Case Report

International Journal of Anatomical Variations (2013) 6: 173–175eISSN 1308-4038

Superficial tortuous brachial artery – a case report

devices are available or not, anatomical knowledge of the SBA is essential.

Case ReportDuring routine dissection of a male cadaver, of unknown age and ethnicity, the left brachial artery was found to be tortuous. It was observed that the superficial brachial artery was arising from the third part of the axillary artery proximal to the origin of the posterior and anterior circumflex humeral arteries (Figures 1, 2). On following it in the arm, it was observed that at the lower border of teres major, the axillary artery was continuing as main brachial artery. The ulnar collateral artery was a branch from the main brachial artery and continued as muscular branches. The tortuous brachial artery next continued in the cubital fossa running superficial to the median nerve, and the deep brachial artery divided into two branches, one continuing in the cubital fossa with the superficial brachial artery and the other continuing behind the medial epicondyle with the ulnar nerve (Figure 3).In the forearm the superficial brachial artery gave origin to the median artery of the forearm, which was being accompanied by the median nerve, and finally divided into ulnar and radial arteries of the forearm (Figure 4).

Satyajit SAHA [1]

Vasanti AROLE [2]

VATSALASWAMY [2]

Department of Anatomy, Calcutta National Medical College, Kolkata, West Bengal [1], Department of Anatomy, Dr. D. Y. Patil Medical College, Maharashtra [2], INDIA.

Satyajit Saha Assistant Professor Department of Anatomy Calcutta National Medical College Kolkata, West Bengal, INDIA. +91 9270510944 drsatyajitsaha@gmail.com

Received February 22nd, 2012; accepted October 18th, 2012

AbstractVariations of the upper limb arterial system are well documented. An accurate knowledge of the usual and variant arterial anatomy of the axillary and brachial arteries is important for the clinical procedures and vascular radiology. In this article we are reporting a case of superficial tortuous brachial artery. During routine dissection of a male cadaver at the Department of Anatomy in the Dr. D. Y. Patil Medical College, the left brachial artery was found to be tortuous. On further dissection it was seen that the superficial brachial artery was arising from the third part of the axillary artery proximal to the origin of the posterior and anterior circumflex humeral arteries. At the lower border of teres major, the axillary artery was continuing as main brachial artery. The ulnar collateral artery was a branch from the main brachial artery. The brachial artery continued in the cubital fossa finally ending as muscular branches. Median artery of the forearm was arising from the superficial brachial artery, which was accompanying the median nerve. The superficial brachial artery finally divided into ulnar and radial arteries of the forearm.

© Int J Anat Var (IJAV). 2013; 6: 173–175.

Key words [superficial] [tortuous] [brachial artery] [variation]

Published online September 26th, 2013 © http://www.ijav.org

IntroductionA superficial brachial artery (SBA) is defined as an artery running superficial to the median nerve. It may replace the main trunk or may be accompanied by an equally important trunk running deep to the median nerve.Variations in the arterial pattern of the upper limb are commonly encountered in routine dissections, and the SBA is one of the major variations [1–3]. According to the literature, its frequency and branching pattern vary among ethnic groups. The SBA originates from the axillary artery and runs superficial to the median nerve [4]. The presence of the SBA can be hazardous because it is very vulnerable to injury [5]. An accidental intra-arterial injection via the SBA can cause thrombosis or gangrene, leading to amputation of the arm or fingers [6]. Conversely, the SBA can be used as a feeding artery to a free flap from medial arm skin [7].Considering these possible complications and benefits, investigations of the arterial pattern in patients’ arms before any invasive procedures may be helpful in avoiding iatrogenic injury or in using an SBA for some procedures. Doppler ultrasound imaging or angiography can assist healthcare providers in treating patients with an SBA. Whether those

174 Saha et al.

DiscussionOntogenyArey is of the view that anomalous blood vessels may arise due to [8]:

The choice of unusual paths in primitive vascular •plexus.The persistence of vessels normally obliterated.•The disappearance of vessels normally retained.•

Incomplete development.•Fusions and absorption of the parts usually distinct.•

In normal morphogenesis, the SBA is not an erroneous variation but an essential blood vessel. The SBA is an important vessel in fetal life for replacing or supporting the definitive brachial artery. Rodríguez-Baeza et al. suggested that the hemodynamic predominance of certain arterial segments during development determines whether the SBA will remain [9].The SBA emerges from the axillary artery during stage IV of upper limb vascular development. It is joined to the axillary artery via several deep branches at the level of the axilla, upper arm, and elbow. A surviving SBA will have one of three possible outcomes:

The SBA may overtake the territory of the definitive •brachial artery.It may form a parallel artery to the deep brachial •artery.

Figure 1. Photograph showing the origin and course of the superficial brachial artery (B). (A: branch passing between the cords of brachial plexus; C: anterior and posterior circumflex humeral arteries; D: deep brachial artery; E: axillary artery)

A

B

CD

E

Figure 2. The superficial brachial artery (A) is arising from the axillary artery. The axillary artery then gives anterior and posterior circumflex humeral arteries (C), and finally continues as the deep brachial artery (B).

A

BC

Figure 3. The superficial brachial artery (D) turns tortuous and continues in the cubital fossa, superficial to the median nerve (F). The deep brachial artery (E) breaks into two branches. One continuing in the cubital fossa (C) and the other (B) accompanied by the ulnar nerve (A) passes with it behind the medial epicondyle.

ABC

D

E

F

Figure 4. Superficial brachial artery (A) gives the median artery of the forearm (B). Finally it breaks into its 2 terminal branches, the radial artery (C) and the ulnar artery (D).

AB

C

D

175Superficial tortuous brachial artery

References

[1] McCormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns; a study of 750 extremities. Surg Gynecol Obstet. 1953; 96: 43–54.

[2] Keen JA. A study of the arterial variations in the limbs, with special reference to symmetry of vascular patterns. Am J Anat. 1961;108:245–261.

[3] Fuss FK, Matula CW, Tschabitscher M. The superficial brachial artery. Anat Anz. 1985; 160: 285–294. (German)

[4] Hollinshead WH. Anatomy for Surgeons. 3rd Ed., Philadelphia:, Harper & Row. 1982; 362.

[5] Anagnostopoulou S, Venieratos D. An unusual branching pattern of the superficial brachial artery accompanied by an ulnar nerve with two roots. J Anat. 1999; 195: 471–476.

[6] Bataineh ZM, Al-Hussain SM, Moqattash ST. Complex neurovascular variation in one upper limb. Ital J Anat Embryol. 2007; 112: 37–44.

[7] Karamursel S, Bagdatli D, Demir Z, Tuccar E, Celebioglu S. Use of medial arm skin as a free flap. Plast Reconstr Surg. 2005; 115: 2025–2031.

[8] Arey LB. Developmental Anatomy. 7th Ed., Philadelphia, Saunders. 1974; 375–377.

[9] Rodriguez-Baeza A, Nebot J, Ferreira B, Reina F, Perez J, Sanudo JR, Roig M. An anatomical study and ontogenetic explanation of 23 cases with variations in the main pattern of the human brachio-antebrachial arteries. J Anat. 1995; 187: 473–479.

[10] Anson BJ. Morris’ Human Anatomy. New York, McGraw Hill Book C. 1966; 708–724.

It can disappear as it turns into small cutaneous blood •vessels.

Generally the SBA arises from the axillary artery between the contributions of medial and lateral cords of brachial plexus to median nerve, which was the finding in this case. Also it was lying lateral to the deep brachial artery before dividing into radial and ulnar arteries in the region of elbow. This type of division had been earlier described by Anson [10].The median artery of the forearm was an additional finding in this case. Previous studies had generally shown that the SBA was ending by dividing into radial and ulnar arteries. But in this case it was found that a median artery of the forearm was also present, which was arising before the SBA divided into its terminal branches.

EmbryologyDuring development of the blood supply of the upper limb, the brachial artery continues and gives the radial and the ulnar arteries. Under certain conditions the superficial branch arises. The fate of the later can be varied. But most commonly it gives the two terminal branches i.e. the radial and the ulnar.

ConclusionThe superficial brachial artery was the main continuation in the forearm in this case. So an occlusion of this artery would lead to complete occlusion in the forearm and gangrene. Being superficial it may be mistaken for a vein and thus may be mistaken for intravenous cannulation or intravenous injection. Also it will be useful for cutaneous flaps.