Upper limb arterial pattern: clinical correlation and embryological perspective / Padrão arterial dos membros superiores: correlação clínica com perspectiva embriológica

Abstract Background Variations in the upper limb arterial pattern are commonplace and necessitate complete familiarity for successful surgical and interventional procedures. Variance in the vascular tree may involve any part of the axis artery of the upper limb, including the axillary artery and brachial artery or its branches, in the form of radial and ulnar arteries, which eventually supply the hand via anastomosing arches. Objectives To study the peculiarities of the arterial pattern of the upper limb and to correlate them with embryological development. Methods The entire arterial branching of forty-two upper limbs of formalin fixed adult human cadavers was examined during routine dissection for educational purposes, conducted over a 3-year period in the Department of Anatomy, Lady Hardinge Medical College, New Delhi. Results The study found: 1) One case in which a common trunk arose from the third part of the axillary artery, which immediately splayed into four branches (2.4%); 2) High division of the brachial artery into ulnar and radial arteries, in 3 cases (7.1%); 3) Pentafurcation of the brachial artery into ulnar, interosseus, radial, and radial recurrent arteries and a muscular twig to the brachioradialis in 1/42 cases (2.4%); 4) Incomplete Superficial Palmar arch in 3/42 cases (7.1%); and 5) Presence of a median artery in 2/42 case(4.8%) Conclusions This study observed and described the varied arterial patterns of the upper limb and identified the various anomalous patterns, supplementing the surgeon's armamentarium in various surgical procedures, thereby helping to prevent complications or failures of reconstructive surgeries, bypass angiography, and many similar procedures.

Resumo Contexto As variações no padrão arterial dos membros superiores são comuns e, assim, necessitam de total familiaridade para que os procedimentos cirúrgicos e de intervenção sejam bem-sucedidos. A variância na árvore vascular pode envolver qualquer parte da artéria axial dos membros superiores, incluindo a artéria axilar, a artéria braquial ou os seus ramos, na forma das artérias radial e ulnar, as quais, em algum momento, suprem as mãos através dos arcos anastomosados. Objetivos Avaliar as peculiaridades do padrão arterial dos membros superiores e correlacioná-las ao desenvolvimento embriológico. Métodos Foram examinados os ramos arteriais completos de 42 membros superiores de cadáveres adultos conservados em formalina, os quais eram rotineiramente dissecados para fins educacionais durante 3 anos no Departamento de Anatomia Lady Hardinge Medical College, Nova Delhi. Resultados O estudo apresentou cinco desfechos. 1. Foi constatado um caso em que um tronco comum surgiu da terceira parte da artéria axilar que imediatamente se disseminou em quatro ramos (2,4%). 2. Houve divisão maior da artéria braquial em artérias ulnar e radial em três casos (7,1%). 3. Em um caso, ocorreu pentafurcação da artéria braquial em ulnar, interóssea, radial, radial recorrente e de um galho muscular em braquiorradial (2,4%). 4. Foi constatado arco palmar superficial incompleto em três dos 42 casos (7,1%). 5. Foi observada a presença da artéria mediana em 2 dos 42 casos (4,8%). Conclusões Este estudo compreende o padrão arterial do membro superior e identifica os diversos padrões anômalos para agregar ao arsenal terapêutico de cirurgiões para diversos procedimentos cirúrgicos, com o objetivo de combater quaisquer complicações ou falhas de cirurgias reconstrutivas, de angiografias de cirurgias de revascularização e muitas outras.

A radial artery originating from the thoracoacromial artery.

PURPOSE: The purpose of this case report is to report a rare vascular variation in the upper limbs because of its clinical importance and embryological implication. METHODS: During the educational dissection of a 73-year-old Korean male cadaver`s right upper limb, we found a variant branch which is originated from the thoracoacromial artery. RESULTS: The variant branch from the thoracoacromial artery ran to the distal forearm in the deep fascia. Because it finally coursed like the radial artery in the forearm and the palm, we defined the variant artery as superficial brachioradial artery (SBRA). In the cubital region a little below the intercondylar line, the brachial artery gave off a small communicating branch to SBRA, and continued as the ulnar artery. CONCLUSIONS: We reported this unique variation and discussed its clinical and embryological implication.

A coincidental variation of the axillary artery: the brachioradial artery and the aberrant posterior humeral circumflex artery passing under the tendon of the latissimus dorsi muscle.

A case of anomalous terminal branching of the axillary artery was encountered and described in a left upper limb of a male cadaver. A series of 214 upper limbs of Caucasian race was dissected. A variant artery, stemming from the very end of the axillary artery followed a superficial course distally. It passed the cubital fossa, ran on the lateral side of the forearm as usual radial artery, crossed ventrally to the palm and terminated in the deep palmar arch. This vessel is a case of the brachioradial artery (incorrectly termed as the "radial artery with high origin"). Moreover, it was associated with another variation, concerning the aberrant posterior humeral circumflex artery passing under the tendon of the latissimus dorsi muscle. The anatomical knowledge of the axillary region is essential for radiodiagnostic, surgical and traumatologic procedures. The superficially located artery brings an elevated danger of heavy bleeding in all unexpected situations, its variant branching can cause problems in radial catheterization procedures and the anomalously coursing other arterial variant poses an elevated danger in surgical procedures concerning the surgical neck of humerus.

Multiple variations of the arterial pattern in upper extremities: a case report and embryological pathogenesis.

During a routine dissection at the Department of Anatomy, Collegium Medicum, Jagiellonian University, one cadaver was found to have multiple variations of the arteries of the upper limbs. The variations pertained to the course of the brachial artery as well as to its distribution. An unusual formation of the superficial palmar arch was observed in both upper limbs. The anatomical peculiarities encountered included: in the left upper limb-the brachioradial artery, which formed the superficial palmar arch by turning to the palmar side of the hand and connecting with the ulnar artery and in the right upper limb-a subscapular-circumflex humeral-deep brachial trunk that correlated with a high division of the brachial artery (in the upper third of the biceps brachii muscle), a large anastomosis between the radial and the ulnar artery, the presence of a persistent median artery, and the unusual formation of the superficial palmar arch, which was created by the median, ulnar, and radial arteries. In this report, we will trace the path of the axillary artery and its branches in detail and emphasize its embryological significance.

High origin of a superficial ulnar artery arising from the axillary artery: anatomy, embryology, clinical significance and a review of the literature.

The superficial ulnar artery (SUA) is an ulnar artery of high origin that lies superficially in the forearm. Its reported frequency ranges from 0.17% to 2%. During anatomical dissection in our department we observed a unilateral case of SUA in a 75-year-old white male human cadaver. It originated from the right axillary artery at the level of the junction of the two median nerve roots and followed a looping course, crossing over the lateral root of the median nerve and running lateral to it in the upper and middle thirds of the arm, whereas in the inferior third of the arm the SUA crossed over the median nerve and ran medially to it. In the cubital fossa, it passed superficially over the medial side of the ulnar aponeurosis and coursed subcutaneously in the ulnar side of the forearm superficially to the forearm flexor muscles. In the hand the SUA anastomosed with the superficial palmar branch of the radial artery, creating the superficial palmar arch. Additionally, it participated in the development of the deep palmar arch. The axillary artery, after the origin of the SUA, continued as the brachial artery and divided into the radial and common interosseous arteries in the cubital fossa. The normal ulnar artery was absent. No muscular or other arterial variations were observed in this cadaver. The embryological interpretation of this variation is difficult and it may arise as a result of modifications to the normal pattern of capillary vessel maintenance and regression. The existence of a SUA is undoubtedly of interest to the clinician as well as to the anatomist. This report presents a case of unilateral SUA along with a review of the literature, embryological explanation and analysis of its clinical significance.

Unilateral double axillary and double brachial arteries: embryological basis and clinical implications / Arterias Axilar y Braquial Dobles Unilaterales. Bases Embriológicas e Implicaciones Clínicas

Este reporte describe la presencia de las arterias axilar y braquial duplicadas en el lado derecho de un cadáver adulto de sexo masculino. La arteria axilar derecha se bifurcó en arterias axilares I y II, localizadas posteriormente al músculo pectoral menor. Ambas arterias, con sus respectivas ramas atravesaron bajo el músculo redondo mayor y continuaron como arterias braquiales I y II, respectivamente. La arteria axilar I, que se continuó como arteria braquial I, tuvo un trayecto superficial y tortuoso, mientras que la arteria axilar II fue de poco calibre y de localización profunda. Las arterias toracoacromial, torácica lateral y subescapular se originaron de la arteria axilar I. La arteria torácica superior se originó de la arteria toracoacromial. Las arterias circunflejas humerales anterior y posterior se originaron desde la arteria axilar II. La arteria braquial profundase originó de la arteria braquial II, mientras que a nivel de la línea intercondílea, la arteria ulnar se originó de la arteria braquial I. En la fosa cubital, la arteria braquial I se dividió en arterias radial e interósea común, mientras que la arteria braquial II terminó anastomosándose con la arteria braquial I. Las arterias ulnar, radial e interóseas común continuaron como arterias independientes y tuvieron un trayecto y distribución normales en el antebrazo. La persistencia de arterias axilar y braquial dobles tiene una base embriológica, pudiendo ser de interés para la embriología experimental. El conocimiento de estas variaciones arteriales múltiples, como el presente caso, es de importancia fundamental durante la medición de flujo en los vasos sanguíneos a través de Doppler, para el diagnóstico clínico y manejo quirúrgico de enfermedades que afectan al miembro superior.

This report presents double axillary and double brachial arteries on the right side of an adult male cadaver. In this case, the right axillary artery bifurcated into axillary artery I and axillary artery II posterior to the pectoralis minor muscle. Both the axillary arteries with their branches traversed upto lower border of teres major muscle and continued further as seperate entities into the cubital fossa as brachial artery I and brachial artery II respectively. The axillary artery I which continued as brachial artery I was superficial and tortuous in its course, while the axillary artery II was slender and deeply situated. The thoraco-acromial, lateral thoracic and subscapular arteries took origin from axillary artery I. The superior thoracic artery was seen arising from the thoraco-acromial artery. The anterior and posterior circumflex humeral arteries arose from axillary artery II.The profunda brachii artery was given off by the brachial artery II, while at the level of intercondylar line, the ulnar artery was given off by brachial artery I. In the cubital fossa, the brachial artery divided into radial and common interosseous artery, while the brachial artery II ended by anastomosis with brachial artery I. The ulnar, radial and common interosseous arteries continued as separate entities and exhibited a normal course and distribution in the forearm.The hypothesis for the embryological basis of persistence of double axillary and double brachical arteries may be useful for experimental embryology. The knowledge of such multiple arterial variations as in the present case is of immense significance during Doppler scanning of blood vessels for clinical diagnosis and surgical management of diseases of superior extremity.

Variations in the subclavian-axillary arterial system.

OBJECTIVE: The objective of this study is to report on the subclavian axillary arterial system variations observed in the dissecting room. METHODS: The morphological study of 106 formalin fixed upper limbs of adult human cadavers of both sexes was carried out at human anatomy laboratory of College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia over a 5 year period, to observe the distribution pattern of the subclavian axillary arterial system. RESULTS: The arterial variations in the upper extremities are quite common and may occur at the level of the thoracic outlet, axilla, arm, cubital fossa and the hand. In the present study, the anomalous topographic pattern of the subclavian axillary arterial system was revealed in 7.5% of the cadavers, whereas 92.5% exhibited classical pattern of the regional arterial anatomy. The study showed: 1. An aberrant right subclavian artery arising from the arch of aorta, distal to the left subclavian artery. 2. A bilateral common subscapular-circumflex humeral trunk (3.8%) emerging from the 3rd part of the axillary artery (branching into the circumflex humeral and thoracodorsal arteries. 3. A bilateral thoracohumeral trunk arising from the 2nd part of the axillary artery (1.9%) and branching into the lateral thoracic, circumflex humeral, subscapular and thoracodorsal arteries. These anomalies were accompanied by anomalous insertion of flexor digitorum superficialis muscle, a bilateral digastric muscle formed by the abductor pollicis longus and brevis, and an anomalous formation of median nerve by 3 roots. CONCLUSION: The aberrant right subclavian artery associated with right non-recurrent laryngeal nerve and variant branching pattern of the axillary artery are of interest to anatomists, surgeons and radiologists and suggested that these anomalies must be evaluated pre-operatively.

Morphogenesis of the primary arterial trunks of the forelimb in the rat embryos: the trunks originate from the lateral surface of the dorsal aorta independently of the intersegmental arteries.

It has been believed that the primary arterial trunk of the mammalian forelimb is derived from the 7th intersegmental artery. Here we examined the early morphogenesis of the arteries and nerves in the forelimb region by adopting a method that combined intravascular dye-injection with nerve staining to whole mounted rat embryos. The study was carried out on greater numbers of specimens at smaller intervals of embryonic stages and from earlier stages than those in previous reports. We report that: (1) The multiple primary arterial trunks in the forelimb region (primary subclavians) originate directly from the lateral surface of the dorsal aorta independently of the intersegmental arteries, previous to the formation of limb buds. (2) The tips of the 8th (and the 9th) primary subclavians that originate from the aorta near the origin of the 8th (or the 9th) intersegmental artery bend cranially and/or caudally. With the formation of limb bud, they extend to form the longitudinal trunks in the presumptive axillary region. The primary arteries in the free arm region branch off from this longitudinal trunk, and one of them develops into the axial artery. (3) The origins of the primary subclavians shift their positions on the surface of the dorsal aorta and approach the origins of the neighboring intersegmental arteries to join them, and then replace the latter. Consequently, the primary subclavians appear to be "the lateral branches of the in tersegmental arteries." (4) The 8th primary subclavian is dominant at first, but is replaced by the 7th primary subclavian, which develops into the definitive subclavian artery. (5) With the brachial nerve plexus formation, the axillary arterial plexus derived from the longitudinal trunk develops to form two stems of the axillary artery.

Report of a rare human variation: absence of the radial artery.

A case of unilateral absence of the radial artery is reported. The arterial system of the specimen was developmentally primitive with the anterior interosseous artery the chief blood supply to the forearm and hand. A "superficial ulnar artery" of small caliber supplemented the supply of the hand. Three large branches of the anterior interosseous artery supplied the hand with the lateral terminal branch replacing the radial artery distal to the wrist. The superficial palmar arch was formed by an anastomosis of the media and lateral terminal branches of the anterior interosseous artery. No deep palmar arch was present, but three palmar metacarpal arteries arose from a perforating artery which branched from a large dorsal branch of the anterior interosseous artery. The median artery was of small caliber and could not be traced beyond the midforearm. Based on this specimen and a review of other forearm and hand arterial variations, it is postulated that the ulnar artery may developmentally precede the median artery.

Estudo de variaçöes na formaçäo da veia axilar / Variations in the axillary vein formation

A formaçäo da veia axilar foi observada em 51 (cinqüenta e um) membros superiores humanos, isolados do tronco. O estudo das variaçöes na formaçäo da veia axilar demonstrou grande variabilidade, sendo a maior freqüência de formaçäo determinada por continuaçäo direta com a veia basílica. Considerando as veias braquiais - medial e lateral - e veia basílica, pudemos constatar a ocorrência de 10 (dez) distintas maneiras de formaçäo da veia axilar e determinamos as freqüências com que elas ocorrem, analisando os vasos formadores e vasos tributários de cada variaçäo