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 Table of Contents  
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 222-226

A study on the unusual course and branching patterns of arteries in the upper limb

1 Department of Anatomy, Sri Venkateswaraa Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India
2 Department of Anatomy, Apollo Medical College, Murukambattu, Andhra Pradesh, India
3 Department of Anatomy, Sri Venkateswaraa Medical College Hospital and Research Institute, Puducherry, India

Date of Submission16-Jul-2022
Date of Acceptance01-Oct-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Dr. Senthil Ganesh P Kannappan
Department of Anatomy, Sri Venkateswaraa Medical College Hospital and Research Institute, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_166_22

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Background and Aim: Human body consists of blood vessels, nerves, and muscles that are not always similar to each one. Anatomical study of abnormal vessels or nerve or muscle arrangements in the body interferes of clinical diagnosis, surgical procedure, and radiological findings. Comprehensive knowledge of anatomical variations present in the body is key for patient management. Arteries of upper limb variations are more common than other variations. Arterial variations may lead to vascular neuropathy. Diagnostic errors can be eliminated by understanding these variations. The aim of the present study is to correlate clinical abnormalities with arterial course variation in the upper limb and contribute some of the previously unknown new variations to medicine. Materials and Methods: A descriptive study was conducted from 2016 to 2021 in the Department of Anatomy, Apollo Medical College, Chittoor. The study was conducted with 56 upper limbs from 28 cadavers. The arterial course and relations of each region in the upper limb were noted carefully. Results: Abnormal arterial courses and variations were considered for data collection. Out of 56 limbs, 6 variations were seen from 5 limbs. Abnormal arterial courses were found in the 2 upper limbs (3%) and abnormal arterial branches were present in the 4 upper limbs (7%). In 51 upper limbs, there were no abnormal arterial courses and branches (90%). Conclusion: Study of anatomical arterial variations helps to guide the diagnosis and treatment of patients. Hence, arterial variations present in the upper limbs are more common than in other regions of the body.

Keywords: Neurovascular variation, subscapulohumeral artery, superficial brachial artery, vascular impairment

How to cite this article:
Kannappan SG, Srivaram HH, Ekambaram G. A study on the unusual course and branching patterns of arteries in the upper limb. Arch Med Health Sci 2022;10:222-6

How to cite this URL:
Kannappan SG, Srivaram HH, Ekambaram G. A study on the unusual course and branching patterns of arteries in the upper limb. Arch Med Health Sci [serial online] 2022 [cited 2023 Feb 5];10:222-6. Available from: https://www.amhsjournal.org/text.asp?2022/10/2/222/364954

  Introduction Top

Arterial flow in upper limb development is complicated and adequate knowledge requires understanding the possible arterial variations in the upper limb. In fetal life, the seventh intersegmental artery continues downward and divides into many branches, and these branches supply all the parts of the upper limb. These arteries are named based on the location of their region in the upper limb. These are the subclavian artery in the subclavicular region, the axillary artery in the axilla, and the brachial artery in the arm (brachium). Accurate understandings of neurovascular variations are important for surgeons to handle upper limb surgeries.

Physicians, surgeons, and radiologists must be aware of these arterial variations in the muscular and neurovascular systems to avoid errors in case diagnosis.[1] It is important to analyze brachial artery variations in the upper limb to conduct a surgical intervention in arteriography.[2] Previous literature sources stated that 20% of brachial artery variations are common in human cadavers. Highly bifurcated brachial artery variations are less common, with an incidence of 8%[3],[4] The axillary artery continues from the subclavian artery and divides into three parts, which gives the superior thoracic artery from the first part, the lateral thoracic artery (LTA) and thoracoacromial artery from the second part, and subscapular artery and anterior and posterior circumflex humeral arteries from the third part. The brachial artery usually continues from the axillary artery at the lower border of the teres major in the arm. Initially, the artery courses medial to the median nerve in the upper arm. At the middle of the arm, an artery crosses the median nerve from medial to lateral and then runs lateral to the median nerve in the lower arm. Commonly, the brachial artery divides into radial and ulnar arteries at the elbow of the cubital fossa. After the division, the ulnar artery runs between the two heads of pronator teres. Several cadavers revealed an ulnar artery that runs superficial to the flexor muscles of the forearm. In such cases, the ulnar artery is easily damaged for minor forearm injuries. It is also vulnerable to intravenous drug administration and brachial catheterization.[5]

  Materials and Methods Top

From 28 cadavers, embalmed cadavers of 56 upper limbs were taken for study. The entire upper limbs were dissected at a routine dissection hour in the Anatomy Department, Apollo Medical College, Chittoor. We examined 19 male cadavers and 9 female cadavers. All the details of the cadaver's age, sex, cause of death, and other details were collected from the log book maintained in the department. Cadavers' ages varied between 43 and 82. The pectoral region, arm, cubital fossa, and forearm regions were dissected by following standard dissection in Cunningham's Manual of Practical Anatomy. Each region was exposed by removing skin; superficial fascia, arteries, and nerves were cleaned and traced using dissection forceps. Initially, we tied a tag with a serial number to each cadaver. Examined axillary arteries with their relations and tracing the course of each axillary artery branch were noted. The brachial artery relations and branches were traced using various forceps. Finally, each terminal division of ulnar artery relations, branches, and radial artery relations, branches were examined thoroughly. All the details of variations present in the cadaver were recorded and separated into arterial variations for further studies.

  Results Top

Variation 1-course of brachial artery superficial to the root of the median nerve

Variation of the axillary artery was found in a 58-year-old male cadaver during dissection. The axillary artery usually runs posterior to two roots of the median nerve. However, a male cadaver showed the third part of the axillary artery runs superficial to the junction of the medial and lateral root of the median nerve. The branches of the brachial artery were not shown any variations [Figure 1].
Figure 1: Showed the abnormal course of brachial artery on median nerve. BA Brachial Artery, MN: Median Nerve, MuN: Musculocutaneous Nerve

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Variation 2-brachial artery gives superficial and deep brachial artery

During the dissection of a 75-year-old female, a cadaver found an abnormal variation present in the brachial artery. There are double brachial arteries, one runs superficial and the other one branch runs deep to the roots of the median nerve [Figure 2].
Figure 2: Showed SBA: Superficial branch of Brachial Artery and DBA: Deep branch of Brachial Artery, UA: Ulnar artery, RA: Radial artery. It showed the immediate division of brachial artery into radial, ulnar artery after fusion of superficial branch of brachial artery and deep branch of brachial artery

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At the lower part of the axilla, the axilla artery divides into two branches: the superficial branch of the brachial artery (SBA) and the deep branch of the brachial artery (DBA). At the elbow, superficial and deep branches are joined together in the cubital fossa. The fused brachial artery was immediately bifurcate into radial and ulnar arteries. The superficial branch is not given any branch to the brachium. All the branches were derived from the DBA.

Variation 3-The brachial artery winds around the median nerve

Our dissection table found an abnormal course of the brachial artery in relation to the median nerve in the left arm of a 58-year-old male cadaver. The course of the brachial artery in this cadaver was abnormally present. At the upper arm, the brachial artery was radiated lateral to the median nerve. At the middle of the elbow, the brachial artery loops around the median nerve and again runs lateral to the median nerve up to the elbow. The brachial artery was typically located medial to the median nerve at the upper arm and lateral to the median nerve at the lower arm. In this cadaver, the brachial artery runs lateral to the median nerve throughout its course except at the middle, forming a loop around the median nerve.

Variation 4-Trunk of subscapulohumeral artery from axillary artery

A 68-year-old male cadaver's right side axilla was found to have a variation of the axillary artery. The third part of the axillary artery gives abnormal subscapulohumeral artery and posterior circumflex humeral arteries. There is extensive collateral circulation associated with the branches of the subclavian and axillary arteries, particularly around the scapula. This clearly becomes of clinically significant during injury of the axillary artery. Usually, the LTA arises from the second part of the axillary artery. However, here, the LTA arises from the common trunk of the subscapulohumeral artery. The circumflex scapular artery starts from the subscapulohumeral artery rather than the third part of the axillary artery [Figure 3] and [Figure 4].
Figure 3: Showed the large branch from the axillary artery act as 2nd and 3rd part of axillary artery. CSA: Circumflex scapular artery, LTA: Lateral Thoracic Artery, LNTA: Long thoracic artery

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Figure 4: Showed SSHA: Subscapulohumeral Artery, PCHA: Posterior circumflex humeral artery, CSA: Circumflex scapular artery, LTS: Lateral Thoracic Artery, LNTA: Long thoracic artery

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Variation 5-The ulnar artery's superficial relationship at the cubital fossa

Dissection of a 64-year-old female cadaver showed an abnormal course of ulnar artery and an abnormal branching pattern of the radial artery. In this study, we found the ulnar artery was radiated superficial to the flexor muscles of the forearm and it does not give common interosseous artery [Figure 5].
Figure 5: Showed ulnar artery radiate superficial to flexor muscles. RA: Radial Artery, UA: Ulnar Artery, RN: Radial Nerve, MN: Median Nerve

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Variation 6-Common interosseous artery

Common interosseous artery arises from the radial artery instead of the ulnar artery [Figure 6].
Figure 6: Showed common interosseous artery arise from the radial artery. CIA: Common interosseous artery, BA: Brachial Artery, RA: Radial Artery, UA: Ulnar Artery

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Embryological explanation

Knowledge of the embryological development of upper limb vessels is required to understand the different variations found during diagnosis. Initially, axis arteries continued from the seventh intersegmental artery. Subsequently, the axis artery differentiates into many changes to form various branches of arteries. First, the median artery arises from the axis artery. It descends downward to join with the digital arteries of the hands. Then, this artery is detached from the digital arteries to form posterior interosseous artery. Next, the ulnar artery starts from the axis artery, which is above the origin of the median artery. It runs downward on the medial side to join with the digital arteries. At the end, the superficial brachial artery arises much higher than the ulnar artery from the lateral side of the axis artery to join with the digital arteries. This artery also receives one branch from the axis artery. The superficial brachial artery was disappearing above the newly formed branch.

  Discussion Top

An abnormal superficial course of arteries can be mistakenly identified as superficial vein. These arteries were at risk of common rupture from surgical interventions. Vascular impairment can cause Volkmann's ischemic contracture of the upper limb. These studies can create awareness of possible developmental vessel variations in the upper limb, and avoid diagnostic and surgical complications during management.

Five different variations were found out of 55 cadavers during routine dissection. Some of the variations have not been reported before. Variation 1 showed the brachial artery was present superficial to the roots of the median nerve. In Maruti Ram et al., 2013 and Solan, 2013 studies, the brachial artery divides into two branches. The superficial branch runs downward throughout the forearm and divides into superficial palmar and deep palmar arch at the palmar region in their studies. In our study, the superficial branch crosses the front roots of the median nerve. Variation number 2 also showed the SBA runs superficial to the fusion of median nerve roots.[6],[7]

Variation 2 was reported by some authors in their studies. Their study showed as similar variation of the axillary artery divide into superficial and deep branches of the brachial artery.[8],[9],[10] The superficial artery coursed in front of the median nerve and continued as the radial artery. Deep branch continues as the ulnar artery. Except for this study, none has reported that superficial and deep branches are joined together and divided as ulnar and radial arteries. Vijayabhaskar et al., 2006 reported that superficial and deep branches of the brachial artery branching pattern have a very rare incidence, which is around 0.12%3.2%.[11]

Variation 3 showed the median nerve wins around the brachial artery in the middle of the arm. None of the authors reported the above rarest variation. This type of variation affects the blood flow to the lower regions as well as the motor and sensory function of the median nerve, which supplies the lower regions of the upper limb.

Singh, 2017 also observed a similar type of 4th variation in his study. He stated that the common trunk arises from the axillary artery, it gives the subscapular artery and the posterior circumflex humeral artery.[12] In our study, the LTA arises from the common trunk of the subscapulohumeral artery along with the subscapular artery and the posterior circumflex artery. Several other authors also reported the axillary artery variations in their studies.[13],[14],[15],[14],[15],[16]

During forearm flap transfer surgery, Sieg et al., 2006 observed a bilateral superficial ulnar artery. The prevalence of variation is found to be 0.7%9.4%. Allen's test is typically used to detect blood flow disruptions in the radial and ulnar arteries. These ulnar arterial variations are noted through palpation at the antecubital region. Careful examination can avoid possible arterial impairment.[17]

Variation 6 was reported by Lydia B et al., in her study, stated that the radial artery gave a medial common branch. In the forearm, the medial common branch is divided into anterior and posterior interosseous arteries.[18] Gaur S et al. reported 28% of abnormal axillary artery branching patterns in their study.[19] In our study, we found 10% of abnormal arterial variation from 56 upper limbs [Table 1].
Table 1: Abnormal arterial course and variations

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  Conclusion Top

Abnormal development of the axis artery gives misinterpretation of angiography in radiological intervention. Our study reported a 10% of abnormal course of arteries and branching patterns in the upper limb. There are 3% of arterial course variations and 7% of arterial branch pattern variations found throughout the study. Previous studies have stated variations of between 9% and 28% in their cadaver dissection. Variations 1 and 2 were not reported in any previous studies. This case series study has contributed a few new courses and branching patterns of arteries.

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  References Top

Chakravarthi KK. Unusual unilateral muscular variations of the flexor compartment of forearm and hand – A case report. Int J Med Health Sci 2012;1:93-8.  Back to cited text no. 1
Hansdak R, Arora J, Sharma M, Mehta V, Suri RK, Das S. Unusual branching pattern of brachial artery – Embryological basis and clinicoanatomical insight. Clin Ter 2015;166:65-7.  Back to cited text no. 2
Panagouli E, Anagnostopoulou S, Venieratos D. Bilateral asymmetry of the highly bifurcated brachial artery variation. Rom J Morphol Embryol 2014;55:469-72.  Back to cited text no. 3
Cherukupalli C, Dwivedi A, Dayal R. High bifurcation of brachial artery with acute arterial insufficiency: A case report. Vasc Endovasc Surg 2007;41:572-4.  Back to cited text no. 4
Shetty SD, Satheesha Nayak B, Ashwini LS, Srinivasa Rao S. Variant origin and course of ulnar artery – A case report. Int J Anat Var 2013;6:45-6.  Back to cited text no. 5
Maruti Ram A, Babu Rao S, Subhadra Devi V. A case report on an unusual presentation of right sided vascular and left sided neural variations in upper limbs of a female cadaver. Int J Biol Med Res 2013;4:3495-7.  Back to cited text no. 6
Solan S. Accessory superficial ulnar artery: A case report. J Clin Diagn Res 2013;7:2943-4.  Back to cited text no. 7
Kodama K. Arteries of the upper limb. In: Sato T, Akita K, editors. Anatomic Variations in Japanese. Tokyo: University of Tokyo Press; 2000. p. 220-37.  Back to cited text no. 8
Tohno Y, Tohno S, Azuma C, Kido K, Moriwake Y. Superficial brachial artery continuing into the forearm as the radial artery. J Nara Med Assoc 2005;56:189-93.  Back to cited text no. 9
Patnaik VV, Kalse G, Singla RK. Bifurcation of axillary artery in its 3rd part – A case report. J Anat Soc India 2001;50:166-9.  Back to cited text no. 10
VijayaBhaskar P, Ritesh R, Shankar PR. Anomalous branching of the axillary artery: A case report. Kathmandu Univ Med J (KUMJ) 2006;4:517-9.  Back to cited text no. 11
Singh R. Abnormal origin of posterior circumflex humeral artery and subscapular artery: Case report and review of the literature. J Vasc Bras 2017;16:248-51.  Back to cited text no. 12
Ramesh Rao T, Shetty P, Suresh R. Abnormal branching pattern of the axillary artery and its clinical significance. Int J Morphol 2008;26:389-92.  Back to cited text no. 13
Samuel VP, Vollala VR, Rao M, Bolla SR, Pammidi N. A rare variation in the branching pattern of the axillary artery. Indian J Plast Surg 2006;39:222-3.  Back to cited text no. 14
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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