Superficial palmar arch with Persistent median artery

Case Report

Super fi cial palmar arch with Persistent median artery

Darioush Bijan Nejad

^a

, Saeed Azandeh

^a

, Mohammad Reza Gholami

^b

, Anneh Mohammad Gharravi

^c,

*, Mohsen Zhaleh

^d

aDepartmentofanatomy,FacultyofMedicine,AhvazJundishapurUniversityofMedicalSciences(AJUMS),Ahvaz,Iran

bDepartmentofanatomy,FacultyofMedicine,LorestanUniversityofMedicalSciences,KhorramAbad,Iran

cSchoolofMedicine,ShahroudUniversityofMedicalSciences,Shahroud,Iran

dDepartmentofanatomy,FacultyofMedicine,KermanshahUniversityofMedicalSciences,Gorgan,Iran

ARTICLE INFO

Articlehistory:

Received3March2015

Receivedinrevisedform5April2016 Accepted1February2017

Availableonlinexxx

Keywords:

PersistentMedianArtery superficialpalmararch CarpalTunnel variation

ABSTRACT

DuringtheroutinecadavericdissectionoftheupperextremitiesattheDepartmentofAnatomyofAhvaz JundishapurUniversityofMedicalScience,onecadaverwasfoundtohavePersistentMedianArtery (PMA)intheCarpalTunnel.ThePMAinpresentcadaverwasaslargeastheradialarteryoriginatedfrom thebrachialarteryandrandistally,passedundertheflexorretinaculum.ThePMAinvolvedinformation ofradio-medio-ulnartypeofsuperficialpalmararch(SPA).AlthoughthistypeofSPAoccursveryrarely, damagecanaffectthearterialsupplyofthefingers.Thisdatacouldprovideinformationforvascular surgeonsharvestingPMAoraradialarteryforcoronaryarterybypassgrafting.

©2017AnatomicalSocietyofIndia.PublishedbyElsevier,adivisionofRELXIndia,Pvt.Ltd.Allrights reserved.

1.Introduction

Neural,vascular,tendinousandmuscularanatomicalvariations in the hand are frequent. Knowledge of these variations is importantduringhandsurgicalproceduressuchasarterialrepairs, vasculargraftapplications.¹

Themedianarteryisatransitoryvesselduringearlyembryonic lifeandafterthe8thweekofgestation,isnormallyregressedby undergoing apoptosis to become as the artery comitans nervi median.PMAcategorizedintoantebrachialandpalmarpatterns.

PalmarPMAislarge,longartery,passthroughthecarpaltunnel andreachesthepalm.²Severalstructuressuchasthemediannerve andtendonsofthemusclesoftheforearm(flexorpollicislongus, flexor digitorum profundus, and flexor digitorum superficialis muscles)passthroughthecarpaltunnel.Carpaltunnelsyndrome occurswhenthemediannerveofthewristiscompressedbythe carpalflexorretinaculum.³Thesyndromeisapainfulprogressive conditionwithburningsensationornumbnessofthefirstthree fingersandsomemuscleatrophy.Carpaltunnelsyndromecanbe associatedwithanyconditionsuchPMAasthatcausespressureon the median nerve at the wrist which leads to compressive neuropathies.³

The superficial palmar arch (SPA) as a dominant vascular structure of the palm is located superficial to flexor tendons.

ClassicaltypeofSPAisformedpredominantlybydirectcontinuity between the superficial branch of the ulnar artery (UA) and superficialpalmarbranchoftheradialartery(RA).Palmardigital arteries arise from the SPA. The SPA has been classified into completeandincompletetypesbasedonthepresenceorabsence ofacommunicationbetweentheconstitutingofUAandRAorthe possibleformationfromasingleUAandRA.⁴

ThePMAcanbeinvolvedintheconstructionoftheSPAwithRA, UAasradio-medio-ulnartypeofSPA.Theincidenceofthistypeof theSPAindifferentpopulationsisnotyetknown.

Inthisarticle,wedescribeacaseofPalmarPMApassinginthe carpal tunnel to formation of radio-medio-ulnar type of SPA.

Knowledgeoftheraretypeof SPAisimportantforthesurgical interventions

2.Casereport

Duringtheroutinecadavericdissectionoftheupperextremi- ties at the Department of Anatomy of Ahvaz Jundishapur UniversityofMedicalScience,weencounteredapersistentmedian artery in the left upper extremity of a male cadaver. Upper extremitiesweredissectedandwereinvestigatedforthepresence ofmedianarteryandapossibleinvolvementintheconstructionof theSPA.PMAwastracedfromorigintotermination.Inthepresent cadaver,normallybrachialarterydividesintoitsterminalbranches

* Correspondingauthor.

E-mailaddress:annehgh@yahoo.com(A.M.Gharravi).

http://dx.doi.org/10.1016/j.jasi.2017.02.003

0003-2778/©2017AnatomicalSocietyofIndia.PublishedbyElsevier,adivisionofRELXIndia,Pvt.Ltd.Allrightsreserved.

JournaloftheAnatomicalSocietyofIndiaxxx(2016)xxx–xxx GModel

JASI169No.ofPages2

Pleasecitethisarticleinpressas:D.B.Nejad,etal.,SuperficialpalmararchwithPersistentmedianartery,JAnatSocIndia(2017),http://dx.doi.

org/10.1016/j.jasi.2017.02.003

ContentslistsavailableatScienceDirect

Journal of the Anatomical Society of India

j o u r n a l h o m e p ag e :w w w . e l s e vi e r . c o m / l o c a t e / j a s i

namelyRAandUAatthecubitalfossa.Dissectionoftheleftupper limbshowedaPMAaslargeastheradialarteryoriginatedfromthe brachialartery(Fig.1).ThePMArandistallyandpassedunderthe flexorretinaculum.PMAanastomosedwiththeSPA.TheSPAwas completeandoriginatedfromthreearteries;RA,UAandPMAas radio-medio-ulnar type of SPA that gave four palmar digital arteries;properpalmardigitalarteryandthreecommonpalmar digitalarteries,whichpasstothemedialthreeinterdigitalclefts.

3.Discussion

Inthisstudy,PMAaslargeastheRAoriginatedfrombrachial artery and involved in the SPA formation in the palm. PMA accompaniesthemediannervealongitscourseintheforearm.A largePMAcanbeassociatedwithseveralclinicalconditionsuch anterior interosseous nerve syndrome, pronator syndrome and carpal tunnel syndrome which leads to compressive neuropa- thies.⁵ Therefore,awarenessof anatomical variationsof PMAis important while surgical procedures are performed in hand.

Regardingorigin, most of the PMA originated in the common

interosseousarteryandanteriorinterosseousartery⁶andonly3.8%

ofPMAoriginatedfrombrachialartery.ThefrequenciesofthePMA incadavericstudiesvaryfrom2to8%.^7–9OtherstudiesreportPMA in the carpal tunnel in 4% of 50 dissected upper limbs.¹⁰ In SouthernAfricancadavers,theincidencewasashighas27.1%.¹¹ PMAinthepresentstudyclassifiedaspalmartypewhichwaslarge, long artery, and reached the palm^2,12 and involved in the constructionofradio-medio-ulnartypesofSPA.¹³Studiesindicat- edthatpalmartypeofmedianarteryisfoundatahigherincidence thantheantebrachialtype.⁸Fourcommondigitalarteriesraised forsupplythesecond,third,andfourthwebspacesofhand.The frequenciesofthistypeofSPAvaryfrom1.2to6%andistheleast commontypesamongallthetypesofSPAinvestigatedbyvarious authors.^4,14,15Takentogether,althoughthistypeofSPAoccursvery rarely, damage can affect the arterial supply of the fingers.

Therefore,itisnecessarysurgeonsandcliniciansshouldbeaware ofsuchanSPAvariationtodo theinvestigationslikeAllentest, angiographyandcolorDopplerstudiesofthehandbeforedoing any invasive procedures on the hand. This data could provide informationforvascularsurgeonsharvestingPMAoraradialartery forcoronaryarterybypassgrafting.

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Fig.1.A:Thepalmartypeofmedianarteryoriginatingfromthebrachialarteryof upperlimb.Cadaverichandexhibitingtheradio-medio-ulnartypeofSPA.B:Pattern ofPMAcontributiontoSPA.

HE,hypothenareminence;PMA,Persistentmedianartery;RA,radialartery;TE, thenareminence;UA,ulnarartery;SPA,Superficialpalmararch;PDA,palmardigital arteries.

2 D.B.Nejadetal./JournaloftheAnatomicalSocietyofIndiaxxx(2016)xxx–xxx GModel

JASI169No.ofPages2

Pleasecitethisarticleinpressas:D.B.Nejad,etal.,SuperficialpalmararchwithPersistentmedianartery,JAnatSocIndia(2017),http://dx.doi.

org/10.1016/j.jasi.2017.02.003