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Journal of the Anatomical Society of India

A Very Rare Absence of Radial Artery : A Case Report

Author(s): Suganthy, J., Koshy, S., Indrasingh I., and Vettivel, S.

Vol. 51, No. 1 (2002-01 - 2002-06)

Department of Anatomy, Christian Medical College,Vellore, INDIA.

Abstract

Brachial artery ends at the level of the neck of the radius by dividing into radial and ulnar arteries. The radial artery descends along the lateral side of the forearm to the wrist, where it is palpable between flexor carpi radialis muscle and the anterior border of the radius. It then curls posterolaterally round the carpus to the proximal end of the first intermetacarpal space,where it dips into the palm and crosses medially to form the deep palmar arch with the deep branch of the ulnar artery. During the dissection course in this department, a very rare absence of radial artery was observed in the right upper limb of a south Indian female. In the lower part of the arm, brachial artery divided into ulnar and common Interosseous artery. Anterior interosseous artery was large in size. Deep to pronator quadratus, it turned laterally and reached the dorsum of the hand, where its lateral branch supplied the thumb and index finger and its medial branch dipped into the plam at the second intermetacarpal space. Superficial palmar arch was absent. Digital arteries from the medial and lateral branches of ulnar artery supplied the fingers. Embryological basis is presented.

Key words: Absence,Brachial artery, Anterior interosseous artery, Common Interosseous artery, Radial artery, ulnar artery.

Introduction:

Brachial artery ends about a centimeter distal to the elbow joint, at the level of the neck of the radius by dividing into radial and ulnar arteries. Radial artery appears a more direct continuation of brachial.It then descends along the lateral side of the forearm to the wrist, where it is palpable between flexor carpi radialis and the salient anterior border of the radius. It then curls posterolaterally round the carpus beneath the tendons of abductor pollicis longus and extensor pollicis longus et brevis, crossing the anatomical snuff-box, to the proximal end of the first intermetacarpal space, swerving medially between the heads of the first dorsal interosseous muscle into the palm and then crosses medially to form the deep palmar arch with the deep branch of the ulnar artery (Gabella 1995).

Ulnar artery, the larger terminal branch of the brachial, reaches the medial side of the forearm midway between elbow and wrist which it passes vertically, crossing the flexor retinaculum lateral to the pisiform bone and medial to the hook of hamate; distal to this, it has a deep branch and then continues across the palm as the superficial palmar arch; about a third of the superficial palmar arches are formed by the ulnar artery alone, a further third are completed by the superficial palmar branch of the radial, and another third either by the arteria radialis indicis or a branch of arteria princeps pollicis or by the median artery (Gabella 1995).

The common interosseous artery, a short branch of the ulnar just distal to the radial tuberosity, it passes back to the proximal border of the interosseous membrane, dividing into the anterior and posterior interosseous arteries. Anterior interosseous artery descends on the anterior aspect of the interosseous membrane with the median nerve's anterior interosseous branch; it is overlapped by contiguous sides of flexor digitorum profundus and flexor pollicis longus. Proximal to pronator quadratus, its continuation traverses the membrane to the back of the forearm, where it anastomoses with its own posterior interosseous branch, descending over the carpal dorsum to join the dorsal carpal arch. (Gabella 1995)

Material and Methods:

During the dissection course in this department the absence of radial artery was observed when the dissection of the arm and cubital fossa was completed. The specimen was the right upper limb of a South Indian female. Arterial tree was carefully dissected but the small branches were sacrificed.

Observations:

The brachial artery divided in the lower part of the arm into ulnar and common interosseous arteries (Fig. 1a). Radial artery was not present. No vessel was observed arising from the brachial or axillary artery that coursed distally with any resemblance to the radial artery.

Common interosseous artery was under cover of pronator teres. It gave two recurrent branches, one passed medially and the other passed laterally. It gave the posterior interosseous artery, which passed to the back of the forearm above the interosseous membrane. The continuation of the common interosseous artery was the anterior interosseous artery (Figs. 1a, 2).It passed in front of the interosseous membrane. It was unusually large in size, approximately the same caliber as the brachial and common interosseous. It passed deep to pronator quadratus muscle, turned laterally and passed deep to flexor carpi radialis and flexor pollicis longus (Figs. 1b, 2). Ulnar, common interosseous and the large anterior interosseous arteries supplied the muscles of the front of the forearm.

Further laterally, the anterior interosseous artery reached the dorsum of the hand, passed deep to abductor pollicis longus, extensor pollicis brevis, and extensor pollicis longus crossing the anatomical snuff box, and also passed deep to extensor carpi radialis longus and brevis (Figs. 1b, 3). It, then,divided into two branches. The lateral branch passed to the first interdigital cleft and divided into digital branches for the thumb and index finger.The medial branch dipped palmarward into the second intermetacarpal space (Figs. 1c, 3) and formed the deep palmar arch.

Ulnar artery passed superficial to pronator teres and flexor carpi radialis. About the junction of upper two thirds and lower one third of the front of the forearm, it divided into a lateral and a medial branches. The lateral branch accompanied the median nerve, passed deep to the flexor retinaculum and gave digital branches to the lateral two and a half fingers. The medial branch passed superficial to the flexor retinaculum and gave digital branches to the medial two and a half fingers (Figs. 1a, d). Superficial palmar arch was absent. A twig from the medial branch passed between abductor pollicis brevis and flexor pollicis brevis muscles and, at the hook of the hamate,accompanied the deep branch of ulnar nerve and completed the deep palmar arch.

Discussion:

Variations and anomalies of the arterial pattern of the upper extremity are fairly common.Detailed descriptions of major and minor variations of the arteries of the upper limb, arm, and hand have been reported (Adachi 1928; Schwyzer and De Garis 1935; Mc Cormack et al. 1953; Skopakoff 1959a, b; Coleman and Anson 1961; Lippert and Pabst 1985; Poteat, 1986; Rodriguez-Beeza et al. 1995; Aharinejad 1997; Celik et al 2001; Clerve et al. 2001).

Frequently, brachial artery divides more proximally than usual into radial, ulnar, and common interosseous arteries. Most often, radial artery arises proximally, leaving a common trunk for ulnar and common interosseous; sometimes the ulnar artery arises proximally, radial and common interosseous forming the other division; the common interosseous may also arise proximally. (Gabella 1995). However, a variation that is quite rare is the complete absense of the radial artery in the forearm. Such cases have been reported (Charles 1894; Kadanoff and Balkansky 1966; Poteat 1986).

The arterial pattem of the present specimen is primitive as the anterior interosseous artery is the dominant supply of the forearm and a "superficial ulnar artery" (Lippert and Pabst, 1985) represents the ulnar artery. The anterior interosseous artery is the part of the axis artery in the developing human forearm, as well as being phylogenetically the oldest of the limb arteries (Woollard 1922; Singer 1933). Axis artery and superficial brachial artery have been implicated in the morphogenesis of the arteries of the upper limb (Schwyzer and De Garis, 1935) Axillary, brachial, and interosseous arteries derive from axis artery. Transiently, median artery arises as a branch of interosseous artery (Singer 1933) and begins to regress, remaining as a residual artery, the commitans artery of the median nerve. A superficial brachial artery is a consistent embryonic vessel coexisting or not with brachial artery (Tountas and Bergman, 1993). Superficial brachial artery has two terminal branches, a medial one, which is superficial antebrachial artery and a lateral one that continues as a part of definitive radial artery (Vancov 1961). Superficial antebrachial artery divides into terminal branches, median and ulnar (Vancov 1961), Each of these branches anastomose with a corresponding branch of the primitive axis artery, which are trunks of origin of median and ulnar arteries. Gradually, superficial antebrachial artery and preanastomotic segment of its terminal branches regress. Therefore, each of median and ulnar arteries, has two segments, a deep segment, which corresponds to trunks of origin in the axis artery and a superficial, which corresponds to the postanastomotic segments of the terminal branches of superficial antebrachial artery. Radial artery develops similar to median and ulnar arteries (Rodriguez-Baeza et al. 1997). The lateral terminal branch of the superficial brachial artery anastomoses with a trunk for the deep origin of radial artery in the axis artery. Distal segments persist as a part of radial artery (Senior 1926; Singer 1933).

To summarize, in early stages of development, a single axis artery supplies the upper limb. The axis artery persists as the brachial artery and anterior interosseous artery. At a later stage, the median artery takes over the place of the main artery of the forearm while the axis artery remains as the small anterior interosseous artery. Still later, two new arteries i.e. ulnar and radial take over from the median as the main vessels of the forearm and the median artery persists only as a small vessel running along the median nerve.

In the case of Poteat (1986), the anterior interosseous artery terminated by bifurcating into medial and lateral terminal branches, whereas in others, it terminated as the lateral terminal branch only. In all three cases, the lateral terminal branch entered the palm similar to a normal radial artery. In the Kadanoff and Balkansky (1966) case, the lateral terminal branch formed the deep palmar arch, instead of the superficial palmar arch as in the Poteat case. Charles (1894) did not describe the distribution of the anterior interosseous artery in the hand. The presence of the superficial ulnar artery makes the Poteat case more primitive, for in the other two, the brachial artery terminated by bifurcating in the cubital fossa, whereas in that case it simply continued as anterior inerosseous artery. In the present case, anterior interosseous artery does not give any branch to the palm, the whole distribution only from the ulnar. The superficial palmar arch is, therefore, absent. Unlike the other three cases, the anterior interosseous artery of the present case, after reaching the dorsum of the hand crossing the anatomical snuffbox, dips to the palm in the second intermetacarpal space and forms a somewhat deep palmar arch. Thus, the present case is different from the three cases reported so far. This report is, probably, the fourth report of a case of absence of the redial artery.

In the present case, anterior interosseous remains as a dominant artery, not replaced by a median artery and while the ulnar artery developed, most of radial artery regressed or was not formed. The developing terminal part of the anterior interosseous artery had joined a vessel somewhat corresponding to the course of the distal part of radial artery. The second perforating artery, rather than the first, conveys the anterior interosseous artery, which has replaced the radial artery, from the dorsum of the hand to the plam. When the median artery persists as a major vessel to the hand, the ulnar artery and radial artery are always present, but when the anterior interosseous artery persists as a major vessel, only the ulnar artery is present in the hand. Manners-Smith (1910) cites several examples in lower primates of the major dorsal continuation of the anterior interosseous artery, which is similar in the present report. In the extensive series of cases reported by Coleman and Anson (1961) on the arterial pattern in the hand, none resembled the pattern exhibited by this specimen.

When the superficial branch of the ulnar artery did not anastomose with either superficial palmar branch of radial artery or median artery or both, the arch is considered incomplete (At-Turk and Metcalf 1984).

Basically, any arterial variation can have both morphological and clinical significance. The case reported here may be of significance to angiologists and radiologists as well as physicians, surgeons, especially traumatologists and vascular surgeons. The finding has a clinical relevance considering the frequency of procedures in this region. The clinical significance of potential vascular problems in this sort of specimen such as carpal tunnel syndrome must be noted. Other clinical points could be an absence of radial pulse available at the normal site, although there would have been a possibility of taking the pulse in the anatomical snuffbox. Also in this case, there would, undoubtdly, have been a strong pulse over the dorsal aspect of the wrist joint, due to the large anterior interosseous artery in the dorsum of the hand. Such arteries may also present a hazard to venupuncture, as do anomalous arteries in the cubital fossa (Hazlett, 1949). The superficial location of the ulnar artery in the present case, can lead to intraarterial injections or ligature instead of the vein in the cubital fossa (Pabst and Lippert 1968; Thoma and Young 1992). The comment of Van Allen et al, (1982) that absence of radial artery is not known to occur in adults indicates the rarity of the specimen such as the one described in the present report.

References:

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Fig. 1

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Fig. 2. Common interosseous artery.

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C - common interosseous artery; P - posterior interosseous artery; A - anterior interosseous artery.

Fig 3. Anterior interoseous artery in the dorsum of hand.

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A - anterior interosseous artery in anatomical snuff-box; B - extensor pollicis brevis; L - extensor pollicis longus; l - lateral branch; m - medial branch.

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