European Journal of Cardiovascular Medicine

Brachial artery, the most important artery of the arm,starts as a continuation of the axillary arteryon the distal border of the tendon of teresmajor muscle with the aid of accompanying the mediannerve, enters into cubital fossa. Under thecover of bicipital aponeurosis, it divides intoulnar and radial arteries anteromedial tothe neck of the radius. Common interosseousartery arises from the ulnar artery whichis again divided into front and backinterosseous arteries [1].

At first it is medial to the humerus, but gradually spirals in front of it until it lies medial

between the epicondyles of the humerus. Its pulsation is palpable at all times [2] and blood pressure and pulsed Doppler ultrasonographymeasurements are commonly evaluated throughdistal part of the brachial artery [3]. Conventional knowledge of brachial artery and theirbranches play a major role in blood vesselsoperations relating to these vessels. Literaturealong with various cadaveric and clinical studiessuggest that the brachial artery varies considerablyorigin, course and pattern of branching assuperficial brachial artery, tortuosity ortrifurcation into radial, ulnar and commoninterosseous arteries.

The superficial brachial artery (SBA) arisesfrom axillary artery and runs superficially to median nerve and may represent a superficial pulse [4]. The superficial course of thesearteries can be confused with veins anddangerous for venipuncture during intravenous procedures, injections, infusions andblood discharge [5]. and may lead to intra-arterial injections or ligation instead of a veinin the elbow socket [6]. That too can have consequencescatastrophic conditions such as gangrene or losshand and the results can be disastrous,such as gangrene or loss of a hand [7].

Twists or loops and sharp bendsbrachial artery or its branches is also one ofcause of access failure in the coronaryinterventions that can close blood vesselscausing ischemia [8]. In the current study, we havetried to elaborate the existingcourse and knowledge branchingbrachial artery pattern. Knowledgesuch variations are extremely importantclinical diagnosis and surgical treatmentdiseases of the upper limbs. It is also important that they are nephrologists and surgeonsaware of these arterial variations becauseusing these anomalous arteries to establishan arterio-venous approach can be considered viablein some cases an alternative route [9].

Knowledge of such unusual variations orchanges in the brachial artery are also importantfor radiologists to reduce diagnostic and therapeutic errors. Hence this study is aimed at observing normal branchingbrachial artery pattern and its variationscourse dates and branches resulting frombrachial artery.

Limbs from 56 cadavers of Central Indian origindifferent age groups and genders (38 men and 18Women). Limbs were produced in the anatomy department for dissection purposesfirst year medical students at a tertiary medical college in Central India.

Upper limbwas carefully dissected to study the course& brachial artery branching pattern usingstandard procedure. [10]

Brachialarteries were identified and traced proximallyto continuity with axillary artery the level of the lower border of the teres major anddistal in the cubital fossa to its bifurcation. Branching pattern and relations of medial cord or brachial plexus in the armobserved. In each corpse, both upperthe limbs were dissected to record the presence orabsence of any variations and if any, whetherpresent unilateral or bilateral.Photographs were taken for documentation of the observedvariations.

In this study, among 112 upper limbs106 (94.5%) limbs showed a normal conditionbrachial artery and its branching pattern. Thebrachial artery arose as a continuation of 3rdpart of the axillary artery at the inferior borderof teres major muscle, was crossed superficiallymedian nerve crossed earlierto artery. All other branches were visiblewith normal origin from brachial arteryin theupper arm. (Table 1,2) i.e. Profundabrachii artery arose from the postero-medialaspect of the proximal humerusartery distal to the teres major muscle, superiorulnar collateral artery arose a little distallymiddle arm and lower ulnarthe lateral artery arose proximally from the elbow.

Table 1: Incidence of morphology and variations of

brachial artery in arm in the present study (2019).

Table 2: Comparison of incidence of Normal Brachial artery

Table 3: Comparison of incidence of Superficial Brachial artery

Table 4: Comparison of incidence of Trifurcation Superficial Brachial artery

Normal termination of the artery into the radial andulnar arteries at the level of neck of radius in thecubital fossa was observed. 6 (5.5%)upper limbs showed variations in brachialartery in the form of superficial brachialartery and trifurcation of brachial artery intoradial artery, ulnar artery and commoninterosseous artery was observed in 1.78% ofcases. (Table 1).

Brachial artery has great anatomic significance.  Our study explores few new variations in its course. As shown in Table 2, the resultsthe occurrence of normal brachial arteries wascompared to various studies that rangedfrom the lowest incidence of 77% to the highestan incidence of 96% that has been reportedMurugapermal G and MelaniRajendran (2014)[11-15]. In this study, the percentagesnormal brachial artery was found at 94.5%which supports the findings of Jayasree& Reddy(2017) [16].

Arterial variations are common in the upper partlimb. Mechanism of developmentarterial variations were subjectmany studies. Usually the brachial arterypasses deep into the median nerve medially to the lateral side in front of the arm.

But when it superficially crosses the median nerve and replaces the main trunk, it is calledas the superficial brachial artery [17,18].

These superficial brachial arteries cancontinue in the elbow and bifurcate asusually to the radial and ulnar arteries, bothsurface running in the forearm [19]with the deep division continuing into the forearm as the interosseous complex [20]. Lalit (2011) shed a flood of light on the earlierliterature that was and was related to this entityreported to be between 0.2% and 22% [18]. Superficial brachial artery formerlyreported as 6.0% by Poirier (1886), Linelle (1921)and Patnaik et al. (2002), 5.0% by Kapur et al.(2000) and Kachlik et al. (2011), 12.2% according to Yanget al (20081) [13,21-25]. However, so was the SBAreported by Nakatani et al. (1996), Kaur et al. (2011) and Alfaouri-Kornieieva (2013) [26-28].

According to Singer (1933) and Baeza et al.(1995) the brachial artery has two trunks origin. One passes deep into the median nerve andothers superficial to the median nerve, i.esuperficial brachial artery. During the later

stagesdevelopment usually gets a deep arteryhemodynamic preference leading to obliteration of the superficial brachial artery located proximal to the anastomosis, while the distal segmentsthey persist as part of the a. radialis. However ifartery passing superficial to the median nervereceives hemodynamic preference (such aspresent case) superficial brachial arterypersists while deep (normal) fades[29,30].

However, in this study, the brachial arteryin the upper two

they showed different endingslimbs of the same body. They were both ulnar and radialrun superficial to superficial flexor groupmuscles and the common interosseous artery wasongoing deep to superficial flexor groupsmuscles, while on the left upper limb,the brachial artery normally branches into the ulnar,and radial arteries. Trifurcation of the armartery to artery radialis, artery ulnaris andcommon interosseous arteries see inthe current study was also reportedHuber (1930), Lockhardt& Hamilton, (1959),Romanes (1964), Williams et al., (1999), Bilodi&Sanikop, (2004) and Vollala et al., (2008)[2,10,31-34].

According to Huber (1930) supernumeraryadditional branches to the usual branches may arisefrom the brachial artery, which may also give originwhen it bifurcates into a common interosseousartery or into the middle artery as a third branchand a radial recurrent branch of radials may arisefrom the distal part of the brachialis artery, which alsoinvolved its bifurcation [31]. William et al. (1999) mentioned under variations on brachialan artery that the brachial artery can bifurcateproximally and rejoin to form a single trunk orsometimes trifurcates proximally into the ulna,radial and common interosseous arteries [2].

Trifurcation in the center of the armthe cubital fossa was also described [14].Patnaik et al (2001) also found radialrecurrent artery as the third branch in trifurcation of the brachial artery in a fifty-year-old mancadaver in one right upper limb, acc2% [35].

Malcic-Gurbuz et al., in 2002 also observed aa case of brachial artery trifurcation to radial, ulnar, and superior ulnar collateralsarteries high in the arm [36]. Howeverindicated brachial artery trifurcation in 10% of themcases [15].

The case was also reported by Bilodi&Sanikop (2004).brachial artery trifurcation into ulnar, radial andcommon interosseous arteries on the left upper limbbut the main artery was not superficialbrachial artery as in this case [33].

For the formation of the common interosseous arteryfrom the superficial brachial artery is mildmodification in the Baeza et al (1995) model,development of the human brachio-antebrachialsystem. Before that, the superficial brachial arterydivision into two terminal branches (stage IIof Baeza et al 1995) reports a branch that mergesaxial artery distal to the origin of the deep component of the radial and ulnar arteries. Usually thisthe folder also disappears ashemodynamic preference runs deeppart of the axial artery.

Currently in ourstudy, we observed loops and acute bendsSBA, radial and ulnar arteries that can occludevessels causing ischemia. A variation on thisstudy are significant because tortuous SBA withkinked origin of the running radial and ulnar arteriesa tortuous course can result in a clinical emergency if medical personnel are not aware of ittype of variation.

An artery that included bifurcation [31]. William et al (1999) mentioned under brachial artery variations thatthe brachial artery may bifurcate proximally andreunite to form a single trunk or sometimes trifurcate proximally into the ulnar, radial, and common interosseous arteries [2]. Trifurcation inthe middle of the arm instead of the elbow socket haswere also reported [14]. Patnaik et al (2001) havealso found the radial recurrent artery as a third branchduring brachial artery trifurcation in the 1950syears old male corpse on one right upper limb,representing 2% [35].

Malcic-Gurbuz et al., in 2002 also observed aa case of brachial artery trifurcationradial, ulnar, and superior ulnar collateralsarteries high in the arm [36]. Howeverindicated brachial artery trifurcation in 10% of themcases [15].

The case was also reported by Bilodi&Sanikop (2004).brachial artery trifurcation into ulnar, radial andcommon interosseous arteries on the left upper limbbut the main artery was not superficialbrachial artery as in this case [33].

For the formation of the common interosseous arteryfrom the superficial brachial artery is mildmodification in the Baeza et al (1995) model.development of the human brachio-antebrachialsystem. Before that, the superficial brachial arterydivision into two terminal branches (stage IIof Baeza et al 1995) reports a branch that mergesaxial artery distal to the origin of the deep component of the radial and ulnar arteries. Usually this component persisted andthe deep component disappeared, leading to anorigin of common interosseous artery fromsuperficial brachial artery [18,30]. Currentlystudy we observed loops and acute bends

SBA, radial and ulnar arteries they can occludevessels causing ischemia. A variation on thisstudy are significant because tortuous SBA withkinked origin of the running radial and ulnar arteriesa tortuous course can result in a clinical emergency if medical personnel are not aware of ittype of variation.

The arteries of the upper limb form the initialcapillary plexus that emerges from the dorsalaorta and develops at the same rate as the limb.There is a rebuilding process involvingmagnification and resolution of the selectedparts [12]. Arey (1957) is of the view It is meantthat variations arise through persistence,disappearance, incomplete development andfusion of enlargement and differentiation of partsthe original network that would normallythey remain as capillaries or even regress [37].

Superficial brachial artery as wellsurface position of the ulnar aradial arteries or tortuosity not only doesare more vulnerable to trauma and therefore tobleeding, but also makes them more accessiblefor cannulation if necessary. These arteries canalso confused with veins. Therefore,overall understanding of the normal patternof brachial artery, its branches and itsvariation is essential for clinicianssurgeons to avoid iatrogenic injuries, for accurate diagnostic interpretation and therapyinterventions to reduce morbidity andmortality rate.

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