Bifurcation of Axillary Artery in Its 3Rd Part - a Case Report

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J Anat. Soc. India 50(2) 166-169 (2001)

Bifurcation Of Axillary Artery In Its 3rd Part - A Case Report

*Patnaik, V.V.G.; **Kalsey, G.; **Singla, Rajan K.

Department of Anatomy, Government Medical College, *Patiala, **Amritsar, INDIA.

Abstract. In the present paper,a case of bifurcation of axillary artery in its 3rd part into radial artery and brachio ulnar artery is being reported. Former branch coursed superficial to median nerve in arm and continued in the forearm as such while later one after giving branches of brachial artery in the arm continued as ulnar artery in forearm and hence named so. Further its ontogeny & elinical implications are discussed in detail.

Key words : Axillary artery, Radial artery, ulnar artery. Superficial brachial artery

Case report : arteries. Keen (1961) christened this variation as During the dissections done in the Anatomy “high origin of radial artery”. Icten and Tuncar (1996) Department of Govt. Medical College, Amritsar differentiated high origin of radial artery and under the project of “Arterial Pattern of Superior superficial brachial artery as separate entities saying Extremity of Human Adult- A Morphological that the former arises from axillary or brachial artery Study”, a case of bifurcation of axillary artery in its and continues in the forearm as does a normal 3rd part was encountered. The limb belonged to the radial artery. On the other hand though the left side of an approximately 40 years old male persistent superficial brachial artery has same origin cadaver. The axillary artery in its 3rd part at a as a high origin radial artery, but on reaching the distance of 7.5 cm from outer border of first rib and forearm, it usually divides into radial and ulnar 3.0 cm proximal to lower border of teres major arteries while the brachial artery merely supplies the (distance between outer border of first rib and lower interosseous. Former condition according to them is border of teres major i.e. total extent of axillary 13 times more common as compared to the later. artery being 10.5 cm) divided into 2 branches. One We feel that it should be called “Bifurcation of of these branches coursed superficial to median axillary artery” into radial and brachio ulnar trunks nerve from medial to lateral side in the middle one with former continuing in forearm as such while later third of the arm and continued in the forearm as giving branches of brachial artery in arm and then radial artery. The other one gave off anterior and continuing in forearm as ulnar artery and hence posterior circumflex humeral, subscapular and named brachio ulnar. arteria profunda brachii branches, coursed deep to the median nerve from lateral to medial side and Ontogeny : continued in the forearm as ulnar artery. (See Arey (1957) is of the view that the anomalous Photograph 1 & 2). Further course, branches, and blood vessels may be due to (i) the choice of termination of radial and ulner arteries in forearm unusual paths in the primitive vascular plexuses, (ii) and hand were normal. the persistence of vessels normally obliterated, (iii) the disappearance of vessels normally retained (iv) Discussion : incomplete development and (v) fusions and Axillary artery dividing in its 3rd part has been absorption of the parts usually distinct. differently named by earlier workers. One of the Ontogenic basis of the present case can be divisions which passes superficial to median nerve easily made out if we look at Singer Staging of and replaces the main trunk is named superficial development of brachial artery according to which it brachial artery by Adachi (1928). Treves and Rogers develops in the following 5 stages (See Text Fig. (1947) opined that there are 2 brachial arteries I) :— instead of one continuing as radial and ulnar J. Anat. Soc. India 50(2) 166-169 (2001) Patnaik, V.V.G. et al 167

Stage V: Finally three changes occur. When the embryo reaches the length of 23 mm the median artery undergoes retrogression becoming a small slender structure, now known as arteria comes nervi mediani. The superficial brachial artery gives off a distal branch which anastomoses with the superficial palmar arch already present. At the elbow an anastomotic branch between brachial artery and superficial brachial artery becomes (I) (II) (III) (IV) (V) enlarged sufficiently to form with the distal portion of Text Fig. 1 the latter, the radial artery, as a major artery of the Stages of Development of arteries of upper limb forearm; the proximal portion of the superficial sc — Subclavian artery ma — Median artery aia — Anterior interosseous sba — Superficial brachial brachial artery atrophies correspondingly. artery artery (Singer, 1933) ua — Ulnar artery spa — Superficial palmar arch ra — radial artery In the present case, (See Text fig. II) the third Stage I: part of axillary artery (e) gave off superficial brachial Originally the subclavian artery extends to the artery (a) which appeared there in Singer’s stage IV wrist, where it terminates by dividing into terminal and continued downwards as radial artery. Ulnar branches for the fingers. The distal portion of the artery (c) had appeared from axial artery at usual artery becomes the interosseous artery of the adult. level. The communicating branch between superfiial brachial artery and axial artery at level of elbow Stage II : failed to develop and so superficial brachial artery did not dissappear but continued as radial artery. On The median artery arises from the the other hand part of axial artery (d) (distal to origin interosseous artery and becomes larger while of ulnar artery) shrunk in size and ultimately it interosseous artery subsequently undergoes appeared as if axial artery continued as ulnar artery retrogression. During this process the median artery (c) and common interosseous (d) arose as its fuses with the lower portion of interosseous artery branch. and ultimately forms the main channel for the digital branches becoming the principle artery of the forearm.

a -Superficial brachial artery Stage III : (Radial division of axillary In embryos of 18 mm, the ulnar artery arises artery) from brachial artery and unites distally with the b -Primitive axial artery (brachial part of brachio- median artery to form superficial palmar arch. ulnar trunk) Digital branches arise from this arch. c -Trunk of origin of ulnar artery (ulnar part of brachio - Stage IV: ulnar trunk) In embryo of 21 mm length, the superficial d - Part of axial artery distal to origin of ulnar artery brachial artery develops in the axillary region and e - Third part of axillary artery traverses the medial surface of the arm and runs f - Median nerve diagonally from the ulnar to the radial side of the forearm to the posterior surface of the wrist. There it divides over the carpus into branches for the Text Fig. 2 dorsum of the thumb and index finger. Ontogenic explanation of Bifurcation of axillary artery J. Anat. Soc. India 50(2) 166-169 (2001) 168 Bifurcation of Axillary Artetry

Baeza et al (1995) look at the normal 3. The superficial antebrachial artery (medial development of upper limb arteries in a slightly branch of superficial brachial) divides into 2 different way (See Text Fig. III). According to terminal branches - median and ulnar (Muller, them :— 1903; Lanz and Wachsmuth, 1959; Vancov, 1. The superficial brachial artery is a consistent 1961). Each of these branches anastomose embryonic vessel that plays an important role with a corresponding branch of primitive axial in the normal arterial morphogenesis of the artery which are trunks in origin of the median upper limb. and ulnar artery respectively. Gradually trunks of deep origin attain a haemodynamic 2. The superficial brachial artery has two terminal predominance and superficial antebrachial branches (Muller; 1903; Vancov, 1961); a artery together with the pre-anastomotic medial one which is superficial antebrachial segment of its terminal branch regresses. artery and lateral one which continues in the Therefore, 2 segments can be distinguished in forearm as a part of the definitive radial artery. both the median and ulnar arteries; a proximal Text Fig. 3 or deep one which corresponds to the trunk of Modifications by Baeza et al (1995) in development of human origin in the primitive axial artery and another brachio-antebrachial system distal or superficial which represents postanastomotic segment of the terminal branch of superficial antebrachial artery. 4. The radial artery usually develops similarl to median and ulnar arteries. Thus the lateral terminal branch of superficial brachial artery anastomoses with a trunk of the deep origin of the radial artery from the primitive axial artery. Deep haemodynamic predominance determines regression of those superficial arterial segments located proximal to the anastomosis, while the distal segments persist as a part of the radial artery. This explanation is in agreement with that given by Senior (1926) and Singer (1933). However, they defined the superficial branch of the anastomosis as the proper superficial brachial artery and not as its lateral terminal branch. This difference may be justified by the fact that once the anastomosis between the trunk for a - Primitive axial artery the deep origin of the radial artery and lateral b - Superficial brachial artery branch of superficial brachial artery is made, c - Lateral branch of superficial brachial artery the definitive patterns of the median and ulnar d -Medial branch of superficial brachial artery (superficial arteries have already been established. ante-brachial artery) e - Trunk of deep origin of radial artery Baeza et al (1995)’s explanation also stands a f - Radial artery good stead in the present case. The lateral branch g - Ulnar branch of superficial ante-brachial artery of superficial brachial artery continued as radial h - Median branch of superficial ante-brachial artery i - Trunk of deep origin of ulnar artery artery and trunk of deep origin of radial artery failed j - Trunk of deep origin of median artery to develop, or if it developed, it failed to attain k - Ulnar artery haemodynamic predominance and the lateral l - Median artery branch of superficial brachial artery continued as m - Common interosseous artery J. Anat. Soc. India 50(2) 166-169 (2001) Patnaik, V.V.G. et al 169 radial. In case of ulnar artery that developed 12. Vancov, V. (1961) : Une Variete extremement complexe des normally with ulnar branch of superficial arteres du membre superieur chez in foetus humain Anatomical Anzeles 109: pp 400-404. antebrachial artery (medial branch of superficial brachial artery) failing to attain haemodynamic predominance and trunk of deep origin from primitive axis artery attaining the same so that ultimately whole of the ulnar artery seems to be a continuation This Article Can be Downloaded / Printed Free from of brachial artery with interosseous coming as its http:\\jasi.net branch.

Clinical implications : Compta (1991) highlighted the diagnostic, interventional and surgical significance of such a variation. Diagnostically, it may disturb the evaluation of angiographic images. Interventionally, accidental puncture of superficially placed arteries may occur while attempting venipuncture. Surgically, it is vulnerable in both orthopaedic and plastic surgery operations.

References : 1. Adachi, B: Das Arteriensystem des japaner, Kyoto, Vol. 1; pp. 8, 205, 208, 210 (1928). 2. Arey, L.B.: Developmental Anatomy In : Development of the Arteries, 6th Edn, W.B. Saunders’ co; Philadelphia, pp. 375- 77 (1957). 3. Baeza, R.A.; Nebot, J; Ferreira, B; Reina, F; Perez, J; Saundo, J.R. and Roig, M (1995): An anatomical study and ontogenic explanation of 23 cases with variations in main pattern of brachio antebrachial arteries. Journal of Anatomy 187(2): pp. 473-9. 4. Campta, X.G. (1991): Origin of radial artery from the axillary artery and associated hand vascular anomalies. Journal of Hand Surgery 16(A): pp. 293-6. 5. Icten, N; Tuncar, I (1996): Variant high origin of radial artery: A bilateral case. Surgery, Radiology, Anatomy, 18(1): pp. 63- 66. 6. Keena, J.A. (1961): A study of arterial variations in the limbs with special references to symmetery of vascular patterns. American Journal of Anatomy, 108: pp. 245-61. 7. Lanz, T; Wachsmuth: Practiche Anatomie Vol. 1: Part 3, Arm Springer, Berlin pp : 82-89 (1959). 8. Muller (1903): Die Arm-Arterian des Mechshen Anat Hefte; 22: p. 379. 9. Senior, H.D. (1926): A note on development of radial artery. Anatomical Record 32: p. 220. 10. Singer, E (1933): Embryological patterns persisting in the arteries of the arm. Anatomical Record, 55: pp. 406-13. 11. Treves, F.B.; Rogers, L: Surgical applied anatomy In: The upper extremity. 11th Edn. Cassell & Co. Ltd. London, pp. 230-1 (1947). J. Anat. Soc. India 50(2) 166-169 (2001) Opp. 166 Bifurcation of Axillary Artery

Photograph 1 Bifurcation of axillary artery (ax) into radial (r) & brachio ulnar (bu). r passed superficial to median nerve (mn) & while bu coursed deep to mn & continued as ulnar artery (u).

Photograph 2 Bifurcation of axillary artery (ax) in its 3rd part. pm - Pectoralis minor; a - anterior et p - posterior circumflex humeral arteries. pb - profunda brachii.