Abstract
Vascular variations in the upper and lower extremities are common entities. Generally speaking, most common are variations in depth, number of vessels, size, takeoff point, branching patterns, persistence of embryonic remnant, and failure of development. These apply to both upper and lower extremities, arteries, and veins. Clinically, these variations can affect surgical planning, such as designing flaps based on certain blood supplies and drainage patterns.
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References
Moore KL, Agur AMR, Dalley AF. Essential clinical anatomy. 4th ed. Baltimore: Lippincott Williams & Wilkins; 2011. p. xxviii, 703.
Standring S, Gray H. Gray’s anatomy: the anatomical basis of clinical practice. 40th ed. Edinburgh: Churchill Livingstone/Elsevier; 2008. p. xxiv, 1551.
Fuss FK, Matula CW, Tschabitscher M. The superficial brachial artery. Anat Anz. 1985;160(4):285–94.
Hazlett JW. The superficial ulnar artery with reference to accidental intra-arterial injection. Can Med Assoc J. 1949;61(3):289–93.
Karlsson S, Niechajev IA. Arterial anatomy of the upper extremity. Acta Radiol Diagn (Stockh). 1982;23(2):115–21.
Wei F-C, Mardini S. Flaps and reconstructive surgery. Amsterdam: Elsevier; 2016. p. 636, online resource.
Mourtialon P, Tixier H, Loffroy R, Maillart JC, Calmelet P, Dellinger P, et al. Vascular complication after insertion of a subcutaneous contraceptive implant. Acta Obstet Gynecol Scand. 2008;87(11):1256–8.
McCormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns; a study of 750 extremities. Surg Gynecol Obstet. 1953;96(1):43–54.
Chakravarthi KK, Siddaraju KS, Venumadhav N, Sharma A, Kumar N. Anatomical variations of brachial artery – its morphology, embryogenesis and clinical implications. J Clin Diagn Res. 2014;8(12):AC17–20.
Rodriguez-Niedenfuhr M, Vázquez T, Nearn L, Ferreira B, Parkin I, Sañudo JR. Variations of the arterial pattern in the upper limb revisited: a morphological and statistical study, with a review of the literature. J Anat. 2001;199(Pt 5):547–66.
Gupta R, Aggarwal A, Gupta T, Kaur H, Gaba S, Sahni D. Superficial upper limb vasculature and its surgical implications. Indian J Plast Surg. 2016;49(2):258–60.
Funk GF, Valentino J, McCulloch TM, Graham SM, Hoffman HT. Anomalies of forearm vascular anatomy encountered during elevation of the radial forearm flap. Head Neck. 1995;17(4):284–92.
Kadanoff D, Balkansky G. 2 cases with rare variations of arteries of the upper extremities. Anat Anz. 1966;118(4):289–96.
Calisir C, Baylam Geleri D, Celik L. Superficial brachioradial artery: multidetector-row computed tomography angiography findings in one case. Diagn Interv Imaging. 2015;96(4):401–3.
Diz JC, Ares X, Tarrazo AM, Alvarez J, Meaños ER. Bilateral superficial radial artery at the wrist. Acta Anaesthesiol Scand. 1998;42(8):1020.
Thoma A, Young JE. The superficial ulnar artery “trap” and the free forearm flap. Ann Plast Surg. 1992;28(4):370–2.
Fatah MF, Nancarrow JD, Murray DS. Raising the radial artery forearm flap: the superficial ulnar artery “trap”. Br J Plast Surg. 1985;38(3):394–5.
Devansh MS. Superficial ulnar artery flap. Plast Reconstr Surg. 1996;97(2):420–6.
Ramani CV, Kundagulwar GK, Prabha YS, Dushyanth J. Anomalous superficial ulnar artery based flap. Indian J Plast Surg. 2014;47(1):124–6.
Pabst R, Lippert H. Bilateral occurrence of a. brachialis superficialis, a. ulnaris superficialis and a. mediana. Anat Anz. 1968;123(2):223–6.
Nakatani T, Tanaka S, Mizukami S. Superficial brachial artery continuing as the common interosseous artery. J Anat. 1997;191(Pt 1):155–7.
Small JO, Millar R. The radial artery forearm flap: an anomaly of the radial artery. Br J Plast Surg. 1985;38(4):501–3.
Morris LG, Rowe NM, Delacure MD. Superficial dorsal artery of the forearm: case report and review of the literature. Ann Plast Surg. 2005;55(5):538–41.
Heden P, Gylbert L. Anomaly of the radial artery encountered during elevation of the radial forearm flap. J Reconstr Microsurg. 1990;6(2):139–41.
Poteat WL. Report of a rare human variation: absence of the radial artery. Anat Rec. 1986;214(1):89–95.
Nunoo-Mensah J. An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting. Ann Thorac Surg. 1998;66(3):929–31.
Ro HS, Roh SG, Shin JY, Lee NH, Yang KM. Unusual anatomic variations associated with bilateral ulnar artery hypoplasia. J Craniofac Surg. 2016;27(3):749–50.
Rodríguez-Niedenführ M, Sañudo JR, Vázquez T, Nearn L, Logan B, Parkin I. Median artery revisited. J Anat. 1999;195(Pt 1):57–63.
Chalmers J. Unusual causes of peripheral nerve compression. Hand. 1978;10(2):168–75.
Beran SJ, Friedman RM, Kassir M. Recurrent digital ischemia due to thrombosis of the persistent median artery. Plast Reconstr Surg. 1997;99(4):1169–71.
Levy M, Pauker M. Carpal tunnel syndrome due to thrombosed persisting median artery. A case report. Hand. 1978;10(1):65–8.
Gainor BJ, Jeffries JT. Pronator syndrome associated with a persistent median artery. A case report. J Bone Joint Surg Am. 1987;69(2):303–4.
Proudman TW, Menz PJ. An anomaly of the median artery associated with the anterior interosseous nerve syndrome. J Hand Surg Br. 1992;17(5):507–9.
Jones NF, Ming NL. Persistent median artery as a cause of pronator syndrome. J Hand Surg Am. 1988;13(5):728–32.
Acarturk TO, Tuncer U, Aydogan LB, Dalay AC. Median artery arising from the radial artery: its significance during harvest of a radial forearm free flap. J Plast Reconstr Aesthet Surg. 2008;61(10):e5–8.
Davidson JS, Pichora DR. Median artery forearm flap. Ann Plast Surg. 2009;62(6):627–9.
Naveen K, Jyothsna P, Nayak SB, Mohandas RKG, Swamy RS, Deepthinath R, et al. Variant origin of an arterial trunk from axillary artery continuing as profunda brachii artery--a unique arterial variation in the axilla and its clinical implications. Ethiop J Health Sci. 2014;24(1):93–6.
Sun R, Ding Y, Sun C, Li X, Wang J, Li L, et al. Color Doppler sonographic and cadaveric study of the arterial vascularity of the lateral upper arm flap. J Ultrasound Med. 2016;35(4):767–74.
Katsaros J, Schusterman M, Beppu M, Banis JC Jr, Acland RD. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg. 1984;12(6):489–500.
Hamahata A, Nakazawa H, Takeuchi M, Sakurai H. Usefulness of radial recurrent artery in transplant of radial forearm flap: an anatomical and clinical study. J Reconstr Microsurg. 2012;28(3):195–8.
Chen HC, Cheng MH, Schneeberger AG, Cheng TJ, Wei FC, Tang YB. Posterior interosseous flap and its variations for coverage of hand wounds. J Trauma. 1998;45(3):570–4.
Pauchot J, Lepage D, Leclerc G, Flamans B, Obert L, Tropet Y. Posterior interosseous free flap because of absence of posterior interossous pedicle. A report of an individualised salvage procedure and of an exceptional anatomical variation. Review of the literature. Ann Chir Plast Esthet. 2010;55(1):56–60.
Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg Br. 1988;13(2):130–5.
Gellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial patterns of the deep and superficial palmar arches. Clin Orthop Relat Res. 2001;383:41–6.
Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet. 1961;113:409–24.
Joshi SB, Vatsalaswamy P, Bahetee BH. Variation in formation of superficial palmar arches with clinical implications. J Clin Diagn Res. 2014;8(4):AC06–9.
Charles CM. On the arrangement of the superficial veins of the cubital fossa in American white and American negro males. Anat Rec. 1932;54:9–14.
Okamoto K. A study of the superficial veins in the superior extremity of live Japanese. Anat Rec. 1922;23:323–31.
Vucinic N, Eric M, Macanovic M. Patterns of superficial veins of the middle upper extremity in Caucasian population. J Vasc Access. 2016;17(1):87–92.
Hapugoda S, Hsu CC-T, Kwan GNC, Watkins TW, Rophael JA. Duplication of the superficial femoral artery: comprehensive review of imaging literature and insight into embryology. Acta Radiol Open. 2016;5(7):2058460116659098.
van Hooft IM, Zeebregts CJ, van Sterkenburg SMM, de Vries WR, Reijnen MMPJ. The persistent sciatic artery. Eur J Vasc Endovasc Surg. 2009;37(5):585–91.
Tsilimparis N, Khare A, Riesenmann PJ, Reeves JG. Persistent left sciatic artery eliminated need for revascularization in a 13-year-old with pseudoaneurysm of the superficial femoral artery. Vasc Endovasc Surg. 2013;47(3):250–3.
Rajani SJ, Ravat MK, Rajani JK, Bhedi AN. Cadaveric study of profunda femoris artery with some unique variations. J Clin Diagn Res. 2015;9(5):AC01–3.
DeLong MR, Hughes DB, Bond JE, Thomas SM, Boll DT, Zenn MR. A detailed evaluation of the anatomical variations of the profunda artery perforator flap using computed tomographic angiograms. Plast Reconstr Surg. 2014;134(2):186e–92e.
Haddock NT, Greaney P, Otterburn D, Levine S, Allen RJ. Predicting perforator location on preoperative imaging for the profunda artery perforator flap. Microsurgery. 2012;32(7):507–11.
Ahmadzadeh R, Bergeron L, Tang M, Geddes CR, Morris SF. The posterior thigh perforator flap or profunda femoris artery perforator flap. Plast Reconstr Surg. 2007;119(1):194–200; discussion 201–2.
Al-Talalwah W. The medial circumflex femoral artery origin variability and its radiological and surgical intervention significance. Springerplus. 2015;4:149.
Macchi V, Vigato E, Porzionato A, Tiengo C, Stecco C, Parenti A, et al. The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study. Clin Anat. 2008;21(7):696–704.
Coquerel-Beghin D, Milliez PY, Auquit-Auckbur I, Lemierre G, Duparc F. The gracilis musculocutaneous flap: vascular supply of the muscle and skin components. Surg Radiol Anat. 2006;28(6):588–95.
Giordano PA, Abbes M, Pequignot JP. Gracilis blood supply: anatomical and clinical re-evaluation. Br J Plast Surg. 1990;43(3):266–72.
Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg. 1984;37(2):149–59.
Lakhiani C, Lee MR, Saint-Cyr M. Vascular anatomy of the anterolateral thigh flap: a systematic review. Plast Reconstr Surg. 2012;130(6):1254–68.
Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg. 1998;102(5):1517–23.
Xu DC, Zhong SZ, Kong JM, Wang GY, Liu MZ, Luo LS, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg. 1988;82(2):305–10.
Zhou G, Qiao Q, Chen GY, Ling YC, Swift R. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg. 1991;44(2):91–6.
Pribaz JJ, Orgill DP, Epstein MD, Sampson CE, Hergrueter CA. Anterolateral thigh free flap. Ann Plast Surg. 1995;34(6):585–92.
Bakri K, Shin AY, Moran SL. The vascularized medial femoral corticoperiosteal flap for reconstruction of bony defects within the upper and lower extremities. Semin Plast Surg. 2008;22(3):228–33.
Dubois G, Lopez R, Puwanarajah P, Noyelles L, Lauwers F. The corticoperiosteal medial femoral supracondylar flap: anatomical study for clinical evaluation in mandibular osteoradionecrosis. Surg Radiol Anat. 2010;32(10):971–7.
Garcia-Pumarino R, Franco JM. Anatomical variability of descending genicular artery. Ann Plast Surg. 2014;73(5):607–11.
Kim D, Orron DE, Skillman JJ. Surgical significance of popliteal arterial variants. A unified angiographic classification. Ann Surg. 1989;210(6):776–81.
Lippert H, Pabst R. Arterial variations in man: classification and frequency. München: J.F. Bergmann; 1985. p. 121.
Abou-Foul AK, Borumandi F. Anatomical variants of lower limb vasculature and implications for free fibula flap: systematic review and critical analysis. Microsurgery. 2016;36(2):165–72.
Zwass A, Abdelwahab IF. A case report of anomalous branching of the popliteal artery. Angiology. 1986;37(2):132–5.
Astarci P, Siciliano S, Verhelst R, Lacroix V, Noirhomme P, Rubay J, et al. Intra-operative acute leg ischaemia after free fibula flap harvest for mandible reconstruction. Acta Chir Belg. 2006;106(4):423–6.
Rosson GD, Singh NK. Devascularizing complications of free fibula harvest: peronea arteria magna. J Reconstr Microsurg. 2005;21(8):533–8.
Blackwell KE. Donor site evaluation for fibula free flap transfer. Am J Otolaryngol. 1998;19(2):89–95.
Carroll WR, Esclamado R. Preoperative vascular imaging for the fibular osteocutaneous flap. Arch Otolaryngol Head Neck Surg. 1996;122(7):708–12.
Sandhu GS, Rezaee RP, Wright K, Jesberger JA, Griswold MA, Gulani V. Time-resolved and bolus-chase MR angiography of the leg: branching pattern analysis and identification of septocutaneous perforators. AJR Am J Roentgenol. 2010;195(4):858–64.
Futran ND, Stack BC Jr, Zachariah AP. Ankle-arm index as a screening examination for fibula free tissue transfer. Ann Otol Rhinol Laryngol. 1999;108(8):777–80.
Harrison DH, Morgan BD. The instep island flap to resurface plantar defects. Br J Plast Surg. 1981;34(3):315–8.
Shanahan RE, Gingrass RP. Medial plantar sensory flap for coverage of heel defects. Plast Reconstr Surg. 1979;64(3):295–8.
Macchi V, Tiengo C, Porzionato A, Stecco C, Parenti A, Mazzoleni F, et al. Correlation between the course of the medial plantar artery and the morphology of the abductor hallucis muscle. Clin Anat. 2005;18(8):580–8.
Adachi B. Arteriensystem der Japaner. Kyoto: Verlag der Keiserlich-Japanischen Universität zu Kyoto; 1928.
Rodriguez-Vegas M. Medialis pedis flap in the reconstruction of palmar skin defects of the digits: clarifying the anatomy of the medial plantar artery. Ann Plast Surg. 2014;72(5):542–52.
Kim JW, Choi YJ, Lee HJ, Yi KH, Kim HJ, Hu KS. Anatomic study of the dorsalis pedis artery, first metatarsal artery, and second metatarsal bone for mandibular reconstruction. J Oral Maxillofac Surg. 2015;73(8):1627–36.
Lutz BS, Siemers F, Shen ZL, Machens HG, Wippermann B, Berger A. Free flap to the arteria peronea magna for lower limb salvage. Plast Reconstr Surg. 2000;105(2):684–7.
Kalicharan A, Rennie C, Pillay P, Haffajee MR. The anatomy of the plantar arterial arch. Int J Morphol. 2015;33(1):36–42.
Ozer MA, Govsa F, Bilge O. Anatomic study of the deep plantar arch. Clin Anat. 2005;18(6):434–42.
Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. In: Daniller A, Strauch B, editors. Symposium on microsurgery. St. Louis: Mosby; 1976.
Gabrielli C, Olave E. Origins of the dorsal metatarsal arteries in humans. Scand J Plast Reconstr Surg Hand Surg. 2002;36(4):221–5.
Hou Z, Zou J, Wang Z, Zhong S. Anatomical classification of the first dorsal metatarsal artery and its clinical application. Plast Reconstr Surg. 2013;132(6):1028e–39e.
Lee JH, Dauber W. Anatomic study of the dorsalis pedis-first dorsal metatarsal artery. Ann Plast Surg. 1997;38(1):50–5.
Park EA, Chung JW, Lee W, Yin YH, Ha J, Kim SJ, et al. Three-dimensional evaluation of the anatomic variations of the femoral vein and popliteal vein in relation to the accompanying artery by using CT venography. Korean J Radiol. 2011;12(3):327–40.
Cherry KJ, Gloviczki P, Stanson AW. Persistent sciatic vein: diagnosis and treatment of a rare condition. J Vasc Surg. 1996;23(3):490–7.
Hamilton HE, Darke SG. Persistent sciatic vein - unusual cause of reflux from the popliteal fossa and sural nerve damage. Eur J Vasc Endovasc Surg. 1999;17(6):539–41.
Srisuwan T, Arworn S, Rerkasem K. Case series of isolated primary persistent sciatic vein. Int J Low Extrem Wounds. 2013;12(3):219–22.
Bhatt D. Cardiovascular intervention: a companion to Braunwald’s heart disease. Philadelphia: Elsevier; 2015.
Yuce I, Oguzkurt L, Eren S, Levent A, Kantarci M, Yalcin A, et al. Assessment of posterior accessory great saphenous vein of the leg using ultrasonography: a preliminary study. Surg Radiol Anat. 2016;38(1):123–6.
Shetty P, D’Souza MR, Nayak SB. An unusual course and termination of Small saphenous vein: a case report. J Clin Diagn Res. 2016;10(3):AD01–2.
Delis KT, Knaggs AL, Khodabakhsh P. Prevalence, anatomic patterns, valvular competence, and clinical significance of the Giacomini vein. J Vasc Surg. 2004;40(6):1174–83.
Prakash, Kumari J, Nishanth Reddy N, Kalyani Rao P, Preethi Ramya T, Singh G. A review of literature along with a cadaveric study of the prevalence of the Giacomini vein (the thigh extension of the small saphenous vein) in the Indian population. Romanian J Morphol Embryol. 2008;49(4):537–9.
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Xu, X., Kim, S., Clune, J.E., Narayan, D. (2021). Upper and Lower Extremity Vascular Variations. In: Narayan, D., Kapadia, S.E., Kodumudi, G., Vadivelu, N. (eds) Surgical and Perioperative Management of Patients with Anatomic Anomalies. Springer, Cham. https://doi.org/10.1007/978-3-030-55660-0_19
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