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.

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.

Prevalence of Perforated Graft in Underlay and Pop-in Technique Myringoplasty.

INTRODUCTION: The radial artery is commonly originated from the brachial artery in the cubital fossa at the level of the neck of the radius. It is the artery of choice for coronary artery angiography, percutaneous coronary artery intervention, cannulation, and others. Radial artery anomalies like high origin, tortuosity, and accessory branches are associated with the failure of such procedures. The main objective of this study is to study the variation in origin and course of the radial artery in cadavers. METHODS: A descriptive cross-sectional study was conducted in 27 formalin-fixed adult human cadavers in the Department of Anatomy, KIST Medical College and Teaching Hospital, Lalitpur, Nepal, from 2075/4/2 to 2076/4/2. Ethical approval was taken on date 02/04/2075 (IRC No. 2074/75/38). Altogether, 53 specimens were enrolled in the study by convenience sampling method. Point estimate at 95% Confidence Interval was done for binary data along with frequency and proportion. The data was analyzed by and Statistical Package for the Social Sciences version 20. RESULTS: Out of of 53 upper limbs, forty-six (86.79%) specimens, the origin of the radial artery was observed to be normal in the cubital fossa, 34.5±6.31mm below the level of the intercondylar line of the humerus with the superficial course. In seven (13.21%) specimens, the radial artery showed variation in the origin. Among them, variations in origin were found to be from sites like the axilla, upper-middle, and lower part of the arm. One cadaver showed a tortuous radial artery bilaterally. CONCLUSIONS: This study concludes that most of the radial artery originates in the cubital fossa from the brachial artery with few variations.

Origen alto de la arteria radial (Arteria braquirradial superficial): Presentación de 3 casos / High origin of the radial artery (superficial brachialarterial artery): Presentation of 3 cases

Se presentan tres casos de nacimiento alto de la arteria radial, todos en el miembro derecho, uno a nivel del tercio superior de la arteria braquial, el segundo caso a nivel del tercio medio de la misma y en el tercer caso el nacimiento de la arteria radial se produce a nivel de la arteria axilar. En todos los casos tienen un trayecto superficial en el brazo y antebrazo. En la mano forman el arco palmar arterial profundo de manera habitual. Estos casos representan el 7,5% de los 40 miembros disecados. El origen alto de la arteria radial es la variante más frecuente dentro de las anomalías del árbol arterial del miembro superior. Su importancia radica en el aumento de los procedimientos percutáneos sobre la arteria radial en cateterismos coronarios y en el cada vez más utilizado colgajo radial en las cirugías reconstructivas. Su trayecto superficial favorece los traumatismos y la confusión con venas, situación que puede ocasionar inyecciones medicamentosas accidentales en estas arterias con sus graves consecuencias.

We present three cases of high birth of the radial artery, all on the right limbone at the upper third of the brachial artery, the second at the middle third of the artery, and in the third case the radial artery arises at the level of the axillary artery. In all cases they have a superficial path in the arm and forearm. In the hand they form the deep arterial arch of the palmar in the usual way. These cases represent 7.5% of the 40 dissected members. The high birth of the radial artery is the most frequent variant within the arterial tree anomalies of the upper limb. Its importance lies in the increase of the percutaneous procedures on the radial artery in coronary catheterisms and in the increasingly used radial flap in the reconstructive surgeries. Its superficial pathway favors trauma and confusion with veins, a situation that can cause accidental drug injections in these arteries with their serious consequences.

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.

Median artery of the forearm in human fetuses in northeastern Brazil: anatomical study and review of the literature.

A persistent median artery is a rare anomaly. It accompanies the median nerve along its course in the forearm and is of variable origin. It is associated with other local anatomical variations and may contribute significantly towards formation of the superficial palmar arch. In embryos, it is responsible mainly for the blood supply to the hand. The objective of this study was to research the frequency, type (forearm or palmar) and origin of the median artery in fetuses, correlating its presence with sex and body side. Red-colored latex was injected into 32 brachial arteries of human fetuses until its arrival in the hand could be seen. Twenty-four hours after the injection, the median arteries were dissected without the aid of optical instruments. Among the 32 forearms dissected, the median artery was present in 81.25 % (26) of the cases, and it was found more frequently in females and on the left side. Regarding origin, most of the median arteries originated in the common interosseous artery (38.5 %) and anterior interosseous artery (34.6 %). The mean length of the median arteries was 21.1 mm for the palmar type and 19.8 mm for the forearm type. The median artery has a high rate of persistence. It is important to be aware of this anatomical variation, since its presence may give rise to difficulties during routine surgical procedures on the wrist. Its presence may cause serious functional complications in the carpal tunnel, anterior interosseous nerve, round pronator syndromes, and ischemia of the hand.

Brachiomedian artery (arteria brachiomediana) revisited: a comprehensive review.

This article reviews in detail the superficial brachiomedian artery (arteria brachiomediana superficialis), a very rare variant of the main arterial trunks of the upper limb. It branches either from the axillary artery or the brachial artery, descends superficially in the arm (similar to the course of the superficial brachial artery) and continues across the cubital fossa, runs superficially in the forearm, approaches the median nerve and enters the carpal canal to reach the hand. It usually terminates in the superficial palmar arch. The first drawing was published, in 1830, and the first description was published, in 1844. Altogether, to our knowledge, only 31 cases of a true, superficial brachiomedian artery have been reported (Some cases are incorrectly reported as superficial brachioradiomedian artery or superficial brachioulnomedian artery). Based on a meta-analysis of known, available studies, the incidence is 0.23% in Caucasians and 1.48% in Mongolians. Knowing whether or not this arterial variant is present is important in clinical medicine and relevant for: The catheterization via the radial or ulnar artery; harvesting the vascular pedicle for a forearm flap based on the radial, ulnar or superficial brachiomedian arteries; the possible collateral circulation in cases of the arterial closure; and the surgical management of carpal tunnel syndrome. Its presence can elevate the danger of an injury to the superficially located variant artery or of an accidental injection.

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.

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.

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".

Unusual branching pattern of brachial artery - Embryological basis and clinicoanatomical insight.

Variations in the arterial pattern of upper limb are of colossal importance to the surgeons as they are liable to iatrogenic injuries. During routine dissection for undergraduate medical students, an anomaly of brachial artery was discovered. The brachial artery terminated at higher level into ulnar and radial artery. The common interosseus artery took origin arising from radial artery. The ulnar artery did not give any branches in the forearm. Both radial and ulnar artery displayed a superficial course in the forearm. The anatomical knowledge of these variations may be of great help for the clinicians in planning and conducting flap harvesting during reconstructive surgeries and in arteriography.

Trifurcation of superficial brachial artery: a rare case with its clinico-embryological implications.

Literatures on vasculature of upper limbs are crammed with reports of distinctly deviant version of normally prevalent vessels having modified origins, altered branching and odd courses. A unique anatomical variation in vascular pattern was observed during routine dissection of right upper limb in gross anatomy laboratory, AIIMS, New Delhi, India. The brachial artery was placed superficial to median nerve in the arm and therefore it was called superficial brachial artery. In the cubital fossa, 2.8 cm distal to intercondylar line of elbow joint, this superficial brachial artery terminated by trifurcation into radial, common interosseous and ulnar branches. Strikingly the ulnar branch, after its origin ran superficially over the median nerve and epitrochlear superficial flexor group of muscles of forearm in succession for the initial third of its course in the forearm, consequently it was addressed as superficial ulnar artery. The existence of superficial brachial artery in place of normal brachial artery, its termination by trifurcation into radial, common interosseous and superficial ulnar arteries with remarkably different courses, leads to confusing disposition of structures in the arm, cubital fossa and in the forearm and collectively makes this myriad of anatomical variations even rarer. The clinico-embryological revelations for combination of these unconventional observations, apprises and guides the specialized medical personnel attempting blind and invasive procedures in brachium and ante-brachium. This case report depicts the anatomical perspective and clinical implications on confronting a rare variant vasculature architecture pattern of upper limb.

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.

Bilateral asymmetry of the highly bifurcated brachial artery variation.

High bifurcation of the brachial artery seems to be a common variation, which can occur in many different forms, and some of them might be rather rare. We report an unusual case of bilateral high bifurcation of the brachial artery in a male cadaver. On the right arm, high origin of the ulnar artery as superficial ulnar artery was observed. The brachial artery continued and divided at the level of the elbow into radial and common interosseous artery. On the left arm, a high bifurcation of the common interosseous artery occurred, while the rest of the brachial artery continued and at the level of the elbow bifurcated into radial and superficial ulnar artery. In both arms, the common interosseous artery followed the branching pattern of the normal ulnar artery. The so formed superficial ulnar arteries gave each four common palmar digital arteries. This case is being reported for the bilaterally different variational anatomy of the upper limb arteries.

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.

Anatomical vascular variations and practical implications for access creation on the upper limb.

BACKGROUND: A profound knowledge of vascular anatomy and an understanding of vascular access functionality with respect to possible complications are critical in selecting the site for arteriovenous anastomosis. METHODS: Outline of vasculature variations of the upper limb with prevalence reported in literature of at least 1%, which may affect access creation, is depicted in this review. RESULTS: Over a dozen arterial anatomical anomalies of the upper limb, the most common is "high origin" of the radial artery (12-20%). Superficial positions of brachial, ulnar and radial artery as well as accessory brachial are another possible anatomic variants (0.5-7%). The most variable venous layout on the upper arm is seen in the anatomy of the brachial vein and the basilic vein forming the axillary vein. Three types of basilic vein course on upper arm have been described. CONCLUSIONS: The mapping technique to assess vascular variants facilitate site selection for AVF creation even in cases with previously attempted failed access (misdiagnosed vascular variant could force to secondary options). Thus, a thorough understanding and evaluation of anatomy, taking into consideration the possible vascular variations of the forearm and upper arm, are necessary in the planning of AVF creation and increase the success of AVF procedures.

Variant origin of an arterial trunk from axillary artery continuing as profunda brachii artery--a unique arterial variation in the axilla and its clinical implications.

BACKGROUND: Axillary artery is known to show different variations mostly in its branching pattern. Similarly, the origin of profunda brachii is often encountered with abnormality. Therefore, when the vascular variations in the upper limb persist, mostly it is confined to its branching pattern followed by its variant origin. But, among all the reported variations of profunda brachii, its variant origin from the 3rd part of the axillary artery with common trunk for the branches of axillary artery is unique. CASE DETAILS: We report here an anomalous origin of profunda brachii as continuation of an arterial trunk arising from 3rd part of the axillary artery. This common trunk at its commencement passed between 2 roots of median nerve and gave branches of 3rd part of axillary artery before it continued as profunda brachii artery. The further course and branching pattern of profunda brachii were normal. CONCLUSION: Since the axillary artery is next choice of artery for arterial cannulation in cardiopulmonary bypass procedures, prior knowledge of existence of such variation in its branching pattern helps in avoiding possible diagnostic or interventional therapeutic errors.