ANATOMICAL STUDY OF SUPERFICIAL PALMAR ARCH AND ITS VARIATIONS WITH CLINICAL SIGNIFICANCE

Background: Superficial palmar arterial arch is a dominant vascular structure of the palm. It is defined asan arterial arcade, formed by superficial branch of the ulnar artery and completed on lateral side by the superficial palmar branch of the radial artery or Arteria radialis indicis or Arteria princeps pollicis or arteria nervimediana. Variations can occur in the vessels contributing to the formation of superficial palmar arch (SPA). Aim: The main objective of the study is to know the formation of superficial palmar arch and different types of formation with an emphasis on its clinical relevance. Result: The present study was conducted on 50 specimens, followingthe classification of Coleman and Anson. We found complete arch of type A in 43 hands (86%) and of type B in 3 hands (6%). In this study incomplete arch was seen in 4 hands (8%, 1 right and 3 left), persistent median artery type H supplying the radial side of the palm and digits was seen in only one hand (2%). Conclusion: Knowledge of such variations is of immense help for microvascular surgeons, plastic surgeons and orthopaedicians to bring a better outcome in their surgical procedures. Also, it will be helpful for cardiovascular surgeons to carryout radial artery harvesting procedures for the purpose of Coronary Artery BypassGrafting.

The present study reporting a variation of superficial palmar arch which is formed alone by superficial branch of ulnar artery and it is also giving branches to radial side of index finger and to the thumb. Normally the branch to the radial side of index finger receives branch from superficial terminal branch of radial artery and it is known as arteria radiclis indicis. A dominant vascular structure of the palm is the superficial palmar arterial arch, also known as an arterial arcade. The superficial palmar branch of the radial artery and the superficial branch of the ulnar artery are anastomosed together. By anastomosing with one of the radial artery's branches, such as the arteria radialis indicis, arteria princeps pollicis, or arteria nervi mediana, the superficial palmar arch is completed. The ARI was given by ulnar artery from the terminal part of radial side along with the princeps pollicis branch. The knowledge of variations of the vascular arches warrants the surgeons while performing surgeries on hands, such as arterial repairs, vascular graft applications. Understanding the variations of the arterial arch patterns of the hand is critical for performing safe surgical procedures on the hand. Surgeons should be aware of this type of variation when performing surgical interventions for arerial repairs and vascular graft applications, because the SPA plays an important role in the majority of traumatic conditions and surgical procedures.

Objective To summarize the cutaneous branches of the superficial branch of radial artery distribution were dissected and to discuss the operational technique and clinical efficacy of repairing hand tissue defect by the flap based on the superficial branch of radial artery. Methods From May, 2014 to February, 2017, 8 fresh hand specimens perfused with red latex to observe the distribution and characteristics. And 24 cases of fingers tissue defects (3 thumbs, 6 index fingers, 5 middle fingers, 9 ring fingers, and 1 litter finger) which were repaired with the free wrist crease flap based on the cutaneous branches of superficial palmar branch of the radial artery. Combined fracture in 5 cases. Combined rupture or defect of the flexor tendon in 8 cases. Combined vascular nerve injury in 6 cases. The maximum area of the flap was 5.5 cm × 3.2 cm, and the minimum was 2.0 cm × 1.5 cm. Regular followed-up was performed after operation. Results Superficial palmar branch of the radial artery came from the level of radial styloid process ulnar palmar then through ulnar of tubercle of scaphoideum and tended to the thenar muscle. It gave 1-3 branches of the direct skin perforators at distal wrist crease and the anatomical location was constant. The vascular pedicle length could achieve 2.0-3.2 cm. All flaps were survived uneventfully. Twenty-four cases were followed-up for 6-29 months (mean, 18.6 months), and the appearance and functional recovered satisfactorily. Flap sensation recovered to S3+. The 2 point discrimination was 8-13 mm. There was no complication in donor area. According to the fingers total active motion (TAM) method to assess: excellent in 17 cases, good in 5 cases, fair in 2 cases. The excellent and good rate was 91.7%. Conclusion The wrist crease cutaneous branches of superficial palmar branch of the radial artery anatomical location is constant. And the flap based on the artery has a reliable blood supply. The vascular pedicle flap is long enough and the operational technique is easy and safe. The postoperative effect is satisfied. It is an ideal method for repairing finger tissue defect. Key words: Superficial palmar branch of the radial artery; Wrist crease flap; Fingers injury; Tissue defect; Repair

The superficial palmar arch (SPA) and its contributing arteries are highly variable. The palmar type of median artery (PMA) can be involved in the formation of the SPA by replacing the superficial palmar branch of the radial artery (RA) or the ulnar artery (UA). The present study was undertaken to investigate the presence of the PMA and its contribution in the formation of SPA in 42 cadavers (84 upper limbs) of Indian origin. When there was a PMA, its outer diameter was measured in the carpal tunnel. The PMA was found in 13 upper limbs (15.4%), and of these ten incidences (11.9%), the PMA took part in the formation of SPA, and in three instances (3.5%), the PMA did not make up part of the SPA. Out of the ten cases in which the PMA contributed to the formation of SPA, in six cases (7.1%), the PMA anastomosed with the UA; in three cases (3.5%), the PMA anastomosed with both the UA and the RA, and in one incidence (1.1%), the PMA joined the arteria radialis indicis (deep branch of the RA) to complete the SPA. The outer diameters of the median arteries varied between 0.8 and 2.6 mm with the mean value of 1.7mm. The present study concludes that the median-ulnar type of SPA was the most common type of SPA when the PMA was encountered as a source of superficial arterial arcade of the hand, followed by the radial-median-ulnar type. The vascular patterns found in this study are important to hand surgeons. The present study of PMA origin, course, and its contribution to the SPA will add to the existing knowledge of the vascular anatomy of forearm and hand.

Variability in the topography of the arteries of the upper extremity is associated with fetal development. Determination of individual anatomical variants of the upper extremity blood supply at diff erent stages of ontogeny, especially in human fetuses, is of great practical importance in vascular surgery.Aim of the study. To study the individual anatomical variability of the ulnar and radial arteries in human fetuses of diff erent ages. Material and methods. The study of variants of the topography of the branches of the radial and ulnar arteries, the peculiarities of the formation of the superfi cial palmar arterial arch was carried out on 46 preparations of the upper extremities of 23 human fetuses 81. 0-375, 0 mm parieto- coccygeal length using macromicroscopic dissection, vascular injection and morphometry without external signs of anatomical abnormalities or congenital malformations of skeletal, fascial- muscular and vascular- nerve structures of the upper extremities.Results and discussion. Our study demonstrated fetal anatomical variability and bilateral asymmetry of the right and left upper extremity arteries in human fetuses. Thus, in a fetus with a PCL of 210.0 mm, the right brachiocephalic artery was found to originate from the right axillary artery. It should be noted that the initial portion of the right brachiocephalic artery passed anteriorly, not posteriorly, to the median nerve, and at the level of the middle third of the anterior shoulder region, the artery occupied a superfi cial position relative to the median nerve, which is located in the lateral bicuspid groove of the shoulder. The brachiocephalic artery was then directed in an oblique lateral direction to the lateral surface of the forearm. In this fetus, a high origin of the right ulnar artery was found, which originated from the trunk of the brachiocephalic artery in the upper third of the right anterior shoulder region. At the border of the middle and lower thirds of the anterior shoulder region, the ulnar artery crossed the ulnar nerve anteriorly and passed with it in the median biceps groove of the shoulder. 3.0 mm below the beginning of the ulnar artery, the superior circumfl ex ulnar artery bifurcated from the brachiocephalic artery, and in the lower third of the anterior shoulder region, a common trunk bifurcated from the brachiocephalic artery and bifurcated into the middle and inferior circumfl ex ulnar arteries. We found arterial anastomoses between the latter and branches of the ulnar artery. The immediate continuation of the right brachiocephalic artery in the palm was the brachiocephalic artery of the thumb. At the level of the base of the proximal phalanx of the thumb, the brachiocephalic artery branched into three palmar fi nger arteries, which were directed to both edges of the palmar surface of the fi rst fi nger and the radial edge of the palmar surface of the second fi nger. The superfi cial palmar arch was formed by the superfi cial palmar branch of the brachial radial artery, the terminal ulnar artery, and the anterior interosseous artery. Four common palmar arteries originated from the superfi cial palmar arch and were directed to the ulnar edge of the palmar surface of the second fi nger and the palmar surfaces of the adjacent edges of the third through fi fth fi ngers.The left superfi cial palmar arch had an atypical structure located under the palmar aponeurosis at the level of the middle of the metacarpals and formed by the terminal parts of the ulnar and anterior interosseous arteries. Because the radial artery in this fetus was traced to the distal part of the forearm (to the scaphoid bone), we did not fi nd branches of this artery in the palm area, especially the superfi cial palmar branch of the radial artery. The ulnar artery was directed caudally to the palmar region, curving slightly in an arc to the radial side of the hand. From the terminal portion of the ulnar artery, three common palmar fi nger arteries bifurcated, which in turn bifurcated into fi ve palmar fi nger arteries of their own. The latter supplied the ulnar edge of the third fi nger and the palmar areas of the fourth and fi fth fi ngers. The radial edge of the third fi nger and the palmar areas of the II-I fi ngers were supplied by fi ve separate palmar arteries originating from the terminal portion of the anterior interosseous artery. Anastomoses were found between the palmar arteries, mainly in the middle and terminal phalanges. In the area of the palm, numerous muscular branches bifurcated from the anterior interosseous and ulnar arteries, providing blood supply to the palm muscles. Conclusions. In the majority of the studied fetuses (82.61 %) the superfi cial palmar arch was closed, in 17.39 % of the observations it was not closed. In 10.5 % of cases, the superfi cial palmar arch was formed by the trunk of the ulnar artery and the median forearm artery, and in 5.2 % – with the participation of the ulnar and anterior interosseous arteries. The ulnar artery is predominantly involved in the formation of the superfi cial palmar arch. In a fetus with a PCL of 210.0 mm, the right brachiocephalic artery was found, as well as a high origin of the right ulnar artery from it and an atypical branching of other branches. In particular, the superfi cial palmar arch was formed by the superfi cial palmar branch of the brachial radial artery, the terminal ulnar artery, and the anterior interosseous artery, while the left superfi cial palmar arch was formed by the terminal ulnar and anterior interosseous arteries.

Superficial palmar arch (SPA) is a dominant vascular structure in the palmar region that provides a major blood supply to fingers. Present case describes a rare formation and branching pattern of SPA in a formalin fixed cadaveric left hand. In this case, SPA was formed by the anastomoses between radial artery (RA) and the superficial brachioulnar artery (SBUA), which is defined as an ulnar artery with a high origin in the arm. More interestingly, unlike classic literature, SPA sends out six branches instead of four, and the principle artery of thumb arises directly from SPA instead of RA. The aforementioned variations have rarely been reported in previous literature and demonstrate important clinical significance for accidental intra-arterial injections, errors in blood pressure readings, as well as orthopedic, plastic and vascular surgeries of the upper limbs.

Equally, the sensitive anastomosis between the median nerve (MN) and the ulnar nerve (UN) in the hand, and the superficial palmar arch (SPA) variants have been broadly publicised to be of clinical and surgical significance. In this study, we aim to analyse metrically, topographic relations between this nervous anastomosis to both the SPA and the transverse carpal ligament. Material and methods 30 10% formalin-fixed adult human cadavers' hands, readily available at the Department of Morphology of Santa Casa de Sao Paulo School of Medical Sciences, have been dissected in order to evaluate primarily, the SPA formation pattern classified in accordance to five types proposed by Loukas et al, 2005. Deep dissection henceforth ensued in 15 specimens to expose the MN and UN ramus and their potential coupling in four patterns as suggested by Meals & Shaner, modified by Bas & Kleinert, 1999. Results Amongst our samples, the SPA variants distribution has been of: 11 (36.7%) type S-I, 13 (43.4%) type S-II, 1 (3.4%) type S-III, 1 (3.4%) type S-IV and 4 (13.4%) S-V. MN and UN distal anastomosis has been found in four hands, three type-I, and one type-III: type-I cases ran profoundly to the APS, and type-III mean distance to the SPA was </a>1.6 cm distally. Conclusion We have been able to assess a topographic relation between the SPA and the sensitive anastomosis in the hand potentially valuable to clinics and surgery; nonetheless, we encourage forward study in this regard.

The most essential prerequisite for hand surgeons is a comprehensive knowledge of variations in the arterial architecture of the hand. There are two well designed arterial arches, superficial palmar arch (SPA) and the deep palmar arch (DPA) situated superficial and deep to flexor tendons and lumbrical muscles respectively. Even though both are formed by the contribution of radial and ulnar arteries, variations are numerous and frequent in SPA that attracts the attention of surgeons. During the routine dissections we found a rare variation in the structural architecture of SPA which was formed by anastomosis of the radial - median and ulnar arteries. This triarterial combination of SPA is an advantage in reconstructive hand surgeries, microvascular surgeries and radial artery harvesting for Coronary artery bypass graft. Presence of incomplete SPA is dangerous to tackle surgically. Screening is essential to know the exact arterial pattern for successful hand surgeries without postoperative complications.

Objective To review the progress on the reconstruction of superficial palmar arch defect with vascular transplantation. Methods The literatures were searched by using the keywords of vascular system injuries, superficial palmar arch, vascular grafting, vein grafts, arterial graft, in the database of PubMed, CNKI, and Wanfang. Articles about reconstruction of superficial palmar arch defect with vascular transplantation before December 2016 were searched and analyzed. Results For the damage injury of superficial palmar arch, the transplantation of superficial vein and small arterial are mainly used to reconstruct the vascular defect. Different methods have different advantages and disadvantages. Foot vein transplantation mainly adopts end-to-side anastomosis, and this method can provide adequate stomas. The operation is difficult. Y-type vein transplantation needs to bridge the vessels in series. The advantage is that the remote can provide multiple stomas. But the operation is complicated. The diameter of the vessel is different from that of the vessel of recipient site. Forearm vein net transplantation can resolve the mismatching of donor site with recipient site. The anatomy of the vein net is instable, and the operative procedure is difficult. The morphology and caliber of dorsal venous arch of hand are similar to those of superficial palmar arch, and the surgical resection and anastomosis are easy. The valve obstruction and obvious scar are the limitations. Reconstruction the defect of superficial palmar arch using arcus venosus dorsalis pedis transplantation can resolve the mismatching of the vessel in diameter and amount, but the difficulty is bloodstream obstruction due to the valves. Reconstruction the superficial palmar arch defect using small arterial graft is reliable, while the disadvantage is the influence on blood supply to the muscle of donor site. Conclusions Vascular graft can be used to reconstruct the defect of superficial palmar arch and restore blood flow to the distal fingers. Repairing of the defect of superficial palmar arch with vascular graft of different site varied in surgical procedure and the difficulty of the surgery, and these methods have some defects in certain aspects. Searching for a new and suitable donor site with a vascular network has become the trend in the reconstruction of the superficial palmar arch defect. Key words: Vascular system injuries; Superficial palmar arch; Vascular grafting; Vein grafts; Arterial graft

Summary In this study, the arterial supply of the thoracic limb was investigated in Kangal dogs. Twelve adult healthy Kangal dogs of either sex were used. Latex was injected into the common carotid artery, and then the axillary artery was dissected. The axillary artery is a continuation of the sub‐clavian artery and supplies the thoracic limb in Kangal dogs. The axillary artery gave off a deltoid branch and external thoracic, lateral thoracic, and subscapular thoracic arteries in its course along the thoracic wall. The axillary artery continues distally as the brachial artery in the arm. The brachial artery gives rise to the cranial humeral circumflex, deep brachial, bicipital, ulnar collateral, superficial brachial, transverse cubital, and common interosseus arteries. It continues as the median artery after giving off the common interosseus artery. It was observed that the deep antebrachial artery arose from the median artery at the proximal third of the forearm. In the distal third of the forearm, the median artery divided into the palmar carpal and dorsal carpal branches. The deep palmar branch of the radial artery and deep branch of the palmar branch of the caudal interosseus artery form the deep palmar arch. The median artery joined the superficial branch of the palmar branch of the caudal interosseus artery to constitute the superficial palmar arch. The radial artery and cranial interosseus artery contributed to the dorsal carpal rete. The ulnar artery contributed to the formation of the deep and superficial palmar arches.

The ulnar artery provides a major blood supply to the hand in the form of the superficial palmar arch, with the assistance of the radial artery. A rare pattern of the superficial palmar arch was observed in a formalin fixed, male cadaveric left hand. The ulnar artery was only involved in the formation of this arch, which provided three common palmar digital arteries which ran into the second, third and the fourth spaces between the corresponding digits and one proper palmar digital artery which ran along the ulnar side of the little finger. The main trunk of the ulnar artery bifurcated to supply the thumb and the index finger. The superficial branch of the radial artery did not participate in the arch formation. The arch was completed by the radial artery proper on the dorsolateral surface of the hand, after joining the point of bifuracation of the ulnar artery.

The supercial palmar arch (SPA) and deep palmar arch (DPA) provide the dominant vascular supply to the hand. The SPA is highly variable with multifarious contributions from the ulnar, radial and persistent median arteries. It is classied into Complete and Incomplete SPA based on the anastomosis of Ulnar artery ( UA) with or without one of these arteries respectively. The study was conducted to estimate the prevalence of Incomplete type of supercial palmar arch. In this study, (1) dissection was done on 60 upper limbs from 30 cadavers and SPA was classied according to Coleman and Anson's classication of Complete and Incomplete SPA. Complete SPA was seen in 63.3% cases and incomplete in 36.6%. Out of the incomplete SPA, Type F was seen in 35% and Type G in 1.6% cases. This study will help in better understanding of the anatomy of the vascular structure of the palm, which can benet General and Plastic Reconstructive Surgeons, Interventional Cardiologists, Cardiothoracic Surgeons and Radiologists.

Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap.

Editor, Arterial cannulation is a commonly performed invasive procedure for continuous blood pressure monitoring in the critically ill and those undergoing major surgery. It is generally viewed as a safe procedure, but complications do occur. Whereas haematoma and temporary arterial occlusion are relatively common, more severe complications such as local infection, sepsis, nerve damage, profuse bleeding, pseudoaneurysm formation and distal ischaemia seem to be rare.1,2 In a retrospective study of 17 840 arterial cannulations, major complications were identified in just 0.084%.3 We report an unusual but severe and avoidable complication of radial artery cannulation. A 38-year-old woman developed severe bleeding during caesarean section and was admitted to the intensive care unit. An arterial cannula (20 gauge with Floswitch; BD, Franklin Lakes, New Jersey, USA) was inserted into her left radial artery. When the cannula was removed 2 days later, the patient described significant pain and a jet of blood, which was difficult to stop. Following this, the patient repeatedly complained about a painful lump on her left wrist, which initially was regarded as a haematoma. Two months later, an ultrasound examination revealed a foreign object resembling a cannula inside the artery (Fig. 1). Allen's test demonstrated total occlusion of the radial artery with perfusion of the hand by the ulnar artery only. The distal 3 cm of a polyurethane cannula was surgically removed from the artery (Fig. 2). The proximal part of the retained cannula appeared to be stretched and was cut at an angle. Fibrosis of the artery was noticed proximal to the location of the cannula, which had migrated distally to occlude the deep branch as well as the superficial palmar arch. The intima layer had suffered irreversible damage making reconstruction of the artery impossible (Fig. 3).Fig. 1: No captions available.Fig. 2: No captions available.Fig. 3: No captions available.Informed consent was obtained from the patient for publication of data from this case, including photographs. A retained cannula fragment in the radial artery can cause serious long-term complications. If collateral blood flow through the ulnar artery and palmar arches is insufficient, it could lead to claudication of the hand or even acute ischaemia due to thrombosis or embolisation.1 Existing reports of retained cannula fragments inside the radial artery point to precipitating factors that include stress on the cannula because of poor fixation, malfunctioning of the cannula itself due to poor manufacture, damage to the cannula when sewing the catheter to the skin or during removal of the securing stitch.4–7 The fact that the cannula fragment in our case was cut at an angle proximally has led us to believe that it had been damaged during placement. This can occur if the needle is re-inserted into the cannula either by accident or in order to re-position the cannula. Upon removal, the cut edge would act as a retention grip against the arterial wall, which would explain the pain and profuse bleeding as well as stretching of the cannula fragment. The retained fragment was not recognised until 2 months after its presumed removal. The intima layer was permanently damaged not just from the arterial tear but also along the course of the cannula due to foreign body reaction. At that stage, simple arterial reconstruction was not possible, something that might have had serious consequences if ischaemic symptoms had developed. The lesson to emphasise here is that reinsertion of a needle into a cannula should not be attempted when the cannula is already in the patient. A Seldinger technique either with a separate or integrated guide-wire would potentially help to avoid such complications. Furthermore, we stress that integrity of the cannula should always be confirmed following removal. Early intervention is essential to allow arterial reconstruction. Ultrasonography is suited for detection of foreign bodies and may reveal other conditions such as haematoma or pseudoaneurysm formation. We suggest that ultrasound examination should be considered if integrity of the removed cannula is uncertain or if patients experience continuous pain and discomfort from the cannulation site. Any invasive procedure carries a potential risk for the patient and to ensure patient safety in everyday procedures, such as radial artery cannulation, clinicians should be aware of the range of problems that can occur. To improve the quality and safety of treatment, an international register of complications due to inserted arterial catheters would provide useful information regarding patient risks as well as implant failure. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.

The surgical procedures on the caecum demand a precise knowledge of vascular anatomy of ileocolic region. The aim of this study is to study the arterial supply of the caecum, findings of which may reveal more anatomical facts about the arteries of caecum and their variations. Total 52 specimens of caecum and appendix with their arteries intact were collected, cleaned and dissected. The ileocolic artery and its branches to the caecum, and ileum were traced carefully and observations were recorded. The ileocolic artery arises independently from superior mesenteric artery in 96.88% of cases and ends by dividing into superior and inferior division in 93.76% of cases. The anterior and posterior caecal arteries arise by a common trunk in 56.25%. The ileocolic artery arises from the superior mesenteric artery independently in 96.88% and terminates into superior and inferior division in 93.76% of cases. Common caecal artery seen in 56.25% of cases, arises from inferior division (43.75%), superior division (9.38%) and ileocolic artery (3.12%).Anterior caecal artery arises from superior division (12.5%), inferior division (15.63%), ileocolic artery (3.12%), ileal branch (6.25%) and arterial arcade (6.25%).The posterior caecal artery arises from superior division (18.76%), inferior division (9.38%), ileal branch (3.12%), ileocolic artery (3.12%), arterial arcade (6.25%) and from ascending colic branch of inferior division (3.12%). 21.87% of cases showed additional anterior and posterior caecal arteries.