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Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Pokhrel R, Bhatnagar R. Unilateral high bifurcation of brachial artery. OA Anatomy 2013 Dec 01;1(4):34. Co

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Unilateral high bifurcation of brachial arteryR Pokhrel*, R Bhatnagar

AbstractIntroductionBrachial artery, the principal artery of the arm, usually divides at the level of neck of radius into two branches. This article reports a case of unilat-eral high bifurcation of the brachial artery.Case reportWe report a case of high division of the brachial artery at the level of in-sertion of the coracobrachialis mus-cle. Further course of the ulnar and radial artery after reaching the fore-arm was usual. DiscussionThis variation, though not very un-common, occurs in the embryo due to persistence of the upper portion of the radial artery arising from the bra-chial artery proximal to the origin of the ulnar artery followed by failure of development of the new connection of the radial artery with the brachial artery at the level of origin of the ul-nar artery. ConclusionHigh division of the brachial artery has a profound applied importance especially in the field of vascular sur-gery and radiology, and the possibil-ity of this variation should be bore in mind before any vascular surgery in the region of the forearm or while in-terpreting arteriograms of the upper limb.

IntroductionThe brachial artery usually begins as a continuation of the axillary artery at the distal border of tendon of teres major and ends at about a centimetre

distal to the elbow joint at the level of neck of radius by dividing into ra-dial and ulnar arteries1. Variations in arterial patterns of the upper limb in adult human bodies have been fre-quently observed either in routine dissections or in clinical practice2. A case of such a variation with its em-bryological basis and clinical signifi-cance is presented and discussed.

Case reportDuring routine dissection for medi-cal undergraduates at our institute, an unusually high origin of radial ar-tery, that is brachioradial artery3, was observed in the left arm of an adult male cadaver of approximately 60 years of age. The radial artery arose at the level of insertion of the coraco-brachialis muscle (Figures 1 and 2). Profunda brachii, superior collat-eral and inferior collateral arteries arose from the brachial artery after the origin of radial artery (Figure 3). The brachial artery continued as ul-nar artery in the forearm. Further course and branching patterns of the radial and ulnar arteries in the fore-arm and palm were usual. The right arm revealed no unusual vascular observations.

DiscussionIn the upper limb bud, the axis artery is derived from the lateral branch of the seventh intersegmental artery, that is subclavian artery (Figure 4). The proximal part of the main trunk of this artery forms axillary and bra-chial arteries and its distal part per-sists as anterior interosseous artery and deep palmer arch. Radial and ul-nar arteries are last to appear in the forearm from the axis artery, that is brachial artery. Initially, the radial ar-tery arises more proximally than the

ulnar artery. Later, it establishes a new connection with the main trunk at or near the level of the ulnar artery. The upper portion of its original stem usually disappears to a large extent. Persistence of the upper portion of the radial artery arising from the bra-chial artery proximal to origin of the ulnar artery followed by failure of de-velopment of the new connection of the radial artery with the brachial ar-tery at the level of origin of the ulnar artery causes this type of anomaly4,5 (Figure 5).

Diagnostically, this variation may disturb the evaluation of arteriog-raphy images and can have serious implications in orthopaedic, plastic

* Corresponding authorEmail: rongon28us@yahoo.com

Department of Anatomy, Armed Forces Medi-cal College, Pune 40, India

Figure 1: Radial artery arising at a higher level in the left arm. TM, teres major muscle; CBM, coracobrachialis muscle; PBA, profunda brachii artery; BA, brachial artery; SUCA, superior ulnar collateral artery; MN, median nerve.

Page 2 of 3

Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Pokhrel R, Bhatnagar R. Unilateral high bifurcation of brachial artery. OA Anatomy 2013 Dec 01;1(4):34. Co

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arteries instead of a single brachial artery.

Incidences of brachioradial artery in earlier studies are depicted in Table 1.

and vascular surgeries. Blood pres-sure, which is normally measured in the arm in the brachial artery, is also affected when there are double

There were no statistical dif-ferences in the sides, that is left or right, and sexes in any of these studies.

Figure 3: Usual branching of brachial artery just distal to elbow joint into radial and ulnar arteries in right arm. BA, brachial artery; RA, radial artery; UA, ulnar artery; RRA, recurrent radial artery.

Figure 2: Origin, branching of brachial artery and course of radial artery in the left forearm. AA, axillary artery; BA, brachial artery; BRA, brachioradial artery; RA, radial artery; UA, ulnar artery.

Figure 4: Lateral branch of seventh intersegmental artery in embryo from wh-ich subclavian artery develops.

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Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Pokhrel R, Bhatnagar R. Unilateral high bifurcation of brachial artery. OA Anatomy 2013 Dec 01;1(4):34. Co

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ting

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References 1. Standring S. Gray’s anatomy: The ana-tomical basis of clinical practice. 40th ed. London: Elsevier Churchill Livingstone; 2008.2. Singh H, Gupta N, Bargotra RN, Singh NP. Higher bifurcation of brachial ar-tery with superficial course of radial artery in forearm. JK Science. 2010;12: 39–40.3. Rodríguex-Niedenfuhr M, Vázquez T, Nearn L, Ferreira B, Parkin I, Sańudo J. Variations of the arterial pattern in the upper limb revisited: a morphological

ConclusionVariations in arterial pattern of the arm and forearm are not uncommon. These variations have an embryolog-ical basis and need to be taken into consideration while analysing arte-riograms and planning surgeries in the upper extremity.

Figure 5: Schematic diagram of development of brachial artery showing the normal pattern (B) and variant as seen in our case (A). 1, brachial artery; 2, radial artery—initial connection; 3, ulnar artery; 4, radial artery—final connection; 5, anterior interosseous artery and 6, median artery.

Table 1 Incidence of high origin of radial artery, that is brachioradial artery, as reported by earlier workers

S. No Author and year n BRA %

1 Quain, 1844 429 53 12

2 Muller, 1903 300 41 13.7

3 Adachi, 1928 410 29 7

4 McCormack, 1953 750 107 14.3

5 Weathersby, 1956 408 64 15.6

6 Skopakoff, 1959 610 55 97 Keen, 1961 284 17 5.9

8 Wankoff ,1962 800 78 9.7

9 Rodriguez-Baeza, 1995 150 6 410 Rodriguez-Niedenfuhr, 2000 385 53 13.8

n, sample size; BRA, total incidence of brachioradial artery; %, incidence of brachioradial artery in percentage. Cited from Anatomy for Surgeons by Hollinshed6

and statistical study, with a review of the literature. J Anat. 2001 Nov;199(5): 547–66.4. Sunitha P, Satayanarayana N, Shaik M, Devi P. Brachial artery with high up di-vision with its embryological basis and clinical significance. Int J Anatom Var. 2010;3:58.5. Arey LB. Developmental anatomy. 6th ed. Philadelphia: WB Saunders; 1957.p375–77.6. Hollinshead WH. Anatomy for sur-geons. Philadelphia: Harper & Row; 1968.p247–50.