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.

Brachial artery injury following opened elbow dislocation associated with accessory brachial artery: two rare entities in a 17-year -old girl: case report.

Elbow dislocations are the most frequently encountered after shoulder dislocations. In their vast majority, these injuries carry a good prognosis. Although, concomitant arterial injury is rare and make them more serious. In this paper, we report a case of a 17 year old woman with opened elbow dislocation with arterial injury associated to an artery variation: "accessory brachial artery".

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.

A rare conglomeration of neurovascular variations in the brachium-antebrachium: clinico-embryological elucidation.

During routine dissection in left upper limb in an elderly male cadaver, variations in the arterial and neural pattern were noticed. The undersized brachial artery divided terminally into radial and ulnar artery at a distance of 15.4 cm from the tip of coracoid process, proximal to its usual division in cubital fossa. Additionally, the superior and inferior ulnar collateral artery instead of arising from the brachial artery, emanated from ulnar artery. The course of the median nerve also deserves a brief mention as it crossed the brachial artery from medial to lateral side to position itself laterally in the midbrachium. Coursing further, it shifted from lateral to medial side over the ulnar artery in the distal third of arm, thus placing itself medial to ulnar artery in the cubital fossa. There was also a communication between a medial offshoot of the musculocutaneous nerve and the median nerve 3 cm from the bifurcation of the brachial artery. Although the variations in the origin, termination, course and branching pattern of upper limb vessels and nerves are well documented, but the multitude of disparity in morphology with confusing neurovascular assembly put together in the same limb denotes an outstanding case. An attempt has been made to correlate the present anatomical variations with embryological aspects. Moreover, the clinical inferences of such variations are discussed for planning, performing and analyzing invasive and noninvasive clinical procedures in this region.

Superficial brachial artery with its high division.

The upper extremity arterial system shows a large number of variations attributed to the complex and multiple sites of their embryonic development. It is important to be aware of arterial variations in this region because upper extremity is a frequent site of injury. Moreover, brachial artery is of significance in cardiac catheterization for angioplasty, pedicle flaps, or arterial grafting. Accurate knowledge and relationships of major arterial conduits and their variational patterns is important in reparative surgery in the arm, forearm and hand. One such variation is superficial brachial artery with prevalence rate of 0.2-25%. In this report, the brachial artery emanated normally but coursed superficial to the median nerve and about five cm above the intercondylar line, bifurcated into its terminal branches i.e. radial and ulnar artery.

A rare case of bilateral variations of upper limb arteries: brief review of nomenclature, embryology and clinical applications.

We present a rare case of bilateral variations of upper limb arteries, namely, the superficial brachioulnoradial artery and the superficial brachioradial artery in a female cadaver. The superficial brachioulnoradial artery presented here is a variant of classical accounts. The superficial arteries replaced the typical arteries and were not additional vessels.

Unilateral duplication of palmar arterial arches--a case report.

Recent progress in hand surgery has engendered a need for precise knowledge of anatomical variations of blood supply of hand. The present paper describes an unusual organization of palmar arterial arches and attempts to discuss its clinical implications. Double superficial palmar arch of the mediano-ulnar variant was observed with a double deep palmar arch of equal caliber, formed by splitting of deep branches of radial artery and ulnar artery. The superficial palmar branch of radial artery was absent.

Report of the anatomic variation of the brachial artery in a patient undergoing transradial cardiac catheterization.

The arterial pattern of the upper limb is one of the systems that shows a large number of variations in the adult human body. Most of these variations occur in either the radial or ulnar artery; brachial artery variations are less common. In this case report we describe the anomaly in the formation of the brachial artery system. Appreciation of variations in the upper extremity vasculature is essential to prevent injury, particularly in patients undergoing arteriography.

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.

Development of the arterial pattern in the upper limb of staged human embryos: normal development and anatomic variations.

A total of 112 human embryos (224 upper limbs) between stages 12 and 23 of development were examined. It was observed that formation of the arterial system in the upper limb takes place as a dual process. An initial capillary plexus appears from the dorsal aorta during stage 12 and develops at the same rate as the limb. At stage 13, the capillary plexus begins a maturation process involving the enlargement and differentiation of selected parts. This remodelling process starts in the aorta and continues in a proximal to distal sequence. By stage 15 the differentiation has reached the subclavian and axillary arteries, by stage 17 it has reached the brachial artery as far as the elbow, by stage 18 it has reached the forearm arteries except for the distal part of the radial, and finally by stage 21 the whole arterial pattern is present in its definitive morphology. This differentiation process parallels the development of the skeletal system chronologically. A number of arterial variations were observed, and classified as follows: superficial brachial (7.7%), accessory brachial (0.6%). brachioradial (14%), superficial brachioulnar (4.7%), superficial brachioulnoradial (0.7%), palmar pattern of the median (18.7%) and superficial brachiomedian (0.7%) arteries. They were observed in embryos belonging to stages 17-23 and were not related to a specific stage of development. Statistical comparison with the rates of variations reported in adults did not show significant differences. It is suggested that the variations arise through the persistence, enlargement and differentiation of parts of the initial network which would normally remain as capillaries or even regress.

An anatomical study and ontogenetic explanation of 23 cases with variations in the main pattern of the human brachio-antebrachial arteries.

Twenty-three cases with variations in the brachio-antebrachial arterial pattern of the human upper limb are reported. According to the artery which showed a variation, 4 groups were recognised: (1) isolated persistence of the median artery; (2) high origin of the ulnar artery; (3) high origin of the radial artery; and (4) duplication of the brachial artery, either with or without anastomosis at the cubital fossa. In addition, in groups 2, 3 and 4 the median artery may have persisted. Based on these arterial variations an anatomical and embryological correlation was established from a morphogenetic pattern which is proposed as being normal. Thus the terminal branches of the superficial brachial artery take part in the development of the radial, ulnar and median arteries, joining with the trunks of deep origin of these arteries in the primitive axial artery. Regression of the superficial arterial segments located proximal to this anastomosis gives rise to the definitive arterial pattern. Either the total or partial persistence of the superficial arterial segments explains those cases of high origin of either the radial or ulnar arteries as well as the duplications of the brachial artery. We postulate that the persistence of the median artery is independent of the presence or absence of any other variation in the arterial pattern.

Embryological development of the arterial system of the forelimb in Tupaia.

BACKGROUND: The arterial system of the upper extremities in man shows drastic developmental changes and many individual variations related to interspecific variations in primates. The ontogenetic development in Tupaia was examined from the viewpoint of comparative embryology. METHODS: Histological specimens of 39 embryos were observed and reconstructed in three dimensions using a computer program. Four adult animals were dissected and examined with angiography to ascertain the end stage of development. RESULTS: At the proximal end of the upper arm the deep brachial artery appears first as a concomitant vessel with the radial nerve. It becomes reduced in size and is succeeded by the posterior circumflex humeral artery, which is accompanied initially by the axillary nerve and finally by the radial nerve. The main arterial passageway to the fingers consists of the brachial and interosseous arteries during early development. The superficial brachial artery and median artery are formed later, and their connection becomes the main route of blood supply for the finger arteries up to the adult stage. The ulnar artery is formed at the end of arterial development to form the ulnar end of the superficial palmar arch. The superficial antebrachial arteries are also recognized. CONCLUSIONS: All the arterial elements of the forelimb in Tupaia are observed in a variety of primates, including man, and the characteristics of Tupaia are thought to represent the primitive conditions of the common ancestor of tree shrews and primates.

Experimental study of the origin of the parathyroid glands.

The origin of the parathyroid glands was investigated in chick embryos (Gallus domesticus). Pieces of the third branchial arch were grafted, and its ectodermal layer formed a new structure (parathyroid III), which became separated from the placodial ectoderm. This structure continued to develop until, together with neural crest cells which gave rise to the mesenchyme, it formed a distinct parathyroid III gland by stage 28 of Hamburger and Hamilton.

The special status of the pulmonary arch artery in the branchial arch system of the rat.

A renewed study of the development of the branchial arch system was essential in view of the special morphologic characteristics of the ductus arteriosus, which derives from the pulmonary arch artery or sixth branchial arch artery. In congenital heart disease certain aorto-pulmonary collateral arteries have a marked histological similarity to the ductus arteriosus. To gain a better insight into the development of these vessels, 27 rat embryos, with the number of somites ranging between 19 and 41, were studied. Most embryos were collected after shortterm in vitro-culture, allowing precise staging of age and development. The vascular system of these embryos was injected with Indian ink, to enable easy recognition of even the smallest endothelium-lined vessels. The embryos were serially sectioned (3-5 microns) and reconstructed using a graphic method. The results show that the pulmonary arch artery differs from the other arch arteries in that it is the most cranial vessel of a system of ventral splanchnic arteries, which connects the pulmonary plexus with the dorsal aortae at an early stage. With the exception of the pulmonary arch artery, these connections are transient. The pulmonary arteries develop from the remaining parts of the plexus. It is argued that these connections can persist in the human as aorto-pulmonary collaterals, in certain cases with abnormalities in the pulmonary part of the cardiac outflow tract.

Unusual variation of the arterial pattern of the human upper limb.

The anomalous brachial artery, after giving off a profunda brachii artery with no collaterals, divides in its upper one-third into two equal-sized arteries, brachial arteries #1 and 2. These arteries lie next to each other in the normal path of the brachial artery. Brachial artery #1 is possibly a high-origin and persisting radial artery. It gives no collaterals in the arm. At the cubital fossa, it becomes subcutaneous and divides into two equal-sized radial and ulnar arteries. These arteries run completely superficial to flexor muscles of the forearm and are terminated by branches running above the thenar and hypothenar eminences, respectively. Brachial artery #2 is possibly a high-origin artery of the common interosseous. The course of this artery resembles the course of the brachial axial artery of the embryo. It supplies the anterior compartment of brachial muscles and continues as the common interosseous artery. This common interosseous artery in turn branches into the superior and inferior ulnar collaterals, and the anterior and posterior interossei. It does not regress, but has a major role in forming the deep palmar arterial arch in the hand. The clinical implications of such an anomaly are discussed.

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.

A light and electron microscopic study on the embryonic development of the rat carotid body.

The embryonic development of the rat carotid body was studied with electron microscopy. In the 11 mm embryo a cell aggregation consisting of undifferentiated cells and unmyelinated nerve fibers appears on the anterior wall of the third branchial artery. Granule-containing cells appear in the 12 mm embryo and continue to increase in number as the cellular aggregation increases in size and becomes separated from the wall of the third branchial artery. Synapse formation and the appearance of fenestrated capillaries occur almost simultaneously at the 17 mm stage. There are two types of synapses, one with membrane densification and vesicles clustered inside the nerve endings, the other with dense material and vesicles inside the granule-containing cells. At the 20 mm stage the undifferentiated cells send enveloping cytoplasmic processes toward adjacent granule-containing cells and the carotid body anlage displays rudimentary lobules.