Loading

Annals of Vascular Medicine and Research

Accessory Brachial Artery: A Rare Clinical Finding While Creating a Proximal Arterio-Venous Fistula

Case Report | Open Access Volume 9 | Issue 3 |

  • 1. Department of Burns & Plastic Surgery, AIIMS Bhubaneswar, Odisha, India
+ Show More - Show Less
Corresponding Authors
Sunil Kumar Rout, Department of Burns & Plastic Surgery, AIIMS Bhubaneswar, Odisha, India, Tel: 993-7176-025 / 674-2720-039
Abstract

Arterio-venous fistula (AVF) creation is a common operative procedure performed to aid hemodialysis in patients with chronic kidney disease (CKD). While attempting to do so, often we encounter multiple issues like - small vein caliber, thrombosed vein, vascular anomaly, abnormal bleeding etc. Knowledge of anatomy of blood vessels, of the specific sites intended for surgical intervention is imperative as the surgeon may come across abnormal variations, which may cause hindrance in performing the procedure or facilitate it. Here, we describe such an unusual anatomical variation in the arm, where we observed the presence of an accessory brachial artery, while creating a proximal AVF.

Keywords

Accessory Brachial Artery, Proximal Arterio-Venous Fistula, Brachio-Cephalic Fistula, Brachio-Basilic Fistula

Citation

Mallik M, Rout SK (2022) Accessory Brachial Artery: A Rare Clinical Finding While Creating a Proximal Arterio-Venous Fistula. Ann Vasc Med Res 9(3): 1152.

INTRODUCTION

AVF is a surgical procedure commonly practiced to create a peripheral vascular channel with reasonable caliber, pressure and wall thickness to be used for hemodialysis. Radio-cephalic anastomosis in non-dominant distal forearm is the initial procedure of choice, failing which the brachial artery in the distal arm is used to anastomose either with the cephalic or the basilic vein. The knowledge of vascular anatomy in distal arm and forearm is important for the operating surgeon, though he may come across rare anatomical variations. Vascular anomalies in the form of accessory brachial artery, high bifurcation of brachial artery, compressive neuropathies of the median nerve by accessory superficial brachial artery has been described in published literature [1-7].

CASE PRESENTATION

Figure 1 Accessory brachial artery (clamped proximal end), cephalic vein (looped laterally), median nerve and the main brachial artery (looped medially) with vena comitans.

Figure 1: Accessory brachial artery (clamped proximal end), cephalic vein (looped laterally), median nerve and the main brachial artery (looped medially) with vena comitans.

A 55-year-old lady with chronic kidney disease was referred to our department for surgical creation of a permanent AVF for hemodialysis. She was planned for radio-cephalic fistula at distal forearm level of her left (non-dominant) hand under local infiltration anesthesia. On dissection, the lumen of the cephalic vein was found to be substantially narrow. Hence, an on-table decision was made in favor of a proximal AVF (Brachio-Basilic) on the same side. With a J-shaped incision above the cubital crease on the antero-medial aspect of the arm, dissection began to identify the basilic vein. On dissection, 2 vessels were noted, a robust pulsatile one more laterally and a thin non-pulsatile one (the basilic vein) medially. The pulsating vessel was distinct in position, extending proximally, without any interconnection with any other vessels. The medial antebrachial cutaneous nerve was found in between the 2 vessels. Exploring deeper along the axis of main brachial artery, the same was found with its vena comitantes separately, in close proximity with the median nerve. The aberrant artery (found initially) was traced till the proximal and middle third junction of the arm with a distinct separate course from the brachial artery proper. This robust pulsating vessel was clamped to note the persistent pulsations of the brachial, radial and ulnar arteries distally. The decision of using the basilic vein was abandoned as its caliber was substantially small for a successful and patent long-term fistula. The cephalic vein was dissected and found to have an adequate caliber. It was decided to anastomose the cephalic vein end-to-end with the aberrant artery (accessory brachial artery) (Figure 1, Video 1). Anastomosis was completed with interrupted 8-0 monofilament polyamide sutures without disturbing the main brachial artery (Figure 2) and the surgical wound closed in a single layer. The post-operative period was uneventful and the patient was discharged from the hospital next day. On follow-up visits, the thrill of the fistula was well palpable in the proximal territory of the cephalic vein in upper arm. Later on, the channel was used for hemodialysis by our Nephrology team.

Figure 2 AVF created with end-to-end anastomosis between the accessory brachial artery (looped) and the cephalic vein.

Figure 2: AVF created with end-to-end anastomosis between the accessory brachial artery (looped) and the cephalic vein.

DISCUSSION

Variation in anatomy of neurovascular structures in the upper limb has been reported in the literature but hardly detected during AVF creation in arm [1-7]. As such, there have been mentions about superficial brachial artery [1,2,7] or accessory brachial artery [3,4,6] occasionally presenting with features of median nerve compression [1,7]. Transient neuropathies or even arterial insufficiency has also been reported as a result of these anomalies [1,5]. An anatomical study has mentioned the incidence of accessory brachial artery to be as high as 11.43% [4]. A classification system has also been developed to classify the anomalous brachial artery [2] and their embryological basis analyzed [6]. However, our literature search did not reveal such anomaly to be encountered while creating AVF in the arm.

Exact nomenclature of the observed anatomical variation is not possible in our case because, it necessitates either contrast study of the upper limb vasculature or extensive dissection of the abnormal vessel to delineate the proximal as well as the distal extent. In patients suffering from CKD most of the metabolic pathways are adversely affected hence, radio-opaque intravascular contrast injection is usually contraindicated. Similarly, most of them are not good candidates for surgical procedures for various reasons and only subjected to surgeries felt essential for them. In order to explore the entire course of the anomalous vessel, dissection is required to be carried form axilla to cubital fossa or beyond these anatomical landmarks. Also subjecting these patients to general anesthesia put them into higher risk, because of which most of these procedures are performed under local infiltration anesthesia as in our case. These are the factors which prevented us to ascertain the exact extent of the anomalous vessel in our patient hence, the name of this vessel we propose, a presumptive one.

Finding such a variation in the arterial anatomy although accidental, is advantageous for the surgeon if proceeding for creation of an AVF. Because, in usual scenario the anastomosis is performed with end of the vein (cephalic / basilic) to the side of the brachial artery. The artery being single, on which the vascularity of the limb depends solely, bears, the risk of occlusion in case gets thrombosed at the site of anastomosis. Whereas if we have an accessory artery to supply the distal part of limb, we can spare one of them fully intact, and use the other for creating AVF with end-to-end anastomosis. Vascular clamp may be applied to confirm the vascular supply to the distal part, before dividing the vessel for anastomosis. This is well known to microsurgical community that an end-to-end anastomosis is easier to perform, carries less risk of hemorrhage and thrombosis at the anastomotic site and has a superior anastomotic patency rate in comparison to end-to-side one. Hence, these types of anatomical variations may not be considered as bolts from the blue, rather blessings in disguise.

Any of the superficial veins available in that anatomical zone can be used for anastomosis for creation of AVF. The choice depends on the proximity of the vein to the artery, caliber of the vein, the surgeon’s preference and at times preference of the nephrologist who will be using the vessel for hemodialysis. Cephalic vein is used most frequently because of its suitable anatomical location unless contraindicated otherwise. Whereas recent literature favors use of basilic vein for this purpose, showing better long-term patency rate [8]. In this particular case though we planned to use basilic vein for anastomosis to start with, finally decided in favor of cephalic vein because of the better caliber match. The anomalous artery was preferred for end-toend anastomosis, due to its comparatively superficial location.

Knowledge of such anatomical variation in arm, is beneficial for the surgeons. If an artery of significant diameter found in the location, not usual for the brachial artery, effort should be made to explore for the same at its natural site. If no other artery is present, the dissected artery is confirmed to be the brachial artery and an end-to-side anastomosis is contemplated. Whereas f another artery is present as an anatomical variation, then the decision may be made taking into consideration its course, caliber and proximity to the vein proposed for anastomosis, preferably end-to-end.

CONCLUSION

Accessory brachial artery is a rare congenital anomaly/ variation and whenever present, may prove to be advantageous for the surgeon as well as the patient undergoing AV fistula creation. In most of the occasions if present, it may be encountered accidentally unless contrast studies for the upper limb vessels performed for other reasons, while the patient’s condition does not contraindicate for the same. Hence, the surgeons should have the knowledge of these anomalies and be prepared to face the situation any time during their surgical practice.

ETHICAL STATEMENT

An approval was obtained from the Institute Ethics Committee; video reference number – T/IM-NF/Burns.Plastic/22/54/ September 24, 2022

REFERENCES

1. Paraskevas G, Lazaridis N, Piagkou M, Natsis K. Superficial brachial artery traversing a median nerve loop in the arm associated with other vascular and muscular anomalies: case report and clinical implications. Ital J Anat Embryol [Internet]. 2018; 123: 17-2.

2. Clarke Edward, Mazurek Agata, Radek Maciej, ?ytkowski Andrzej, Twardok?s Wojciech, Polguj Micha?, et al. Superficial brachial artery – A case report with commentaries on the classification. Translational Research in Anatomy. 2021; 23: 100112.

3. Kachlik David, Konarik Marek, Urban Miroslav, Baca Vaclav. Accessory brachial artery: a case report, embryological background and clinical relevance. Asian Biomedicine. 2017; 5: 151-155.

4. Chakravarthi KK, Ks S, Venumadhav N, Sharma A, Kumar N. Anatomical variations of brachial artery - its morphology, embryogenesis and clinical implications. J Clin Diagn Res. 2014; 8: AC17-AC20.

5. Cherukupalli C, Dwivedi A, Dayal R. High Bifurcation of Brachial Artery with Acute Arterial Insufficiency: A Case Report. Vasc Endovascular Surg. 2008; 41: 572-574.

6. Tsoucalas G, Eleftheriou A, Panagouli E. High Bifurcation of the Brachial Artery: An Embryological Overview. Cureus. 2020; 12: e7097.

7. Tsoucalas G, Eleftheriou A, Panagouli E. High Bifurcation of the Brachial Artery: An Embryological Overview. Cureus. 2020; 12: e7097.

8. Dix FP, Khan Y, Al-Khaffaf H. The brachial artery-basilic vein arteriovenous fistula in vascular access for haemodialysis--a review paper. Eur J Vasc Endovasc Surg. 2006; 31: 70-9.

Mallik M, Rout SK (2022) Accessory Brachial Artery: A Rare Clinical Finding While Creating a Proximal Arterio-Venous Fistula. Ann Vasc Med Res 9(3): 1152.

Received : 18 Nov 2022
Accepted : 30 Nov 2022
Published : 30 Nov 2022
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X