteries.
artery, and in that case the superficial branch is called the
"superficial cervical artery" and the deep branch the "dor-
sal scapular or descending scapular artery".
For this reason there is some disagreement and confu- Materials and methods
sion in the literature with regard to the nomenclature and
The 67 Japanese bodies (totalling 130 sides), which were
description of cervical arteries, mainly pertaining to varia-
dissected in the anatomical practice during a period of 3
tions in the origin of the arteries. These variations have
years (1989, 1991 and 1992) at the Iwate Medical Univer-
usually been discussed only in terms of their frequency.
sity School of Medicine, were used for this study. For
Discussions concerning the variation in the origin of
convenience in describing the subclavian artery and its
cervical arteries from the developmental aspect refer to the
branches, the authors follow the division of the subclavian
branches of the embryonic dorsal aorta. They are clas-
artery in three parts as generally adopted in textbooks of
sified into three groups: ventral, dorsal and lateral (Evans
human anatomy (Schaeffer 1953; Romanes 1972; Gardner
1912; Arey 1949). The ventral group (gut branches)
et al. 1975; Williams and Warwick 1980; Woodbume and
occurs first, the dorsal group (dorsal intersegmental
Burkel 1988). The first part is medial to the scalenus
arteries) follows, and then the lateral group (nephric bran-
anterior muscle, the second lies behind the muscle and the
ches) appears. At first the dorsal intersegmental arteries
third extends from its lateral margin.
supply only the central nervous system, but they subse-
After observing the first and the third parts of the sub-
quently develop to distribute to the parietal or body wall
clavian artery and its ramifications with special attention
of the embryo (Evans 1912; Patten 1948; Arey 1949). On
to the ascending cervical artery and its branches, the inser-
this embryological ground, the primary branches of cervi-
tion of the scalenus anterior muscle (1st rib) was cut off
cal arteries in adults are thought to be the spinal branches.
and all branches from the second part were examined,
Branches to the body wall arise secondarily after the spi-
even though they were extremely slender. The findings
nal branches have been formed. In the cervical region,
were recorded by line drawings and photographs.
longitudinal anastomoses of these dorsal intersegmental
arteries are formed; they are vertebral artery, the ascend-
ing cervical artery and the deep cervical artery. According
to these facts, the ascending cervical artery, which has Nomenclature
some spinal branches, should be considered as a funda-
mental artery in the adult cervical region. The inferior Although there are some morphological and embryological
thyroid artery and the transverse cervical artery, which problems to be discussed arising from the nomenclature
supply the cervical viscera, visceral muscles and upper used in the Nomina Anatomica, in this paper the authors
limb muscles, should be interpreted as secondarily follow that of the 6th edition in order to avoid further
developed branches of the ascending cervical artery. confusion in the description of cervical arteries. This
The above-mentioned morphological significance of the means that the names "superficial and deep branches of
ascending cervical artery as a primary artery has not been the transverse cervical artery" are retained even when they
discussed, probably because it is slender and of little sur- arise independently from the subclavian artery. For this
gical importance (Daseler and Anson 1959) In most text- reason we do not use the terms "superficial cervical
books of anatomy the ascending cervical artery is briefly artery" and "dorsal scapular (descending scapular) artery",
mentioned as a branch of the inferior thyroid artery (Goss which are equivalent to the superficial and the deep bran-
1976; Schaeffer 1953; Romanes 1972; Gardner et al. ches respectively.
1975; Williams and Warwick 1980; Woodburne and Bur-
kel 1988).
Aware of this interpretation of the ascending cervical
artery and its ramifications, the authors noticed that a con- Results
stant small branch which arose from the subclavian artery
I. The deep ascending cervical artery (Ca-p)
behind the scalenus anterior muscle ran upwards to give
some twigs to the scalenus anterior and medius muscles A typical case is shown in Figure I. In this case, the
and spinal roots of lower cervical nerves. Although no inferior thyroid artery (Ti), the ascending cervical artery
description of this ascending branch could be found in any (Ca), the suprascapular artery (Ss) and the transverse cer-
article or textbook, it is thought to have the same mor- vical artery (Tc) arose from the first part of the subclavian
phological significance as the ascending cervical artery artery (Sc) and formed a common trunk (the thyrocervical
itself because this branch constantly occurs and, like the trunk; Ttc). Except for the inferior thyroid artery, which
ascending cervical artery, gives some spinal branches to ran medially, all passed laterally and superficial to the
the spinal roots of lower cervical nerves. In this paper we scalenus anterior muscle. After continuing laterally over
therefore propose the new name "deep ascending cervical the brachial plexus, which was composed of five nerves
artery" for this small ascending branch and attempt to from the 5th cervical (C 5) to the Ist thoracic (Th I), the
234
 the scalenus anterior and medius muscles between cervical
nerves C 6 to C 8. As mentioned before in the Introduc-
tion, the authors have called this twig the "deep ascending
cervical artery (Ca-p)".
This Ca-p was observed in 100 of the 130 specimens
(77 %). In the remaining 30 cases (23 %), a typical Ca-p
did not exist. Instead a similar branch was observed which
originated from the root of the costocervical trunk and
ascended behind the scalenus anterior muscle, sending spi-
nal branches to the roots of C6, C7 and C8, and muscular
branches to the scalenus medius muscle between cervical
nerves C 6 to C 8. Except for its origin, this ascending
branch had the same course and distribution as the Ca-p.
The authors therefore defined this branch as the costocer-
Ss
vical type of Ca-p (Ca-pe). In II of 130 cases (8 %) both
Ca-p and Ca-pe existed on one side. Consequently, if the
"Ca-pe" type is included, a deep ascending cervical artery
was found in all the specimens observed.
On the other hand, with reference to the relationship
between the origins of the Ca-p and the costocervical
trunk, the 130 specimens were classified into four groups
(Figs. 4a-4b). In Group I the typical Ca-p and the cos-
tocervical trunk were present; the former arising from the
I second part of the subclavian artery and the latter from the
SAN
first part. In this group 67 of the 130 cases (52 %) were
92Vlld included. In Group 2 a typical Ca-p and the costocervical
trunk existed the same as in Group I, but an additional
Fig. 1. A typical case in which the Ca-p (solid lines) runs deep to Ca-p (Ca-pe) arose from the costocervical trunk. Eleven of
the scalenus anterior muscle (shaded). Right side view of the neck the 130 cases (8 %) belonged to this group. In Group 3 the
region. The Ca-p, arising from the second part of the subclavian typical costocervical trunk was absent, but a similar
artery, gives muscular branches to the scalenus medius (*) and branch arose from the Ca-p (22 out of 130 cases - 17 %).
anterior (*) muscles, and spinal branches to the roots of C6 and In Group 4 the typical Ca-p was absent, but a similar
C 7. On the other hand, the typical Ca ascends giving muscular branch arose from the costocervical trunk (30 out of 130
branches to the levator scapulae muscle and spinal branches to C 3, cases - 23 %).
C4 and C5.

transverse cervical artery gave off three superficial bran- II. The distribution of the Ca and Ca-p
ches (Rs) and ended up as a deep branch (Rp). The super-
ficial branches supplied the levator scapulae and trapezius 1) The Ca
muscles, and the deep branch passed deep to the levator In 77 cases of 91 specimens observed in 1991 and 1992,
scapulae muscle, descending along the medial border of the lowest cervical nerve along which the spinal branch
the scapula under the rhomboid muscles to supply these from the Ca entered the intervertebral foramen was
and the trapezius. The Ca ascended on the scalenus examined. The results were as follows:
anterior muscle and sent spinal branches medially along
the roots of the 5th (C5), 4th (C4) and 3rd (C3) cervical lowest nerve frequency
nerves, besides supplying lateral twigs to the levator C4 25 cases (33 %)
scapulae muscle (LS) between the cervical nerves C3 to C5 46 cases (61 %)
C 5. The costocervical trunk arose from the deep surface C6 6 cases (6%)
of the first part of the subclavian artery and gave off the In more than half of the specimens the lowest nerve was
deep cervical artery (Cp), which ran deeply between the C5. Usually spinal branches from the Ca ascended super-
first rib and the root of the 8th cervical nerve (C8). There- ficial to the scalenus anterior muscle and ran towards the
after the costocervical trunk became the superior intercos- roots of C4, C5 and C6 over the upper margin of the
tal artery (Is). Furthermore, a small twig was observed scalenus anterior muscle. However, they sometimes pene-
under the scalenus anterior muscle (solid lines in Fig. 1). trated the scalenus anterior muscle to reach the roots of
This twig originated from the second part of the subcla- C5 (22 cases) and/or C6 (5 cases).
vian artery and ascended over the root of C 7. It sent The lowest muscular branch to the scalenus medius or
spinal branches to C 6 and C 7, and muscular branches to the levator scapulae muscle from the Ca was then
235
examined in 57 cases, with special reference to its relation- Type B (10 cases)
ship to the brachial or cervical plexus. The results were as In addition to the spinal and muscular branches to the
follows: scalenus anterior and medius muscles, the Ca-p sent muscu-
position where the lowest frequency lar branches to the uppermost part of the serratus anterior
muscular branch penetrated muscle (Fig. 2). This branch ran laterally between C6-7
between C3-4 21 cases (37 %,)
C4-5 32 cases (56 °lr,)
C5-6 4 cases (7°/.»
In almost all cases (93 %) the muscular branches passed
beyond the brachial plexus.
Detailed observation of the highest spinal branch and the
muscular branch of the Ca above C 3 was impossible because
the extremity of the Ca was in many cases damaged just over
the root of C 3. However, the spinal branch to the root of C 3
was confirmed in almost all cases and the muscular branch
between C 2 and C 3 was sometimes found.

2) The Ca-p
The highest spinal branch from the Ca-p was examined in 85
cases and the results obtained were as follows: 55
highest nerve frequency
C5 2 cases (2 %)
C6 63 cases (74%)
C7 20 cases (24 %)
The majority corresponded to C6.
Among cases which had a typical Ca-p (in Groups I, 2
and 3; 100 cases), only 3 cases had a Ca-p which sent spinal
branches to the roots of cervical nerves lower than C 7. In the
remaining 97 cases the lowest spinal branch of the Ca-p was
to the root of C7.
There was no overlapping of spinal branches of the Ca and
Fig. 2. Left side view of the case in which a lateral muscular
of the Ca-p except in 4 cases in which both the Ca and Ca-p branch of the Ca-p (solid lines) has developed to penetrate the
sent the spinal branch towards C6. scalenus medius muscle and to supply the uppermost part of the
The highest position at which the muscular branch from serratus anterior. The muscular branches to the scalenus medius and
the Ca-p penetrated the plexus was then investigated in 87 *
anterior muscles are indicated by * and respectively.
cases, the results were as follows:
between C 6- 7 76 cases (87 %l)
C7-8 11 cases (13 (Yo) and superficial to the scalenus medius muscle (1 case), or
between C7-8 and superficial to the muscle (2 cases) or
In conclusion, the boundary between the distribution areas
piercing the muscle (7 cases). On the way to the serratus
of the Ca and Ca-p was generally marked between C 5 and
anterior muscle this branch gave off a few muscular branches
C6, i.e. the Ca supplied the region of C 5 and above, and the
to the scalenus medius.
Ca-p that of C6 and below.

Type C (25 cases)

III. The relationship between the Ca-p and the trans-
verse cervical artery The Ca-p gave off the deep branch of the transverse cervical
artery, in addition to the spinal and muscular branches to the
The relationship between the typical Ca-p and the terminal scalenus anterior and medius muscles (Fig. 3). After running
branches of the transverse cervical artery (deep and superfi- between C 6- 7 or C 7- 8, this deep branch pierced the
cial branches) was examined in all cases in which the Ca-p scalenus medius or ran laterally and superficial to this
.was observed (Groups I, 2 and 3; 100 cases). muscle. The frequency was as follows:
piercing the muscle running superficial
Type A. A' (47 cases)
to the muscle
The Ca-p sent only spinal and muscular branches to the between C6-7 o 9 (5)
scalenus anterior and medius muscles (Fig. I). between C 7- 8 8 (3) 8 (I)
236
 IV. The branches from the 3rd part of the subclavian
artery
The transverse cervical artery or its deep branch originated
from the third part of the subclavian artery or from the
axillary artery irrespective of the Ca-p in 12 out of 130
cases (9 % ) . The transverse cervical artery or its deep
branch passed between C6-7 (7 cases) or caudal to the
brachial plexus (5 cases).

Type F (9 cases)
Only the deep branch arose from the third part of the
subclavian artery. In 5 cases the deep branch gave off
muscular branches to the serratus anterior. In one anomal-
ous case (91-17 d), the deep branch originated from the
supreme thoracic artery and ran backwards under the ser-
ratus anterior muscle.

Type G (3 cases)
Both deep and superficial branches arose from the third
part of the subclavian artery. In one case the deep branch
sent branches to the serratus anterior.

V. The relationship between the Ca-p and the cos-

tocervical trunk
As stated above in the title " I. The deep ascending cervi-
Fig. 3. Cervical arteries in the case in which a lateral muscular cal artery", specimens were classified into four groups
branch from the Ca-p (solid lines) has developed to penetrate the with reference to the relationship between the origins of
scalenus medius muscle , finally to become the deep branch of the
the Ca-p and the costocervical trunk.
transverse cervical artery. It sends a branch to the serratus anterior
muscle. The superficial branch of the transverse cervical artery
In Group I (67 out of 130 cases - 52 %) a typical Ca-p
originates from the Ca. In this case. both the superior intercostal and the costocervical trunk were both present , the former
and deep cervical artery also arise from the Ca-p. arising from the second part of the subclavian artery and
the latter from its first part. In 3 cases from this group,
the superior intercostal artery (one of the two terminal
The numbers given in parenthesis indicate the frequency branches of the costocervical trunk) was not observed , and
of cases in which the deep branch gave off muscular bran- the posterior intercostal artery ran from the thoracic aorta
ches to the upper part of the m. serratus anterior . up to the first intercostal space.
In group 2 (II out of 130 cases - 8 % ) an additional
Type D (3 cases) Ca-p (Ca-pe) arose from the costocervical trunk .
In Group 3 (22 out of 130 cases - 17 % ) the typical
The transverse cervical artery originated directly from the
costocervical trunk was absent but a similar branch arose
second part of the subclavian artery, j ust distal to the
from the Ca-p. In one case only the deep cervical artery
origin of the Ca-p. This transverse cervical artery passed
(one of the two terminal branches of the costocervical
between C6-7 (2 cases, running superficial to the
trunk) arose from the Ca-p. the superior intercostal artery
scalenus medius muscle) or between C 7- 8 (I case . pierc-
maintaining its origin from the first part of the subclavian
ing the scalenus medius muscle).
artery. In 7 cases the deep branch of the transverse cervi-
cal artery also branched off from the Ca-p (Type C) .
Type E and E' (8 cases) In Group 4 the typical Ca-p was absent, but a similar
The Ca-p gave off both deep and superficial branches of branch (Ca-pe) arose from the coste cervical trunk (30 out
the transverse cervical artery . In other words, the trans- of 130 cases - 23 %) . In 3 cases the deep branch also
verse cervical artery arose from the Ca-p. This transverse took origin from the costocervical trunk (Type C) .
cervical artery passed between C 6- 7 (4 cases) or C 7- 8 The costocervical trunk and its terminal branches, the
(4 cases, in all of which it penetrated the scalenus medius deep cervical and superior intercostal arteries, were not
muscle). Type E' was the case in which the superficial examined intensively , because this was not the purpose of
branch from the thyrocervical trunk was also observed . this study. The authors mention here only that, in some
237
 c
c

o
o

E
E
(E')

F
Rp
F \ " " . L..J~

G
G
Fig .4b. In Group 3, some types in which the typical costocervi-
Fig. 4 a. Schematic diagram s of the ramifications of some cer vi- cal trunk is absent and the equ ivalent deep cervical and/or the
cal arteries with special reference to the Ca-p and its lateral superior intercostal arteries arise from the Ca-p are included.
branches. All case s are show n as if they were from the left side . Some types in which the typical Ca-p is absent and the equiva-
The superfic ial branch (Rs) and/or the deep bran ch (Rp) of the lent artery arises from the costocervical trunk are from Group 4.
tra nsverse cervical artery shown by broke n lines ar ise from the
thyrocervical trunk. Th e shaded parts indicate the scale nus
anterior muscle which covers the Ca -p and Ca-pe . Group I
includes the various types in which the Ca and Ca-p arise inde- cases, 23 % ) it took origin from the third part of the sub-
pendently from the first and second parts of the subclavian artery clavian artery or from the proximal part of the axillary
respectively . Several types in which an additional Ca-p arises
from the costocervical trunk (costocervical type of Ca-p) are
artery, and rarely (6 cases , 5 % ) it branched off from the
shown in Group 2. The numbers of each case are shown in the internal thoracic artery . There were no cases in which the
figure . All types are described in the text. suprascapular artery arose from the second part of the
subclavian artery and had any relationship with the Ca-p
or Ca-pe,
cases, a branch from the Ca or Ca-p pierced the scalenus
medius muscle and compensated for an unusually slender
deep cervical artery.
Discussion
VI. The suprascapular artery I. The Ca and Ca-p
In most cases (92 out of 127, 72 %), the suprascapular According to Arey (1949), the embryonic interse gmental
artery arose from the thyrocervical trunk. Sometimes (29 arteries only supply the central nervous system at first.
238
Later they also distribute to the body wall through their ing this classification to the ramifications of another lon-
dorsal and ventral branches. In the cervical region the gitudinal trunk, the Ca-p, the lateral branches are the
original intersegmental arteries lose connections with the transverse cervical artery and muscular branches to the
dorsal aorta and become branches of the secondarily serratus anterior muscle, and the medial are the spinal
developed longitudinal anastomoses. Among these anas- branches.
tomoses, the postcostal anastomosis is thought to become
the vertebral artery and the precostal to become the thy- Ccom
rocervical trunk and the superior intercostal artery. Con-
sidering the fact that the Ca has spinal branches which
were originally the main branches of the intersegmental
arteries, it is thought to be an actual precostal anastomosis
among branches of the thyrocervical trunk. However, the
results of this study show that in more than 90 % of the
specimens observed, the Ca does not send spinal branches
to the roots of C 6 and the lower cervical nerves. Although Int- 1
spinal branches of the Ca pierce the scalenus anterior mus- 2
cle to reach the roots of lower cervical nerves in some 3
cases, the scalenus anterior muscle may prevent the dis-
4
tribution of the Ca to lower cervical nerves. Where then
5
do spinal branches to the roots of lower cervical nerves
6
take origin? The small spinal branches were observed to
have branched off from a small artery arising from the 7
second part of the subclavian artery (76 %) or the costocer- 8
vical trunk (24 %) in all the specimens examined. This
9
small artery has been overlooked, presumably because it is
situated behind the scalenus anterior muscle and is usually
quite small. However, judging from the fact that the artery
ascends ventral to the cervical vertebrae and sends spinal Fig. 5. The schematic diagram of the human aortic arches and
branches and muscular branches to the scalenus medius their derivatives modified from Arey (1949). Ventral view. The
which is the derivative of the cervical myotome, it is unshaded arteries disappear in the adult. The solid lines show the
intersegmental arteries and their three precostal anastomoses (the
reasonable to suppose that this ascending artery is also the
Ca, the Ca-p and the superior intercostal artery). Intersegmental
precostal anastomosis of cervical intersegmental arteries arteries higher than the 5th usually anastomose to form the Ca
and has the same morphological significance as the Ca. and the 6th and the 7th anastomose to form the Ca-p. The
For this reason, the authors propose to give the new name scalenus anterior muscle (lined area) is situated between the Ca
"deep ascending cervical artery (Ca-p)" to this small deep and Ca-p.
ascending artery.
In Figure 5 three precostal anastomoses are shown. Two
There are almost no reports in which the Ca is treated
of them are ascending precostal anastomoses. The Ca is
as an artery with the morphological significance described
thought to be the precostal anastomosis of the upper cervi-
above. Only Takafuji and Sato (1991) mentioned the
cal intersegmental arteries and the Ca-p to be that of the
embryological significance of the Ca in their study on the
lower cervical intersegmental arteries, both arising from
subclavian artery. The authors first reported on the Ca-p at
the 7th cervical intersegmental artery (subclavian artery).
the 96th meeting of the Japanese Association of Anato-
Their border can fluctuate between C5 and C6. Whereas
mists (Sekiya et al. 1991). Although some papers (Daseler
the Ca ascends superficial to the scalenus anterior muscle,
and Anson 1959; Hollinshead 1982; Lischka et al. 1982)
the Ca-p ascends deep to it.
report that two or more Ca may occur and in Pernkopf's
In most textbooks (Goss 1951; Schaeffer 1953; Roma-
Atlas (1980) double Ca are illustrated, there are no more
nes 1972; Gardner et al. 1975; Williams and Warwick
detailed descriptions of the Ca in those publications and it
1980; Woodbume and Burkel 1988), the Ca is described
is not clear whether the additional Ca corresponds to the
as a branch of the inferior thyroid artery. probably because
Ca-p proposed by us.
the inferior thyroid artery is usually far thicker than the
Ca. However, from the above-mentioned embryological
viewpoint, the Ca should be considered to be the main
trunk of the thyrocervical trunk. Only a Japanese textbook
II. The relationship with the transverse cervical artery
by Yamada and Man'nen (1985) has pointed out that the
Ca is a longitudinal trunk and has two groups of branches, The origin of the transverse cervical artery varies consider-
the medial group consisting of spinal branches and the ably. In some cases, both superficial and deep branches of
inferior thyroid artery, and the lateral group consisting of it arise from the Ca (apparently from the thyrocervical
the transverse cervical and suprascapular arteries. Apply- trunk) (Fig. I), but in others the superficial and deep bran-
239
ches ongmate from the second or the third part of the the root of Ca-p , and the ongm was secondarily incor-
subclavian artery independently or forming a common porated into the wall of the subclavian artery by the
trunk . Among these variat ions, the transverse cervical expansion of its wall during development. Therefore , it
artery arising from the Ca (the thyrocervical trunk ) is is thought that there is little difference between these
named "English type" and that from the second part of three cases and the above-mentioned Type C (25 cases).
the subclavian artery is named "German type" (Adachi In 12 cases the deep branch or the transverse cervical
1928). This variation has been discussed only from the artery itself arose from the third part of the subclavian
aspect in frequency of type s, the morphological signifi- artery or the axillary artery independently of the Ca-p ,
cance of this variation never having been considered. and passed through or caudal to the brachial plexus
In this study , minute observation of the branche s of (Ty pes F, G). Lischka et al. (1982) described the trans-
the transverse cervical artery revealed that any deep verse cervical artery as appearing to originate from the
branch arising independently from the second part of the third part of the subclavian artery , becau se the boundary
subclavian artery sent spinal and muscular branches to between the 7th segmental artery and the upper limb
the scalenus mediu s. Although these branches differed in arter y shifted more distall y durin g the development of
thickness from those of the Ca-p, the course and dis- the subclavian artery. However, the Ca-p took its origin
tribution were the same (Fig . I). Consequently, the deep fro m the second part with out shifting in such cases .
branch from the second part of the subclavian artery can Therefore, the deep branch or the transverse cervical
be explained as a branch of the Ca-p. The thickness of artery from the third part or the axillary artery is
each artery should in this respect be disregarded. thought to have no relationsh ip with the Ca-p, and
In 10 cases the muscul ar branches to the scalenu s should rather be discu ssed in relation to the upper limb
medius muscle from the Ca-p supplied the uppermo st arterie s.
part of the serratu s anterior muscle (Type B). We con-
sider that this case shows the intermediate stage betwe en
the usual Ca-p and a Ca-p with a deep branch. That is
III. The relationship with the costocervicaI trunk
to say, the muscular branch to the scalenus medius mus-
cle from the Ca-p first develop s into the branch which According to Hamilton and Mo ssman (1978), the deep
penetrates or runs superficial to the scalenus mediu s cervical artery, which is the one of the two terminal
muscle to supply the upperm ost part of the serr atus branches of the costocervical trunk , is developed out of
anterior (Type B, 10 cases) and secondarily develop s the post-tran sverse anastomo sis of cervical inter segmental
into the deep branch which reaches the rhomboid musc- arteries . The superior intercostal artery, which is the
les (Type C of Groups I , 2 and 3 , in 25 cases) . It other terminal branch of the costocervical trunk , and the
finally develops into the artery with deep and superficial Ca are out of the precostal anastomosis. Moreover , our
branche s , which is nothin g but the transverse cervical study makes it clear that the Ca-p is another precostal
artery (Type E, 8 cases). Meanwhile , there was no case anastomosis of cervical inter segmental arterie s.
in which only the superfi cial branch arose from the Ca- In almost all cases the deep cervical artery formed a
p. Thus, branches of the Ca-p are considered to develop common trunk, the costocervi cal trunk, with the superior
in the following order; Ca-p ~ Ca-p + muscular bran- intercostal artery. Although we did not make a detailed
ches to the serratus anterior muscl e (Rsan) ~ + Ca-p + observation of the terminal distribution and anastomosis
Rsan + deep branch of the transverse cervical artery ~ of the deep cervical artery , in some cases it was quite
Ca-p + Rsan + transverse cervical artery (deep and slender and a branch from the Ca or Ca-p was thou ght
superficial branches) . The Rsan , the deep and the supe r- to compensate , as in the cases described by Quain
ficial branches supplied mainly the serratus anterior . the (1844) and Elze (1960 ). We observed one specimen in
rhomboids and the trape zius respectively. The y are in which a deep cervical artery arising from the costocervi-
the segmental order of the cervical nerves innervating ca l trunk was absent and replaced by a branch from the
those muscles, becau se the serratus anteri or muscle is Ca-p (Type A ' of Group 3). In an extreme case , not
supplied by the lower cervical nerves, the rhomb oids by only the deep cervical artery but also the superior inter-
the middle cervical nerves and the trapeziu s by the costal artery, that is to say the costocervical trunk itself,
upper cervical nerves. The se facts suggest that the was compensated by a bran ch from the Ca-p as shown
branch to the muscle innervated by the lower cerv ical in Type s A , C and F of Group 3. On the other hand ,
nerves can more easily form a common trunk with the there were many cases in which a Ca-p arising from the
Ca-p . Thi s may have some relation to the fact that the seco nd part of the subclavian artery was small or absent
Ca-p is the longitudinal anastomosis between the lower and a branch from the costocervical trunk compensated
cervi cal intersegmental arteries (Fig. 5 ). for it (the costo cervicaI type of Ca-p (Ca-pe) in Groups
In three cases, the deep branch arose hom the second 2 and 4). Furthermore, in 3 cases (2. 3%) this type of
part of the subclavian artery independently and ju st dis- Ca-p (Ca-pe) gave off the deep branch of the transverse
tal to the origin of the Ca-p (Type 0). Because the ori- cervical artery (Type C of Group 4) . Cases in which the
gin of the Ca-p and the deep branch were quite close , it transverse cervical artery arose from the first part of the
was surmised that the deep branch originally came from subclavian artery and ran laterally deep to the scalenu s

240
 --_. ( R s)
ing the total compensation or shifting of ongms among
precostal anastomoses will be discussed later.

,- - - ..
. (As) IV. The relationship with the suprascapular artery
In more than half of the specimens used in this study, the
suprascapular artery originated from the first part of the
Rp • Rs subclavian artery as a lateral branch of the Ca. In other
cases, it arose from the third part of the subclavian artery,
axillary artery or internal thoracic artery. We never
........- - - -, - - (Rs)
observed a case in which the Ca-p gave off the supra-
scapular artery. However, a suprascapular artery arising
Rp • Rp + Rs
from the second part of the subclavian artery behind the
scalenus anterior muscle was reported in 2 out of 138
Rp • Rp +Rs
cases by Adachi (1928) and in 1.4 % by Takafuji and Sato
(1991). Although they mentioned nothing about the Ca-p,
these suprascapular arteries might have some relationship
with it.

V. Conclusion
Is
All the above results are summarized in Figure 6. The
Fig. 6. A schematic diagram of the ramifications of the Ca, the ascending cervical artery (Ca) originates from the first part
Ca-p and the costocervical trunk, Left side view, The shaded of the subclavian artery (Sc), ascends superficial to the
part shows the scalenus anterior muscle and the chained lines scalenus anterior muscle and sends spinal branches
indicate the Ca-p and its branches. which run deep to the medially to the roots of the 3rd, 4th and 5th cervical
scalenus anterior muscle. The Ca ascends superficial to the nerves (C3, C4, C5) and muscular branches to the levator
scalenus anterior muscle, sending spinal branches toward the scapulae muscle laterally which pass between the cervical
roots of C3-5 and muscular branches to the levator scapulae
nerves from C2 to C5 and rarely C5-6. On the other
muscle (*), passing between the cervical nerves C2 to C5.
hand, the Ca-p arises from the second part of the subcla-
Rarely it gives rise to the muscular branch to the scalenus
medius (*) between C5-6, On the other hand, the Ca-p ascends vian artery, ascends deep to the scalenus anterior muscle
deep to the scalenus anterior, sending spinal branches to the and gives off spinal branches medially to the roots of the
roots of C6-8 and muscular branches to the scalenus medius (*) 6th, 7th and 8th cervical nerves (C6, C7, C8) and later-
between the nerves C6 to C8. Any of these muscular branches ally muscular branches to the scalenus medius or the
can develop into the deep. superficial or both branches of the levator scapulae muscles, which run between the cervical
transverse cervical artery. The branches indicated by dotted lines nerves from C 6 to C 8. From the first part of the subcla-
were not observed in this study. but reported by other inves- vian artery the costocervical trunk is given off. The lateral
tigators. muscular branch from the Ca or Ca-p occurs as one for
each intersegmental space. The lateral muscular branch
medius muscle were reported by Adachi (1928) in 2 out of between C4-5 usually develops into deep and superficial
186 specimens and by Phillips (1989) in II 'Yo. This trans- branches of the transverse cervical artery. Some cases in
verse cervical artery is thought to be equivalent to the which the lateral muscular branch between C3-4 or
deep branch arising from the costocervical type of the Ca- C 2- 3 developed into an additional superficial branch
p (Ca-pe). were described by Yamada and Man'nen (1985) as the
The above-mentioned compensational relationships or accessory superficial cervical artery. Moreover, a superfi-
shiftings of origins among cervical arteries are understood cial branch (Takafuji and Sato 1991) or a transverse cervi-
as follows: the deep cervical artery, which is the postcos- cal artery (Kagi 1959) arising from the Ca and passing
tal longitudinal anastomosis of cervical intersegmental between C5-6 has also been reported. These unusual su-
arteries, can form a common trunk with any precostal perficial branches and transverse cervical arteries are con-
longitudinal anastomosis of intersegmental arteries from sidered to have developed from the lateral muscular
the cervical to the upper thoracic region. It usually arises branch of the Ca. In this study there were some cases in
with the superior intercostal artery. which is the precostal which the deep branch or the transverse cervical artery
longitudinal anastomosis of the upper thoracic region, but arose from the first or second part of the subclavian artery
in some cases it arises from the Ca-p. which is an anas- and passed between C 6 - 7 or C 7 - 8. These unusual
tomosis of the lower cervical region, and in rare cases it arteries are also thought to have developed from the lateral
can also arise from the Ca, which is an anastomosis of the muscular branch which arises from the Ca-p and passes
upper cervical region (Figs. 5, 6) The mechanism produc- between C6-7 or C7-8.
241
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