The High Origin of the Radial Artery (Brachioradial Artery): Its Anatomical Variations, Clinical Significance, and Contribution to the Blood Supply of the Hand

Upper limb computed tomography (CT) angiography in the emergency department

A range of abnormalities may acutely affect the upper limb (UL) extremity vasculature including trauma, peripheral vascular disease, and inflammatory conditions. Significant technical advances in computed tomography angiography (CTA) have led to the widespread adoption of this noninvasive modality for rapid evaluation of UL arterial abnormalities in the emergency department setting. A key advantage of CTA over traditional digital subtraction angiography (DSA) is the ability to evaluate concurrent osseous and soft tissue injuries. Accurate identification of pathology requires knowledge of normal UL arterial anatomy in addition to a high-quality study, which may be achieved with a robust CTA protocol. We describe the spectrum of imaging findings on upper limb CTA associated with various acute presentations. Traumatic vascular injuries may occur secondary to penetrating and blunt aetiologies appearing on CTA as contrast extravasation, pooling, pseudoaneurysm, occlusion, and arteriovenous fistula. Peripheral vascular disease manifests as atherosclerotic plaques with thready downstream opacification, and these may precipitate acute thromboembolic events. Inflammatory conditions affecting the UL vasculature includes large and small vessel vasculitides characterised by arterial mural thickening. The use of modalities, including ultrasound and magnetic resonance angiography (MRA), should be considered for further characterisation where appropriate.

Rare Variant of the Radial Artery Causing Compression of the Superficial Radial Nerve: A Case Report

CASE

This case report describes a patient with paresthesia in the distribution of the superficial sensory branch of the radial nerve that was treated with surgery. Intraoperatively, there was a unique cause of internal compression by a rare superficial radial artery variant running adjacent to it. The nerve was mobilized from the artery with fascial releases. The patient had symptom resolution postoperatively.

CONCLUSION

To our knowledge, this cause of compression has not been described before and should be considered in a differential diagnosis. In addition, clinicians should be aware of this anatomical variant during venipunctures and surgical approaches.

Seven-year follow-up of endovascular treatment of iatrogenic brachioradial artery injury complicating percutaneous coronary intervention: a case report

The radial artery has been used increasingly for percutaneous coronary intervention because of its safety and feasible access route. Nevertheless, transradial complications are possible because of the variation in radial artery anatomy. We experienced a case of the brachioradial artery injury secondary to catheterization, presenting as hypovolemic shock. A 76-year-old woman presented at our emergency department complaining of effort-induced angina. Coronary angiography via the right radial artery showed critical stenosis in the middle of the left anterior descending coronary artery. After wiring into this vessel, balloon angioplasty using a 6-Fr Judkin left guiding catheter was performed with the deployment of the zotarolimus-eluting stent. There was difficulty in negotiating the guidewire and balloons in that resistance was experienced while passing the catheter in the upper arm. Therefore, retrograde radial arteriography was performed to determine any injury to radial artery. This showed contrast extravasation in the brachioradial artery. Initially, manual compression was tried. However, 2 hours later, the patient developed cold sweating and went into a stupor. Laboratory findings showed a decline in hemoglobin, leading to suspicion of hemorrhagic shock. We applied over 30 minutes of balloon inflation, but this was ineffective. While surgical repair was not available, a 6.0 × 50 mm Viabahn stent was placed over the axillary artery. Subsequent angiography showed no further leakage or occlusion of the brachioradial artery. The postprocedural period was uneventful, and the patient was discharged with dual antiplatelet agents. At a 7-year clinical follow-up, the patient was free from limb ischemia symptoms.

A Cadaveric Study on the High Origin of the Radial Artery

INTRODUCTION

Among the upper limb's vascular variations, the radial artery's high origin from the axillary artery is rare, and literature regarding the same is limited. Anomalous origin of radial artery can cause failure of radial approach to coronary angiography and reconstructive surgeries of upper limbs and hence is of clinical significance. With this background, the current cadaveric study was planned to describe the branching pattern of the axillary artery and its variations.

METHODS

We conducted this descriptive, cross-sectional study on sixty adult human cadaveric upper limbs at the anatomy departments of Government TD Medical College, Alappuzha, and Government Medical College, Thiruvananthapuram, over two years from 2021 to 2023. The axillary artery's branching pattern and termination were noted, and the prevalence of high origin of the radial artery from the axillary artery was documented.

RESULTS

High origin of radial artery from axillary artery was observed in four (6.70%) limbs and was higher than the prevalence reported in earlier literature. Among these variations, one was a female cadaver with a bilateral high origin of radial artery arising from the third part of the axillary artery. The other two were from separate male upper limbs, both from the right upper limb.

CONCLUSION

The prevalence of the high origin of the radial artery from the axillary artery was high compared to earlier reported literature. This calls for further research in the anatomy of arterial patterns of the upper limb to avoid complications during arterial procedures of the upper limb.

Retained radial catheters associated with variant radial anatomy in neurointerventional procedures

BACKGROUND

Transradial artery access (TRA) for neurointerventional procedures is gaining widespread acceptance. However, complications that were previously rare may arise as TRA procedures increase. Here we report a series of retained catheter cases with a literature review.

METHODS

All patients who underwent a neurointerventional procedure during a 23-month period at a single institution were retrospectively reviewed for a retained catheter in TRA cases. In cases of retained catheters, imaging was reviewed for anatomical variances in the radial artery, and clinical and demographic case details were analyzed.

RESULTS

A total of 1386 nondiagnostic neurointerventional procedures were performed during the study period, 631 (46%) initially via TRA. The 631 TRA cases were performed for aneurysm embolization (n=221, 35%), mechanical thrombectomy (n=116, 18%), carotid stent/angioplasty (n=40, 6%), arteriovenous malformation embolization (n=38, 6%), and other reasons (n=216, 34%). Thirty-nine (6%) TRA procedures crossed over to femoral access, most commonly because the artery of interest could not be catheterized (26/39, 67%). A retained catheter was identified in five cases (1%), and one (0.2%) patient had an entrapped catheter that was recovered. All six patients with a retained or entrapped catheter had aberrant radial anatomy.

CONCLUSION

Retained catheters for neurointerventional procedures performed via TRA are rare. However, this complication may be associated with variant radial anatomy. With the increased use of TRA for neurointerventional procedures, awareness of anatomical abnormalities that may lead to a retained catheter is necessary. We propose a simple protocol to avoid catheter entrapment, including in emergent situations such as TRA for stroke thrombectomy.

Anatomical and biometric study of the radial artery on human cadavers dissected in the anatomy laboratory

OBJECTIVE

To study the anatomy and biometry of the radial artery and to report the implications of this study for daily practice in Cardiac Surgery.

METHOD

Radial arteries from 45 human cadavers (28 males and 17 females, average age 79.2 (92) fixed in 10% formalin were dissected. The proximal and distal internal calibers and lengths of these radial arteries were measured.

RESULTS

Our results showed the presence of a single radial artery variation in 2.3% of the entire sample (1.1% of the 90 dissected upper limbs). The distance between the epicondyle and the emergence of the radial artery was 32.4 (6.67) mm in men and 30.7 (9.00) mm in women, with an average of 31.8 (7.58) mm. For the right upper limb, the mean proximal internal caliber of the radial artery was 3.16 (0.56) mm and its mean distal internal caliber was 2.62 (0.66) mm. For the left upper limb, the mean proximal internal caliber of the radial artery was 3.17 (0.59) mm and its mean distal internal caliber was 2.64 (0.68) mm. The mean length of the left radial artery was 197.0 (17) mm. The mean length of the right radial artery was 201.0 (33) mm.

CONCLUSION

It is very important to be aware of the possible anatomical variation of the radial artery. Despite its rarity, this knowledge may ensure a better safety and reliability of the harvesting technique for use as a graft.

Morphological variations of the brachial artery and their clinical significance: a systematic review

PURPOSE

Morphological variations of the brachial artery are quite commonly discovered in routine dissection and have been the subject of many studies. However, there is a need for a clear classification. This work presents morphological variations of the brachial artery, based on numerous case reports and studies created for the appropriate classification and interpretation among surgeons and radiologists. It also discusses the most important clinical aspects of the given varieties.

METHODS

The research method is based on the combined interpretation of the researches based on numerous publications concerning both the principles of correctly classifying the described morphological variations of the brachial artery and the resulting clinical implications. This work considers atypical variations such as the presence of the superficial brachial artery, brachoradial artery, accessory brachial artery and absence of the brachial artery. Variations of the brachial artery in relation to the external and internal diameter of the vessel have also been discussed.

RESULTS

After conducting a complex analysis of the collected data, the fundamental principles for classifying such variability as superficial brachial artery, brachioradial artery and accessory brachial artery were defined. Additionally, clinical implications resulting from the above like the impact of the superficial brachial artery on the median nerve neuropathy and the positive correlation between the brachioradial artery and increased danger of incorrect transradial catheterization were demonstrated.

CONCLUSIONS

The clinical implications of the atypical arterial pattern within the upper limb are crucial during the angiography and surgical procedures so the variations affect the appropriate diagnosis and surgical intervention. Hence, the knowledge about the morphological variations of the brachial artery should be constantly broadened by radiologists and surgeons to improve the accuracy and effectiveness of the treatment process.

Predicting difficult transradial approach guiding into left internal carotid artery on unruptured intracranial aneurysms

BACKGROUND

The transradial approach (TRA) is less invasive than the transfemoral approach (TFA), but the higher conversion rate represents a drawback. Among target vessels, the left internal carotid artery (ICA) is particularly difficult to deliver the guiding catheter to through TRA. The purpose of this study was thus to explore anatomical and clinical features objectively predictive of the difficulty of delivering a guiding catheter into the left ICA via TRA.

METHODS

Among 78 consecutive patients who underwent coil embolization for unruptured intracranial aneurysms through TRA in a single institution between March 1, 2021, and August 31, 2022, all 29 patients (37%) who underwent delivery of the guiding catheter into the left ICA were retrospectively analyzed. Clinical and anatomical features were analyzed to assess correlations with difficulty in guiding the catheter into the left ICA.

RESULTS

Of the 29 aneurysms requiring guidance of a catheter into the left ICA, 9 aneurysms (31%) required conversion from TRA to TFA. More acute innominate-left common carotid artery (CCA) angle (P < 0.001) and older age (P = 0.015) were associated with a higher conversion rate to TFA. Receiver operating characteristic analysis revealed that optimal cutoff values for the innominate-left CCA angle and age to distinguish between nonconversion and conversion to TFA were 16° (area under the curve [AUC], 0.93; 95% confidence interval [CI], 0.83-1.00) and 74 years (AUC, 0.79; 95% CI, 0.61-0.96), respectively.

CONCLUSION

A more acute innominate-left CCA angle and older age appear associated with difficulty delivering the guiding catheter into the left ICA for neurointervention through TRA.

Compartment syndrome associated with vascular avulsion caused by transradial access in neurointervention for unruptured intracranial aneurysm: illustrative case

BACKGROUND

Transradial access (TRA) has a lower risk of access-site complications than transfemoral access but can cause major puncture-site complications, including acute compartment syndrome (ACS).

OBSERVATIONS

The authors report a case of ACS associated with radial artery avulsion after coil embolization via TRA for an unruptured intracranial aneurysm. An 83-year-old woman underwent embolization via TRA for an unruptured basilar tip aneurysm. Following embolization, strong resistance was felt during removal of the guiding sheath due to vasospasm of the radial artery. One hour after neurointervention via TRA, the patient complained of severe pain in the right forearm, with motor and sensory disturbance of the first 3 fingers. The patient was diagnosed with ACS causing diffuse swelling and tenderness over the entire right forearm due to elevated intracompartmental pressure. The patient was successfully treated by decompressive fasciotomy of the forearm and carpal tunnel release for neurolysis of the median nerve.

LESSONS

TRA operators should be aware that radial artery spasm and the brachioradial artery pose a risk of vascular avulsion and resultant ACS and warrant precautionary measures. Prompt diagnosis and treatment are essential because ACS can be treated without the sequelae of motor or sensory disturbance if properly addressed.

Anteroposterior Cannulated Screw Fixation of Coronoid Fractures in Terrible Triad Injuries: A Simple Syringe-guided Technique

OBJECTIVE

The fixation of the coronoid fractures in terrible triad injuries is quite challenging. In this study, we introduce a minimally invasive technique using a syringe as a guide for insertion of the cannulated screw in an anterior to posterior fashion to fix the coronoid fracture in patients with terrible triad injuries.

METHODS

In this retrospective study, clinical data of patients suffering from terrible triad injuries between 2012 and 2019 were analyzed. Fifteen patients with an average age of 38.2 years old (21-56 years) were enrolled in this study, of which 12 were males and three were females. The Regan-Morrey type II and type III coronoid fractures in these patients were treated with cannulated screws, inserted anteriorly using a 1 mL syringe as a guide. Outcome measures included pain, range of motion, stability and daily function using Mayo Elbow Performance scores (MEPs). The anteroposterior and lateral radiographs were used for evaluating a healing fracture.

RESULTS

After a mean follow up of 44.2 months (range 13-80), the mean elbow flexion was 128.2°, extension was 12.3°, forearm pronation was 74.6° and supination was 73.6°. A concentric reduction was maintained without severe pain, stiffness, and radiographic evidence of instability in all patients during the follow-up period. The mean MEPs was 89.7 points.

CONCLUSION

The anteroposterior cannulated screw fixation via simple syringe guide is a minimally invasive and safe option for surgical treatment of coronoid fractures in terrible triad injuries.

The Unusual High Origin Radial Artery in a Black Kenyan Population: A Cadaveric Study

Background

The anatomy of the radial artery draws great interests among anatomists for its frequent involvement in variations. Equally, these variations have gained significant attention from clinicians because of the preference to use the radial artery for catheterization. The commonest of radial artery variations involve its site of origin. In published literature, data on this variations exist, but the prevalence of such variations in a Kenyan population has hitherto been unknown.

Methods

Sixty-two upper limbs from 50 formalin-fixed cadavers were studied during dissection in the Department of Human Anatomy, University of Nairobi.

Results

Fifty-four (87.1%) radial arteries arose within the cubital fossa, while eight (12.9%) had a high origin. Out of the eight high arteries, two (3.2%) branched off from the axillary artery, another two (3.2%) were branches of the proximal third of the brachial artery and four (6.5%) arose from the middle third of the brachial artery. The high origin radial arteries were more common on the right upper limbs (5 out of the 8 cases). Both axillary and brachial origins were seen bilaterally.

Conclusion

The present study details important variations in the anatomy of the radial artery in a Kenyan population. With the radial artery being utilized during clinical, surgical and radiological interventions so frequently, an increased understanding and anticipation of such topographic variances is paramount.

Radial artery access anatomy: considerations for neuroendovascular procedures

Although enthusiasm for transradial access for neurointerventional procedures has grown, a unique set of considerations bear emphasis to preserve safety and minimize complications. In the first part of this review series, we will review important anatomical considerations for safe and easy neuroendovascular procedures from a transradial approach. These include normal and variant radial artery anatomy, the anatomic snuffbox, as well as axillary, brachial, and great vessel arterial anatomy that is imperative for the neuroendovascular surgeon to be intimately familiar prior to pursuing transradial access procedures. In the next part of the review series, we will focus on safety and complications specific to a transradial approach.

Topography and Anatomical Variations of the Axillary Artery

Knowledge of anatomical variations of the limb's main arteries is significant for the clinicians. Thus, this study is aimed at examining the branching pattern and anatomical variations of the axillary artery. We conducted research on 59 upper limbs of adult human donated cadavers. All axillary artery branches' origins were assessed, and the correlations between points of origins and variations of specific branches were evaluated. The average length of the axillary artery was found to be 11.22 cm, and this length was defined as reference line. Based on this reference line, the first, second, and third parts were 37.56%, 39%, and 30.05%, respectively. The STA was originated from 25.11%. The TAA and LTA were 42.67% and 54.82%, respectively. The SSA, ACHA, and PCHA were 64.72%, 83.89%, and 84.53%, respectively. The origin of LTA was correlated with that of SSA (R = 0.473, P < 0.05) and AHCA (R = 0.307, P < 0.05), respectively. And there was a positive correlation between AHCA and PHCA (R = 0.705, P < 0.05). The number of branches ranged from 3~6, and 9 types were shown. The most frequent branching pattern was common origin of the LTA and SSA (22/59). And AHCA and PHCA were originated together in 19 cases, and both patterns were combined in 12 cases. TTA and LTA branched together in 9 cases, and common trunk for the SSA, PHCA, and AHCA was found in 2 cases. According to this pattern, the origin of LTA and PCHA was significantly different. This information is particularly useful for surgeons and clinicians.

Median nerve compression caused by superficial brachial artery: an unusual clinical case

An iatrogenic pseudoaneurysm of the radial artery and spontaneous venous malformation are associated with median nerve compression. However, the superficial brachial artery (SBA) has rarely been described as the cause of neurological deficits due to median nerve compression. A 61-year-old man was admitted to our clinic with a 1-year history of intermittent aching palsy in the left thumb that had progressed to the first three fingers. Clinical examination revealed mild sensory disturbance and hyperpathia in the first three fingers and weakness of the opponens pollicis. Ultrasound and magnetic resonance imaging confirmed that the SBA was compressing the median nerve by almost one-third. When anomalies of the SBA impinge on the median nerve, pulsatile pressure is applied to the nerve trunk. This may trigger ectopic stimulation of sensory fibers, leading to severe pain, sensory neuropathy, and motor disturbance. Considering the substantial difficulties and risks of a surgical operation as well as the patient’s wish to undergo conservative treatment, we performed muscle relaxation and acupuncture to relieve the pressure of the surrounding soft tissue and in turn decrease the impingement of the SBA on the median nerve. A satisfactory treatment effect was reached in this case.

Staged brachioradial artery to brachioradial vein arteriovenous fistula creation for hemodialysis access in three patients with a high origin of the radial artery

When patients lack suitable superficial veins in the upper extremity to create an arteriovenous fistula, surgeons are faced with a decision between a synthetic graft or autologous fistula using deep veins, such as a brachial artery to brachial vein arteriovenous fistula. In patients with a high radial artery origin (or brachioradial artery) and inadequate superficial veins, arteriovenous fistula creation will be even more challenging. In the present report, we describe a technique used in three such patients who underwent successful staged brachioradial artery to brachioradial vein arteriovenous fistula creation.

Anatomical variations and evolution: re-evaluating their importance for surgeons

For several decades, anatomists and biological anthropologists have made an intensive study in anatomical variations in ancestral and living humans. While many anatomical variants do not require clinical attention, some may present diagnostic problems or augur adverse symptoms. It is only in the last few decades that a plausible argument has been made that anatomical changes in human individuals and lineages demonstrate ongoing microevolution. Since the mid-19th century, there has been a reduction in differential mortality. Increased variation of heritable traits is a consequential outcome of relaxation of natural selection. Consequently, this has contributed to various anatomical variations in musculo-skeletal anatomy, vascular anatomy as well as congenital disorders such as spina bifida occulta. The authors argue that surgeons and anatomists should improve their knowledge of evolution and its continuing influence on human morphology. Simply repeating the old mantra that anatomical variations are important because knowledge of them minimizes surgical complications, albeit important, is inadequate.

Imaging primer for CT angiography in peripheral vascular trauma

The use of computed tomography angiography (CTA) for the evaluation of peripheral vascular trauma has become increasingly prevalent in the past decade with the development of multidetector CT (MDCT) and multiple studies subsequently demonstrating high sensitivity, specificity, and diagnostic accuracy when compared with conventional angiography. Additional benefits of MDCT include the ability to rapidly acquire the images, perform multiplanar and 3D reconstructions, and assess the adjacent soft tissues and bones. Rapid intravenous injection of iodinated contrast material is required for optimal arterial enhancement. CTA manifestations of an arterial injury may be direct, and include active contrast extravasation, pseudoaneurysm, arteriovenous fistula (AVF), intimal injury, dissection, or occlusion. There are also indirect signs which have a high association with vascular injury, and should raise suspicion, when present. Pitfalls related to image acquisition or patient factors can be mitigated with appropriate planning and post-processing techniques.

Arm reconstruction

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

Early Predictors of Arteriovenous Fistula Maturation: A Novel Perspective on an Enduring Problem

BACKGROUND

Preoperative ultrasound mapping is routinely used to select vessels meeting minimal threshold diameters for surgical arteriovenous fistula (AVF) creation but fails to improve AVF maturation rates. This suggests a need to reassess the preoperative ultrasound criteria used to optimize AVF maturation.

METHODS

We retrospectively identified 300 catheter-dependent patients on hemodialysis with a new AVF created between 2010 and 2016. We then evaluated the associations of preoperative vascular measurements and hemodynamic factors with unassisted AVF maturation (successful use for dialysis without prior intervention) and overall maturation (successful use with or without prior intervention). Multivariable logistic regression was used to identify preoperative factors associated with unassisted and overall AVF maturation.

RESULTS

Unassisted AVF maturation associated with preoperative arterial diameter (adjusted odds ratio [aOR], 1.50 per 1-mm increase; 95% confidence interval [95% CI], 1.23 to 1.83), preoperative systolic BP (aOR, 1.16 per 10-mm Hg increase; 95% CI, 1.05 to 1.28), and left ventricular ejection fraction (aOR, 1.07 per 5% increase; 95% CI, 1.01 to 1.13). Overall AVF maturation associated with preoperative arterial diameter (aOR, 1.36 per 1-mm increase; 95% CI, 1.10 to 1.66) and preoperative systolic BP (aOR, 1.17; 95% CI, 1.06 to 1.30). Using receiver operating curves, the combination of preoperative arterial diameter, systolic BP, and left ventricular ejection fraction was fairly predictive of unassisted maturation (area under the curve, 0.69). Patient age, sex, race, diabetes, vascular disease, obesity, and AVF location were not associated with maturation.

CONCLUSIONS

Preoperative arterial diameter may be an under-recognized predictor of AVF maturation. Further study evaluating the effect of preoperative arterial diameter and other hemodynamic factors on AVF maturation is needed.

The Superficial Venous System of the Forelimb of the Anubis Baboon (Papio anubis): The Distribution of Perforating Veins and Venous Valves

The superficial veins of the forelimb show high variability, both in man and in other primates, regarding the number of main venous trunks, their course, as well as the origin and location of openings. The distinction between two venous systems–the superficial and deep was made based on the relation of specific venous channels to the deep fascia; both groups of veins anastomose to each other through perforators piercing the deep fascia. In our work, we paid special attention to the organization of the venous system within the forelimb of the Anubis baboon (Papio anubis), as well as communications between the superficial and deep venous system. The main aim of the study was a detailed examination of the location of venous valves and perforating veins in forelimb of Anubis baboon. In the Anubis baboon, we observed the absence of the basilic vein. The main vessel within the forelimb, in the superficial venous system, was a well-developed cephalic vein. In all the cases, the cephalic vein opened into the external jugular vein. Also, in all of the examined specimens, there was an additional anastomosis connecting the cephalic and external jugular vein, i.e., persistent jugulocephalic vein located anterior to the clavicle. The venous vessels in the Anubis baboon were arranged in two main layers: superficial and deep, with both systems being connected by perforators located at the level of the carpus and cubital fossa. The number of venous valves within the cephalic vein was greater on the forearm the same as the mean intervalvular distance.

Variations in terminal branches of the popliteal artery: cadaveric study

INTRODUCTION

Identifying the branching pattern of the popliteal artery (PA) is a vital step in planning radiological and surgical procedures involving the anterior and posterior tibial and fibular arteries. The aim of this study was to characterize the course and morphology of the terminal branches of the PA.

MATERIALS AND METHODS

The anatomical variations in the branching patterns of the anterior and posterior tibial and fibular arteries were examined in 100 lower limbs fixed in a 10% formalin solution. A dissection of the popliteal region of the leg was carried out according to a pre-established protocol, using traditional techniques. Morphometric measurements were then obtained twice by two researchers.

RESULTS

In most cases (72%) the PA divides to form the anterior tibial artery (ATA) and a common junction for the posterior tibial and fibular arteries (type I), which further splits into the fibular artery and the posterior tibial artery (PTA). This type was subdivided into two subgroups according to whether the ATA (subgroup a) or the common junction of the posterior tibial and fibular arteries (subgroup b) had the larger diameter. Other identified variations included division of the PA into the ATA and PTA-8% (type II), trifurcation-12% (type III), the division of the PTA into the ATA and FA-8% (type IV), and aplasia of the PTA-8% (type IV).

CONCLUSION

Although the typical PA branching type was observed, it can be classified further into two additional sub-types based on the diameter of the ATA and the common junction of the posterior tibial and fibular arteries.

Anatomical Variations of the Pectoralis Major Muscle: Notes on Their Impact on Pectoral Nerve Innervation Patterns and Discussion on Their Clinical Relevance

BACKGROUND

The presented study attempts to classify individual anatomical variants of the pectoralis major muscle (PM), including rare and unusual findings. Rare cases of muscular anomalies involving the PM or its tendon have been presented. An attempt has also been made to determine whether anatomical variations of the PM may affect the innervation pattern of the lateral and medial pectoral nerves.

MATERIAL AND METHODS

The research was carried out on 40 cadavers of both sexes (22 males, 18 females), owing to which 80 PM specimens were examined.

RESULTS

Typical PM structure was observed in 63.75% of specimens. The most frequently observed variation was a separate clavicular portion of the PM. In one female cadaver (2.5% of specimens) the hypotrophy of the clavicular portion of the PM was noticed. In two male cadavers (5% of specimens) the fusion between the clavicular portion of the PM and the deltoid muscle was observed. In one of those cadavers, small sub-branches of the lateral pectoral nerve bilaterally joined the clavicular portion of the deltoid muscle. The detailed intramuscular distribution of certain nerve sub-branches was visualized by Sihler's stain. PM is mainly innervated by the lateral pectoral nerve. In all specimens stained by Sihler's technique, the contribution of the intercostal nerves in PM innervation was confirmed.

CONCLUSIONS

Surgeons should be aware of anatomic variations of the PM both in planning and in conducting surgeries of the pectoral region.

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.

Persistent Median Artery as an Unusual Finding in the Carpal Tunnel: Its Contribution to the Blood Supply of the Hand and Clinical Significance

BACKGROUND Knowledge of the variable relation of the persistent median artery (PMA) to the median nerve and its contribution to the formation of the superficial palmar arch is of great clinical significance. This study presents a proposal of specific variables which might be introduced to characterize the PMA in the wrist region. MATERIAL AND METHODS One hundred and twenty-five randomly selected, isolated upper limbs fixed in 10% formalin solution were subjected to anatomical dissection. RESULTS Of the 125 upper limbs, PMA was found in 5 specimens (4% of the total number of limbs). In the carpal tunnel, the artery occupied the anterolateral position (2 cases), the anterior position (2 cases) or the anteromedial position (1 case) in relation to the median nerve. Two types of superficial palmar arches with significant contributions from the PMA were observed in the studied material: complete medio-ulnar arch and an incomplete arch without a connection between the territories of the ulnar and median arteries. The mean ratio of the diameter of the PMA to the diameter of ulnar artery at the level of the wrist was 0.59 (min.=0.38, max=0.83, SD=0.19). CONCLUSIONS Orthopedic and hand surgeons should be aware of the probability of occurrence of the PMA in both planning and conducting surgeries within the wrist region and within the carpal tunnel, as this anomalous vessel might present significant contributions to the arterial blood supply of the hand and might potentially play an important role in the presence of notable clinical symptoms and presentations.

Anatomy of the Cun Position at Wrist and Its Application in Pulse Diagnosis

Information on anatomy of the Cun position at wrist is lacking; whether the blood vessel taking pulse in Cun is the radial artery or the superficial palmar branch is also clinically controversial. The objective was to investigate the boundaries and contents, and the vascular distribution and their pulse points in Cun. Thirty-two upper extremities of 16 human cadavers were investigated for dissection and observation. The boundaries, contents, and blood vessel distribution in Cun were observed; the location of pulse points in Cun was identified; the length of the superficial palmar branch in wrist pulse (L1), the pulp width of the index finger (L2), and the angle between the radial artery and the superficial palmar branch were measured. The results showed that the Cun was located in the region formed by the bulge of the prominent bone proximal to the palm, the radial flexor tendon, the tubercle of scaphoid, and the abductor longus muscle tendon. In this area, the radial artery could be pulsed part in the medial side of the abductor longus muscle tendon, while the superficial palmar branch lied near the surface and was easy to pulse in the lateral side of the radial flexor tendon and the medial side of the tubercle of scaphoid. The ratio of L1 to L2 was 1.2±0.8, and the angle was 23.3±9.9°. The results suggested that it could not be generalized that the blood vessel taking pulse in Cun was the radial artery or the superficial palmar branch; it might depend on the vascular distribution in Cun, the region of finger positioning, and the patient's pulse condition.