Translational Research in Anatomy 24 (2021) 100114

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Translational Research in Anatomy

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Duplication of the median cubital – Case report with commentaries on clinical significance

˙ a b,c,d,e b,d,f g Andrzej Zytkowski , R. Shane Tubbs , Joe Iwanaga , Agata Olszewska , Beata Kunikowska h, Grzegorz Wysiadecki g,* a Faculty of Philology, Department of Polish Dialectology and Logopedics, University of Lodz, Poland b Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA c Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA d Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA e Department of Anatomical Sciences, Saint-George’s University, Grenada, West Indies f Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Fukuoka, Japan g Department of Normal and Clinical Anatomy, Chair of Anatomy and Histology, Medical University of Lodz, Poland h Department of Nursing Theory and Skills in Nursing, Chair of Nursing Teaching, Medical University of Lodz, Poland

ARTICLE INFO ABSTRACT

Keywords: The median cubital vein is the most prominent superficialvein in the cubital region and usually the most clearly Anatomical variation outlined vein in the entire human body. It can be found quite easily, even in obese, swollen, or shocked patients. Bicipital aponeurosis It runs diagonally upwards, leaving the cephalic vein and traveling medially to the basilic vein. Topographical Cubital fossa relationships make the vein particularly convenient for access in various procedures such as venous punctures. Medial cutaneous nerve of the forearm However, high-risk procedures are usually performed in other areas because unusual anatomical variations are Median cubital vein Superficial possible. A detailed anatomical description of an unusual variant of median cubital vein duplication is presented Venipuncture in this report, including its communications with deep veins and topographical relationships to the bicipital aponeurosis, brachial , medial cutaneous nerve of the forearm, and the median nerve. The potential clinical significance of this variant is discussed.

1. Introduction against a physician’s knife during phlebotomy, which gave this structure the nickname graceˆ a` Dieu fascia (“Praise God for her”) [2]. Even now, The median cubital vein (Latin vena mediana cubiti) is the most topographical relationships make this vein particularly convenient for prominent superficial vein in the cubital region and usually the most access in a range of procedures such as venipunctures or intravenous clearly outlined vein in the entire human body. It transfers blood from cannulation [4,5]. The median cubital vein can also be used for surgical the radial to the ulnar side of the forearm. It can be found quite easily, creation of arteriovenous fistulas for hemodialysis [6]. Therefore, even in obese, swollen, or shocked patients [1,2]. It runs diagonally medical practitioners should be aware of potential anatomical variations upwards, departing from the cephalic vein and traveling medially to the in the cubital fossa [4–13]. basilic vein. It also anastomoses with deep veins. Owing to those com­ A detailed anatomical description of an unusual variant of median munications it fillswith blood quickly, facilitating the collection of even cubital vein duplication is presented in this report, including its com­ large blood samples for diagnostic purposes [1]. From the practical point munications with deep veins and topographical relationships to the of view, it is crucial that the median cubital vein lies in front of the bicipital aponeurosis, and medial cutaneous nerve of the brachial artery, separated by a thickened bicipital aponeurosis (also forearm, and the median nerve. The potential clinical significanceof this known as lacertus fibrosus) [3]. Straightening the joint tightens variant is discussed. this aponeurosis, further increasing the safety of the vessel. In historical times, the bicipital aponeurosis was the only protection of the artery

* Corresponding author. Department of Normal and Clinical Anatomy, Chair of Anatomy and Histology, Medical University of Lodz, ul. Zeligowskiego˙ 7/9, 90–752 Łod´ ´z, Poland. E-mail address: [email protected] (G. Wysiadecki). https://doi.org/10.1016/j.tria.2021.100114 Received 30 January 2021; Accepted 5 February 2021 Available online 11 February 2021 2214-854X/© 2021 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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2. Case description vein on the lateral side of the cubital fossa (Figs. 1 and 2). It ran anterior to the radial artery with accompanying veins in its initial course. It then The anatomical variation described in this report was an incidental crossed over the distal part of the bicipital aponeurosis and the brachial finding during routine dissection of an isolated right male artery with accompanying veins (separated from those structures by the fixed in 10% formalin with phenol. The neurovascular structures were bicipital aponeurosis). It also crossed the median nerve, medially to the dissected following classical gross anatomical dissection methods. bicipital aponeurosis. It was separated from the nerve only by the thin Stratigraphic dissection of was performed according to previously antebrachial fascia. The medial cutaneous nerve of the forearm crossed described protocols [14–16]. those veins anteriorly, just at the point where the vein opened into the After the skin and subcutaneous fat tissue were removed, the pattern basilic vein. of subcutaneous veins was revealed (Fig. 1). A single cephalic vein The second median cubital vein originated slightly superior to the traveled along the lateral border of the forearm on the external surface first (Figs. 1 and 2). It anastomosed with the veins accompanying the of the brachioradialis muscle. The basilic vein was also single and radial artery, piercing the antebrachial fascia. It ran obliquely in front of coursed on the medial side of the forearm. Within the cubital fossa, it the bicipital aponeurosis, but it was not adjacent to the brachial vessels anatomosed with the venous network in the region of the elbow. at this point. It crossed over to the brachial artery with accompanying Dissection of the cubital fossa revealed duplication of the median cubital veins and the median nerve at the level of the interepicondylar line of vein (Figs. 1 and 2). The first,dominant median cubital vein arose from the humerus, medially to the bicipital aponeurosis, separated from those the cephalic vein in the proximal quarter of the forearm, ran along the structures by a thin fascia. The medial cutaneous nerve of the forearm superolateral border of the pronator teres muscle, and joined the basilic also crossed over the second median cubital vein at the point where it emptied into the basilic vein. After receiving both median cubital veins, the basilic vein pierced the brachial fascia and then accompanied the brachial vessels. It joined one of the brachial veins (the medial one) in the middle of the length (Fig. 2b).

3. Discussion

According to Bergman et al. [8], the median cubital vein is remarkably constant and can be identifiedin 84% of cases. In one study, the cephalic vein failed to give rise to the median cubital vein in only four of 300 cases [8]. The median cubital vein can receive the median antebrachial vein as a tributary. It can also be doubled. In such in­ stances, an accessory median cubital vein is found proximal to the main trunk, as in the case presented in this report. Yammine and Eri´c [9], in their meta-analysis of patterns of the superficial veins of the cubital fossa, found that the prevalence of median cubital vein duplications reported by different authors ranges from 0.6% to 8.5%. However, Berry and Newton reported that 16% of cases show this variation [17]. The arrangement and prevalence of different variants of superficial veins in the upper limb are highly variable. Yammine and Eri´c [9] stress the proximity of those veins to adjacent and nerves. According to those authors, several arrangements of the superficial veins can be distinguished, two variants being most common. Type “M” (also called “classical” or “Y” type) is the variant in which the median antebrachial vein is divided into two terminal channels, the median cephalic and median basilic veins (the latter corresponds to the median cubital vein in this type) [9]. The prevalence of this type reported by various authors ranges from 0.78% to 56.13% [9]. Type “N” (also described as “embryonal type” or type “H”) is the most common pattern, with a prevalence ranging from 9% to 98% [9]. In this variant, the median antebrachial vein is thin and opens into the median cubital vein, which connects the cephalic and basilic veins in the cubital region. Duplication of the median cubital vein resembles type “N,” in which an accessory venous channel appears. On the basis of their study, Pires et al. [5] describe duplication of the median cubital vein as the least observed pattern. Those authors found no such variant in one hundred healthy individuals. The relationships of the median cubital vein to the bicipital aponeurosis, brachial artery, and median nerve are highly variable. Fig. 1. Duplication of the median cubital vein. Wet specimen of the isolated They are crucial from the clinical point of view. Typically, the bicipital right upper extremity. General view. The quality of the specimen was affected aponeurosis separates the median cubital vein from the brachial artery by phenol as a preservative. Phenol oxidizes, causing the brownish color of the [1,2]. In our report, those relationships were observed in the first(lower specimen. The presented photograph therefore shows little contrast between and more prominent) channel of the median cubital vein. However, an anatomical structures. BA – brachial artery; BV – basilic vein; CV – cephalic vein; MAV – median antebrachial vein (opening); MCNF – medial cutaneous accessory channel was separated from the brachial vessels only by a thin nerve of the forearm; MCV1 – the first, more prominent median cubital vein; fascia. Such relationships can lead to accidental intraarterial drug in­ MCV2 – the second, accessory median cubital vein; MN – median nerve; UN – jection [16]. ulnar nerve. (For interpretation of the references to color in this figure legend, Moreover, both channels of the duplicated median cubital vein the reader is referred to the Web version of this article.) crossed over the median nerve, which could cause a risk of accidental

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Fig. 2. Duplication of the median cubital vein. Wet specimen of the isolated right upper extremity. In this dissections, important vessels and nerves have been digitally color enhanced to improve the clarity and understanding topographical relations. A. Anterior view of the cubital fossa. Topographical relationships of both channels of the median cubital vein are visualized. B. View of anteromedial aspect of the arm. Both channels of the median cubital vein open into the basilic vein. Arrangement of the main venous channels is shown. AN – anastomosis between an accessory median cubital vein and radial veins; BA – brachial artery; BBM – brachii muscle; BM – brachialis muscle; BRM – brachioradialis muscle; BV – basilic vein; BVV – brachial veins; CV – cephalic vein; LF – lacertus fibrosus(bicipital aponeurosis); MCNF – medial cutaneous nerve of the forearm; MCV1 – first, most prominent, median cubital vein; MCV2 – sec­ ond, accessory, median cubital vein; MN – median nerve; UN – ulnar nerve. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

nerve injury during procedures involving this vein. Terminal parts of can also be useful for clinicians in their daily practice [19]. both channels were also closely related to the medial cutaneous nerve of the forearm, which ran above them. The observations of Yamada et al. 4. Conclusions [10] indicate that the medial cutaneous nerve of the forearm can run above the median cubital vein in 21.1% of cases, as in our report, or can The arrangement of superficial veins in the cubital fossa can vary. be located inferior to the vein in 28.9%. According to these authors [10], Both channels of the duplicated median cubital vein can be close to the “the distribution of cutaneous veins and nerves widely varies, and while nerves and brachial artery, potentially increasing the risk of iatrogenic no single area suitable for all individuals was identified,puncture of the injury to those structures. MCBV near the cephalic vein is the least likely to cause nerve damage.” That statement is consistent with our observations since neither of the Funding sources duplicated median cubital vein channels were closely related with the nerves in their lateral parts, near their origin from a cephalic vein. There This research did not receive any specific grant from funding can also be an anomalous relationship between the median cubital vein agencies in the public, commercial, or not-for-profit sectors. and bicipital aponeurosis [7]. Close relationships between the duplicated median cubital vein and Ethical statement the nerves can increase the risk for iatrogenic nerve injury during venipuncture [9–11]. As Arbique and Arbique [11] stress, a nerve injury N/a. during venipuncture can be caused by direct puncture or compression. An accidental direct puncture of the nerve usually causes immediate Declaration of competing interest symptoms, including sharp acute pain at the venipuncture site, the pain sensation changing in severity depending on needle position: pain or None declared. tingling discomfort in hand or fingertips, and pain that persists after needle removal [11–13]. There can even be “electric-type pain” Acknowledgments accompanied by paresthesia [12]. Nerve compression can be caused by a subcutaneous hematoma or infiltrationof intravenous fluidclose to the The authors sincerely thank those who donated their bodies to sci­ nerve or by a tourniquet applied improperly (i.e., too tightly or for an ence so that anatomical research could be performed. Results from such excessively long period) [11,13]. Anatomical variations of the median research can potentially increase humankind’s overall knowledge, cubital vein should also be considered during the surgical creation of thereby improving patient care. Therefore, these donors and their some arteriovenous fistula types for hemodialysis [6]. families deserve our highest gratitude [20].

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