Normal vascular variants of the upper extremity Poster No.: C-1039 Congress: ECR 2014 Type: Educational Exhibit Authors: P. Paixao, A. P. Gomes, M. S. C. Sousa, I. Santiago, A. S. C. C. Germano; Amadora/PT Keywords: Anatomy, Vascular, Extremities, Ultrasound, Ultrasound-Colour Doppler, Ultrasound-Spectral Doppler, Normal variants, Education and training DOI: 10.1594/ecr2014/C-1039 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 35
Learning objectives - To illustrate some of the normal vascular anatomical variants of the upper extremity at Doppler ultrasound examination. Background Upper extremity disease is relatively uncommon, unlike peripheral lower extremity vascular disease. There are, however, various possible disorders, from deep vein thrombosis to acute ischemia. In all cases, and particularly in the preoperative evaluation before construction of a vascular access for hemodialysis, the knowledge about the normal anatomy and variants is important. Figures 1 and 2 depict the simplified "classical" arterial and venous pattern, as shown in anatomy textbooks. Page 2 of 35
Fig. 1: Arteries of the upper extremity References: P. Montelone Page 3 of 35
Fig. 2: Veins of the upper extremity References: Allan P, Dubbins P, Pozniak M, Dicken W 2006. Clinical Doppler Ultrasound. There are a number of vascular anatomical variations to this pattern. In the arterial system, the most common anatomic variants include the left subclavian artery having a common origin with the common carotid artery from the aortic arch, or the radial artery showing a high origin. Rarer variants include a low origin of the ulnar artery or a ulnar artery origin from the brachial or axillary artery. The upper-limb veins can also show anatomical variations, like the absence of a cephalic or basilic vein in the forearm, or a duplicated axillary vein. Images for this section: Page 4 of 35
Fig. 1: Arteries of the upper extremity Page 5 of 35
Fig. 2: Veins of the upper extremity Page 6 of 35
Findings and procedure details ANATOMIC VARIANTS Classical - Normal brachial artery division and normal flow waveform (Fig. 3): Fig. 3 References: - Amadora/PT - Normal subclavian vein (Fig. 4). Note increased flow with inspiration. Normal paired deep veins accompanying the arm and forearm arteries (brachial and radial ex.): Page 7 of 35
Fig. 4 References: - Amadora/PT - Normal cephalic and basilic veins (Fig. 5). The basilic is the largest superficial vein in the arm and is also known as royal vein. Both veins run in a fascial folding. The classical cephalic-axillary confluent is at the highest portion of the delto-pectoral groove, the fosseta of Morhenheim or sub-clavicular fosseta of Gerdy: Page 8 of 35
Fig. 5 References: - Amadora/PT Arteries - High bifurcation of the brachial artery in the upper arm (Fig. 6). High origin may be a cause of slow access maturation. In this pattern, the interosseous artery arises from the radial: Page 9 of 35
Fig. 6 References: - Amadora/PT - Two other possible arterial variants (Fig. 7): A)The interosseous arises from the brachial and the radial and ulnar arise from a common trunk; B)An aberrant radial artery arises from the axillary: Page 10 of 35
Fig. 7 References: - Amadora/PT - Abnormal trifurcation of the brachial artery at the elbow level (Fig. 8): Page 11 of 35
Fig. 8 References: - Amadora/PT - Low division of the brachial artery (Fig. 9). The radial and ulnar arteries can also have variable sizes or be absent. Different sizes of the radial artery in two different patients (A and B): Page 12 of 35
Fig. 9 References: - Amadora/PT Deep veins - Paired axillary veins (Fig. 10): Page 13 of 35
Fig. 10 References: - Amadora/PT - Brachial veins: Variability in the number (1 to 3) and disposition around the brachial artery (Fig. 11): Page 14 of 35
Fig. 11 References: - Amadora/PT - Basilic-brachial confluent at variable levels in the upper arm (Fig. 12): Page 15 of 35
Fig. 12 References: - Amadora/PT - There is high variability of the classically described cephalic-axillary confluent (Fig. 13): Page 16 of 35
Fig. 13 References: - Amadora/PT - Communicating vein of the elbow (Fig. 14). Classically described at the "M" tip, but seen at various levels, depending on the anatomy of the superficial veins. We also noted on Doppler examination that the direction of the flow in this vein is almost always from the deep system to the superficial system. This is the opposit of what is described in textbooks: Page 17 of 35
Fig. 14 References: - Amadora/PT Superficial veins The superficial vein system is the most variable. We present only some possible patterns. - It is important to recognize accessory basilic and cephalic veins and variable vein diameters (Fig. 15): A and B) Normal sized (A) and residual (B)cephalic veins; C and D) Normal sized (C) and residual (D) basilic veins: Page 18 of 35
Fig. 15 References: - Amadora/PT - The "Y" type (A) and the "W" type (B). Note the accessory basilic vein (arrow) (Fig. 16): Page 19 of 35
Fig. 16 References: - Amadora/PT Images for this section: Page 20 of 35
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Fig. 16 Page 34 of 35
Conclusion There is a huge normal variability in upper limb arteries and veins, seldom mentioned in textbooks. The knowledge of these anatomical features is of the utmost importance for the radiologist, especially in the preoperative vascular mapping for arteriovenous fistula creation. The aim of this presentation was to show some possible anatomical variants that can appear in our daily practice. Personal information References - Paturet G. 1951. Traité d'anatomie humaine, tome II. Masson editeurs. Librairie de l'academie de medicine, Paris,pp 435-440. - Testut L, Latarjet A 1972. Tratado de Anatomia Humana, vol2. Barcelona Salvat. pp287-430. - Allan P, Dubbins P, Pozniak M, Dicken W 2006. Clinical Doppler Ultrasound. Elsevier, China,pp 73-126. Page 35 of 35