Anatomically aberrant forearm arteries: an absent radial artery with co-dominant median and ulnar arteries

Study of course and termination of brachial artery by dissection and computed tomography angiography methods with clinical importance

The Brachial artery is a continuation of the axillary artery, from the inferior border of the tendon of teres major to the neck of the radius, terminating into radial and ulnar arteries just a cm distal to the elbow joint. Unlike veins, variations in the arteries are comparatively less common. Anatomical variations of the brachial artery occur in almost 20% of the cases and are commonly found during routine dissection or clinical practice. To observe the variations in the course and termination of brachial artery by dissection and computed tomography (CT) angiography methods. The present study was conducted on 40 upper limbs each in the department of Anatomy & Radiology of JSS Medical College and Hospital, Mysuru. The brachial artery was traced from origin to termination and variations were noted and photographed. Patients who were undergoing CT angiography of the upper limbs in JSS Hospital were included in the study. Variations noted and compared with the dissection method. In the present study, normal patterns of the brachial arterial course and termination were observed in 31 specimens. The remaining 9 specimens showed variant course and termination in the brachial artery like an unusually tortuous superficial brachial artery, superficial brachio-ulnar artery and brachio-radial artery. CT angiography showed 6 variations and a tortuous brachial artery. A detailed description of the vascular pattern of upper limbs especially variations in their origin and termination is of extreme importance in clinical practice. The knowledge of these variations is important for catheterization, graft harvesting, arteriovenous fistula creation, shunt application and astrup examination.

Branching patters of the vascularization and innervation of the primate forelimb

In this study, we investigate the branching patterns of the vascularization and innervation of the primate forelimb by performing detailed dissections of five unembalmed nonhuman primate specimens belonging to five different species, i.e., rhesus macaque (Macaca mulatta), white-handed gibbon (Hylobates lar), Western gorilla (Gorilla gorilla), chimpanzee (Pan troglodytes), and bonobo (Pan paniscus). Results are compared with five embalmed human specimens (Homo sapiens), and anatomical data of previous studies on nonhuman primates are also included to provide a broader comparative framework. The results show that the overall configuration of the forelimb blood vessels and nerves of the different primate species is similar, although some apparent interspecific differences are found. In all nonhuman primates, in contrast to humans, the superficial vena basilica is absent. Moreover, in gorilla, chimpanzee, and bonobo the superficial v. cephalica is confined to the forearm. In humans, both an arteria interossea anterior and posterior are present, while in the nonhuman primates only an a. interossea anterior is present, which migrates to the posterior side at the level of the musculus pronator quadratus. For the innervation, the nervus medianus and n. ulnaris connect in the forearm of the gorilla and macaque. In the gibbon, the brachial plexus shows some differences in the branching pattern at the fasciculus level compared to the other primates. We conclude that the forelimb innervation branching pattern shows some minor differences between the nonhuman primate species, compared to a higher plasticity in the vascularization. However, the exact functional implications of these differences still remain unclear. Therefore, more research in a broader range of primate species and sampling more specimens for each taxon is needed. This article is protected by copyright. All rights reserved.

Preoperative Doppler Ultrasonography Allen Test for Radial Forearm Free Flap in Oral Cancer Reconstruction: Implications in Clinical Practice

The Radial Forearm Free Flap (RFFF) is one of the most widely used microsurgical flaps for intraoral reconstruction. Although the Clinical Allen Test (CAT) is the most widely used preoperative diagnostic method with which to study the distal patency of the hand prior to the use of RFFF, several authors have reported potentially preventable serious vascular complications. This study included 87 consecutive patients with cancer of the oral cavity and RFFF as the flap of choice who were treated between 2010 and 2020, and compares the results of the Clinical Allen Test (CAT), the Doppler Allen Test (DAT) and the Surgical Allen Test (SAT). The preoperative vascular study found vascular abnormalities severe enough for the surgical team to change the preoperative flap of choice in 39% of patients. The Kappa index showed a weak concordance between the CAT and DAT. The study reflected a total concordance in the preoperative results of the Doppler study and the intraoperative results of the SAT. Due to its excellent agreement with SAT, the DAT would be the preoperative test of choice in patients who are candidates for RFFF. This study of vascular mapping tests with Doppler is intended to inform therapeutic decisions and present methods to gain information that cannot be obtained by physical examination alone.

Erfolgreiche freie mikrovaskuläre A. radialis-Lappenplastik zur Phalluskonstruktion bei persistierender A. mediana (PMA)

Hintergrund Anomalien des Gefäßsystems des Unterarmes können bei der mikrochirurgischen Hebung einer A. radialis-Lappenplastik von großer Bedeutung sein. Insbesondere bei der Verwendung der fasziokutanen Radialislappenplastik zur Bildung eines Penoids ist auf Grund der erforderlichen Größenausmaße der Lappenplastik eine suffiziente arterielle Versorgung von grundlegender Bedeutung. Beim Auftreten einer persistierenden A. mediana können dabei die Perfusionsverhältnisse im Versorgungsgebiet der A. radialis und der A. ulnaris verändert oder diese sogar vollständig rückgebildet worden sein.

Patienten und Methoden Es erfolgte eine retrospektive Auswertung aller in unserer Klinik durchgeführten Phalloplastiken mit Radialispenoid von Januar 2016 bis Dezember 2018. Bei allen Patienten wurde die Technik nach Gottlieb und Levine oder nach Chang angewandt.

Ergebnisse In der retrospektiv untersuchten Kohorte von 48 Patienten wurde bei zwei Patienten intraoperativ eine persistierende A. mediana gefunden, was einer Inzidenz von 4,2 % entspricht. Bei beiden Patienten gelang die hinsichtlich der Perfusion komplikationslose Bildung eines Radialispenoids ohne Einschränkungen der Lappenperfusion oder der Perfusion der Hand. Eine Literaturübersicht liefert einen Überblick über die Inzidenz auftretender Aberrationen der Vaskularisierung des Unterarmes und die daraus ableitbaren Konsequenzen für die Planung einer A. radialis-Lappenplastik.

Schlussfolgerung Auch im Falle einer verlässlichen mikrochirurgischen Lappenplastik wie der A. radialis-Lappenplastik sollten dem mikrochirurgisch tätigen Chirurgen die Möglichkeiten der anatomischen Varianten der arteriellen Versorgung des Unterarmes, wie das Vorhandensein einer persistierenden A. mediana, bekannt sein. Der standardmäßig durchzuführende Allen-Test liefert in vielen Fällen keine eindeutige Rückschlussmöglichkeit und bedingt somit häufig erst intraoperative Zufallsbefunde. Eine sorgfältige präoperative Planung und Evaluation der Perfusion sowie die Erörterung von Alternativtechniken sind hierbei notwendig.

The Anomalous Radial Artery: A Rare Vascular Variant and Its Implications in Radial Forearm Free Tissue Transfer

The radial forearm free flap (RFFF) has become a workhorse for soft tissue reconstruction following surgical ablation of head and neck cancer. Given the popularity of the RFFF, it is important to understand potential variants of upper extremity vascular anatomy and the effects of these findings on pre- and intraoperative planning. The purpose of this series is to synthesize the existing literature to raise awareness for potential radial artery aberrations during planned reconstruction.

Dealing with vascular anomalies during radial forearm free flap harvest: report of two cases and review of the literature

Radial forearm free flap reconstruction for head and neck cancer is very common, and it is widely considered a workhorse flap. Although this flap has a relatively reliable anatomy, surgeons need to be aware of possible anatomical variations and how to deal with them. This paper presents the cases of two patients who underwent oral reconstruction, in whom anomalies of the radial artery were identified while raising a radial forearm free flap. Case 1 demonstrates the dominant branch of the radial artery joining the common interosseous artery approximately 9 cm from the first wrist crease. Case 2 demonstrates abnormal distal branching of the radial artery approximately 4 cm from the first wrist crease. Reconstruction with the flap was successful in both cases. A literature review of reported anomalies of the radial artery is presented, and how to deal with such vascular anomalies is discussed.

A Practical Training Program for Peripheral Radial Artery Catheterization in Adult Patients: A Prospective, Randomized Controlled Trial

BACKGROUND

The main cause of unsuccessful peripheral radial artery catheterization using traditional palpation is imprecisely locating the arterial center. The authors evaluated factors causing disparities between the arterial centers determined by palpation versus ultrasound. The authors applied them to create and test a novel catheterization training program.

METHODS

The arterial central axis was determined by ultrasound and palpation in 350 adults. Potential independent predictors of disparity included sex, body mass index, pulse pressure, transverse arterial diameter, subcutaneous arterial depth, chronic hypertension, and experience as an anesthesiologist (less than 3 vs. greater than or equal to 3 yr). Using the results, the authors developed a radial artery catheterization training program. It was tested by enrolling 20 first-year interns, randomized to a training or control group. The time to successful insertion was the primary outcome measure. The success rate and time required for catheterization by palpation were evaluated in 100 adult patients per group.

RESULTS

Independent predictors of central axis disparity were pulse pressure, subcutaneous radial artery depth, years of experience, and chronic hypertension. Training improved the catheterization time (training group 56 ± 2 s vs. control group 109 ± 2 s; difference -53 ± 3 s; 95% CI, -70 to -36 s; P < 0.0001) and total success rate (training group 83 of 100 attempts, 83%; 95% CI, 75 to 90 vs. control group 57 of 100, 57%; 95% CI, 47 to 66; odds ratio, 3.7; 95% CI, 2.7 to 5.1).

CONCLUSIONS

Misjudging the central axis position of the radial artery is common with a weak pulse and/or deep artery. The authors' program, which focused on both these issues, shortened the time for palpation-guided catheterization and improved success.

A rare variant of the ulnar artery with important clinical implications: a case report

BACKGROUND

Variations in the major arteries of the upper limb are estimated to be present in up to one fifth of people, and may have significant clinical implications.

CASE PRESENTATION

During routine cadaveric dissection of a 69-year-old fresh female cadaver, a superficial brachioulnar artery with an aberrant path was found bilaterally. The superficial brachioulnar artery originated at midarm level from the brachial artery, pierced the brachial fascia immediately proximal to the elbow, crossed superficial to the muscles that originated from the medial epicondyle, and ran over the pronator teres muscle in a doubling of the antebrachial fascia. It then dipped into the forearm fascia, in the gap between the flexor carpi radialis and the palmaris longus. Subsequently, it ran deep to the palmaris longus muscle belly, and superficially to the flexor digitorum superficialis muscle, reaching the gap between the latter and the flexor carpi ulnaris muscle, where it assumed is usual position lateral to the ulnar nerve.

CONCLUSION

As far as the authors could determine, this variant of the superficial brachioulnar artery has only been described twice before in the literature. The existence of such a variant is of particular clinical significance, as these arteries are more susceptible to trauma, and can be easily confused with superficial veins during medical and surgical procedures, potentially leading to iatrogenic distal limb ischemia.

Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations

Consistent anatomic accessibility, ease of cannulation, and a low rate of complications have made the radial artery the preferred site for arterial cannulation. Radial artery catheterization is a relatively safe procedure with an incidence of permanent ischemic complications of 0.09%. Although its anatomy in the forearm and the hand is variable, adequate collateral flow in the event of radial artery thrombosis is present in most patients. Harvesting of the radial artery as a conduit for coronary artery bypass grafting, advances in plastic and reconstructive surgery of the hand, and its use as an entry site for cardiac catheterization has provided new insight into the collateral blood flow to the hand and the impact of radial arterial instrumentation. The Modified Allen's Test has been the most frequently used method to clinically assess adequacy of ulnar artery collateral flow despite the lack of evidence that it can predict ischemic complications in the setting of radial artery occlusion. Doppler ultrasound can be used to evaluate collateral hand perfusion in an effort to stratify risk of potential ischemic injury from cannulation. Limited research has demonstrated a beneficial effect of heparinized flush solutions on arterial catheter patency but only in patients with prolonged monitoring (>24 h). Conservative management may be equally as effective as surgical intervention in treating ischemic complications resulting from radial artery cannulation. Limited clinical experience with the ultrasound-guided arterial cannulation method suggests that this technique is associated with increased success of cannulation with fewer attempts. Whether use of the latter technique is associated with a decrease in complications has not yet been verified in prospective studies. Research is needed to assess the safety of using the ulnar artery as an alternative to radial artery cannulation because the proximity and attachments of the ulnar artery to the ulnar nerve may potentially expose it to a higher risk of injury.

Trifurcation of brachial artery with variant course of radial artery: rare observation

Variations in the arterial pattern of the upper limb have been observed frequently, either in the routine dissections or in clinical practice. The aim of the present study was to describe the anatomical, surgical and embryological importance of major arteries of upper limbs of human beings. The present article is the report of low division and trifurcation of brachial artery and abnormal course of radial artery (passing deep to the pronator teres muscle) found in a 45-year-old embalmed male cadaver. Knowledge of the arterial variations in the upper limb is of considerable importance during invasive and non-invasive investigative procedures or orthopedic, reconstructive, or surgical procedures.

Dealing with aberrant vessels in radial forearm flaps - report of a case and review of literature

INTRODUCTION

Anomalies of the radial artery are uncommon. A brief tabulated review of the literature is presented.

CASE REPORT

We report a rare anomaly of the forearm vascular anatomy we encountered when elevating a radial forearm free flap. This is a previously unreported anatomical variation. The radial artery divided into medial and lateral branches (accompanied by their respective venae commitantes) about 1.5 cm below the bifurcation of the brachial artery. The skin paddle was predominantly supplied by the aberrant medial branch and was raised on this branch along with its venae commitantes up to the point of division.

CONCLUSION

This case highlights the need for vigilance when raising free flaps and the techniques employed to avoid compromising both limb and skin paddle perfusion.

Rare Presentation of Subclavian Artery Isolation in a Neonate With a Family History of Aortic Arch Anomalies

Isolation of the left subclavian artery is a rare aortic arch anomaly in which the artery originates from the pulmonary artery through a ductus arteriosus rather than the aorta. In neonates it is usually diagnosed incidentally with other aortic or cardiac anomalies and can be associated with chromosomal deletions. We describe an extremely rare presentation whereby subclavian artery isolation was presented with left arm ischemia in a 6-day-old child. There were also a concurrent right aortic arch, ventricular septal defect, persistent left superior vena cava, and both radial and ulnar artery hypoplasia. A family history of aortic arch anomalies with no known chromosomal aberration was also present, whereby all the male family members on the maternal side had undergone aorto-cardiac surgery as neonates. Diagnosis and surgical management are discussed.

A case of an anomalous radial artery arising from the thoracoacromial trunk

We present a case of an anomalous radial artery (ARA), which arose as a branch of the thoracoacromial trunk. After giving rise to the lateral thoracic artery, the ARA continued superficially through the brachium and antebrachium, terminating as the deep palmar arterial arch. This anomalous artery was found to completely replace the radial artery which normally arises from the brachial artery. Embryological considerations and possible clinical consequences are discussed.

Multiple arterial variations in the upper limb of a South Indian female cadaver

In a routine dissection of a female cadaver, a variation in the course of the radial artery in the cubital fossa and a communication between the brachial artery and radial artery were observed. A rare origin and course of the median artery was also found. These anomalies are discussed in detail and their clinical relevance is highlighted.

Recognition of potential morbidity after use of the radial artery as a conduit for coronary artery revascularization

The use of the radial artery as an alternative vascular conduit for coronary bypass surgery has become increasingly popular. The plastic surgery experience with radial forearm flaps has shown that sacrifice of the radial artery is not always a benign maneuver. The potential morbidity after using this conduit donor site in terms of hand dysfunction or wound healing problems can be significant, and frequently must ultimately be addressed as part of the role of the reconstructive surgeon. Case examples of skin necrosis, subsequent forearm wound infection and hypertrophic scarring after radial artery harvest are presented to introduce this as a real concern and to allow a review of the entire spectrum of potential problems in this regard. Any selection process where the radial artery may be chosen as the coronary revascularization conduit must anticipate these known donor site complications.

Accidental intraarterial drug injections via intravascular catheters placed on the dorsum of the hand

IMPLICATIONS

Two cases of placement of a catheter in the dorsum of a hand into an artery mistaken to be a vein are described. Diagnosis and treatment of such mishaps are discussed.