Hypoplastic superficial brachioradial artery coexisting with atypical formation of the median and musculocutaneous nerves: a rare combination of unusual topographical relationships.

The use of the term "brachioradial artery" was introduced for the high origin of the radial artery. Although the prevalence of the brachioradial artery reported by different authors varies from 4.67 to 15.6%, the presence of the hypoplastic brachial segment of the brachioradial artery is rare with an occurrence rate of 0.83%. Moreover, in just 0.6% of cases the loop of the median nerve may be placed near half of the length of the brachial artery, as in the case described in our report. A comprehensive understanding of anatomical variations of neurovascular structures in the upper limb is of great clinical significance. The presented case report illustrates a rare manifestation of persistent primitive developmental relationships in the arterial pattern of the upper limb (persistent, hypoplastic brachial segment of the superficial brachioradial artery), coexisting with atypical formation of the median and musculocutaneous nerves. Anatomical variations of vessels and nerves may coexist which should be taken into account when performing vascular, reconstructive or orthopedic surgery.

A rare disease with a rare presentation: hemi-atrophy caused by fibromuscular dysplasia in a 27 month old girl.

We discuss the case of a 27-month-old girl afflicted with fibromuscular dysplasia. She presented with hemiatrophy of left upper and lower limbs, nail dystrophy, ulcers on the tips of her toes, cold and painful limbs, foot drop, and hypertension. The initial appearance started at 2 months of age and other diagnoses such as complex regional pain syndrome, reflex sympathetic syndrome, vasculitis and coagulation disorders had been considered. Angiography revealed that all the arterial branches of the left lower and upper limbs, from brachial to ulnar and radial, and from iliac and femoral to tibialis arteries were affected. Sural nerve biopsy confirmed the diagnosis. In the follow-up visits until 2 years after the patient's discharge she did not develop any new problem and her blood pressure was controlled by enalapril and amlodipine.

Superficial brachial artery: a possible cause for idiopathic median nerve entrapment neuropathy.

Nerve entrapment syndromes occur because of anatomic constraints at specific locations in both upper and lower limbs. Anatomical locations prone to nerve entrapment syndromes include sites where a nerve courses through fibro-osseous or fibromuscular tunnels or penetrates a muscle. The median nerve (MN) can be entrapped by the ligament of Struthers; thickened biceps aponeurosis; between the superficial and deep heads of the pronator teres muscle and by a thickened proximal edge of flexor digitorum superficialis muscle. A few cases of MN neuropathies encountered are reported to be idiopathic. The superficial branchial artery (SBA) is defined as the artery running superficial to MN or its roots. This divergence from normal anatomy may be the possible explanation for idiopathic MN entrapment neuropathy. This study presents three cases with unilateral presence of the SBA encountered during routine undergraduate dissection at the University of Johannesburg. Case 1 - SBA divided into radial and ulnar arteries. Brachial artery (BA) terminated as deep brachial artery. Case 2 - SBA continued as radial artery (RA). BA terminated as ulnar artery (UA), anterior and posterior interosseous arteries. Case 3 - SBA continued as UA. BA divided into radial and common interosseous arteries. Arteries that take an unusual course are more vulnerable to iatrogenic injury du-ring surgical procedures and may disturb the evaluation of angiographic images during diagnosis. In particular, the presence of SBA may be acourse of idiopathic neuropathies.

An arterial island pattern of the axillary and brachial arteries: a case report with clinical implications.

The variability of axillary and brachial arteries is often associated with neural anomalies in arrangement of the brachial plexus. The current report is focused on the coexistence of two brachial arteries of axillary origin with an atypical median nerve formatted by three (two lateral and a medial) roots in the right arm of a 68-year-old male cadaver. Medially, the brachial artery located in front of the median nerve was named superficial brachial artery and anastomosed with the brachial artery situated posterolateral to the median nerve, hence it is referred as the main brachial artery or brachial artery. Subsequently, the two arteries were recombined and the created arterial complex, like an island pattern, ended dividing into radial and ulnar arteries, at the level of the radial neck. To our knowledge, the combination of the above-mentioned arterial pattern to an abnormally formatted median nerve has not yet been cited. The current neurovascular abnormalities followed by an embryological explanation may have clinical implications.

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.

Five Roots Pattern of Median Nerve Formation.

An unusual combination of median nerve's variations has been encountered in a male cadaver during routine educational dissection. In particular, the median nerve was formed by five roots; three roots originated from the lateral cord of the brachial plexus joined individually the median nerve's medial root. The latter (fourth) root was united with the lateral (fifth) root of the median nerve forming the median nerve distally in the upper arm and not the axilla as usually. In addition, the median nerve was situated medial to the brachial artery. We review comprehensively the relevant variants, their embryologic development and their potential clinical applications.

Beneficial cardiovascular remodeling following arterio-venous fistula ligation post-renal transplantation: a longitudinal magnetic resonance imaging study.

Despite improvements in survival following renal transplantation, high rates of cardiovascular morbidity and mortality remain. Persistence of arterio-venous fistulae (AVF) may contribute to maladaptive cardiovascular remodeling and poor health outcomes in this cohort. Utilizing recent advances in cardiovascular magnetic resonance imaging (CMR), we prospectively evaluated alterations in cardiac and vascular structure and function six months after elective ligation of AVF, following stable, successful renal transplantation. Eighteen subjects underwent CMR evaluation of cardiac structure and function, aortic distensibility and endothelial function prior to AVF ligation and at six months. At follow-up, while left ventricular ejection fraction was unchanged, mean cardiac output decreased by 15.6% (9.6 ± 2.9 L/min vs. 8.1 ± 2.3 L/min, p = 0.004) and left ventricular mass had regressed by 10% (166 ± 56 g vs. 149 ± 51 g, p = 0.0001). Significant improvements were also noted in right ventricular and biatrial structure and function. Aortic distensibility was unchanged at follow-up, but endothelial dependent vasodilatation had improved (2.5 ± 6.5% vs. 8.0 ± 5.9%, p = 0.04). Elective AVF ligation following successful renal transplantation is associated with improvements in left ventricular mass, right ventricular, and biatrial structure and function. Further randomized studies are warranted to determine the potential clinical improvement following AVF ligation in this cohort.

[Combined methods of treatment the congenital arterio-venous fistulas of peripheral vessels].

A 10-year experience and results of combined methods of surgical treatment of arterio-venous fistulas of peripheral vessels in 50 patients were analyzed. The patients were systematized on the basis of existing classifications, clinical manifestations of the disease, methods of invasive (ultrasound dopplerography and duplex scanning) and invasive (angiography) examinations. According to many authors no one of conventional methods of surgical treatment of arterio-venous fistulas which are used singly can be effective and must not be recommended as the most optimal. Stepwise employing of traditional operations and endovascular techniques are the main conditions for preventive measures of ischemic disorders in the limbs.

Impact of radial-to-aorta vascular anatomical variants on risk of failure in trans-radial coronary procedures.

OBJECTIVES: To assess the impact of an "operative" classification of vascular anatomic variants on the feasibility of trans-radial approach. BACKGROUND: Vascular anatomic variants located from the wrist to the aorta may influence the feasibility of trans-radial procedures. Recently, a new "operative" classification of these variants was proposed. METHODS: Consecutive trans-radial diagnostic or interventional catheterizations were considered. Vascular anatomic variants were classified according to 10 categories and sub-grouped according to the ABC classification (A: radial-brachial arterial axis; B: axillary-subclavian-anonymous axis; C: aortic arch). Primary study end-point was failure of trans-radial approach (necessity to cross-over to another approach to complete the procedure). RESULTS: Three thousand four hundred seventy-seven consecutive radial procedures were considered. Anatomic variants were diagnosed in 308 procedures (8.8%): A variants: 7.2%, B variants: 1.9%; C variants: 0.3%. Failure occurred in 2.0% of procedures. Failure rate was 0.7% in the absence of variants vs.15.2% in the presence of any variant (P < 0.0001, OR 27.7, 95%CI 16.3-46.9). Each of the 10 variants was significantly associated with increased failure rate. Each of the three level-subgroups of variants was significantly associated to the risk of failure (failure 14.7% in A level, 13.9% in B level, 33.3% in C level; P < 0.0001 vs. absence of variants). CONCLUSIONS: Failure of trans-radial procedures is associated to anatomic variants located from the wrist to the aorta. The "operative" ABC classification of anatomic variants is useful not only to categorize these anatomic variants, but also to predict the risk of failure of trans-radial approach.

High brachial artery bifurcation: clinical considerations and practical implications for an arteriovenous access.

High brachial artery bifurcation (HiBAB) is not a rare occurrence. Recent data have emphasized that HiBAB can have major clinical implications including high failure rate and decreased functional patency of an arteriovenous (AV) fistula. In this retrospective study, we investigated the incidence of HiBAB. Patients with advanced chronic kidney disease and end-stage renal disease on chronic hemodialysis undergoing preoperative vascular mapping for the creation of an AV access were included in this analysis. Ultrasound examination was used to map the arteries of the upper extremities. Four hundred and eighty-one arms in 340 patients were examined (right arm = 181, left arm = 300). Sixty-nine of the 481 (12.3%) demonstrated HiBAB. The internal diameter of the radial and ulnar arteries measured at the elbow region was found to be 2.9 ± 0.8 and 3.6 ± 1.0 mm, respectively (p = 0.0001). There were no statistically significant differences in terms of race, gender, and right versus left arms regarding the incidence of HiBAB. As HiBAB can be present in a significant number of patients and have an impact on the AV access, its presence should be evaluated during vascular mapping prior to an AV access creation.

Variations in the formation of the median nerve and its clinical correlation.

Variations in the formation of the median nerve are of interest to anatomists, radiologists, and surgeons. These variations may be vulnerable to damage in surgical operations, but their knowledge also helps in the interpretation of a nervous compression having unexplained clinical symptoms. We studied the variation in the formation of the median nerve in 87 cadavers, i.e. 174 upper limbs of formalin preserved cadavers at the department of Anatomy, Subharti medical college. We observed an additional root taking part in the formation of the median nerve in 26.4% of upper limbs, unusual low formation of the median nerve in the arm in front of the brachial artery in 18.4% of upper limbs, and median nerve formation medial to the axillary artery in 10.3% of upper limbs. Knowledge of such anatomical variations is of interest to the anatomist and clinician alike. Surgeons who perform procedures involving neoplasm or trauma repair need to be aware of these variations.

Asymmetric bilateral variations in the musculocutaneous and median nerves with high branching of brachial artery.

Brachial Plexus is formed by the union of the anterior rami of cervical 5, 6, 7, 8 and thoracic 1 nerves. These nerves unite and divide to form the key nerves innervating the upper limb. Variations in the course of these nerves are clinically important to anesthetists, neurologists and orthopedicians. We report bilateral variations in the arterial and neural structures in the upper limb of a 65 year old cadaver. The muscles of the arm on one side were innervated by the median nerve with absence ofmusculocutaneous. While on the other side the musculocutaneous nerve contributed to the formation of the median nerve. There was a presence of high bifurcation of brachial artery on both sides. Knowledge of such variations in the innervations of muscles and the arterial supply of the limbs are important to remember before performing any reconstructive procedures or interventions on the limb.

Arterial entrapment syndrome in the cubital fossa: a rare cause of acute stress-related arterial thrombosis in a patient with brachial artery duplication.

Arterial entrapment syndrome (AES) at elbow level is very rare and to our knowledge no case of AES by lacertus fibrosus in the cubital fossa in presence of brachial artery duplication has been described to date. We describe a rare case of acute arterial thrombosis of one of two brachial arteries highlighted in the cubital fossa which developed after strenuous right elbow flexor muscle activity and hyper-extensions presumably related to AES by lacertus fibrosus at elbow level. A 43-year-old right-handed woman, experienced paleness, coldness and numbness of the right hand, after 8 consecutive hours of gardening. As she worked, her ipsilateral flexor elbow muscles remained in prolonged and inappropriate tension. Clinical examination evidenced the absence of radial artery pulse in the wrist and mild hypothermia in the second and third finger. During surgical exploration two anastomosed brachial arteries were detected in the cubital fossa under the lacertus fibrosus. The lateral superficial brachial artery was occluded. Intraoperative arteriography evidenced brachial artery duplication at the third superior of the arm and normal vascular pattern at the forearm level. In cases of unexplained atypical intermittent upper extremity claudication or acute ischemic symptoms an AES should always be ruled out, particularly when symptoms are exacerbated by strenuous upper extremity activity or when upper limb muscular hypertrophy is evident. In these cases a thorough dynamic clinical and instrumental examination is mandatory to confirm a diagnosis of AES and to avoid possible future ischemic complications.

Unrecognized high brachial artery bifurcation is associated with higher rate of dialysis access failure.

A thorough consideration of all factors contributing to successful dialysis access creation is necessary to achieve optimal outcomes. A high bifurcation of the brachial artery (brachioradial variant) occurs in greater than 20% of patients. Dialysis access was created in 22 limbs with this variant--15 fistula, and 7 prosthetic grafts. Nonmaturation occurred in 33% of fistula. Early thromboses occurred in 29% of prosthetic bridge grafts. In this experience, the brachioradial variant is associated with a relatively higher rate of fistula nonmaturation and prosthetic graft thromboses. These findings reinforce the critical role of preoperative imaging studies in dialysis access creation. A sound algorithm for the surgical management of the brachioradial variation facilitates decision making and will improve dialysis access outcomes.

High origin of radial arteries: a report of two rare cases.

Variations in the arterial supply of the upper limb are relatively common, with reported prevalence rates ranging from 11 to 24.4%. Of these, the most commonly encountered variation in the arm is a high origin of the radial artery. However, after consecutively dissecting and examining 600 Singaporean Chinese cadavers (1,200 upper limbs), we found only two cases of this. In both cases, the brachioradial artery originated from the upper one-third of the brachial artery and continued distally as the radial artery in the forearm. The local prevalence of 0.33% of this variation is significantly lower compared against populations from other geographical regions. Although rare, recognition of the variation is of fundamental importance to clinical practice.

[Subclavian-carotid transposition for subclavian artery stenosis causing recurrent brachial artery embolism: case report]. / Tekrarlayan brakiyal arter embolisi olusturan subklavyen arter stenozunda subklavyo-karotid transpozisyon: Olgu sunumu.

Subclavian artery stenosis represents a relatively lower rate for upper extremity emboli source. Subclavian artery stenosis with thrombus localized distal to the stenosis was diagnosed on the arteriography of a patient who had a history of three previous brachial artery embolectomies. In this report, a case with subclavian artery stenosis causing recurrent brachial artery embolism who was successfully treated using subclavian-carotid transposition is presented.

Crucial neurovascular structures entrapped in a brachial intramuscular tunnel.

We report a case where the median nerve accompanied by brachial vessels were found to traverse an intra-muscular tunnel within the brachialis muscle, in the floor of the cubital fossa. The muscular tunnel commenced 5 cm proximal to the neck of radius, measured 4.4 cm in length, and was present unilaterally. This unusual tunnel was distally found to blend with the brachial fascia. The present study was planned with an endeavor to elucidate in an improved way the clinical implications of compressed median nerve and brachial vessels. There are several sites where median nerve maybe compressed along its course in the arm and forearm. The relevance of the present documentation lies in the fact that these vital neurovascular structures may be compressed leading to neuropathies and vascular changes.

Superficial brachioradial artery (radial artery originating from the axillary artery): a case-report and its embryological background.

A case of anomalous terminal branching of the axillary artery, concerning the variant called superficial brachioradial artery (arteria brachioradialis superficialis) was described, with special regard to its embryological origin. The left upper limb of a male cadaver was dissected in successive steps from the axillary fossa distally to the palmar region. A variant artery, stemming from the end of the third segment of the axillary artery, followed a superficial course distally. It skipped the cubital fossa, ran on the lateral side of the forearm, crossed ventrally to the palm, and terminated in the deep palmar arch. This vessel is a case of so-called "brachioradial artery" (inexactly called a "radial artery with a high origin"). The origin of the brachioradial artery directly from the axillary artery belongs to the rare variants of the arterial pattern of the upper limb. Its incidence is approximately 3%. Moreover, this vascular variant was associated with another one concerning the brachial plexus. The medial cutaneous nerve of the forearm joined the median nerve in the middle third of the arm and ran further distally as a common trunk, as the normal median nerve does. Anatomical knowledge of the axillary region is crucial for radiodiagnostic and surgical procedures, especially in cases of trauma. The superficially located artery brings an elevated risk of bleeding complications in unexpected situations.

Bilateral superficial brachial artery.

Variations of the upper limb arterial system are well documented. Accurate knowledge of the normal and variant arterial anatomy of the axillary artery is important for clinical procedures and vascular radiology. In this article, a rare bilateral variation of superficial brachial artery is being reported. The axillary artery on both sides divided in its third part into a superficial brachial artery passing superficial to the lateral root of median nerve and brachial artery proper. The former terminated in the cubital fossa by dividing into ulnar and radial arteries while the later descended deep to the medial root of median nerve and gave anterior and posterior circumflex humeral branches of axillary artery and profunda brachii of brachial artery. Then it terminated by giving twigs to muscles of arm. Earlier superficial brachial artery is reported with a prevalence rate varying from 0.2-25 % but a bilateral variation is extremely rare. Further its ontogeny and clinical implications are discussed in detail.

Multiple arterial anomalies in upper limb.

An isolated neurovascular variation is common but multiple vascular anomalies on same upper limb is a very rare case. We observed an unusual variations in right upper limb during routine dissection of a Nepali cadaver. The variations were observed in Axilla, Forearm and Palm. In axilla, fi rst part of axillary artery did not give any branch, the second part of axillary artery gave off only two branches - (a) thoracoacromial artery and (b) a large common trunk which later gave off lateral thoracic, thoracodorsal, subscapular, posterior circumflex scapular and then continued as posterior circumflex humeral artery. The third part of axillary artery gave off only anterior circumflex humeral artery. In forearm, the ulnar artery runs downward superficial to flexor muscles. Here, radial artery gave off common interosseous artery. In palm radial artery did not give any contribution to superficial palmar arch which is solely formed by the continuation of ulnar artery. This type of anomalies are very rare and is not reported in Nepalese cadaver at all. These anomalies are described in detail and their clinical relevance is highlighted.