A Study of Brachial Artery, Its Branching Pattern and Variations with Clinical Applications

Home , Brachial artery, Radial collateral artery

Dissertation on

A STUDY OF BRACHIAL ARTERY, ITS BRANCHING PATTERN AND VARIATIONS WITH CLINICAL APPLICATIONS

Submitted in partial fulfillment for

M.D. DEGREE EXAMINATION BRANCH- XXIII, ANATOMY

Upgraded Institute of Anatomy Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai - 600 003

THE TAMILNADU Dr.M.G.R. MEDICAL UNIVERSITY CHENNAI – 600 032 TAMILNADU

OCTOBER 2017

CERTIFICATE

This is to certify that this dissertation entitled

“A STUDY OF BRACHIAL ARTERY, ITS BRANCHING PATTERN AND VARIATIONS WITH CLINICAL APPLICATIONS” is a bonafide record of the research work done by Dr.GOHILA.G, Post graduate student in the Institute of Anatomy, Madras Medical College and

Rajiv Gandhi Government General Hospital, Chennai-03, in partial fulfillment of the regulations laid down by The Tamil Nadu Dr.M.G.R. Medical

University for the award of M.D. Degree Branch XXIII-Anatomy, under my guidance and supervision during the academic year from 2014-2017.

The Dean, Dr. Sudha Seshayyan, Madras Medical College, M.B.B.S,M.S, Rajiv Gandhi Govt.General Hospital, Director & Professor, Chennai- 600003. Institute of Anatomy, Madras Medical College, Chennai – 600003.

ACKNOWLEDGEMENT

I wish to express exquisite thankfulness and gratitude to my most respected teachers, guide Dr.Sudha Seshayyan, Director and Professor, Institute of Anatomy, Madras Medical College, Chennai – 3, for their invaluable guidance, persistent support and quest for perfection which has made this dissertation take its present shape.

I am thankful to Dr. K. Narayanasamy, M.D., D.M., Dean, Madras Medical College, Chennai – 3 for permitting me to avail the facilities in this college for performing this study.

My heartfelt thanks to, Dr.B.Chezhian, Dr.V.Lokanayaki and Dr.B.Santhi, Associate Professors, Dr.V.Lakshmi, Dr.T.Anitha, Dr.P.Kanagavalli, Dr.J.Sreevidya, Dr.Elamathi Bose, Dr.S.Arrchana, Dr.B.J.Bhuvaneshwari, Dr.Mohanapriya Assistant Professors, Institute of Anatomy, Madras Medical College, Chennai – 3 for their valuable suggestions and encouragement throughout the study.

I earnestly thank my seniors, Dr.S.Keerthi, Dr.P.R Prefulla and Dr.N.V. Ganga who have been supportive and encouraging throughout the study.

I extend my thanks to my colleagues Dr.V.Srinivasan, Dr.S.Saravanan, and Dr.K.Suganya for their constant encouragement and unstinted co-operation.

I am especially thankful to Mr.R.A.C.Mathews and Mr. E.Senthilkumar, technicians, who extended great support for this study and all other staff members including Mr.Jagadeesan, Mr.Maneesh Mr.Narasimhalu and Mr. Devaraj for helping me to carry out the study.

I thank my parents, Mrs.K.Dhanalakshmi and Mr.K.Ganesan, and My Sister Mrs.G.Bhuvaneswari and My Brother in law Mr.P.T.Vijaya rajakumar who have showered their choicest blessings on me and supported me in my every step.

I am grateful beyond words to my Husband Dr.A.Karthikeswaran and My children K.Rithvik Eshwar and K.Rithanya who in all possible ways supported me in making this study a reality.

Above all, I thank the Almighty, who has showered his blessings on me and helped me complete this study successfully.

LEGEND

AA - Axillary Artery

ABA - Accessory Brachial Artery

BA - Brachial Artery

CT - Common Trunk

DBA - Deep Brachial Artery

HRA - High origin of Radial Artery

HUA - High origin of Ulnar Artery

ICL - InterCondylar Line

IUCA - Inferior Ulnar Collateral Artery

MN - Median Nerve

NA - Nutrient Artery

PBA - Profunda Brachi Artery

PCHA - Posterior Circumflex Humeral Artery

SBA - Superficial Brachial Artery

SRA - Superficial Radial Artery

SUCA - Superior Ulnar Collateral Artery

SUA - Superficial Ulnar Artery

CONTENTS

SL.NO TITLE PAGE NO

1. INTRODUCTION 1

2. AIM OF THE STUDY 9

3. REVIEW OF LITERATURE 12

4. EMBRYOLOGY 40

5. MATERIALS AND METHODS 42

6. OBSERVATION 45

7. DISCUSSION 59

8. CONCLUSION 78

9. BIBLIOGRAPHY 81

Introduction

INTRODUCTION

Anatomical knowledge about the branches of Brachial artery and variations in the branching pattern is important for surgeons, physicians, radiologists and interventionists since new diagnostic and therapeutic approaches can be proposed based on anatomical studies.

Brachial artery begins as the continuation of the axillary artery at the distal border of the teres major muscle. At first it is medial to the humerus, but gradually spirals anterior to it until it lies midway between the humeral epicondyles. It ends about a centimeter distal to the elbow joint at the level of neck of radius by dividing into radial and ulnar arteries87.

Relations of Brachial artery

The Brachial artery is wholly superficial, covered by skin, superficial and deep fasciae. Anteriorly, the bicipital apooneurosis crosses it at the elbow, separating it from the median cubital vein. The median nerve crosses in front of the artery from lateral to medial side near the distal attachment of coracobrachialis ( middle of the arm).

Posteriorly, the long head of triceps, separated by the radial nerve and profunda brachii artery, the medial head of triceps, the attachment of coracobrachialis and brachialis are related to the Brachial artery.

Laterally, in the proximal part of the arm, the median nerve and coracobrachialis while in the distal part of the arm, the biceps and the muscles overlap the artery.

Medially in the proximal part of arm, the median cutaneous nerve of the forearm and ulnar nerve are related while in the distal part, the median nerve and basilic vein. With the artery two venae commitantes , connected by transverse and oblique intercommunications. At the elbow the Brachial artery deeply descends in the triangular cubital fossa87.

Branches of Brachial artery-

1. Profunda brachii artery is a large branch from the posteromedial aspect of

the brachial artery, distal to teres major. It follows the radial nerve closely,

at first it lies posteriorly between the long and medial heads of triceps , then

in the spiral groove covered by the lateral head of triceps. It supplies

muscular branches, the nutrient artery of humerus and finally divides into

terminal radial collateral and middle collateral branches.

 Middle collateral artery ( Posterior descending branch) is a large terminal

branch from profunda brachii artery. It arises posterior to the humerus

and descends down the posterior surface of the lateral intermuscular

septum to the elbow. Proximally the artery lies between brachialis

(anteriorly) and the lateral head of triceps (posteriorly) while distally it

lies between the brachioradialis (anteriorly) and lateral head of triceps

( posteriorly). It may pierce the deep fascia and become cutaneous or

remain deep to the fascia until anastomosing with the interroseus

recurrent branch of posterior interroseus artery behind the lateral

epicondyle. It gives off about five fasciocutaneous perforators and

sometimes a small branch that accompanies the nerve to anconeus.

 Radial collateral artery ( anterior descending branch ) is the continuation

of profunda brachii artery. It accompanies radial nerve through lateral

intermuscular septum, descending between the brachialis and

brachioradialis anterior to the lateral epicondyle, anastomosing with

the radial recurrent branch of radial artery. It supplies the brachialis,

brachioradialis, the radial nerve and few fasciocutaneous perforators.

2. Nutrient artery to the humerus arises near the middle of the arm and

enters the nutrient foramen of the humerus. It is directed distally near the

attachment of the coracobrachialis, posterior to the deltoid tuberosity.

3. Superior ulnar collateral artery arises a little distal to the middle of the arm,

usually from the brachial artery, but often as a branch of profunda brachii

artery. It accompanies the ulnar nerve, piercing the medial intermuscular septum

to descend in the posterior compartment and supply the medial head of

triceps. It passes between the medial epicondyle and olecranon and ends by

anastomosing with the posterior ulnar recurrent branch of ulnar artery and

inferior ulnar collateral branch of brachial artery. A branch sometimes passes

anterior to the medial epicondyle and anastomoses with the anterior ulnar

recurrent branch of ulnar artery.

4. Middle ulnar collateral artery ( if present) arises from the Brachial artery

between the superior and inferior ulnar collateral branches. It passes anterior to

the medial epicondyle and anastomoses with the anterior ulnar recurrent

artery. It supplies triceps and sends small fasciocutaneous perforators to the skin.

5. Inferior ulnar collateral ( supratrochlear) artery arises approximately 5cm

proximal to the elbow, passes medially between the median nerve and

brachialis and piercing the medial intermuscular septum,curls around the

humerus between the triceps and the bone. It forms an arch by its junction

with the middle collateral branch of the profunda brachii artery, proximal to

the olecranon fossa. As it lies on brachialis it gives off branches which

descend anterior to the medial epicondyle to anastamose with the anterior

ulnar recurrent artery. Behind the epicondyle a branch anastomoses with the

superior ulnar collateral and posterior ulnar recurrent arteries.

6. Muscular branches are distributed to the coracobrachialis, brachialis and

biceps brachii.

7. Deltoid (ascending branch) ascends between the lateral and long head of

triceps, and anastomoses with a descending branch of the posterior

circumflex humeral artery.

8. Terminal branches ( radial and ulnar arteries)

Radial artery starts 1cm distal to the flexor crease of the elbow as a small

terminal branch in the cubital fossa at the level of neck of radius.

Ulnar artery is the largest terminal branch of brachial artery. It starts 1cm

distal to the flexor crease of the elbow at the level of the neck of the radius

and reaches the medial side of forearm between the elbow and wrist56,87.

ORIGIN, COURSE, AND BRANCHES OF BRACHIAL ARTERY IN THE ARM

In the cubital fossa, from medial to lateral side,

 Median Nerve

 Brachial Artery

 Tendon of biceps brachii and bicipital aponeurosis

 Radial nerve

Brachial veins

Two venae comitantes of the Brachial Artery accompany the artery throughout its course. They are connected by horizontal and oblique intercommunications. Near the lower margin of subscapularis they join the basilic vein and form axillary vein.The brachial veins are the deep veins of the arm and have numerous communications with the superficial venous system subserved by cephalic and basilic veins.

Median nerve in relation to Brachial Artery in the Arm

Median nerve is formed by the union of the lateral and medial roots which arise from the corresponding cords of brachial plexus. It lies lateral to the axillary artery and enters the arm lateral to the Brachial artery. Near the insertion of coracobrachialis it crosses in front of (rarely behind ) the artery. In the cubital fossa the median nerve lies medial to the brachial artery, posterior to the bicipital aponeurosis and anterior to Brachialis separated from the latter by elbow joint.

It gives off vascular branches to the brachial artery and usually a branch to pronator teres, a variable distance proximal to the elbow joint87.

RELATION OF BRACHIAL ARTERY WITH MEDIAN NERVE IN THE CUBITAL FOSSA

Aim of the Study

AIM OF THE STUDY

Vascular anatomy of the upper limb, especially the variations in origin, course and branching pattern have much importance anatomically and clinically.

These variations have drawn the attention of surgeons, physicians, radiologists and interventionists due to the advanced surgical procedures practiced in vascular surgery, plastic reconstructive surgeries and also for diagnostic and therapeutic purposes.

Brachial Artery is commonly used for determining the blood pressure by applying sphygmomanometer cuff in the arm. Brachial artery in the cubital fossa is a convenient site for collection of arterial blood samples.

Awareness of variations of Brachial artery and its branches is important to avoid serious complications while treating the cases of arteriovenous fistulae, aneurysms, abscess drainage in the region of axilla , arm or cubital fossa. Accidental crush injuries around the elbow may lead to torrential hemorrhage if brachial artery is involved.

Superficial Brachial Artery passes superficially in the arm, it is at high risk of trauma and it can be mistaken for a vein and may result in erroneous administration of drugs which lead to gangrene and other complications. It can be avoided by careful palpation of the vessel before administration of any drug.

Brachial artery is used in diagnostic angiography, cardiac catheterization for angioplasty, carotid stenting , transbrachial access for endovascular renal artery stenting, embolectomy through arteriotomy. The Brachial Artery catheterization is gaining popularity because of early ambulation.

In congenital, metabolic and regenerative diseases the study of basic anatomy is important in understanding the circulation of blood flow to improve the operative outcome.

Variations in the arterial tree may be encountered during arteriographic examination, percutaneous brachial catheterization and skin flap elevation from the arm or forearm.

The fasciocutaneous branches of the Brachial Artery and Radial Artery provide the anatomical basis for skin flap. The flap can be either used as a free flap or pedicle flap based on the artery and its venae commitantes.

Knowledge about the profunda brachii artery is essential for orthopaedicians and vascular surgeons during treatment of fracture of humerus.

Superficial brachial artery and Superficial radial artery have been encountered during the lateral arm and forearm flaps.

The superficial course of radial artery with high origin in arm is more susceptible to accidental injury and may be mistaken for a vein during intravenous injections.

As the Brachial artery and its branches have wide clinical applications, it is essential to know the normal course and branching pattern of Brachial artery and variations if present any , before proceeding with any diagnostic and interventional procedures.

PARAMETERS

1. Length of the Brachial Artery (BA) (from its origin to termination)

2. Course of the Brachial Artery (BA) ( normal/ superficial )

3. Level of termination in relation to Intercondylar line (ICL)

4. Variations in the branching pattern

a) Profunda Brachii Artery (PBA)

b) Nutrient Artery to humerus (NA)

c) Superior Ulnar Collateral Artery (SUCA)

d) Inferior Ulnar Collateral Artery (IUCA)

e) Terminal branches – Radial & Ulnar artery

High origin of Radial Artery (HRA)

High origin of Ulnar Artery (HUA)

5. Incidence of trifurcation of Brachial artery (BA)

6. Relation of median nerve (MN) to Brachial Artery

Review of Literature

REVIEW OF LITERATURE

1.LENGTH OF BRACHIAL ARTERY (FROM ITS ORIGIN TO

TERMINATION)

Patnaik V.V.G et al55 (2002) in his morphological study on branching pattern of BA in 25 cadavers , observed the mean length of BA was 26.29cm.

Suresh bidarkotimath et al 86 ( 2011) in his study on BA, observed the mean length of BA was 22.65cm.

Shuba R et al79 (2013) in her study on variations in the termination of BA in

95 cadaveric upperlimbs, observed the mean length of BA was 30.82cm.

Chaunhan et al14 (2013) in his study on morphology and branching pattern of BA in 100 upperlimbs of 50 cadavers, observed the mean length of the artery was

24.56cm.

Sunil pundge et al85 (2014) dissected 100 upperlimbs from 50 adult embalmed cadavers,reported that the mean length of the BA was 27.5cm.

Sathialakshmi et al70 (2014) in her study on variations in the branching pattern of BA, observed the mean length of the artery was 21.5cm.

2. COURSE OF BRACHIAL ARTERY ( NORMAL/ SUPERFICIAL)

Quains 62 (1844) dissected 506 cadaveric upperlimbs and reported 0.2% prevalence of Superficial Brachial Artery (SBA), presence of anastamotic vessel in the antecubital fossa in 2.5% and presence of Superficial Ulnar Artery (SUA) in

1.7%.

Gruber25 (1948) dissected 1200 cadaveric upperlimbs in his routine dissection and observed 8.6% of variations of BA, he reported 0.4% of SBA and 0.5% anastamotic vessel in the antecubital fossa.

Poirier 57 (1886) has described in his textbook of anatomy , in 100 dissections he observed SBA in 6% of cases. In 6 limbs BA crossed superficial to the MN. HUA was observed in 20 times in 440 dissection.

Muller48 (1903) dissected 100 upperlimbs found that 14% of variations in BA. 1% incidence of SBA , 2% incidence of SUA and 6% of anastamotic vessel in the antecubital fossa.

Hofer & Hofer 29 (1910) reported that BA passed between the two heads of pronator teres, not dividing above the level. There is no similar type of course of BA in literature.

Linell et al42 ( 1921) dissected 34 upperlimbs 6% Prevalance of SBA, BA runs superficial to the MN.

Degaris & swartley et al 17 (1928) dissected 512 cadaveric upperlimbs, observed

23 different patterns of AA and reported that 9% incidence of SBA that is the BA runs superficial to the MN.

Beuntaro Adachi et al2 (1928) a Japanese anatomist described that BA normally run deep to the MN. When a large arterial trunk runs superficial to the nerve, this is the "arteria brachialis superficialis". It may replace the main trunk, or it may be accompanied by an equally important, less important, or more important trunk running parallel and deep to the MN in the normal position. In these cases the superficially placed vessel may continue as the RA or more rarely as the Ulnar

Artery (UA). He further subdivided the "arteria brachial superficialis into superior, medial and inferior according to its point of origin for the main arterial trunk. The point of origin may be from the AA,most frequently it is from the upper part of the

BA, but SBA may also arise from the lower part of the BA nearer the elbow.

Huber30 (1930) described that sometimes the BA accompanies MN behind the supracondylar process of humerus from which a fibrous arch is thrown over the artery.

Piersol56 (1936) he wriiten in his text book of anatomy, variations in the BA are numerous and important, in that they affect the origin of radial and ulnar arteries. In a well developed supracondylar process the BA accompanies MN behind it. In such cases they arise from the upper part of BA or Axillary Artery (AA).This has been

14 termed as vas aberrans. a vessel which descends upon the anterior surface of the arm, lying superficially and sending branch. brachialis superficialis, or the radialis superficialis, and it appears to be normally present, but much reduced in size and included among the muscular branches to the biceps and brachialis muscles.

Singer 80 (1933) described that the HRA as a kind of persistent SBA.

Schwyzer & Degaris et al 71 (1935) found 2 cases of SBA dividing into RA and

UA at the level of cubital fossa ,then the UA runs superficial to the flexors of forearm in one case and in another case it runs superficial to all flexors except palmaris longus. This type of UA is called as arteria antebrachi superficialis ulnaris.

Miller46 (1939) dissected 480 cadavers, reported that 3% incidence of SBA, the

BA runs superficial to the MN.

Treves & Rogers et al91 (1947) said that the presence of 2 arteries instead of one artery, these 2 arteries may be 1) Radial Artery (RA) & Ulnar Artery (UA) 2) 2nd branch may be interosseus 3) the 2 vessels may be normal brachial and vas aberrans.

Thorek et al 90 (1951) described that the BA gives 3 branches ( PBA, SUCA,

IUCA). He named SUCA as inferior profunda.

Lawrence J.McCormack et al 45 (1953) in his series of 750 cadaveric upperlimb dissection reported variations in origin and course of BA. He observed a rare entity i.e. Accessory Brachial Artery (ABA) which emerge from the BA 21cm proximal to

15 the intercondylar line. In its course it is wholly medial to the main BA, midway in the arm it passed deep to the MN and 4cm proximal to it termination crossed backover the MN, it rejoined the BA in the antecubital fossa 23cm beyond its origin.

W.Henry Hollinshed28 (1958) written in his book Anatomy for surgeons volume

III said that BA as the continuation of AA , at the level of lower border of teres major muscle.

Skopakoff et al81 (1959) dissected 610 dissections reported that 19.7% incidence of

SBA. He described that the smaller branches of the BA which run superficial to the

MN and resolved themselves into muscular branches without a downward continuation.

J.A.Keen et al32(1961) dissected 284 upperlimbs in his routine dissection observed that 12.3% of SBA. He further divides BA into 3 types

1) 3.6% SBA continue in the cubital fossa and terminates into RA and UA.

2) 5.9% SBA continues as RA and known as HRA.

3) 2.8% SBA continue as UA and known as HUA.

Romanes65 (1964) said that the BA accompanies MN sometimes behind the supracondylar process of humerus from which a fibrous arch is thrown over the artery. This condition similar to normal condition in carnivores.

Anson4 (1966) in his routine series of dissection, observed that SBA arises from the

AA or from the proximal one third of BA between the medial and lateral cords of brachial plexus to the MN. It is superficial to the muscles of arm under brachial fascia lying more lateral than the BA and divides in to RA and UA at the elbow.

Vare and Bansal et al94 (1969) observed that high division of BA and the SBA divides into RA and UA. The deep division continuing in the forearm as interosseous complex and giving a large median artery forming the superficial palmar arch with

UA.

Lippert and Pabst et al 43 (1985) observed that 22% of incidence of SBA and the

HRA is the persistent SBA.

Fuss et al 22 (1985) observed that 17% incidence of SBA in his study.

Jurjus A, Sfeir R, Bezirdjian R et al34 (1986) observed that an anomalous BA , after giving PBA with no collaterals, terminates in the upper one third of arm into two arteries BA 1 & 2. BA one is high origin and persisting as RA. BA 2 is a high origin of common interosseus.

Lengele B, Dhem.A. et al 40 (1989) reported in his routine dissection that the unilateral existence of SBA

J.C.Boileau Grant24 (1989) he written in his book A Method of anatomy descriptive and deductive that the BA is the largest artery whose walls can be felt

17 satisfactorily in the living subject. It can be palpated along the medial bicipital furrow throughout the length of the arm to the point where it disappears behind the bicipital aponeurosis. It divides into two terminal branches the large UA and smaller

RA at the level of neck of radius 1cm below the elbow joint.

Baeza et al 6 (1995) observed in his study ,SBA was found in 11.95%.

Natkatani T, Tanaka S, Mizukami.S. et al49 (1996) Dissected 69 year old Japanese cadaver, observed the anomalies of the bilateral SBA. The right and left SBA were found to originate from the AA, run over the lateral root of the MN, course laterally and superficially to the MN, and terminates by dividing into the RA and UA in the cubital fossa. The right BA terminates in the posterior aspect of the elbow. The left

BA terminates in the anastomosis with the UA at the site opposite to the origin of the common interosseous artery.

William et al99 (1999) said that the BA, as the continuation of the AA from the distal border of the tendon of teres major and ends about a centimeter distal to the elbow joint (at the level of the neck of the radius) by dividing into RA and UA. At first it is medial to the humerus, but gradually spirals anterior to it until it lies midway between the humeral epicondyles. Its pulsation can be felt throughout.

They also said the NA of the humerus arises near the mid-level of the upper arm, and enters the nutrient canal near the attachment of coracobrachialis.

Kapur et al35 (2000) observed 5% incidence of SBA in his study.

Rodriguez-Baeza A. et al 64 (2000) observed 23 cases with variations in the brachio- antebrachial arterial pattern of the human upper limb are reported. According to them the BA showed, 4 groups of variation; a) Isolated persistence of the median artery; b) High origin of the ulnar artery (HUA); c) High origin of the radial artery (HRA); and d) Duplication of the BA, either with or without anastomosis at the cubital fossa.

Patnaik. V.V.G et al55 (2002) Dissected 50 upperlimbs from 25 embalmed cadavers observed that 6% of BA run superficial to the MN( SBA).

Susan standring87 (2008) “ text book of grays anatomy” described that the BA is the continuation of AA at the inferior border of teres major muscle and ends about

1cm distal to the elbow joint at the level of neck of radius.

Hee jun-young et al27 (2008) observed that 37 superficial BA emerging from the

AA in 304 korean arms,. Unilateral occurrence was observed in 16 cadavers and bilateral occurrence in 10 cadavers.the SBA had a tendency to occur more in right side but the difference had no statistical significance.

Sharma T et al75 (2009) dissected a 50 year old female cadaver reported that SBA, it runs superficial to the lateral root of MN and descended in the cubital fossa lying lateral to the MN in the arm.

Bojana et al10 (2010) during her routine dissection noticed double BA in single limb.

One is the SBA runs superficial to the MN another one is BA which is smaller deeply and medially.

David kachlik et al 16 (2011) dissected 130 cadaveric upperlimbs ,reported that 5% incidence of SBA In his study.

Rajan kumar singla et al63 (2011) reported in a 60 year old male cadaver that the

BA running superficial to the MN in the middle of the arm from medial to lateral side as SBA.

Vatsala AR et al95 (2013) dissected 54 upperlimbs reported that 1.9% of specimens showed SBA that runs infront of the MN.

Kosuri kalyan chakravarthi et al 37 (2014) dissected 140 upper limb specimens of

70 embalmed cadavers , reported that 11.43% of ABA was noted in 8 female cadavers, out of 8 cadavers 4.29% an unusual bilateral accessory BA arising from the AA and it is continuing in the forearm as superficial accessory ulnar artery.

7.14% of unilateral accessory BA and its reunion with the main BA in the cubital fossa.

Sathialakshmi et al 70 (2014) dissected 40 upperlimbs from 20 adult cadavers, reported that the SBA, the BA running superficial to the MN in one specimen 5%.

3.LEVEL OF TERMINATION IN RELATION TO INTERCONDYLAR LINE

J.E.Frazer, University of London21 (1937) written in his Manual of anatomy, the

BA may divide at higher level than usual, in many of the cases the abnormal early branch is RA .rarely UA, and in these cases the interosseus trunk arise from the RA, more rarely the premature branch is a interosseus trunk or a vas aberrans. The level of division of BA most frequently in the upper 1/3rd of arm, less frequently in the lower1/3rd and very rarely in middle 1/3rd. If there is presence of vas aberrans, it usually arises from the upper part of BA, lies infront of the MN, and ends below by joining, most commonly the RA. In rare cases the BA divides high up into two vessels of equal size, which become reunited into one trunk a little above the elbow.

J.A.Keen 32 (1961) observed 5-9% of the BA dividing above the InterCondylarLine

(ICL).

Anson (1966) reported 15% of high division of BA.

Karrlson & Niechajev36 (1982) in his angiographic observations, reported that 10%

Of High division of BA.

Bilodi AK et al 9 (2004) observed variation in termination of BA into RA, UA and common interroseus artery in left upperlimb and RA and UA in right upperlimb , the common interroseus artery arise from RA.

Vandana Mehta et al93 (2008) reported a case with high division of BA , divides in to RA and UA 9.8cm proximal to the neck of the radius.

Namani satyanarayana et al 50 (2010) dissected a 40 year old male cadaver noted that an unusually short segment of BA with high up division of BA at the level of insertion of coracobrachialis in the middle of the right arm. The short segment of

BA was 11.5cm in length.

Harbans singh et al 26 (2010) reported that bilateral symmetrical higher division of

BA into RA and UA about 7.5cm above the line joining the two humeral epicondyles

(ICL).

Rossi junior et al66 (2011) dissected 56 cadavers, in a male cadaver high division of BA was noted. In the right arm , 20cm above the cubital fossa and 8.5cm below the axilla. In the left arm it is 21.5cm above the cubital fossa 7cm below the axilla.

Suresh bidarkotimath et al 86 (2011) dissected 50 cadavers,he observed that the BA divides at the level of middle of the arm into RA and UA.

Priya G et al60 (2012) dissected 10 cadavers, reported that high division of BA in two cadavers. The BA divides in to RA and UA just below the origin of PBA.

Sainu susan et al69 (2012) dissected a 80 year old male cadaver observed that the

BA divide 21.5cm above the neck of radius at the level of insertion of coracobrachialis.

Shewale SN et al 76 (2012) in his routine dissection observed a 50 year old male cadaver high division of BA into RA and UA at the level of lower border of teres major.

K.Smitha Elizabeth82 (2013) observed a case the BA divides just below the level of lower border of teres major tendon into RA and UA.

Jayasabarinathan et al33 (2013) reported that the level of termination of BA in the left upperlimb of 70 years old male cadaver in routine dissection. The BA divides beow the level of lower border of teres major at the junction of upper 1/3rd and lower

2/3rd of the arm into RA and UA.

Padma varlekar et al 54 (2013) dissected 96 upperlimbs,reported 3 specimens showed high division of BA with SRA.the variant was present unilaterally in the left upperlimb of three males(6.25%).

Sharadkumar pralhad sawant et al 74 (2013) dissected 90 male and 10 female cadavers high level of division was observed in 54 specimens . Among these 6 specimens at the level of axilla, 12 specimens in the upper arm, 8 specimens in the middle of the arm and 22 specimens in the lower part of the arm above the cubital fossa.

Shuba R et al 79 (2013) dissected 95 upperlimbs observed that 2% of BA bifurcates at the level of ICL.

Chandrika teli et al 18 (2013) dissected a 45 year old male cadaver, observed the

BA terminates into RA and UA about 1.5cm distal to the lower border of teres major muscle in the upper third of arm.

Pokhrel R et al58 (2013) reported a case of high division of BA at the level of insertion of coracobrachialis and in the lateral side it continued as brachio radial artery and gives PBA, SUCA, IUCA after the bifurcation.

Sugna choudhary et al84 (2014) dissected 60 year old male cadaver ,reported that high division of BA into RA and UA at the level of upper arm where the lateral root and medial root of the MN unite to form the MN.

Subhash M Gujar et al83 (2014) dissected 30 upperlimb specimens reported that

6% of upperlimb showed high division of BA ino RA and UA at the level of middle third of arm.

Sunil pundge et al 85 (2014) dissected 100 upperlimbs observed that 4% of specimens showed high division of BA into RA and UA above the level of intercondylar line.2% of specimens showed at the level of union of medial and lateral root of MN.

Sathialakshmi et al70 (2014) in her study on 40 upperlimbs from 20 cadavers reported that 5% of specimens the division was above the ICL and 5% was at the level of intercondylar line.

Fatemah fadai fathabadi et al20 (2014) observed that the BA bifurcated in the proximal part of middle 1/3 of the arm in right upperlimb of a male cadaver during his routine dissection.

Selda yieldiz et al 72 (2014) dissected left upperlimb of 38weeks old female fetus cadaver observed that the high division of BA 5cm above the ICL.

Uma shivanal et al92 (2015) dissected 50 upperlimbs, reported that 2% of specimens showed high division of the BA in the proximal third of the arm.

4.VARIATIONS IN BRANCHING PATTERN a) Profunda brachi artery ( Deep Brachial Artery)

Charles et al13 (1931) described 7 types of origins of PBA (Deep Brachial Artery)

T.M – Teres Major D.B – Deep Brachial Artery (PBA) A – Axillary Artery

B – Brachial Artery S.U.C – Superior Ulnar collateral Artery

A.H.C – Anterior Circumflex humeral Artery P.H.C – Posterior circumflex humeral artery

TYPE I : Branch from BA in 54.7%

TYPE Ia : 2 Separate branches 0.7% from BA

TYPE Ib : 3 Separate branches 0.3% from BA

TYPE II : Common Trunk (CT) with SUCA in 22.3% from BA.

TYPE III : Arising at the lower border of teres major either AA or BA 8.7%

TYPE IV : From 3rd part of AA

TYPE V : CT With Posterior Circumflex Humeral Artery (PCHA).

TYPE VI : Arose as a CT with subscapular and both PCHA from AA In 0.7%

TYPE VII : Absent PBA in 0.7% .

J.A.Keen et al 32 (1961) observed in his dissection, 61% of PBA arose from BA. In

13% of specimens arose from a CT with SUCA. In 26% of specimens the PBA arose from AA.

Anson 4 (1966) reported 55% of PBA arose from the BA.22% arose from a CT with

SUCA. 7% of PBA arose from PCHA. 16% arose from AA.

Patnaik VVG et al 55 (2002) dissected 50 upperlimbs from 25 cadavers ,observed that the PBA has separate origin of anterior and posterior descending branches 4%,

CT with SUCA in 2%, arising from 3rd part of AA in CT with subscapular and

PCHA in 2% in his study.

David hacklic et al16 (2011) dissected 130 upperlimbs, reported that the PBA arise from AA .the AA trifurcates into SBA, PBA, subscapular artery.

Rajan kumar singla et al 63 (2011) dissected a 60 year old male cadaver observed that the PBA originates from the third part of the AA and entered the radial groove along with the radial nerve.

Suresh bidarkotimath et al86(2011) dissected 100 upperlimbs from 50 cadavers, observed that in a male 57 years aged cadaver the PBA , originated from the 3rd part of the AA.and continued downwards between the medial and lateral roots of MN.

Annie pulei et al 3( 2012) dissected 144 upperlimbs from 72 cadavers reported that

1.7% arises from a CT with SUCA and 1.4% from AA and 96.9% arise from BA.

Chandrika teli et al18 ( 2013) has reported that PBA arose from a CT with the

SUCA in the proximal part of BA.

Vatsala AR et al95 (2013) dissected 54 upperlimbs observed that the PBA showed variant origin of 46.3 % .out of these 29.6% arose from CT, 9.3% from Deep

27 brachial artery, 3.7% from brachio radial artery, 1.9% from 3rd part of AA, 1.9% 2

PBA arose from deep brachial artery.

Chaunhan et al 14 (2013) dissected 100 upperlimbs from 50cadavers , observed that the PBA arise from

TYPE I : Three separate branch from BA in 64%,

TYPE II : Two separate branch from BA in 1%,

TYPE III :CT with SUCA in 19%, 3rd part of AA in 4% ,

TYPE IV :CT with PCHA in 2%.

Sathialakshmi et al70 (2014) reported in her study on 40 upperlimbs ,the PBA arose from BA in 87.5%, CT with SUCA in 5%, arose from PCHA in 2.5%, AA in 2.5%.

Pratima baisakh et al59 (2015) observed that the PBA originate from a CT with NA and SUCA from the BA 11cm from the coracoid process.

Uma shivanal et al 92 (2015) studied the variations in BA and its branching pattern, reported 2% of specimen showed PBA

b) Nutrient artery to the humerus

Quains62 (1844) described that the Nutrient artery arose from the BA at the midlevel of the upper arm.

Poirier57 (1886) found that the NA enterted the Nutrient canal of the humerus at the level of insertion of coracobrachialis muscle.

Piersol56 (1936 ) reported that NA arises from BA and enters the nutrient foramen on its medial surface.

Frazer21 (1937) stated that the NA entered the nutrient foramen near the lower border of insertion of coracobrachialis muscle.

Russel T Woodburne68 (1961) described that the NA arises about the middle of the arm and enters the nutrient canal on the anteromedial surface of the humerus.

C.J.Romanes65 (1964) described that the NA a branch of the BA entered the nutrient canal on the medial surface of humerus.

J.C.B.Grant24(1989) stated that the NA arises from the middle of BA and entered the nutrient foramen on the anteromedial surface of the humerus.

Chaunhan et al14 (2013) dissected 50cadavers and reported that the NA arose from

BA in 94%, and PBA in 6%.

Pratima baisakh et al59 (2015) reported that the NA originate from a CT with PBA and SUCA from the BA 11cm from the coracoid process.

29 c) Superior ulnar collateral artery

Patnaik VVG et al 55 (2002) in his study ,dissection of 50 upperlimbs ,reported that

SUCA arising from a CT with PBA in 2%, and a branch of PBA in 2%.

Chandrika teli et al18 (2013) has reported that SUCA arose from a CT with the

PBA and PCHA in the proximal part of BA.

Chaunhanet al 14 (2013) dissected 100 upperlimbs of 50 cadavers, observed the

SUCA arise from BA in 81%, CT with PBA in 18%, CT with IUCA in 1%.

Sathialakshmi et al70 (2014) study on 40 upperlimb specimen from 20 adult cadavers, observed that 90% arose from BA ,5% from CT with PBA and 5% separate branch from PBA.

Pratima baisakh et al59 (2015) reported that the SUCA originate from a CT with

PBA and NA from the BA 11cm from the coracoid process.

d) Inferior ulnar collateral artery

Huber30 (1930) described that IUCA arise 4cms above the termination of BA.

Piersol56 (1936) stated that the IUCA a branch of the BA arose on its medial side just before bifurcation.

Frazer 21 (1930) said that the IUCA a branch of BA arose 2cms above the elbow and passes behind the brachialis muscle.

Russel T Woodburne 68 (1961) the IUCA arises about 3cm above the medial epicondyle. It divides on the brachialis muscle into anterior and posterior branch.

C.J.Romanes 68 (1964) described in his textbook of Anatomy, the IUCA arose 5cms above the Elbow.

Anson4 (1966) said that the IUCA arose 5cms proximal to the elbow.

Williams et al99 (1999) described that the IUCA artery begins 5cms above the elbow. Patnaik VVG et al55 (2002) reported in his study of 50 upperlimbs that

IUCA is absent in 4%.

Susan standring 87 (2008) Stated that the IUCA begins 5cms proximal to the elbow and passes behind the MN and Brachialis muscle.

Priya G et al60 (2012) dissected 20 upperlimbs from 10 embalmed cadavers, reported that the IUCA was absent in one limb specimen.

Chaunhan et al14 (2013) had reported that IUCA arose from BA in 98%, CT with

SUCA in 1%, absent in 3%.

Pratima baisakh et al59 (2015) during his routine dissection ,noticed that the IUCA originated from UA just above the medial epicondyle.

31 e) Terminal branches – Radial & Ulnar artery

HIGH ORIGIN OF RADIAL ARTERY (HRA)

J E Frazer21 (1937) stated in his book of manual anatomy, RA may arise from the

AA or proximal part of BA,associated with superficial course.

C J Romanes 65 (1964) in his textbook of cunninghams anatomy has mentioned that

RA may arise from the AA or from the BA in the arm.

W Henry Hollinshed28 (1969) in his textbook of anatomy for surgeons stated that , in mcCormack et al study, the RA arose from the AA in 2.13% and from BA in

12.14%.he also stated that HRA may be associated with a communicating branch of

RA infront or behind the tendon of biceps to reach the BA in cubital fossa.

Baral P et al7 (2002) reported the arterial system of upperlimb specimens ,observed that 4.9% of RA arose from BA and had a superficial course.

Omer faruk dogan et al53 (2004) conducted a study on CT angiograms of 32 patients planning to undergo CABG with radial artery graft, observed that HRA was present in one patient.

Priya S patil et al 61 (2004) observed a case of HRA from first part of AA, associated with recurrent radial artery arising from BA.

C Pelin et al 11 (2006) observed the origin of RA from BA 12cm above the intercondylar line.

Susan standring et al87 (2008) has reported that sometimes the RA arose from AA or BA in the arm.

Madhyastha et al44 (2009) in his case report observed that, RA arose from BA 4cm distal to the lowerborder of teres major tendon.

Ileana dinea et al31(2010) reported in his study the RA arose from BA in middle 1/3 rd of arm in one specimen among 14 cadaveric upperlimbs associated with superficial course.

Harbans singh et al 26 (2010) reported that unilateral HRA from BA about 10.5cm above the intercondylar line running superficial to the muscles..

Suresh bidarkotimath et al86 (2011) in his study ,he dissected 50 cadavers, reported that in a 30 year old male cadaver RA was originating at a higher level about

44.2cm and from 2nd part of AA runs superficially in the forearm.

Swaroop N et al88 (2011) observed a case of HRA from BA, which passes between the two divisions of MN, also reported a communicating branch from RA to UA in cubital fossa.

Chandni gupta et al12 (2012) dissected 75 cadavers in her study,observed that

HRA in 5.32% among these 2.66% from AA and another 2.66% from BA 16cm above the intercondylar line associated with superficial course.

Sainu susanet al69 (2012) dissected a 80 year old male cadaver found that HRA

21.5cm above the neck of radius at the level of insertion of coracobrachialis associated with superficial course.

Nasar A Y et al 51 (2012) reported HRA in 16% of specimens in his study.

Chandrika teli et al18 (2013) reported that the HRA above the intercondylar line which runs superficial to all the muscles..

Shiny et al78 (2013) observed a case of HRA from third part of AA proximal to the formation of MN.

Sharadkumar pralhad et al74 (2013) observed 13% of HRA in 200 cadavers.

Jayasabarinathan et al33 (2013) reported a case with RA take origin from the upper part of BA ,below the lower border of teres major.

Padma varlekar et al54 (2013) studied 96 upperlimb specimens,observed HRA in

3.12% of specimens associated with superficial course.

Li L et al41 (2013) studied the origin of RA in 1400 patients who underwent transradial coronary angiogram and observed 1.7% of HRA which runs superficial to the muscles.

Shuba R et al79 (2013) dissected 69 upperlimbs for bifurcation of BA , reported that 10.1% of RA had high origin from BA associated with superficial course.

Sathialakshmi et al70 (2014) observed that HRA was noted in 5% of specimen from

40 upperlimbs .It runs superficial to all the flexor group of muscles in the forearm.

Aparna G et al 5 (2014) in her case report, bilateral HRA from the AA at the lower border of pectoralis minor and a communicating branch from RA reaching the

BA in the cubital fossa.

Sugna choudry et al84 (2014) observed a case of RA arising from the BA at the level of union of lateral and medial roots of MN.

Shaik ahamed peera et al 73 (2014) dissected 60 upperlimb specimens and reported a that RA arose from third part of AA, proximal to the roots of MN in 1 upperlimb specimen (1.7%).

Waseem Al talalwah et al98 (2015) dissected 68 upperlimbs, reported HRA in

8.1% of specimens.

Nitin M mudirraj et al 52 (2015) dissected 45 upperlimbs , reported 13.33% of RA arose from BA.

Uma shivanal et al92 (2015) reported HRA in 2% of specimens among 50 upperlimbs associated with superficial course.

Shilpi agarwal et al77 (2016) the RA arose from the AA in 3.12%. it arose from

2cm above the lower border of teres major runs superficial to the MN in the forearm and superficial to the forearm muscles.

HIGH ORIGIN OF ULNAR ARTERY (HUA)

K Natsis et al38 (2006) reported a frequency of 0.17 to 2% HUA that runs superficial to the flexor muscles of forearm.

Venkata ramana vollala et al96 (2011 ) reported a case of HUA from the BA. It runs over the bicipital aponeuroses in the cubital fossa superficial to the flexor muscles in the forearm terminated as the superficial palmar arch in the hand.

Mohanadas rao et al47 (2012) during his routine dissection reported a case of HUA from the BA in the middle of the arm about 13cm above the medial epicondyle of the humerus and runs superficial to the forearm muscles.

RS Swamy et al67 (2013) during his routine dissection in a 55year old male cadaver observed the UA originate from the 3rd part of AA just above the lower border of teres major muscle.the variant UA was much smaller than the RA.

Sathialakshmi et al 70 (2014) observed that HUA was noted in 5% of specimen from 40 upperlimbs.

KPS Adinarayana et al 39 (2015) noticed a right upper limb during his routine dissection observed that the UA take origin from BA in the arm at a distance of

12.3cm from the acromian process of the scapula.

Abhinitha et al1 (2016) reported a incidence of HUA from BA was about 0.7 to

9.4%.

5. INCIDENCE OF TRIFURCATION OF BRACHIAL ARTERY

Patnaik VVG et al 55 (2002) dissected 50 upperlimbs, observed that unilateral trifurcation of BA into RA,UA, radial recurrent artery about 2%.

Bilodi AK et al 9 (2004) dissected 20 upperlims from 40 cadevers reported that

10% of BA trifurcates intoRA, UA and common interosseus arteries at the neck of the radius. Both UA and RA running superficial to the superficial flexor group of muscles and common interosseus artery running deep to the flexor group of muscles.

CK Reddy et al15 (2011) reported bilateral trifurcation of BA into RA, UA, radial recurrent artery in an adult female cadaver found during routine dissection in the department of anatomy.

Shuba R et al 79 (2013) dissected 95 upperlimbs reported that 26.3% of upperlimbs showed trifurcation of BA.out of these, 96% of third artery was radial recurrent artery and 2% of specimen ulnar recurrent artery and 2% of BA terminated into 5 branches RA, UA, radial recurrent and two muscular branches to the pronator tetres and brachioradialis.

Sharadkumar pralhad sawant et al 74 (2013) dissected 20 upperlimbs from 100 cadavers reported that 11% of specimen have trifurcation of BA.

Ganesa murugaperumal et al 23 (2014) reported that BA trifurcates into RA, UA,

PBA in one cadaver and RA, UA and common interosseus artery in another cadaver.

Uma shivanal et al 92 (2015) dissected 50 upperlimb specimens,observed the 10% of BA trifurcated in to RA, UA, and radial recurrent arteries.

6. RELATION OF MEDIAN NERVE TO BRACHIAL ARTERY

Poirier57 (1886) reported that 6% of BA was passed superficial to the MN.

Linelle 42 (1921) stated that 5.8% of BA crossed superficial to the MN.

Piersol 56 (1936) described that the MN was anterolateral to the BA proximally and beyond the insertion of coracobrachialis muscle it was anteromedial to the artery.

C.J.Romanes65 (1964) MN crossed the BA at the middle of the arm from lateral to medial side.

J.C.Grant 24 (1989) said that MN was lateral to the BA proximaly, and medial to it in the distal part of the arm.

Patnaik V.V.G. et al 55 (2002) in their morphological study on branching pattern of

BA reported 2% of BA are superficial to MN.

Susan standring 87 (2008) Stated that the MN was lateral to the BA proximally and crossed over to the medial side beyond the insertion of coracobrachialis.

Sathialakshmi et al70 (2014) found that 5% of specimens showed BA superficial to the MN.

Embryology

EMBRYOLOGY

The limb buds develop as outpouchings from the ventrolateral aspect of bodywall by the end of the fourth week. A number of small arteries arise from the dorsal aortae and reach the developing limb bud to form a primitive capillary plexus which drain into the anterior cardinal vein. Out of these small arteries only one trunk persist as the axis artery of upperlimb and it has the position and relation to the 7th cervical inter segmental artery. This trunk later develops into subclavian, axillary, brachial and anterior inter osseous artery and grows deep to the muscle mass of the forearm and terminates in the developing hand as superficial and deep palmar plexus.

Proximal part of the main trunk forms the Axillary and Brachial arteries and its distal part persists as anterior inter osseous artery and the capillary plexus which it ends forms the deep palmar arch.

A branch from the main trunk passes dorsally between the developing radius and ulna as posterior inter osseous artery. A little below that, another branch of axis artery accompanies median nerve upto the hand where it ends by forming the deep palmar plexus. After that the distal part of the axis artery losses its connection with the plexus.

A short distance below the elbow, the axis artery gives a branch which becomes the ulnar artery. It grows distally to join with the superficial capillary plexus of palm to form the superficial palmar arch later. After that, the median artery

40 regresses near the middle of the arm, another branch is given off from the axis artery, and is known as the primary radial artery. The proximal part of the radial artery above this level degenarates and disappears. The radial artery grows down to join the deep capillary plexus of the hand which forms the deep palmar arch87.

The following structures are derived from the Axis artery of upper limb

a) Axillary Artery

b) Brachial Artery

c) Proximal part of ulnar Artery

d) Common inter osseous Artery

e) Anterior Inter osseous Artery

Materials & Methods

MATERIALS AND METHODS

STUDY MATERIALS

50 adult upper limb specimens

METHOD OF STUDY

Conventional dissection method

SPECIMEN COLLECTION

Adult upper limb specimens were obtained from the embalmed cadavers allotted for routine academic dissection to the first year MBBS and BDS students at the Institute of Anatomy, Madras Medical College, Chennai-3.

CONVENTIONAL DISSECTION METHOD

A vertical incision was made in the anterior aspect of the arm and the skin, superficial fascia and deep fascia were reflected carefully upto the elbow. A transverse incision was made at the level of the elbow. Flaps were reflected to uncover the biceps brachii muscle, the muscle was reflected laterally. The neurovascular bundle present medial to the biceps was dissected carefully.

The structures present in the arm were followed upto the insertion of coracobrachialis. The brachial artery was identified and it continued from the

Axillary artery at the distal border of teres major muscle. The BA was seen medial to the humerus but gradually curls anterior to it until it lies midway between the two

42 humeral epicondyles. The median nerve was traced from the brachial plexus. Its relation to brachial artery was studied.Then the artery was traced distally upto the cubital fossa. In the cubital fossa, the Brachial artery was dissected lateral to the median nerve and deep to the bicipital aponeurosis.

The length of the Brachial artery was measured from its origin to the intercondylar line and intercondylar line to level of termination (neck of the radius).

The branches of Brachial artery was noted at various levels. The profunda brachii artery arose from the posteromedial aspect of the brachial artery distal to the teres major muscle. It runs closely with the radial nerve between the long and medial heads of triceps upto the radial groove.

The nutrient artery to the humerus was dissected from its origin at the midlevel of the arm and observed to enter the nutrient foramen near the attachment of coracobrachialis.

Superior ulnar collateral artery was identified a little distal to the midlevel of the arm. Along with ulnar nerve it pierced the medial inter muscular septum and was found between the medial epicondyle and olecranon.

Inferior ulnar collateral artery was dissected 5cm proximal to the elbow joint.

It was traced between the median nerve and brachialis muscle where it pierce the medial inter muscular septum.

From the transverse incision at the elbow, an another vertical incision was made from the cubital fossa to the wrist and the BA was traced upto the termination where it divides into radial and ulnar arteries at the level of neck of radius. The

Origin and course of radial and ulnar artery was noted.

Observation

OBSERVATION

1. LENGTH OF THE BRACHIAL ARTERY (BA)

Length was measured by 3 points

a) Mid point of width of the BA at the level of lower border of teres major (

Where it begins)

b) Mid point of width of the BA at the level of Intercondylar line (the line

between medial and lateral epicondyles of humerus)

c) Mid point of width of BA at the level of termination.

First the distance between the lower border of teres major tendon and intercondylar line was measured along the artery(X) and then the distance between the intercondylar line and termination of BA where it divided into UA and RA was measured (Y).

Then the length of the BA was calculated by adding these two values (X+Y) if the BA divided below the intercondylar line, or by substracting 2nd distance from the first (X-Y) if the BA divided above the Intercondylar line.

Measurement was taken with the help of Inch tape.

The minimum length of BA was 2cms, maximum length was 25.2cms and the mean length was 22.5cms (Table No:1). Out of the 50 specimens, 8 specimens (16%) were less than the mean length and 42 specimens (84%) were more than the mean length (Table No.1).

Table No : 1 Length of Brachial Artery (BA)

Minimum length 2cms

Maximum length 22.5cms

Mean length 25.2cms

Chart No : 1 Length of the Brachial Artery (BA)

PERCENTAGE 90

40 PERCENTAGE

0 ABOVE MEAN LENGTH BELOW MEAN LENGTH

Fig.1 : Superficial Brachial Artery (SBA)

SBA

BB - Biceps Brachi MN - Median Nerve UN - Ulnar Nerve

Fig.2 : Superficial Brachial Artery (SBA)

RA SBA

UA MN

BB - Biceps Brachi MN - Median Nerve RA - Radial Artery UA - Ulnar Artery

2. COURSE OF BRACHIAL ARTERY

Out of 50 upper limbs dissected, in 48 specimens (96%) the course of BA was found to be normal. In 2 specimens (4%) of upper limb the BA runs superficial to the median nerve.

In one specimen BA crossed the median nerve superficially from medial to lateral and divided normally at the level of the neck of the radius into RA and UA

(Table No.2) (Fig.1).

In another specimen BA was superficial to the median nerve and divided at the level of neck of radius in to RA and UA. Then the RA coursed downwards superficial to the flexor muscles of forearm (Table No.2) (Fig.2).

Table No: 2 Course of the Brachial Artery (BA)

Course of Brachial Frequency Percentage (%) Artery (n=50)

Normal 48 96%

Superficial Brachial 2 4% Artery (SBA)

Fig.3 : High division of Brachial Artery

UA BA

BB RA

BB - Biceps Brachi BA - Brachial Artery MN - Median Nerve UN - Ulnar Nerve

Fig.4 : High origin of Radial Artery with Superficial Course

UA HRA

M MN CNF

BA - Brachial Artery BB - Biceps Brachi HRA - Highorigin of Radial Artery MN - Median Nerve MCN - MusculoCutaneous Nerve

Chart No : 2 Course of the Brachial Artery (BA)

PERCENTAGE 120

100

60 PERCENTAGE 40

0 NORMAL SBA

3. LEVEL OF TERMINATION OF BRACHIAL ARTERY

Out of 50 upperlimbs dissected, in 46 specimens (92%) the BA divided below the level of intercondylar line ( at the level of neck of radius). In 4 specimens ( 8%)

BA divided above the level of Intercondylar line into RA and UA. (Table No.3)

Out of 4 specimens, in 2/4 specimens (4%) it divided 9cm above the level of intercondylar line ( 1cm below the level of tendon of teres major) (Table No.4)

(Fig.3&4).

In 1/4 specimen (2%) it divided 6cm above the intercondylar line (Table No.4)

(Fig 5).

In 1/4 specimen (2%) it divided 2cm above the intercondylar line (Table No.4)

(Fig 6).

Fig.5 : High division of Brachial Artery

AA - Axillary Artery BA - Brachial Artery MN - Median Nerve UN - Ulnar Nerve RA - Radial Artery UA - Ulnar Artery

Fig.6 : High division of Brachial Artery

UA BA MN

BB - Biceps Brachi BA - Brachial Artery MN - Median Nerve RA - Radial Artery UA - Ulnar Artery

Table No : 3 level of termination of Brachial Artery (BA)

Frequency Percentage Level of termination of BA (n=50) (%)

Below the Intercondylar line 46 92% (at the level of neck of radius)

Above the Intercondylar line 4 8%

Chart No :3 Level of Termination of Brachial Artery (BA)

Percentage 100

50 Percentage 40

0 BELOW THE INTERCONDYLAR LINE ABOVE THE INTERCONDYLAR LINE

Table No : 4 Level of termination of BA – Above the Intercondylar line

Percentage Above the Intercondylar line Frequency (%) 9cm above the intercondylar line (1cm below the 2 4% lower border of teres major tendon)

6cm above the intercondylar line 1 2%

2cm above the intercondylar line 1 2%

Chart no : 4 Level of termination of BA – Above the Intercondylar line

PERCENTAGE 4.5

3.5

2.5

2 PERCENTAGE

1.5

0.5

0 9CM ABOVE THE 6CM ABOVE THE 2CM ABOVE THE INTERCONDYLAR LINE INTERCONDYLAR LINE INTERCONDYLAR LINE

Fig.7 : Origin of Profunda brachia Artery a common trunk with SUCA from BA

A PB RN MCNF

SUCA

BA - Brachial Artery UN - Ulnar Nerve RN - Radial Nerve PBA - Profunda Brachi Artery SUCA - Superior Ulnar Collateral Artery MCA - Middle Collateral Artery RCA - Radial Collateral Artery AA - Axillary Artery

Fig.8 : Origin of Profunda Brachi Artery (PBA) from 3rd part of Axillary Artery (AA)

BA AA A B P

BA - Brachial Artery UN - Ulnar Nerve 4. VARIATION IN THE BRANCHING PATTERN OF BRACHIAL ARTERY

(BA)

a) PROFUNDA BRACHI ARTERY (PBA)

Out of the 50 upperlimbs dissected, 48 specimens ( 96%) the PBA arose from the BA in the posteromedial aspect distal to the teres major tendon and closely followed the radial nerve and it passed downward between the medial and lateral head of triceps to reach the posterior aspect of the humerus.

Out of 2 specimens, in 1/2 specimen (2%) it arose from a CT with SUCA from the BA in the posteromedial aspect just below the teres major tendon. It then gave middle collateral and radial collateral arteries.( Table No.5) (Fig.7).

In 1/2 specimen (2%) the PBA arose from the third part of the AA, and the

AA continued downwards as the BA at the lower border of teres major tendon.

(Table no .5) (Fig.8).

Table No : 5 origin of Profunda brachi Artery

Origin of profunda Frequency Percentage brachi Artery (n=50) (%)

From the BA 48 96%

CT with SUCA from BA 1 2%

From the 3rd part of AA 1 2%

Chart No : 5 Origin of Profunda brachi artery (PBA)

PERCENTAGE 120

100

60 PERCENTAGE

0 From BA CT WITH SUCA FROM BA FROM 3RD PART OF AA

b. Nutrient artery of the Humerus (NA)

In all the 50 specimens dissected, the NA arose from the BA near the middle of the upper arm ,enterted the nutrient canal on the medial surface of humerus near the attachment of coracobrachialis.

c. Superior ulnar collateral artery (SUCA)

Out of the 50 upperlimbs dissected, in 49 specimens (98%) the SUCA arose from the medial side of the BA just distal to the middle of the upper arm. The SUCA accompanied the ulnar nerve and pierced the medial inter muscular septum to lie in the posterior aspect between the medial epicondyle and olecranon and terminated deep to the flexor carpi ulnaris by anastomosing with the posterior ulnar recurrent and IUCA (Fig.8).

In one specimen (2%) the SUCA arose from a CT with PBA from BA in the posteromedial aspect just below the teres major tendon which gave radial collateral artery and middle collateral artery.

Table no: 6 Origin of Superior ulnar collateral artery (SUCA)

Origin of Superior ulnar collateral Frequency Percentage artery(SUCA) (n=50) From BA 49 98% From BA (CT with PBA Which gives radial 1 2% collateral and middle collateral)

Chart No : 6 Origin of Superior Ulnar Collateral Artery (SUCA)

PERCENTAGE 120

100

60 PERCENTAGE

0 From BA Common trunk with PBA from BA

4. Inferior ulnar collateral artery (IUCA)

In all the 50 specimens dissected the IUCA arose from the BA 5cm proximal to the elbow and divided into anterior and posterior branches .The anterior branch descended in front of the medial epicondyle and anastomosed with the anterior ulnar collateral artery, the posterior branch pierced the medial inter muscular septum and divided into transverse and descending branches. The transverse branch ended by anastamosing with the middle collateral branch of PBA close to the olecranon fossa

The deep branch passed behind the medial epicondyle and anastomosed with the

SUCA and posterior ulnar recurrent arteries. No variation was found.

5. Terminal Branches – Radial & Ulnar artery

Out of 50 upper limbs dissected, in 46 specimens (92%) the RA and UA arose from the BA at the level of the neck of the radius ( below the intercondylar line). In 4 specimens high division of BA above the intercondylar line into RA and UA from the BA in the arm.

In 1/4 specimens (2%) RA and UA arose from the BA 9cm above the ICL

(1cm below the level of lower border of teres major tendon).

In 1/4 specimen (2%) RA and UA arose from BA at the level of middle of the arm 6cm above the ICL.

In 1/4 specimen (2%) RA and UA arose from BA 2cm above the ICL.

Fig.9 : High origin of Radial Artery with Superficial Course

UA HRA

M MN CNF

BA - Brachial Artery BB - Biceps Brachi HRA - Highorigin of Radial Artery MN - Median Nerve MCN - MusculoCutaneous Nerve In 1/4 specimen, 1cm below the level of the teres major tendon the BA bifurcated into RA and UA and the vessel on the lateral side (radial side) descended superficial to the all the muscles upto the wrist joint and then entered the anatomical snuff box and turned to the dorsal aspect of hand. The NA, SUCA, IUCA arose from the RA in the arm. This was termed as HIGH ORIGIN OF RADIAL ARTERY.

(Fig.9).

Table no : 7 Origin of terminal branches – Radial and Ulnar artery

Frequency Origin of Radial and Ulnar artery Percentage (n=50) From BA in the forearm 46 92 (at the level of neck of radius) From BA in the arm 4 8 ( above the intercondylar line)

Chart No: 7 Terminal branches – Radial & Ulnar arteries

percentage 100 90 80 70 60 50 percentage 40 30 20 10 0 FROM BA (IN THE FOREARM) FROM BA (IN THE ARM)

Table No : 8 High Origin Of Radial Artery (HRA)

Frequency High origin of radial artery Percentage (n=50)

From BA in the forearm 46 92%

From BA in the arm 3 6% High origin 1 2% (from BA in the arm)with superficial course

Chart No : 8 High origin of Radial artery (HRA)

PERCENTAGE 100 90 80 70 60 50 40 PERCENTAGE 30 20 10 0 FROM BA IN THE FROM BA IN THE ARM HIGH ORIGIN (FROM BA FOREARM IN ARM WITH SUPERFICIAL COURSE

High origin of Ulnar Artery (HUA)

Ulnar artery which originating from BA high in arm and continuing downwards superficial to the all flexor muscles of forearm is called as HIGH

ORIGIN OF ULNAR ARTERY.

In present study did not find high origin of ulnar artery with Superficial course.

Fig.10 : Brachial Artery (BA) in relation to Median Nerve (MN)

SBA

AA SUCA PBA MR

IUCA MN

L R BB

BB - Biceps Brachi MR - Medial Root LR - Lateral Root BV - Basilic Vein MCNF - Medial Cutaneous Nerve of Forearm

5. INCIDENCE OF TRIFURCATION OF BRACHIAL ARTERY

Out of the 50 upperlimbs dissected, the trifurcation of BA was not found. The

BA divided normally into RA and UA.

6. RELATION OF MEDIAN NERVE TO BRACHIAL ARTERY

Out of 50 specimens dissected, in 48 specimens (96%) the MN was formed in the proximal part of arm, anterior to the BA. In 1/48 specimen the MN was medial to the BA throughout without crossing.

In 2 specimens (4%) the MN was posterior to the BA in the proximal part of arm and the BA was superficial to the MN. This is termed as Superficial brachial artery (SBA) (Fig.10).

Table no : 9 Relation of Median Nerve to Brachial Artery

Relation of Median Nerve to Brachial Frequency Percentage Artery (n=50) Anterior 48 96%

Medial (without crossing) 1 2%

Posterior 2 4%

Chart No : 9 Relation of Median Nerve to Brachial Artery

percentage 100 90 80 70 60 50 percentage 40 30 20 10 0 ANTERIOR MEDIAL (NO CROSSING) POSTERIOR

Discussion

DISCUSSION

1. LENGTH OF THE BRACHIAL ARTERY (BA)

Suresh bidarkotimath86 (2011) in his study, observed the mean length of the BA was 22.65cm.

Chaunhan et al14(2013) in his study ,reported the mean length of the artery was

24.56cm.

Sathialakshmi 70(2014) found the mean length of the BA was 21.5cm.

In the present study the mean length of the BA was 22.2cms (Table no:10).

Quains62(1844), Poirie57(1886), Adachi 2 (1928), Piersol56 (1936), J.E.Frazer 21

(1937), W.Henry Hollinshed 28 (1958), J.C.Grant24 (1989), Williams99 (1999),

Henry Gray87 (2008), in their text book of Anatomy the BA as the continuation of

AA at the level of lower border of teres major tendon to the point of termination at the level of neck of radius ( below the intercondylar line). They had not given the

Statistical data regarding the length of BA.

The knowledge about the length of the BA from its origin to termination is useful before during any interventional procedures. BA is used in various invasive and interventional procedures like diagnostic angiography, carotid stenting and transbrachial access for endovascular renal artery intervention.

Table No : 10 Mean length of the BA ( in cms)

Mean length of the BA Name of the studies ( in cms) Suresh Bidarkotimath et al (2011) 22.65

Chaunhan et al (2013) 24.56

Sathialakshmi et al (2014) 21.5

Present study (2016) 22.2

Chart No : 10 Mean length of the Brachial Artery (BA)

LENGTH OF BA IN CMS 25 24.5 24 23.5 23 22.5 22 LENGTH OF BA IN CMS 21.5 21 20.5 20 19.5 Suresh Chaunhan et al Sathialakshmi et Present study Bidarkotimath (2013) al (2014) et al (2011)

2.COURSE OF THE BRACHIAL ARTERY (BA)

Poirier57 (1886) in his textbook of Anatomy, in 100 dissections,observed SBA in 6% of cases. BA Crossed superficial to the MN.

Muller48 (1903) in his study found that 1% of SBA.

Linell et al42 (1921) reported that 6% of SBA.

Miller 46 (1939) reported that 3% of SBA, the BA runs superficial to the MN.

Mccormack et al45 (1953) observed 5.7% SBA.

Kapur et al 35 (2000) observed 5% incidence of SBA in his study.

Patnaik. V.V.G et al55 (2002) in his study observed that 6% of BA runs superficial to the MN.

David kachlik et al16 (2011) , in his study observed that 5% incidence of SBA in his study.

Vatsala AR et al95 (2013) observed that 1.9% of specimens showed SBA that runs infront of the MN.

Sathialakshmi et al70 (2014) found that the SBA, in one specimen 5%.

In the present study the prevalence of SBA was 4% which coincides with the above mentioned studies (Table No: 11).

SBA is more prone to injuries involving the arm which may lead to severe haemorrhage. Sometimes it may mistaken for median cubital vein which may lead to puncture of the artery during intravenous injection leading to heavy bleeding.

The SBA compress the MN and produce severe pain in the distribution of MN which may be confused with carpal tunnel syndrome.

Table No : 11 Superficial Brachial Artery (SBA)

Name of the studies Percentage

Poirier (1886) 6%

Muller (1903) 1%

Linell et al (1921) 6%

Miller (1939) 3%

Mc Cormack et al (1953) 5.7%

Kapur et al (2000) 5%

Patnaik V.V.G et al (2002) 6%

David haclik et al (2011) 5%

Vatsala A R et al (2013) 1.9%

Sathialakshmi et al(2014) 5%

Present study (2016) 4%

Chart No : 11 Superficial Brachial Artery (SBA)

Superficial Brachial Artery (PERCENTAGE) 7

Superficial Brachial Artery (PERCENTAGE)

3. LEVEL OF TERMINATION OF BRACHIAL ARTERY

The point of division above the level of intercondylar line is considered as

High Division of BA.

J.A.Keen32 (1961) found that 9% of the BA divided above the Intercondylar line.

Anson 4 (1966) reported about 15% of high division of BA.

Karlsson and Niechajev36 (1982) found in his angiographic observation 10% of BA dividing above the intercondylar line. 63

Priya G et al60 (2012) observed that the high division of BA was 10%.

Padma Varlekar et al54 (2013) found 6.25% prevalence of high division of BA.

Subash M Gujar et al83 (2014) reported that 6% the upperlimb specimens showed high division of BA.

Sunil Pundge et al85 (2014) reported that 4% of specimens showed high division of

BA.

Sathialakshmi et al 70 (2014) reported 5% prevalence of high division of BA.

The division of BA above the Intercondylar line varies from 0.7% to 15%.

In the present study, the high division of BA was noted in 8% of specimens. In two specimens the BA bifurcates 9cm above the ICL (1cm below the teres major tendon) .In one specimen the BA divides in the Middle Of the Arm 6cm Above the

ICL. In one specimen the BA divides 2cm above the ICL (Table No :12).

Knowledge about the high division of BA is more useful before any invasive procedures. BA is used in carotid artery stenting, trans brachial access for renal artery intervention, embolectomy through arteriotomy and coronary angioplasty.

Table No : 12 Level of termination of Brachial Artery (BA)

Name of the studies Percentage J.A.Keen (1961) 9% Anson (1966) 15% Karisson & Niechejav et al (1982) 10% Priya G et al (2012) 10% Padma Varlekar et al (2013) 6.25% Subash M Gujar et al (2014) 6% Sunil pundge et al (2014) 4% Sathialakshmi et al (2014) 5% Present study (2016) 8%

Chart No : 12 High division of Brachial Artery (BA)

PERCENTAGE 16 14 12 10 8 6 4 2 PERCENTAGE 0

4. Variations in the Branching Pattern of Brachial Artery a) Profunda Brachi Artery

Patnaik V.V.G et al55 (2002) reported 2% of PBA arose from a CT with SUCA and

2% from 3rd part of AA.

Suresh Bidarkotimath et al86 (2011) reported that 1% of PBA arose from AA.

Annie pullie et al3 (2012) observed that the PBA and SUCA arose as a CT from BA was 1.7% and 1.4% from AA.

Chaunhan et al14 (2013) reported that 4% of PBA arose from 3rd part of AA.

Vatsala A R et al95 (2013) found that 1.9% of PBA from 3rd part of AA.

Sathialakshmi et al70 (2014) found that a CT from BA gives PBA and SUCA in 5% of specimens and 2.5% from AA.

In the present study the PBA arose from a CT with SUCA which gives RCA and

MCA about 2% and 2% from AA (Table No :13).

Charles et al13 (1931), J.A.Keen et al32 (1961), Anson et al 4(1966), Vatsala A R et al95 (2013), Chaunhan et al 14 (2013) all the above studies the CT for PBA and

SUCA was more than 10%. Compared to the above mentioned studies, the PBA variation is less in the present study. Numerous other types of variations for the origin of PBA was noticed in the above mentioned studies.

PBA has a high incidence of duplication and early branching, so high susceptibility to inadvertent injury during fracture of humerus, BA catheterization and may complicate lateral forearm flaps. Preoperative angiographic evaluation is recommended before any invasive procedures.

Knowledge about these variations is also useful in orthopaedic surgeons when preparing the soft tissue flap for covering the stump after an above elbow amputation.

Table No : 13 Origin of Profunda Brachii Artery.

Common trunk with Name of the studies From AA SUCA from BA

Patnaik V.V.G et al (2002) 2% 2%

Suresh Bidarkotimath et al (2011) - 1%

Annie Pullie et al (2012) 1.7% 1.4%

Chaunhan et al (2013) - 4%

Vatsala A R et al (2013) - 1.9%

Sathialakshmi et al (2014) 5% 2.5%

Present study (2016) 2% 2%

Chart No :13 Origin of Profunda Brachi Artery

0 Patnaik V.V.G Suresh Annie Pullie et Chaunhan et al Vatsala A R et Sathialakshmi Present study et al (2002) Bidarkotimath al (2012) (2013) al (2013) et al (2014) (2016) et al (2011)

Common trunk with SUCA from BA From AA

b) Nutrient Artery

Quains62 (1844) stated that the NA arose from the BA at the midlevel of the upper arm.

Poirier57 (1886) described that the NA enterted the Nutrient canal at the level of insertion of coracobrachialis muscle.

Piersol56 (1936) stated that NA arises from BA and enters the nutrient foramen of the humerus on its medial surface.

Frazer21 (1937) described that the NA entered the nutrient foramen of the humerus near the lower border of insertion of coracobrachialis muscle

Russel T Woodburne 68 (1961) stated that the NA arises about the middle of the arm and enters the nutrient canal on the anteromedial surface of the humerus.

C.J.Romanes65 (1964) Described that the NA a branch of the BA entered the nutrient canal on its medial surface.

J.C.B.Grant24 (1989) described that the NA arises from the middle of BA and entered the nutrient foramen on the anteromedial surface of the humerus.

In the present study, in all the 50 upperlimbs specimens the NA arose from the

BA about 3 to 4cm proximal to the elbow (middle of the arm) and entered the nutrient canal on its medial surface close to the insertion of coracobrachialis muscle.

The NA to the humerus is a branch from BA, any injury involving the arm leading to avulsion of the artery which may result in avascular necrosis of humerus.

c) Superior ulnar collateral Artery

Patnaik et al 55 (2002) stated that the 2% of SUCA arose from a CT with PBA, and

2% as a branch of PBA and 96% from BA.

Annie Pullie et al3 (2012) observed that 1.7% of SUCA arose from a CT with PBA.

Sathialakshmi et al70 (2014) reported that 5% of SUCA arose from a CT with PBA.

In the present study 2% of the SUCA arose from a CT with PBA from BA

(Table No :14).

Charles et al 13 (1931), J.A.Keen et al 32 (1961), Anson 4 (1966), Vatsala AR et al95 (2013), Chaunhan et al14 (2013), compared to the above mentioned studies the

CT for SUCA and PBA was low in the present study. Numerous types of variant origin of SUCA and PBA were noted in the above mentioned studies.

Variant origin of SUCA is important because it participates in the anastomosis around the elbow joint, it may cause bleeding in elbow injury..

Table No :14 Variant Origin of Superior ulnar collateral Artery (SUCA)

Origin of SUCA and PBA arose a CT Name of the studies from BA (Percentage)

Patnaik V.V.G et al (2002) 2%

Annie Pullie et al (2012) 1.7%

Sathialakshmi et al (2014) 5%

Present study (2016) 2%

Chart No :14 Variant Origin of Superior Ulnar Collateral Artery (SUCA)

ORIGIN OF SUCA AND PBA FROM A COMMON TRUNK (PERCENTAGE) 6

0 Patnaik V.V.G et al Annie Pullie et al (2012) Sathialakshmi et al Present study (2016) (2002) (2014)

ORIGIN OF SUCA AND PBA FROM A COMMON TRUNK (PERCENTAGE)

d) Inferior Ulnar collateral Artery (IUCA)

Huber30 (1930) described that IUCA arise 4cms above the termination of BA.

Russel T Woodburne68 (1961) the IUCA arises about 3cm above the medial epicondyle.

C.J.Romanes 65 (1964) described in his textbook of Anatomy, the IUCA arose 5cms above the Elbow.

Anson4 (1966) said that the IUCA arose 5cms proximal to the elbow.

Williams et al99 (1999) described that the IUCA begins 5cms above the elbow.

Susan standring 87 (2008) Stated that the IUCA begins 5cms proximal to the elbow and passes behind the MN and Brachialis muscle.

In the Present study, all the 50 specimens the IUCA arose from the BA 5cms

Proximal to the elbow.

IUCA is involved in arterial anastomoses around the elbow joint , it may cause bleeding in case of elbow injury. Ligation of all the arteries taking place in anastomoses is essential to control the bleeding.

e) Terminal branches – Radial & Ulnar arteries

HIGH ORIGIN OF RADIAL ARTERY

Out of the 50 upperlimb specimens, in 4 specimens the RA arose from the BA in the arm and remaining 46 specimens it arose from the BA in forearm.

BA bifurcates into RA and UA above the intercondylar line and the vessel on the lateral side(radial side) descend superficial to the all the muscles upto the wrist joint enter the anatomical snuff box and then turned to the dorsal aspect of hand. The

NA, SUCA, IUCA arose from the RA in the arm.This vessel is termed as HIGH

ORIGIN OF RADIAL ARTERY. Among the 4 high division specimens, in one specimen the HRA was present and it continued down ward as superficial to all the muscles.

J E Frazer21 (1937) described in his book of manual anatomy, RA may arise from the AA or proximal part of BA, associated with superficial course

C J Romanes65 (1964) in his textbook of cunninghams anatomy has mentioned that

RA may arise from the AA or from the BA in the arm.

Baral P et al 7(2002) reported that 4.9% of RA arose from BA and continues as

SRA.

Chandni gupta et al12 (2012) found that HRA from BA in 2.66%.

Li L et al 41 (2013) found in his study on transradial coronary angiogram and observed 1.7% of HRA.

Padma varlekar et al54 (2013) reported that HRA in 3.12% of specimens.

Sathialakshmi et al 70 (2014) reported that HRA was noted in 5% of specimen which continued as SRA.

Uma shivanal et al 92 (2015) reported HRA in 2% of specimens .

Present study (2016) 2% prevalence of HRA.(Table No :15)

RA is the second most common artery( after internal mammary artery) used as a graft for Coronary Artery Bypass Graft, because the diameter of the RA is equal to that of coronary artery. HRA in the arm is more prone to injuries leading to heavy

73 bleeding. It can be mistaken for vein and ligated during surgeries in the forearm leading to gangrene of hand.

RA arising at a high level in the arm sometimes have smaller diameter which cannot be used for grafting and also lead to failure of catheterization. SRA is used in the elevation of forearm flap.

Table No : 15 High origin of Radial Artery

Name of the studies Percentage

Baral P et al (2002) 4.9%

Chandni Gupta et al (2012) 2.6%

Li L et al (2013) 1.7%

Padma varlekar et al (2013) 3.1%

Sathialakshmi et al (2014) 5%

Uma shivanal et al (2015) 2%

Present study (2016) 2%

Chart No : 15 High origin of Radial Artery

PERCENTAGE 6

1 PERCENTAGE

5. Incidence of trifurcation of brachial artery

In all the 50 upperlimbs the BA bifurcated into RA and UA. There was no variation of trifurcation in the study.

The trifurcation of BA prevalence in literature range from 2 to 20%.

6. Relation of Median Nerve to Brachial Artery

Poirier57 (1886) reported that 6% of specimens the MN was deep to the BA.

Linelle 42 (1921) stated that 5.8% the formation of MN was behind the BA

Patnaik V.V.G. et al55(2002) in their morphological study on branching pattern of

BA reported 2% of BA are superficial to MN.

Sathialakshmi et al70 (2014) found that 5% of specimens showed BA superficial to the MN. Showed BA runs superficial to the MN.

In the present study , 4% of specimens the MN is formed posterior to the BA

(Table No :16).

The knowledge of BA in relation to MN is important, the uneven tortuous and anomalous course of BA compress the MN in the lower part of anterior compartment of arm. Sometimes it can be mistaken for basilic vein during cannulation. Such a neurovascular variation is clinically important because symptoms of MN compression may arise from such variation which is often confused with more common causes of MN compression like radiculopathy, pronator teres syndrome and carpal tunnel syndrome.

Table No :16 Relation of Median Nerve to Brachial Artery

Relation of median nerve to Sathialakshmi et al Present study brachial artery (2014) (2016)

Anterior to the brachial artery 95% 94%

Posterior to the brachial artery 5% 4%

Without crossing of median nerve from lateral to medial side 5% 2% (medial throughout)

Chart No :16 Relation of Median Nerve to Brachial Artery

120

100

0 Anterior to the BA Posterior to the BA No crossing (Medial throughout)

Sathialakshmi et al (2014) Present study (2016)

Conclusion

CONCLUSION

The Brachial artery and its branching pattern have been of great interest to anatomists and surgeons, interventionists and radiologists, due to wide clinical and radiological implications. This study was carried out by routine dissection method.

The present study provide information of both normal and variant morphology of the

Brachial artery in adult human cadavers.

The following conclusions were drawn,

 The Axillary artery continues as Brachial artery at the level of lower border

of teres major in all the 50 upperlimb specimens..

 The mean length of the Brachial artery is 22.5cms.

 The course of the Brachial artery in 96% of specimens is found to be normal.

In 4% of specimens the Brachial artery runs superficial to the Median nerve

and it is considered as Superficial brachial artery.

 The level of termination of Brachial artery is below the intercondylar line

(neck of radius) in 92% of specimens. In 8% of specimens the level of

division is above the Intercondylar line. In 2/4 specimens 9cm above the

intercondylar line and 1/4 specimen 6cm above the intercondylar line, 1/4

specimen 2cm above the intercondylar line.

 Variations in the branching pattern is studied. 96% of specimens the Profunda

brachii artery arise from the Brachial artery, in 2% of specimens it arise from

a Common trunk with Profunda brachi artery from Brachial artery. In 2% of

specimens it arise from 3rd part of Axillary artery.

 Nutrient artery to the humerus arise from the Brachial artery in the middle of

the arm ( near the insertion of coracobrachialis ) and it enters in to the nutrient

canal of humerus in all the specimens. No variation found.

 Superior ulnar collateral artery arise from Brachial artery in 98% of

specimens. In 2% of specimens it arise from a Common trunk with Profunda

brachii artery from Brachial artery.

 Inferior ulnar collateral artery arise from the Brachial artery 5cm above the

elbow in all the 50 specimens. No variation found.

 High origin of radial artery with superficial course in the forearm is found in

2% of specimens. High origin of ulnar artery with superficial course is not

found .

 The formation of Median nerve (union of medial and lateral root of Median

nerve) is anterior to the Brachial artery in 96% of specimens. In one specimen

no crossing of Median nerve from lateral to medial side was found. Median

nerve is posterior to the Brachial artery in 4% of specimen.

 Trifurcation of Brachial artery is not found in my study.

The variations with respect to origin, course , branching pattern and level of termination of the BA are found in the present study . Such variations have clinical importance in the field of vascular surgeries like CABG, Orthopaedic surgeries,

Plastic and reconstructive surgeries.

The Superficial brachial artery make them vulnerable to trauma and also make them more accessible to cannulation. The Superficial radial artery and Superficial ulnar artery have been encountered during elevation of the radial forearm flap.

Arteriographic misinterpretation results when the contrast dye is injected distal to the origin of variant arteries. Accidental intraarterial injection may lead to the gangrene of fingers, hand and forearm.

Doppler ultrasound and BA angiography can be used to identify the arterial pattern of arm before proceeding any invasive and interventional procedures.

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99. Williams, Bannister, Berry MM, Collins P, Dussek JE, Ferguson MW, eds. Gray’s Anatomy 38th edition, London, Churchill Livingstone. 1999; 319,1539. MASTER CHART Specimen Length of the BA Level of Termination Origin of Course of the BA Origin of PBA Origin of NA Origin of SUCA HRA HUA Trifurcation BA in relation to MN No (cm) of BA IUCA 1 21.7 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

2 22.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

3 22.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

4 24.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

5 24.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

6 23.4 N Below the ICL BA BA BA BA From BA in arm A Not found Anterior to the BA

7 2 N Above the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

8 21.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

9 24.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

10 23.7 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

11 23.2 SBA Below the ICL BA BA BA BA From BA in forearm A Not found Posterior to the BA

12 24.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

13 24.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

14 25.1 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

15 23.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

16 22.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

17 22.7 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

18 3 N Above the ICL BA BA BA BA HRA(From BA in arm) A Not found Anterior to the BA

19 22.7 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

20 22.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

21 23.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

22 23.7 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

23 24.2 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

24 24.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

25 25.2 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

26 24.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

27 25.1 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA 28 24.1 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

29 24.8 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

30 17 N Above the ICL BA BA BA BA From BA in arm A Not found Anterior to the BA

31 21.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

32 23.8 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

33 21.4 N Below the ICL 3rd part of AA BA BA BA From BA in forearm A Not found Anterior to the BA

34 23.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

35 24.8 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

36 24.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

37 25.2 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

38 23.6 SBA Below the ICL BA BA BA BA From BA in forearm A Not found Posterior to the BA

39 22.7 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

40 23.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

41 18 N Above the ICL BA BA BA BA From BA in arm A Not found Anterior to the BA CT with SUCA CT with PBA 42 21.6 N Below the ICL BA BA From BA in forearm A Not found Anterior to the BA from BA from BA 43 22.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

44 24.3 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

45 24.6 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

46 24.7 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

47 23.2 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

48 24.1 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

49 24.8 N Below the ICL BA BA BA BA From BA in forearm A Not found Anterior to the BA

50 23.2 N Below the ICL BA BA BA BA From BA in forearm A Not found