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

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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.

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Fig. 1: Arteries of the upper extremity
References: P. Montelone

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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:

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Fig. 1: Arteries of the upper extremity

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Fig. 2: Veins of the upper extremity

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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.):

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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:

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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:

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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:

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Fig. 7
References: - Amadora/PT

- Abnormal trifurcation of the brachial artery at the elbow level

(Fig. 8):

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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):

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Fig. 9
References: - Amadora/PT

Deep veins

- Paired axillary veins (Fig. 10):

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Fig. 10
References: - Amadora/PT

- Brachial veins: Variability in the number (1 to 3) and disposition around the brachial
artery (Fig. 11):

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Fig. 11
References: - Amadora/PT

- Basilic-brachial confluent at variable levels in the upper arm (Fig. 12):

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Fig. 12
References: - Amadora/PT

- There is high variability of the classically described cephalic-axillary confluent (Fig. 13):

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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:

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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:

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Fig. 15
References: - Amadora/PT

- The "Y" type (A) and the "W" type (B). Note the accessory basilic vein (arrow) (Fig. 16):

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Fig. 16
References: - Amadora/PT

Images for this section:

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Fig. 3

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Fig. 4

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Fig. 5

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Fig. 6

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Fig. 7

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Fig. 8

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Fig. 9

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Fig. 10

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Fig. 11

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Fig. 12

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Fig. 13

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Fig. 14

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Fig. 15

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Fig. 16

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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.

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