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Normal vascular variants of the upper extremity Poster No.: C-1039 Congress: ECR 2014 Type: Educational

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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and any other multimedia files are not available in the pdf version of presentations. www.myESR.org Page

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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1 and 2 depict the simplified "classical" arterial and venous pattern, as shown in anatomy textbooks.
Fig. 1 : Arteries of the upper extremity References: P. Montelone Page 3 of 35

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

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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,

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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absence of a cephalic or basilic vein in the forearm, or a duplicated axillary vein. Images
Fig. 1: Arteries of the upper extremity Page 5 of 35

Fig. 1: Arteries of the upper extremity

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Fig. 1: Arteries of the upper extremity Page 5 of 35
Fig. 2: Veins of the upper extremity Page 6 of 35

Fig. 2: Veins of the upper extremity

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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):

brachial artery division and normal flow waveform (Fig. 3): Fig. 3 References: - Amadora/PT - Normal

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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inspiration. Normal paired deep veins accompanying the arm and forearm arteries (brachial and radial ex.): Page
Fig. 4 References: - Amadora/PT - Normal cephalic and basilic veins (Fig. 5). The basilic

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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highest portion of the delto-pectoral groove, the fosseta of Morhenheim or sub-clavicular fosseta of Gerdy: Page
Fig. 5 References: - Amadora/PT Arteries - High bifurcation of the brachial artery in the

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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may be a cause of slow access maturation. In this pattern, the interosseous artery arises from
Fig. 6 References: - Amadora/PT - Two other possible arterial variants (Fig. 7): A)The interosseous

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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and the radial and ulnar arise from a common trunk; B)An aberrant radial artery arises from
Fig. 7 References: - Amadora/PT - Abnormal trifurcation of the brachial artery at the elbow

Fig. 7 References: - Amadora/PT

- Abnormal trifurcation of the brachial artery at the elbow level

(Fig. 8):

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Fig. 7 References: - Amadora/PT - Abnormal trifurcation of the brachial artery at the elbow level
Fig. 8 References: - Amadora/PT - Low division of the brachial artery (Fig. 9). The

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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have variable sizes or be absent. Different sizes of the radial artery in two different patients
Fig. 9 References: - Amadora/PT Deep veins - Paired axillary veins (Fig. 10): Page 13

Fig. 9 References: - Amadora/PT

Deep veins

- Paired axillary veins (Fig. 10):

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Fig. 9 References: - Amadora/PT Deep veins - Paired axillary veins (Fig. 10): Page 13 of
Fig. 10 References: - Amadora/PT - Brachial veins: Variability in the number (1 to 3)

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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- Brachial veins: Variability in the number (1 to 3) and disposition around the brachial artery
Fig. 11 References: - Amadora/PT - Basilic-brachial confluent at variable levels in the upper arm

Fig. 11 References: - Amadora/PT

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

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11 References: - Amadora/PT - Basilic-brachial confluent at variable levels in the upper arm (Fig. 12):
Fig. 12 References: - Amadora/PT - There is high variability of the classically described cephalic-axillary

Fig. 12 References: - Amadora/PT

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

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- Amadora/PT - There is high variability of the classically described cephalic-axillary confluent (Fig. 13): Page
Fig. 13 References: - Amadora/PT - Communicating vein of the elbow (Fig. 14). Classically described

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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from the deep system to the superficial system. This is the opposit of what is described
Fig. 14 References: - Amadora/PT Superficial veins The superficial vein system is the most variable.

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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sized (A) and residual (B)cephalic veins; C and D) Normal sized (C) and residual (D) basilic
Fig. 15 References: - Amadora/PT - The "Y" type (A) and the "W" type (B).

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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- The "Y" type (A) and the "W" type (B). Note the accessory basilic vein (arrow)
Fig. 16 References: - Amadora/PT Images for this section: Page 20 of 35

Fig. 16 References: - Amadora/PT

Images for this section:

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Fig. 16 References: - Amadora/PT Images for this section: Page 20 of 35
Fig. 3 Page 21 of 35

Fig. 3

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Fig. 3 Page 21 of 35
Fig. 4 Page 22 of 35

Fig. 4

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Fig. 4 Page 22 of 35
Fig. 5 Page 23 of 35

Fig. 5

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Fig. 5 Page 23 of 35
Fig. 6 Page 24 of 35

Fig. 6

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Fig. 6 Page 24 of 35
Fig. 7 Page 25 of 35

Fig. 7

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Fig. 7 Page 25 of 35
Fig. 8 Page 26 of 35

Fig. 8

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Fig. 8 Page 26 of 35
Fig. 9 Page 27 of 35

Fig. 9

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Fig. 9 Page 27 of 35
Fig. 10 Page 28 of 35

Fig. 10

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Fig. 10 Page 28 of 35
Fig. 11 Page 29 of 35

Fig. 11

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Fig. 11 Page 29 of 35
Fig. 12 Page 30 of 35

Fig. 12

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Fig. 12 Page 30 of 35
Fig. 13 Page 31 of 35

Fig. 13

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Fig. 13 Page 31 of 35
Fig. 14 Page 32 of 35

Fig. 14

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Fig. 14 Page 32 of 35
Fig. 15 Page 33 of 35

Fig. 15

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Fig. 15 Page 33 of 35
Fig. 16 Page 34 of 35

Fig. 16

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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.

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- Allan P, Dubbins P, Pozniak M, Dicken W 2006. Clinical Doppler Ultrasound. Elsevier, China ,pp