Folia Morphol. Vol. 80, No. 2, pp. 344–351 DOI: 10.5603/FM.a2020.0048 O R I G I N A L A R T I C L E Copyright © 2021 Via Medica ISSN 0015–5659 eISSN 1644–3284 journals.viamedica.pl Revisiting the anatomy of the cephalic vein, its origin, course and possible clinical correlations in relation to the anatomical snuffbox among Jordanian M.A. Salameh1 , A.T. Shatarat2 , D.H. Badran3 , M.A. Abu-Abeeleh4 , T.M. Kanaan5, A.M. Bani-Hani4 , M.Q. Hamdan5 1Department of Basic Medical Science, Faculty of Medicine, Al Balqa Applied University, Al Salt, Jordan 2Department of Anatomy and Histology, Faculty of Medicine, University of Jordan, Amman, Jordan 3Dean of the Faculty of Medicine, Hashemite University, Zarqa, Jordan 4Department of General Surgery, Faculty of Medicine, University of Jordan, Amman, Jordan 5Department of Special Surgery, Faculty of Medicine, University of Jordan, Amman, Jordan [Received: 11 January 2020; Accepted: 27 March 2020] Background: The cephalic vein is one of the most distinguished superficial veins of the upper limb. Its clinical value lies in venous access. There is little known about the variation of its formation in relation to the anatomical snuffbox. Hence, anatomical variants in the origin of the cephalic vein are important in clinical practice. Subsequently, this study was designed to examine the variation of the cephalic vein formation in relation to the anatomical snuffbox. Materials and methods: A cross-sectional study of 438 subjects (722 hands), was prepared to study the cephalic vein among Jordanian students and staff of one of the major governmental Medical College in Jordan, by using infrared illumination system. The obtained data was analysed according to; gender, sid- edness, and handedness. Results: Four sites for the formation of the cephalic vein in relation to the ana- tomical snuffbox were found. There was a significant relation between gender and sidedness, and the sites of formation of the cephalic vein (p < 0.0001 and p = 0.048, respectively). Conclusions: For the first time this study identified different sites for the formation of the cephalic vein in relation to the anatomical snuffbox. However, regardless of its sites of formation, the cephalic vein was running in 98% of the examined hands in the anatomical snuffbox. (Folia Morphol 2021; 80, 2: 344–351) Key words: anatomic variation, cannulation, hand, veins, venous access INTRODUCTION term was translated to Latin, cephalic inaccurately was The cephalic vein (CV) as a term originates from selected to replace the Arabic origin of the term [3]. the Arabic word al-kefal, which means “outer” and The CV is a superficial vein that originates from the was first used by Muslim physician Ibn Sina, when the radial aspect of the dorsal venous network of the Address for correspondence: Dr. S.T. Amjad, Department of Anatomy and Histology, Faculty of Medicine, University of Jordan, Amman, 11942, Jordan, tel: 00962 6 5355000, ext. 23434, e-mail: [email protected] This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to down- load articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. 344 M.A. Salameh et al., Cephalic vein and anatomical snuffbox hand. It is formed when the dorsal digital vein from which include the transferred digit or the reimplanted the radial side of the index finger and the two dorsal digit gives the CV another clinical importance [9, 14, digital veins of the thumb join each other. It arises 21]. The large diameter of the distal part of the CV on the roof of the anatomical snuffbox (AS) then has been suggested for vein puncture, especially; crosses the radial styloid process and courses upward because this part is easier to view and palpate [9]. on the anterolateral side over the forearm. Then it Furthermore, it was reported that the vein puncture passes upwards over the antecubital region, where of CV adjacent to the AS is the ideal site beside the it may receives blood from the median cubital vein, cubital fossa [9]. However, other studies have chal- and continues to ascend on the anterolateral side of lenged the access of the CV in the AS and the distal arm lateral to the biceps muscle in the deltopectoral part of the forearm, for example, Robson et al. [15] groove. Later on, the vein passes through the axilla, and Samarakoon et al. [18] stated that cannulation by piercing the clavipectoral fascia to drain and end of the CV in the distal third of the forearm should be into the axillary vein. Throughout its course, the CV avoided; to prevent any possible injury of the SBRN. has three clinical important regions; it’s origin on the Besides, Vialle et al. [24] recommended that CV punc- hand in the AS, in the cubital fossa and its termina- ture must be at least 12 cm above the styloid process tion in the axillary vein. The latter two regions were of the radius to avoid injury to SBRN. studied and it has been concluded that the CV has This valuable relationship between the CV and AS different anatomical patterns in those regions [6, 8, has been mentioned in some studies as findings but 13, 22]. However, the anatomical patterns of the CV not as a full study about these two valuable anatom- in the AS seemed to be overlooked. ical structures. For example, it has been reported that The AS is a descriptive anatomical term for the sometimes the origin of the CV from the dorsal venous triangular hollow on the radial part of the dorsum network of the hand can be recognized in the roof of of the hand, which is formed by depressing skin of the AS. Another study has demonstrated that the SBRN muscle contraction; the base is directed to the wrist was largely related to the CV in 80% of the studied while the apex is directed to the thumb. The impres- forearms, which underlay the CV [14]. Furthermore, sion is most apparent when the thumb is abducted within the AS there were connections between the and extended. It is limited on the ulnar (posterior) vena comitantes of the RA and the CV, and the CV was side by the extensor pollicis longus (EPL) tendon, found considerably in the ulnar part of the AS [16, 20]. whereas on the radial (anterior) side by tendons of A case study for dissecting upper limbs of 2 months the abductor pollicis longus (APL) and extensor pollicis infant showed normal beginning of CV in the roof of brevis (EPB). The base is formed by the distal margin the AS, no variation in the vein of the right upper limb, of the extensor retinaculum, while the apex is created while the left upper limb showed abnormal running by the attachment of EPL and EPB tendons [5]. The up and continuation of CV [15]. A cadaveric study of terminal part of the superficial branch of the radial 10 cadavers was carried out to demonstrate the vari- nerve (SBRN) and the CV pass through the superficial ations in the tendons of the AS in a Malaysian, it was fascia that forms in addition to the skin the roof of found that 2 hands of different specimens showed the the AS. The floor is formed by the base of the first CV in the AS [23]. Therefore, the present study aimed metacarpal bone, trapezium, scaphoid and the distal to study and describe in details the origin of the CV radius [5]. The radial artery (RA) and the extensor carpi in relation to AS. Also, to characterize any possible radialis tendons are at the bottom of AS [2]. anatomical patterns for CV in the AS. The relation between the CV and the AS has al- ways been underestimated regardless of its clinical MATERIALS AND METHODS value. For example, clinical procedures such as venous Subjects cannulation of the CV in the AS is a well known site A total number of 438 subjects were included in [12]. Placing an arteriovenous fistula which is ap- the study; 217 males and 221 females. A total number plied surgically to obtain vascular access between the of 722 hands were examined. They were chosen ran- RA and CV in patients on haemodialysis is another domly from the Hashemite University. The age group procedure used in this area [10, 19, 25]. Also, it has considered was from 18–35 years. A total of 239 hands been shown that, maintaining satisfactory venous with injuries, scars, burns and hairy skin, were exclud- drainage of the hand using neurovascular pedicles, ed (exclusion rate 33%). In females; 39 right hands 345 Folia Morphol., 2021, Vol. 80, No. 2 and 49 left hands were excluded, while in males; Table 1. Demographic and experimental characteristics of the 69 right hands and 84 left hands were excluded. final population of the formation of the cephalic vein in relation Subjects were informed in detail about the pro- to anatomical snuffbox cedure and written consent was signed. The study Characteristic Number Total number Hands excluded was approved by the Institution Review Board of the of subjects of hands in from the study Hashemite University (IRB#) P.0/222/1704841. the study Gender: Instruments Male 217 (49%) 368 (51%) 151 (63%) The infrared (IR) vein illumination system (Sure Female 221 (51%) 354 (49%) 88 (37%) vein ZD-JM-260-01) has been used to identify the Hand: formation of the CV.