|Year : 2018 | Volume
| Issue : 1 | Page : 43-46
Unilateral higher division of brachial artery
R Balasubramanian, Chaitanya Subramanium, Rajendrakumar Dundappa Virupaxi, Sanjay Kumar Yadav
Department of Anatomy, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
|Date of Web Publication||27-Jul-2018|
61, Chanakya Boys Hostel, JNMC Campus, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Arterial variations are common in upper extremity. The present article describes a case of higher division of brachial artery. Higher division of brachial artery occurred above the level of insertion of coracobrachialis muscle. Further, the brachial artery proper continues lateral to median nerve in the cubital fossa and divides into radial and ulnar artery at the level of neck of radius. Higher division of brachial artery continues downward and medially, medial to the median nerve in cubital fossa, forming the superficial palmar arch in the palm. Knowledge of such variation is extremely important, especially for the limb surgeons (for carrying out surgeries in arm, creating arteriovenous fistulas for dialysis), routine blood pressure measurements, radiographic imaging, and interventionists. The relevant topics of embryology, anatomy, and its clinical importance have been discussed in the literature review. The purpose of this article is to highlight the need for the awareness of the potential existence of such anatomical variation and how it can be preoperatively detected by color Doppler imaging, which would help the surgeons and clinicians to plan out surgery and therapeutic interventions.
Keywords: Brachial artery, radial artery, superficial palmar arch, ulnar artery, variations and development
|How to cite this article:|
Balasubramanian R, Subramanium C, Virupaxi RD, Yadav SK. Unilateral higher division of brachial artery. J Sci Soc 2018;45:43-6
| Introduction|| |
Brachial artery is the continuation of 3rd part of axillary artery at the lower border of teres major muscle. It gives its first branch called the profunda brachii artery at the surgical neck of humerus.
It further gives two branches, superior ulnar collateral artery and inferior ulnar collateral artery just above the insertion of the coracobrachialis muscle which anastomoses with posterior and anterior ulnar recurrent arteries, the branches of ulnar artery, on posterior and anterior surface of medial epicondyle of humerus, respectively. These branches ensure collateral circulation around the elbow joint during flexion of the same.
At the cubital fossa, it passes lateral to median nerve and medial to the tendon of biceps brachii to divide into a radial and ulnar artery. In 25% of the individuals, brachial artery variations are common, according to the Compendium of Human Anatomic Variation.
Cardiac ventriculography is done using brachial artery when femoral artery in inaccessible.
Such variation can cause confusion while performing arteriovenous (AV) fistula involving the radial artery and the cephalic vein to treat chronic renal failure. They are the first and best choice of the treatment for dialysis because they are long lasting and need less maintenance. The aim of this case report is to elucidate the incidence, prevalence, embryological causes, and clinical significance of such variation.
| Case Report|| |
During routine dissection of the upper limb in Jawaharlal Nehru Medical College, Belagavi, Karnataka, India, in 20 cadavers of both sexes, one of the male cadavers of age 65 years, in the left upper limb, showed the division of brachial artery into brachial artery proper and higher division of brachial artery just above the insertion of coracobrachialis muscle. The division was found to be 12 cm [Figure 1] from the beginning of 3rd part of axillary. The profunda brachii artery originated from the brachial artery at the surgical neck and descends posteriorly with radial nerve and winds around the spiral groove on the posterior surface of the shaft of the humerus. The superior ulnar collateral artery and inferior ulnar collateral artery originated from the brachial artery at the same point of division of brachial artery just above the insertion of coracobrachialis muscle. They were traced till their anastomoses at the medial epicondyle. The brachial artery proper which runs from the point of bifurcation of brachial artery at midshaft position till its division into radial and ulnar artery at the level of neck radius measured 19 cm. The median nerve from the lateral and medial cord crosses the brachial artery proper ventrally at the midshaft position and lies medial to it in cubital fossa, whereas it (median nerve) lies lateral to the higher division of brachial artery and further penetrates through the 2 heads of pronator teres.
|Figure 1: The length of 3rd part of axillary artery (12 cm) and its point of bifurcation|
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The higher division of brachial artery was traced superficially and extended medially in arm and forearm. A prominent muscular branch to biceps brachii was observed in the arm [Figure 2]. It was found medial to the median nerve in cubital fossa [Figure 3] and [Figure 4] and continued medially in the forearm. It was found medial to the 1st tendon of flexor digitorum superficialis and lateral to the tendon of flexor carpi ulnaris and passes anterior to the flexor retinaculum in the wrist region. At a distance of 44 cm [Figure 5] from its origin, it terminates as superficial palmar arch [Figure 6] which was unlike the usual cases wherein the ulnar artery forms the superficial palmar arch. No such variation was found on the right upper limb.
|Figure 2: The bifurcation of brachial artery into brachial artery proper (laterally) and higher division of brachial artery (medially) and the course of higher division of brachial artery (lifted) (running medially in arm, medial to median nerve in cubital fossa, and between 1st tendon of flexor digitorum superficialis and flexor carpi ulnaris in forearm). A prominent muscular branch to biceps brachii is also seen immediately after its bifurcation. HDBA = Higher division of brachial artery, MBTBB = Muscular branch to biceps brachii, BAP = Brachia artery proper, AA = Axillary artery|
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|Figure 3: The arrangement of contents in cubital fossa. BAP = Brachial artery proper, RA = Radial artery, PT = Pronator teres, FDS = Flexor digitorum superficialis muscle, MN = Median nerve, UA = Ulnar artery, HDBA = Higher division of brachial artery|
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|Figure 4: Division of brachial artery (lateral to median nerve) into radial and ulnar artery and higher division of brachial artery running medial to the median nerve. BB = Biceps brachii, MCN = Musculocutaneous nerve, BAP = Brachial artery proper, RA = Radial artery, B = Brachialis muscle, MN = Median nerve, UA = Ulnar artery, HDBA = Higher division of brachial artery|
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|Figure 5: The length of higher division of brachial artery from point of bifurcation of brachial artery till formation of superficial palmar arch = 44 cm. HDBA = Higher division of brachial artery, SPA = Superficial palmar arch|
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|Figure 6: Higher division of brachial artery running between 1st tendon of flexor digitorum superficialis and flexor carpi ulnaris and forming the superficial palmar arch. FDS = Flexor digitorum superficialis muscle, HDBA = Higher division of brachial artery, SPA = Superficial palmar arch|
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| Discussion|| |
Brachial artery is main blood supply of upper limb. Variations in the vasculature of upper limb are pretty common. Various workers in their studies found different types of variations in the course of the arterial tree of the upper limb. It was first noted by Von Haller in 1813.
Arey gave six explanation of the variation in the blood vessels of upper limb which are as follows: the choice of unusual paths in the primitive vascular plexus, the persistence of vessels which are normally obliterated (as in our case), the disappearance of vessels which are normally retained, an incomplete development, the fusion and absorption of parts which are normally distinct, and a combination of factors leading to an atypical pattern normally encountered.
Shewale et al. reported a case of division of brachial artery at its commencement. In their study, they reported a case of termination of brachial artery at its commencement below the lower border of teres major. Both the terminal branches, ulnar and radial arteries, had superficial course along the medial aspect of biceps brachii, radial more superficial than ulnar.
Chakravarthi et al. reported unusual bilateral accessory brachial artery arising from the axillary artery, and it is continuing in the forearm as superficial accessory ulnar artery forming the superficial palmar arch.
Jayasabarinathan et al. have described the division of brachial artery high up at the level of midshaft of humerus into radial and ulnar artery and further the radial artery giving rise to common interosseous artery unusually.
Kumar and Rathnakar reported a case of higher division of brachial artery in which there was high division of brachial artery into medial and lateral branches, 9.5 cm distal to the lower border of teres major muscle. It was also observed that the two branches are crossing over near the lower part of the front of arm, and the lateral branch continued into the cubital fossa and trifurcated at the proximal border of pronator teres muscle.
Pokhrel and Bhatnagar also reported a high division of brachial artery at midshaft position.
Gujar et al. have reported in their study an unusual short segment of the brachial artery which divided at middle of right arm of one cadaver and a high origin of the radial artery from axillary artery found in right upper limb of another cadaver.
Gupta et al. noted a short segment brachial artery bifurcating into radial and ulnar artery in the middle of the left arm.
Satyanarayan et al. and Satnami et al. have reported an unusually short segment brachial artery in the right arm. This short segment brachial artery bifurcated more proximally at the level of insertion of coracobrachialis in the middle of the right arm into radial and ulnar arteries both of the same caliber.
There are only a few references in the literature on sex and laterality about accessory brachial artery. Fuss et al., Rodríguez-Niedenführ et al., and Musaed et al. reported that the incidence of superficial brachial artery was more frequent in males and on the right side.
Whereas the prevalence of accessory brachial artery noted in this study was more in females and on the left side.
However, our case has reported the division in a male in the left upper limb.
The axis artery of the upper limb bud is the lateral branch of the seventh intersegmental artery (subclavian artery). This grows along the ventral axial line and ends in the capillary plexus of the hand. The digital arteries arise from the plexus. The proximal part of the main trunk forms the axillary and brachial arteries, and the distal part forms the anterior interosseous. The median artery arises from the anterior interosseous, which later regresses. At the bend of the elbow, the axis artery gives a radial and ulnar arteries (radial proximal to ulnar). The palmar capillary plexus differentiates into superficial arch, which communicates with ulnar artery, and the deep arch, which communicates with the radial artery. The median artery regresses from the palmar arches. The radial is connected to the ulnar artery close to its origin, and the proximal connection of the radial artery with the axis artery is withdrawn [Figure 7].
|Figure 7: The development stages (13–21) of arteries of upper limb. S = Subclavian artery, A = Axillary artery, I = Interosseous artery, R = Radial artery, B = Brachial artery, M = Median artery, U = Ulnar artery, PA = Palmar arch|
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The failure of the median artery to regress gives rise to the superficial course of the artery continuing to form the superficial palmar arch. Here, the ulnar artery running deep disappears by giving muscular braches.
Preoperative diagnosis of such variants
Such variation must be identified preoperatively to avoid grievous complication during AV fistula or other surgeries of arm like plastic reconstructive surgeries. This can be overcome by performing a routine arterial color Doppler which is noninvasive before performing any invasive procedures in upper limb.
| Conclusion|| |
A thorough knowledge about the anatomy and the normal variations and prior knowledge of existence of such a variation cannot be overemphasized.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]