ORIGINAL COMMUNICATION

Persistent Median Artery

Cadaveric Study and Review of the Literature
N. EID, Y. ITO, M.A. SHIBATA, AND Y. OTSUKI
*
Department of Anatomy and Cell Biology, Division of Life Sciences,
Osaka Medical College, Takatsuki, Osaka, Japan
The persistent median artery (PMA) may compress the median nerve (MN)
and may be a signicant supply of blood to the hand. Two cases of unilateral
PMA (4%) were detected during the dissection of 50 upper limbs. The rst
case was a 75-year-old, right-handed male who suffered from chronic pain in
both upper limbs, especially the left side. A dissection of his left upper limb
revealed a PMA piercing both the MN and the medial branch of the anterior in-
terosseous nerve. This artery coursed distally, deep to the transverse carpal
ligament (TCL), forming a median-ulnar pattern for the supercial palmar arch
(SPA). The PMA was supercial to two nerves at the distal edge of the TCL;
the extraligamentous recurrent thenar (RT) branch of the MN and the third
common digital nerve (TCDN). The second case was from the left side of an
80-year-old female found to have a high origin of the radial artery with trifur-
cation of the latter into PMA, common interosseous, and ulnar arteries. The
PMA passed deep to the TCL forming a radial-median-ulnar pattern of SPA.
Both the transligamentous RT branch of the MN and the TCDN passed deep to
the PMA inside the carpal tunnel, before the abnormal crossing of the latter
nerve ventral to the SPA on its way to the digits. The relationships of the PMA
to various MN branches may have important implications regarding the diag-
nosis and treatment of MN compressive neuropathies. Clin. Anat. 24:627633,
2011. V VC
2011 Wiley-Liss, Inc.
Key words: persistent median artery; median nerve, carpal tunnel; palmar
arch; Gantzers muscle; kentai
INTRODUCTION
Entrapment or compressive neuropathies are wide-
spread clinical problems caused by compression of a
nerve when it passes through bro-osseous or
muscular tunnels or deep to aponeurotic and vascu-
lar channels such as a persistent median artery
(PMA), especially in patients with various occupa-
tions or with certain diseases (Spinner et al., 1991;
Dellon, 2004; Lee and LaStayo, 2004; Eid and
Otsuki, 2009).
The median artery is usually only a transitory
vessel that represents the arterial axis of the fore-
arm during early embryonic life, providing the main
blood supply to the hand in the embryo. After the
8th week of gestation, the ulnar and radial arteries
develop, and the median artery usually regresses
by undergoing apoptosis to become a small vessel
accompanying the MN, the arteria comitans nervi
mediani (Henneberg and George, 1992; Higgins and
James, 2010). The median artery may persist in
adult life in two different patterns, palmar and ante-
brachial. The antebrachial type, which represents a
partial regression of the embryonic artery is slender,
short, and terminates before reaching the wrist.
The palmar type, which represents the embryonic
*Correspondence to: Y. Otsuki, Department of Anatomy and Cell
Biology, Division of Life Sciences, Osaka Medical College, 2-7 Dai-
gaku-Machi, Takatsuki, Osaka 569-8686, Japan.
E-mail: an1001@art.osaka-med.ac.jp
Received 24 October 2010; Revised 1 December 2010;
Accepted 7 December 2010
Published online 12 January 2011 in Wiley Online Library
(wileyonlinelibrary.com). DOI 10.1002/ca.21127
V VC
2011 Wiley-Liss, Inc.
Clinical Anatomy 24:627633 (2011)
pattern, is large, long, and reaches the palm (Rodri-
guez-Niedenfuhr et al., 1999). Therefore, the term
PMA refers to the palmar type of median artery
(Natsis et al., 2009).
The presence of a PMA may result in numerous
complications related to proximal and distal MN com-
pression. Carpal tunnel syndrome (CTS) was
reported to be caused by a PMA (Jones and Ming,
1988; Proudman and Menz, 1992) or secondary to
abnormal pathology of the PMA as calcication (Dick-
inson and Kleinert, 1991), thromboses (Maxwell et
al., 1973; Beran et al., 1997; Khashaba et al., 2002;
Kele et al., 2002) atherosclerosis (Luyendijk, 1986),
dilatation (Feldkamp et al., 1995; Gassner et al.,
2002), and trauma (Tsagarakis et al., 2004). The
PMA was also reported to be involved in compression
of the MN and anterior interosseous nerve (AIN)
in the proximal forearm, resulting in pronator
syndrome (PS) and anterior interosseous nerve
syndrome (AINS), respectively (Gainor and Jeffrid,
1987; Jones and Ming, 1988; Proudman and Menz,
1992; Lee and LaStayo, 2004). Persistence of the
median artery may also occur in conjunction with
anomalies of the MN. Several authors have described
division of the MN by the median artery (Jones
and Ming, 1988; Srivastava and Pande, 1990), while
others have reported the occurrence of PMA associ-
ated with high division of the nerve and involvement
in an arteriovenous malformation (Al-Turk and
Metcalf, 1984; Krishnamoorthy et al., 1998; Gutow-
ski et al., 2000; Lindley et al., 2003; Krol et al.,
2005; Pierre-Jerome et al., 2010).
The PMA may contribute signicantly to blood ow
of the upper limb. A case report by Bataineh and
Moqattash (2005) described a complex variation in
the SPA in the left hand of a female cadaver where
the PMA terminated uniquely in the hand as the prin-
cips pollicis and radialis indicis arteries. A review of
the anatomy and embryology suggests that there is
an association between the PMA and an incomplete
palmar arch, and that the PMA may arise from the
radial artery, leading to an increased risk of hand
ischemia if it is sacriced during harvesting of a
radial forearm ap (Varley et al., 2008). Davisdon
and Pichora (2009) reported the elevation of a free
forearm ap based on an anomalous PMA arising
from the common interosseous artery for a case of
oropharyngeal reconstruction. A PMA, arising as a
branch of the radial artery, was noted to supply
the dominant septocutaneous perforators to the
overlying forearm skin paddle based on a radial
artery ap (Acarturk et al., 2008).
Persistent median arteries vary in their mode of
origin and have been described as arising from the
ulnar, common or anterior interosseous, radial, or
brachial arteries (Claassen et al., 2008; Natsis et al.,
2009; Nayak et al., 2010). The palmar pattern of
termination is variable: the artery may terminate
either in a complete SPA (median-ulnar or radial-
median-ulnar) or in an incomplete one. In the latter
pattern, the artery continues either as the 2nd com-
mon palmar digital artery or divides into the 1st two
common palmar digital arteries (Coleman and
Anson, 1961; Loukas et al., 2005 Claassen et al.,
2008; Natsis et al., 2009). However, the radial-
median pattern of incomplete SPA has also been
reported (Sanudo et al., 1994; Tsuruo et al., 2006;
Varley et al., 2008; Nayak et al., 2010). The various
patterns of PMA contribution to SPA are shown in
Figure 1 based on the above-mentioned studies.
The external diameter of the PMA is important,
especially in the carpal tunnel (CT). According to
Barfred et al. (1985), a PMA with an external dia-
meter of more than 2.0 mm can cause MN compres-
sion. They operated on 239 patients with CTS and
found a PMA of considerable caliber in 4% of cases
(Barfred et al., 1985). The PMA is variable in size,
with a diameter ranging from 0.8 to 2.7 mm in dif-
ferent cadaveric studies (Claassen et al., 2008;
Nayak et al., 2010).
Common variations of the path of the RT branch
of the MN in relationship to the exor retinaculum
or the TCL were reported to be extraligamentous,
subligamentous, and transligamentous (Lanz, 1977;
Sacks et al., 2007). The TCDN has been described as
the most commonly injured digital nerve during car-
pal tunnel release. Engineer et al. (2008) identied
three specic anatomic variations for the origin of
the TCDN: Type 1, originating proximal to the distal
edge of the TCL (15%); Type 2, originating distal to
the TCL but proximal to the SPA (70%); and Type 3,
originating distal to the TCL and at/or distal to the
SPA (15%).
Studies investigating the palmar patterns of the
PMA in kentai (donated cadavers) (Tobbs et al.,
2009), and their relationship to the MN branches,
especially the RT and TCDN, and more importantly,
the clinical impact of these relationships, are lacking
in the literature. Here, the morphological patterns
of PMA and their relationships to the MN branches
in the upper limbs of 25 cadavers were investigated.
A brief review of the clinical importance of the
PMA and its various patterns in the hand is pre-
sented.
MATERIALS AND METHODS
Fifty upper limbs of donated adult cadavers from
the Department of Anatomy, Osaka Medical College,
Japan were studied. These limbs were investigated
during the routine dissection performed by under-
graduate medical students. The forearms were care-
fully dissected and observed for the presence of the
PMA. When the PMA was observed, it was carefully
dissected from its origin to its termination. The origin
of the PMA and its relation with the MN, AIN, and
Gantzers muscle (GM) were studied in detail. The CT
was explored to identify the relationship of the PMA
to the MN and its branches (RT and TCDN). The
external diameters of the PMA were measured at its
origin and termination at the distal edge of the TCL
by a caliper, with a precision of 0.05 mm. The medi-
cal history of the cases with PMA was obtained by
direct contact with the relatives.
RESULTS
From our series, two cadavers were identied with
PMA. These cases are further detailed below.
628 Eid et al.
Case 1
A 75-year-old-man was found to have a left PMA
arising from the anterior interosseous artery and
piercing both the MN and the medial branch of the
AIN (Figs. 2 and 3). The MN, shortly after its perfora-
tion and division by the PMA into medial and lateral
branches, reformed again into a single trunk
(Fig. 2). The PMA passed supercial and lateral to
Fig. 3. The left PMA passes supercial to both the
TCDN and RT nerve at the distal edge of the TCL and
forms a median-ulnar pattern of complete SPA. The
short red arrows show the common palmar digital
arteries, while the long red arrow marks the thin part of
the SPA. The short black arrow points to a perforating
branch, while the bent arrow indicates the RT branch of
MN. The star marks the TCDN. The inset is a higher
magnication of the marked area in the main gure.
UA, ulnar artery; PMA, persistent medial artery; MN,
median nerve; TCL, transverse carpal ligament.
Fig. 2. A left PMA perforating both the MN and the
medial branch of the AIN. The sites of perforation are
marked by red circles. The red arrow indicates the
posterior interosseous artery, while the black arrow
marks the fascial sheath. RA, radial artery; CIA,
common interosseous artery; PT, pronator teres; AIN,
anterior interosseous nerve; AIA, anterior interosseous
artery; PMA, persistent median artery; MN, median
nerve; UA, ulnar artery; GM, Gantzers muscle; FPL,
exor pollicis longus muscle.
Fig. 1. Patterns of PMA contribution to SPA. The main patterns include median-
ulnar (A), radial-median-ulnar (B), and radial-median (E, F). Note the SPA is
complete only in A and B, while incomplete in C, D, E, and F. RA, radial artery; MA,
median artery; UA, ulnar artery.
629 Clinical Importance of the Persistent Median Artery
the MN during its course distally. Both the PMA and
MN passed deep to the single head of the pronator
teres muscle and then descended supercial to both
the GM and the exor digitorum profundus muscle.
The AIN descended lateral to the PMA deep to the
tendon of the GM (Fig. 2). The PMA accompanied the
MN toward the hand, where it changed its direction
slightly toward the medial side of the nerve in the
lower third of the forearm before passing deep to
the TCL inside the CT (Fig. 3). The PMA joined the
supercial branch of the ulnar artery forming a
median-ulnar pattern of complete SPA. The connect-
ing branch between the PMA and the ulnar artery
was thin. The SPA received or sent a perforating
branch possibly from or to the deep palmar arch.
The SPA gave rise to four common palmar digital
arteries. The external diameters of the PMA were
1.6 mm at the origin and 2.1 mm at its termination.
The RT branch of the MN arose at the distal edge of
the TCL (extraligamentous) and then passed deep to
the PMA, coursing toward the thenar muscles later-
ally (Fig. 3, inset). The TCDN originated deep to the
PMA just distal to the TCL at the level of the SPA
(Engineer type-3). The right upper limb was normal,
and the PMA was absent. The only available medical
history of this case was that he had suffered from
chronic pain in both upper limbs, in particular the left
side, which was increased by work as a carpenter.
Case 2
An 80-year-old female was found to have a PMA
on the left side (Figs. 4 and 5). This limb demon-
strated a high origin of the radial artery from the
lower third of the brachial artery above the elbow.
The brachial artery trifurcated below the elbow into
three divisions: ulnar artery medially, common inter-
osseous artery laterally, and PMA between them
(Fig. 4, inset). The PMA followed the MN in the fore-
arm, passing supercial and lateral to it without any
perforation or compression of related nerves (Fig. 4).
The PMA coursed distally toward the hand accompa-
nying the MN deep to the TCL. In the hand (Fig. 5),
the PMA joined both the ulnar artery and the super-
cial palmar branch of the radial artery, forming a
complete SPA of the radial-median-ulnar pattern.
The arch gave rise to four common palmar digital
arteries, in addition to branches to the thenar
muscles. Inside the CT, the RT nerve arose from the
volar aspect of the MN and then pierced the TCL
(transligametous) deep and just lateral to the PMA.
Then, the RT nerve passed through the TCL in a
short, intraligamentous course before its termination
inside the thenar muscles (Fig. 5, inset). The TCDN
originated from the MN inside the CT (Engineer type-
1) and crossed abnormally over the SPA toward the
third web space. The diameter of the PMA was
1.7 mm at its origin and 1.9 mm at its termination.
The right upper limb had no PMA. This donor was
diabetic and suffered from diabetic neuropathy.
DISCUSSION
Dissection of the left upper limb in the rst
cadaver showed a PMA perforating both the MN and
the medial branch of the AIN (innervating exor digi-
torum profundus). The piercing of both the MN and
AIN by the PMA was reported in only one prior case
cadaveric study (120 cases) (Rodriguez-Niedenfuhr
et al., 1999). Because of the perforation of both the
Fig. 4. A PMA arising from a trifurcated brachial
artery. The arrow marks the approximate level of the
elbow joint. BA, brachial artery; RA, radial artery; CIA,
common interosseous artery; AIN, anterior interosseous
nerve; AIA, anterior interosseous artery; PIA, posterior
interosseous artery; PMA, persistent median artery;
MN, median nerve; UA, ulnar artery; PQ, pronator
quadrates.
Fig. 5. The PMA crosses both the TCDN and the
RT branch of the MN within the CT and forms a radial-
median-ulnar pattern of complete SPA. The red arrows
mark the medial three common palmar digital arteries,
while the red star indicates the rst common digital
artery. The TCDN is marked by a black star, while the
RT branch of the MN is indicated by a curved arrow.
TCL, transverse carpal ligament; UA, ulnar artery; PMA,
persistent median artery; MN, median nerve; RA, radial
artery.
630 Eid et al.
MN and AIN and the coursing of the AIN deep to the
tendon of GM, this donor may have suffered from
symptoms related to PS and AINS (Gainor and
Jeffrid, 1987; Proudman and Menz, 1992; Eid and
Otsuki, 2009). There is also the possibility that this
donor had suffered from chronic CTS, because the
PMA, with a diameter of 2.1 mm, was supercial to
the MN inside the CT (Barfred et al., 1985; Gassner
et al., 2002; Barbe et al., 2005). In fact, the actual
diameter of the PMA before death may have been
larger. In addition, the possibility of a double-crush
lesion due to multiple sites of MN compression by the
PMA cannot be ruled out (Jones and Minges, 1988;
Spinner et al., 1991; Claassen et al., 2008). The
TCDN in this donor was Engineer type 3 (Engineer
et al., 2008), while the RT branch of the MN was
extraligamentous (Lanz, 1977), so that both nerves
may be injured during surgical operations for CTS.
The formation of a median-ulnar pattern of SPA in
our case has been reported by others with varying
incidences due to racial and sample size differences.
Table 1 shows various patterns of PMA contribution
to SPA and the incidence in different studies. The
segment of the SPA connecting the PMA and the
ulnar artery was thin and gave or received a perfo-
rating branch possibly to or from the deep palmar
arch in a similar manner to the ulnar-deep palmar
arch pattern of SPA reported by others (Ikeda et al.,
1988; Loukas et al., 2005).
The second donor was an elderly woman who had
suffered from chronic diabetes mellitus and associ-
ated neuropathy. It is known that diabetes itself,
as a metabolic disease, can also cause CTS. Some
studies found that decompression of the MN in the
CT in patients with diabetes gives excellent relief of
CTS symptoms (Dellon, 2004). In the second case,
the origin of the PMA from a trifurcated brachial ar-
tery associated with a high origin radial artery from
the latter has been reported (Rodr guez-Baeza et al.,
1995). The abnormal origin of the radial artery could
possibly complicate radiographic, surgical, and
orthopedic procedures not only in the arm, but also
during harvesting of the radial artery for coronary
artery bypass procedures (Loukas and Curry, 2006;
Tubbs and Loukas, 2006). The PMA coursed distally,
accompanying the MN deep to the TCL, forming a
radial-median-ulnar pattern of SPA (Table 1). The
relationships of the PMA to the TCDN and the RT of
the MN in the second case differed from those of
the rst case. The TCDN was type 1 according to
Engineer et al. (2008), while the RT branch of the
MN was classied as transligamentous based on the
study by Lanz (1977). In fact, the RT nerve also had
an additional short intraligamentous course within
the limbs of the TCL before diving into the thenar
muscles (Green and Morgan, 2008). It has been
reported that the transligamentous RT branch of the
MN is more liable to be compressed by the bers of
the TCL (Lanz, 1977; Sacks et al., 2007). Because
the transligamentous RT nerve and type 1 TCDN
arose inside the CT, they are directly deep to the
PMA, with a great possibility of their compression
resulting in CTS. Further, both nerves are liable to
be injured, particularly during endoscopic surgical
decompression in CTS patients (Vinding et al., in
press). Moreover, the TCDN crossed supercial to
the SPA, which is an abnormal pattern not reported
by Engineer et al. (2008) and should be considered
during surgical procedures in the hand.
The developmental basis for the presence of the
PMA has been explained by two theories. In the rst,
the median artery was formed as a branch of the
embryological axial artery via sprouting angiogene-
sis, and its persistence may be due to retention
of primitive patterns. This theory may provide the
reason for the abnormal branching pattern of
the brachial artery and the high origin of the radial
artery in the second case. A recent hypothesis
proposed that the arterial supply of the upper limb
develops from a plexus of capillaries that undergo
progressive differentiation from proximal to distal
(Rodr guez-Niedenfuhr et al., 2001, 2003; Roy,
2003).
During human evolution, the arteries of the upper
extremity have remained separate and deep to the
nerves. This may account for the supercial position
of the TCDN in relation to the SPA in the second
case. An artery penetrating a nerve is usually consid-
ered to be a phylogenetic remnant, because this
structural feature is common in lower primates and
correlates with their extreme muscular development,
which requires an extensive blood supply (Roy,
2003). This may explain the association of the PMA
with the GM in the rst case of our study. Vessels
that penetrate or drape across a nerve have been
reported to cause several nerve compression syn-
TABLE 1. Studies Investigating the Incidence and Patterns of the Persistent Median Artery
Anastmosis With Ulnar and Radial Arteries
Author/year/method/No of cases Median-ulnar Radial-median-ulnar Radial-median
Colman and Anson (1961) CD, No. 650 3.8% 1.2%
Al-Turk and Metcalf (1984), DUS, No. 25 4% 2%
Ikeda et al. (1988) angiography, No. 110 0.9%
Gellman et al. (2001) CD, No. 55 13.3% 2.2%
Loukas et al. (2005) CD, No. 100 15% 6%
Bilge et al. (2006) CD, No. 26 4%
Claassen et al. (2008) CD, No. 27 5.5%
Natsis et al. (2009) CD, No. 36 2.78%
Nayak et al. (2010) CD, No. 42 7.1% 3.5% 1.1%
Eid et al. (current study) CD, No. 25 2% 2% -
CD, cadaveric dissection; DUS, Doppler ultrasound.
631 Clinical Importance of the Persistent Median Artery
dromes. The perforation of the MN by the PMA in the
rst case may be either a phylogenetic remnant, as
in lower primates, or a remnant of the capillary
plexus around the MN that anastomosed with the
PMA (Jones and Ming, 1988; Rodr guez-Niedenfuhr
et al., 2003; Roy, 2003).
To the best of our knowledge, this is the rst
report showing combinations of different palmar
patterns of the PMA with various relationships to
proximal and distal branches of the MN, specically
the RT and TCDN. These relationships may have
important clinical implications for the diagnosis and
treatment of various tunnel syndromes related to the
MN or its branches.
REFERENCES
Acarturk TO, Tuncer U, Aydogan LB, Dalay AC. 2008. Median artery
arising from the radial artery: Its signicance during harvest of
a radial forearm free ap. J Plast Reconstr Aesthet Surg 61:e5
e8.
Al-Turk M, Metcalf WK. 1984. A study of the supercial palmar arteries
using the Doppler Ultrasonic Flowmeter. J Anat 138:2732.
Barbe M, Bradeld J, Donathan M, Elmaleh J. 2005. Coexistence of
multiple anomalies in the carpal tunnel. Clin Anat 18:251259.
Barfred T, Hjlund AP, Bertheussen K. 1985. Median artery in carpal
tunnel syndrome. J Hand Surg Am 10:864867.
Bataineh ZM, Moqattash ST. 2006. A complex variation in the
supercial palmar arch. Folia Morphol (Warsz) 65:406409.
Beran SJ, Friedman RM, Kassir M. 1997. Recurrent digital ischemia
due to thrombosis of the persistent median artery. Plast Reconstr
Surg 99:11691171.
Bilge O, Pinar Y, Ozer MA, Go vsa F. 2006. A morphometric study on
the supercial palmar arch of the hand. Surg Radiol Anat 28:
343350.
Claassen H, Schmitt O, Wree A. 2008. Large patent median arteries
and their relation to the supercial palmar arch with respect to
history, size consideration and clinic consequences. Surg Radiol
Anat 30:5763.
Coleman SS, Anson BJ. 1961. Arterial patterns in the hand based
upon a study of 650 specimens. Surg Gynecol Obstet 113:409
424.
Davidson JS, Pichora DR. 2009. Median artery forearm ap. Ann
Plast Surg 62:627629.
DCosta S, Narayana K, Narayan P, Nayak SR, Madhan SJ. 2006.
Occurrence and fate of palmar type of median artery. ANZ J
Surg 76:484487.
Dellon AL. 2004. Diabetic neuropathy: Review of a surgical
approach to restore sensation, relieve pain, and prevent ulcera-
tion and amputation. Foot Ankle Int 25:749755.
Dickinson JC, Kleinert JM. 1991. Acute carpal-tunnel syndrome
caused by a calcied median artery. A case report. J Bone Joint
Surg Am 73:610611.
Eid N, Otsuki Y. 2009. A case of double Gantzers muscle and its
possible role in nerve entrapment. Clin Anat 22:881882.
Engineer NJ, Hazani R, Mowlavi A, Neumeister MW, Lee WP,
Wilhelmi BJ. 2008. Variations in the anatomy of the third com-
mon digital nerve and landmarks to avoid injury to the
third common digital nerve with carpal tunnel release. Eplasty
8:e51.
Feldkamp MM, Gentili F, Hudson AR, Guha A. 1995. A persistent
median artery causing carpal tunnel syndrome in a patient with
chronic renal failure: Case report. Neurosurgery 37:140143.
Gainor BJ, Jeffries JT. 1987. Pronator syndrome associated with a
persistent median artery. A case report. J Bone Joint Surg Am
69:303304.
Gassner EM, Schocke M, Peer S, Schwabegger A, Jaschke W, Bodner
G. 2002. Persistent median artery in the carpal tunnel: Color
Doppler ultrasonographic ndings. J Ultrasound Med 21:455461.
Gellman H, Botte MJ, Shankwiler J, Gelberman RH. 2001. Arterial
patterns of the deep and supercial palmar arches. Clin Orthop
Relat Res 383:4146.
Green DP, Morgan JP. 2008. Correlation between muscle morpho-
logy of the transverse carpal ligament and branching pattern of
the motor branch of median nerve. J Hand Surg Am 33:1505
1511.
Gutowski KA, Olivier WA, Mehrara BJ, Friedman DW. 2000. Arte-
riovenous malformation of a persistent median artery with a
bifurcated median nerve. Plast Reconstr Surg 106:1336
1339.
Henneberg M, George BJ. 1992. A further study of the high inci-
dence of the median artery of the forearm in Southern Africa.
J Anat 181:151154.
Higgins JP, McClinton MA. 2010. Vascular insufciency of the upper
extremity. J Hand Surg Am 35:15451553.
Ikeda A, Ugawa A, Kazihara Y, Hamada N. 1988. Arterial patterns in
the hand based on a three-dimensional analysis of 220 cadaver
hands. J Hand Surg Am 13:501509.
Jones NF, Ming NL. 1988. Persistent median artery as a cause of
pronator syndrome. J Hand Surg Am 13:728732.
Kele H, Verheggen R, Reimers CD. 2002. Carpal tunnel syndrome
caused by thrombosis of the median artery: The importance
of high-resolution ultrasonography for diagnosis. Case report.
J Neurosurg 97:471473.
Khashaba A. 2002. Carpal tunnel syndrome from thrombosed
persistent median artery. J Emerg Med 22:5557.
Krishnamoorthy L, Murison MS, Sykes PJ. 1998. Arteriovenous
malformation of the forearm as a result of a persistent median
artery. J Hand Surg Br 23:820821.
Kro l A, Palczak A, Jedrzejewski KS. 2005. Split median nerve. A
report of two cases. Folia Morphol 64:341344.
Lanz U. 1977. Anatomical variations of the median nerve in the
carpal tunnel. J Hand Surg Am 2:4453.
Lee MJ, LaStayo PC. 2004. Pronator syndrome and other nerve
compressions that mimic carpal tunnel syndrome. J Orthop Sports
Phys Ther 34:601609.
Lindley SG, Kleinert JM. 2003. Prevalence of anatomic variations
encountered in elective carpal tunnel release. J Hand Surg Am
28:849855.
Lippert H. 1984. Variabilitat der Hand und Fussarterien (Variability
of hand and foot arteries). Handchir Mikrochir Plast Chir 16:
254258.
Loukas M, Curry B. 2006. A case of an atypical radial artery. Clin
Anat 19:706707.
Loukas M, Holdman D, Holdman S. 2005. Anatomical variations
of the supercial and deep palmar arches. Folia Morphol 64:78
83.
Maxwell JA, Kepes JJ, Ketchum LD. 1973. Acute carpal tunnel
syndrome secondary to thrombosis of a persistent median
artery. Case report. J Neurosurg 38:774777.
Luyendijk W. 1986. The carpal tunnel syndrome. The role of a
persistent median artery. Acta Neurochir 79:5257.
Natsis K, Iordache G, Gigis I, Kyriazidou A, Lazaridis N, Noussios G,
Paraskevas G. 2009. Persistent median artery in the carpal
tunnel: anatomy, embryology, clinical signicance, and review
of the literature. Folia Morphol 68:193200.
Nayak SR, Krishnamurty A, Ramanathan L, Prabhu LV, Kumar SJ,
Prabhu LV, Potu BK, DCosta S, Ranade AV. 2010. Palmar type
of median artery as a source of supercial palmar arch: A cada-
veric study with its clinical signicance. Hand 5:3136.
Pierre-Jerome C, Smitson RD Jr, Shah RK, Moncayo V, Abdelnoor M,
Terk MR. 2010. MRI of the median nerve and median artery
in the carpal tunnel: Prevalence of their anatomical variations
and clinical signicance. Surg Radiol Anat 32:315322.
Proudman TW, Menz PJ. 1992. An anomaly of the median artery
associated with the anterior interosseous nerve syndrome.
J Hand Surg Br 17:507509.
Rodr guez-Baeza A, Nebot J, Ferreira B, Reina F, Pe rez J, Sanudo
JR, Roig M. 1995. An anatomical study and ontogenetic explana-
tion of 23 cases with variations in the main pattern of the human
brachio-antebrachial arteries. J Anat 187:473749.
632 Eid et al.
Rodr guez-Niedenfuhr M, Sanudo JR, Va zquez T, Nearn L, Logan B,
Parkin I. 1999. Median artery revisited. J Anat 195:5763.
Rodr guez-Niedenfuhr M, Burton GJ, Deu J, San udo JR. 2001.
Development of the arterial pattern in the upper limb of staged
human embryos: Normal development and anatomic variations.
J Anat 199:407417.
Rodr guez-Niedenfuhr M, Vazquez T, Parkin IG, Sanudo JR. 2003.
Arterial patterns of the human upper limb: Update of anatomical
variations and embryological development. Eur J Anat 1:2128.
Roy TS. 2003. Median nerve penetration by a muscular branch of
the brachial artery. Clin Anat 16:335339.
Sacks JM, Kuo YR, Mclean K, Wollstein R, Lee WP. 2007. Anatomical
relationships among the median nerve thenar branch, supercial
palmar arch, and transverse carpal ligament. Plast Reconstr
Surg 120:713718.
Sanudo JR, Chikwe J, Evans SE. 1994. Anomalous median nerve
associated with persistent median artery. J Anat 185:447 451.
Spinner RJ, Carmichael SW, Spinner M. 1991. Partial median nerve
entrapment in the distal arm because of an accessory bicipital
aponeurosis. J Hand Surg Am 16:236244.
Srivastava SK, Pande BS. 1990. Anomalous pattern of median
artery in the forearm of Indians. Acta Anat 138:193194.
Tsagarakis M, Tarabe M, Minoyiannis N, Tserotas P, Komninakis E.
2004. Management of traumatic complete laceration of the
median artery at the carpal tunnel: Repair or ligate? Plast
Reconstr Surg 114:10141015.
Tsuruo Y, Ueyama T, Ito T, Nanjo S, Gyoubu H, Satoh K, Iida Y,
Nakai S. 2006. Persistent median artery in the hand: A report
with a brief review of the literature. Anat Sci Int 81:242252.
Tubbs RS, Loukas M. 2006. An unusual formation of the deep
palmar arch. Clin Anat 19:708709.
Tubbs RS, Loukas M, Kato D, Ardalan MR, Shoja MM, Gadol AA. 2009. The
evolution of the study of anatomy in Japan. Clin Anat 22:425435.
Varley I, Wales CJ, Carter LM. 2008. The median artery: Its
potential implications for the radial forearm ap. J Plast Reconstr
Aesthet Surg 61:693695.
Vinding MT, Tarnowski JR, Benyahia M. 2010. A rare anatomical
variant of the thenar branch discovered during open decompres-
sion of the median nerve. Scand J Plast Reconstr Surg Hand
Surg 44:322324.
633 Clinical Importance of the Persistent Median Artery