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BioMed Research International

Volume 2018, Article ID 1520929, 11 pages
https://doi.org/10.1155/2018/1520929

Research Article
The High Origin of the Radial Artery (Brachioradial
Artery): Its Anatomical Variations, Clinical Significance,
and Contribution to the Blood Supply of the Hand

Robert HaBadaj ,1 Grzegorz Wysiadecki ,1 Zbigniew Dudkiewicz,2

MichaB Polguj ,3 and MirosBaw Topol1
1
Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
2
Clinic of Hand Surgery, Chair of Traumatology and Orthopaedics, Medical University of Lodz, Poland
3
Department of Angiology, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland

Correspondence should be addressed to Robert Haładaj; [email protected]

Received 3 March 2018; Revised 27 April 2018; Accepted 20 May 2018; Published 11 June 2018

Academic Editor: Sudhir Rathore

Copyright © 2018 Robert Haładaj et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. This study thoroughly analyzes the anatomic variations of the brachioradial artery (radial artery of high origin) based
on the variability of its origin, the presence and types of anastomosis with the brachial artery in the cubital fossa (“cubital crossover”
or “cubital connection”), and the pattern of radial recurrent arteries, as well as the vascular territory within the hand. Material and
Methods. One hundred and twenty randomly selected, isolated upper limbs fixed in 10% formalin solution were dissected. Results.
The radial artery was found to have a high origin in 9.2% of total number of the limbs: two cases from the axillary artery; nine
cases from the brachial artery. Anastomosis between the brachioradial and “normal” brachial arteries in the cubital fossa was also
frequently observed (54.6%). The anastomosis (“cubital crossover”) was dominant in one case, balanced in three cases, minimal in
two cases, and absent in five cases. Conclusions. The brachioradial artery may originate from the brachial and, less frequently, from
the axillary artery. Anastomosis between the brachioradial and “normal” brachial arteries in the cubital fossa may be dominant,
balanced, minimal, or absent. A complete radioulnar arch was found more often when the brachioradial artery was present as a
variant.

1. Background originating from the brachial (or axillary) artery [10], a

high bifurcation of the brachial artery [27], the continuance
A comprehensive understanding of the possible arrange-
of the superficial brachial artery as the radial artery [28,
ments of the arterial pattern of the upper limb is of great clin-
29], or a double brachial artery [30]. Rodrı́guez-Niedenführ
ical importance [1–6]. In particular, the radial artery demon-
strates high anatomical variability regarding its origin [7–15], et al. [12, 13] propose a clear and unified nomenclature for
various arrangements of radial recurrent arteries [16–18], and these variations, with the term “brachioradial artery” being
the vascular territory within the hand [6, 10, 19]. The origin of used for the “high origin of the radial artery”. In the case
the radial artery is commonly located in the cubital fossa at of the brachioradial artery, the accessory artery is observed
the level of the neck of the radius [20]. However, the artery can in the medial bicipital sulcus, running superficially to the
display a high origin from the brachial artery or even from the median nerve and continuing along the forearm as the radial
axillary artery [7, 8, 10, 12–14, 21, 22]. Moreover, in rare cases, artery, following its usual course; in this variant, the brachial
the radial artery may demonstrate a more distal origin, under artery assumes a typical position and runs deep to the median
the pronator teres muscle [15, 23–25], or even it can be absent nerve. The brachioradial artery often forms an anastomosis
[26]. with the “normal” brachial artery in the cubital fossa (so-
Various terminology has been used to describe the high called “cubital crossover” or “cubital connection”) [10, 12, 13,
origin of the brachial artery, for example, a radial artery 17].
2 BioMed Research International

Since the radial artery is often used in vascular, plastic, of female limbs). Moreover, this variation was found on the
and reconstructive surgery [2, 3, 31], as well as for arte- right side in six cases (6/63; 9.5% of right limbs) and on the
rial puncture and cannulation (transradial access) [32–35], left side in five cases (5/57; 8.8% of left limbs). No statistically
knowledge of its variations can be of great clinical signifi- significant difference was found between both the frequency
cance. In this context, it is also important to know the possible of the occurrence of the brachioradial artery and either sex or
anatomic variations of the brachioradial artery, including the the side of the body.
variability of its origin, the presence of anastomosis with the
brachial artery in the cubital fossa (“cubital crossover”), the 3.2. Anatomical Variations of the Origin of the Brachioradial
pattern of recurrent radial arteries, and the vascular territory Artery. The brachioradial artery was found to arise in the
in the hand. This is the study summarizing current knowledge axillary cavity in two out of 120 dissected upper limbs (i.e.,
of the anatomy of the brachioradial artery, based on all the 1.67% of all limbs and 18.1% of brachioradial arteries); both
variables listed above. The study also sets out a proposal cases were observed in male, right limbs. In one specimen,
of unified classification of the “cubital crossover” and dis- a thin and hypoplastic brachioradial artery branched off the
cusses the developmental background of the observed varia- first part of the axillary artery, just above the medial border of
tions. the pectoralis minor muscle (Figure 1(a)). In the second case,
the brachioradial artery was well developed and branched
2. Material and Methods off the second part of the axillary artery (posterior to the
pectoralis minor muscle) (Figure 1(b)). In both cases, the
One hundred and twenty randomly selected, isolated upper brachioradial artery branched off the anterior aspect of the
limbs fixed in 10% formalin solution were dissected. The axillary artery and ran anterior to the roots of the median
limbs came from male cadavers (total 65, right 36, left 29) nerve.
and from female cadavers (total 55, right 27, left 28). The The nine remaining cases (7.5% of all limbs; 81.8% of
study was approved by the Local Ethics Committee (No: brachioradial arteries) all arose on the arm within the medial
RNN/517/14/KB). bicipital groove (Figure 2). This variation was observed in
The research was carried out in accordance with anatom- four male and five female upper limbs. In this variant, the
ical dissection techniques. Prior to each procedure, a thor- brachioradial artery branched off the medial aspect of the
ough visual external inspection was performed to exclude brachial artery and ran superficial to the median nerve, with
specimens with deformations or traces of trauma or surgical its course initially being slightly medial to it (Figure 2). How-
procedures. Furthermore, limbs demonstrating anatomical ever, the brachial artery occupied a normal position behind
variations of the arterial pattern not associated with the the median nerve. The branching site of the brachioradial
radial or brachioradial arteries and their branches were artery was located from 5 mm to 67 mm below the lower
also excluded from further analysis. The classification of margin of the pectoralis major muscle. In eight specimens
anatomical variations of the arterial pattern in the upper limb representing this variant, the brachioradial artery branched
used in this study was based on those proposed by Rodrı́guez- off below the profunda brachii artery. In one case, the
Niedenführ et al. [12, 13, 17]. The preparation of blood vessels brachioradial artery branched off at the level of the lower
was performed using microsurgical instruments at a mag- margin of the pectoralis major muscle, just above the origin
nification of 2.5 x; these procedures were performed using of the profunda brachii artery. Further, along its course, the
HEINE HR 2.5 X High Resolution Binocular Loupe (HEINE artery crossed the anterior surface of the median nerve
Optotechnik GmbH & Co. KG, Herrsching, Germany). between 57 mm and 95 mm from the intercondylar line of the
A Digimatic Caliper (Mitutoyo Corporation, Kawasaki- humerus (mean 75 mm, ± 13 mm), moving to the lateral side
shi, Kanagawa, Japan) was used to take the following mea- of the nerve (Figure 2).
surements: vessel diameter, the distance between the origin of The brachioradial artery arose at a point between 126
the radial or brachioradial artery, and the intercondylar line mm and 260 mm above the intercondylar line (mean 178
of the humerus. Each measurement was taken twice, and the mm, ± 44 mm). However, in typical cases the division of the
mean of both measurements was accepted as the final result. brachial artery into terminal branches (namely, brachial and
The Chi Square test was used to test relationships between radial arteries) was located in the cubital fossa below the
selected variables, for example, the frequency of occurrence intercondylar line of humerus. The distance of the site of
of the brachioradial artery with regard to sex or side of the origin of the radial and brachioradial arteries from the
body. The significance level adopted in the analysis was p = intercondylar line of humerus is presented in Table 1. In all
0.05. The calculations were made with STATISTICA software, cases, the brachioradial artery ran under the deep (brachial
version 10.0 PL. and antebrachial) fascia and passed deep to the bicipital
aponeurosis (Figure 2(a)).
3. Results
3.3. Anatomical Variations of the Cubital Crossover and Radial
3.1. Frequency of the High Origin of the Radial Artery (Brachio- Recurrent Arteries. Anastomosis between the brachioradial
radial Artery). Among the 120 examined upper limbs, the and “normal” brachial arteries in the cubital fossa was fre-
radial artery was found to have a high origin in 11 specimens quently observed (6/11 = 54.55%). This anastomosis, known as
(11/120; 9.2% of the total number of limbs): six male limbs “cubital crossover” or “cubital connection”, was characterized
(6/65; 9.2% of male limbs) and five female limbs (5/55; 9.1% by high variability. It occurred in three variants, classified
BioMed Research International 3

AA
LRMN
MRMN
AA
PMi AV
LRMN PMa UN
MRMN

BRA BRA
PMa

(a) (b)

Figure 1: Two variants of the brachioradial artery originating within the axillary fossa. In both cases the brachioradial artery ran anterior
to the roots of the median nerve. (a) Brachioradial artery arising from the first part of the axillary artery, just above the medial border of
the pectoralis minor muscle. (b) Brachioradial artery branching off the second part of the axillary artery (posterior to the pectoralis minor
muscle). AA: axillary artery; AV: axillary vein; BRA: brachioradial artery; LRMN: lateral root of the median nerve; MRMN: medial root of
the median nerve; PMa: pectoralis major muscle; PMi: pectoralis minor muscle; UN: ulnar nerve.

Table 1: Comparison between the origin of the radial and brachioradial arteries in relation to the intercondylar line of the humerus.

Typical origin of the radial artery, distance below the intercondylar line [mm]
Mean Median Minimal value Maximal value Standard deviation
Male limbs 39.1 37.2 23.7 52.9 8.4
Female limbs 31.3 30 19.8 43.4 8.9
Total 35.2 36.4 19.8 52.9 9.4
High origin of the radial artery (brachioradial artery), distance above the intercondylar line [mm]
Mean Median Minimal value Maximal value Standard deviation
Male limbs 196 180 145 260 42
Female limbs 157 141 126 225 36
Total 178 170 126 260 44

as dominant, balanced, and minimal, depending on their cubital crossover branched off the brachial artery (4.96 mm
diameter. in diameter) 50 mm beneath the intercondylar line of the
A dominant cubital crossover was found on one right humerus, at the level of radial neck, from where it followed a
male upper limb (1/11 = 9% of brachioradial artery cases; 1/120 tortuous course (Figure 3). The diameter of the brachioradial
= 0.83% of the examined upper limbs) (Figure 3). This anasto- artery almost doubled (by 73.5%) just below the anastomosis.
mosis had a larger diameter than the brachial part (segment) A single recurrent radial artery of 1.55 diameter arose 83 mm
of the brachioradial artery. In other words, brachioradial below the intercondylar line of the humerus.
artery was present, but it was hypoplastic (Figure 3). In the Three examples of balanced cubital crossover were
described case, a hypoplastic brachioradial artery (1.85 mm observed (27.3% of brachioradial arteries; 2.5% of all exam-
in diameter), originating in the axillary fossa, joined a well- ined limbs): two male limbs (1 right and 1 left) and one female
developed cubital crossover (3.21 mm in diameter) in the limb (Figure 4). This anastomosis type was characterized by a
area of the cubital fossa and then continued in the forearm diameter similar to that of the brachioradial artery: 2.45mm
as the radial artery of a similar diameter. The dominant in male limbs and 2.34 mm in female limb. In this variant,
4 BioMed Research International

BA
MN UN

BV
MN
BRA
BA
BRA
MCNF
CV
MCV

(a) (b)
Figure 2: Two examples of the brachioradial artery originating in the arm. In both cases the brachioradial artery ran superficially to median
nerve. (a) Right female upper limb. Anatomical relations within the medial bicipital groove. The brachioradial artery runs under the bicipital
aponeurosis; within the forearm, it continues as the radial artery and occupies a typical position. (b) Left male upper limb. Two arterial trunks
(brachioradial and “normal” brachial artery) are visible within the medial bicipital groove. In its course, the brachioradial artery crosses the
anterior surface of the median nerve above the intercondylar line of the humerus running to the lateral side of this nerve. BA: brachial artery;
BV: basilic vein; BRA: brachioradial artery; CV: cephalic vein; MCNF: medial cutaneous nerve of forearm; MCV: median cubital vein; MN:
median nerve; UN: ulnar nerve. White arrowhead shows the origin of the brachioradial artery.

the diameter of the brachioradial artery just below the

anastomosis increased, respectively, by 17.1% (from 2.51 mm
BA to 2.94 mm) in the male right limb, by 10.7% (from 2.71 mm to
MN 3 mm) in the male left limb, and by 6% (from 2.33 mm to 2.47
hBRA
mm) in the identified female limb. In all cases, small muscular
branches ran downwards from the anastomosis, whereas
a well-developed radial recurrent artery ran upwards, the
diameter of which was 2.14 mm and 2.05 mm in the right and
left male limbs and 1.35 mm in the female limb (Figure 4).
RA In one case, in the right female limb, this anastomosis
ran posterior to the distal biceps tendon (Figure 4(b)). This
anastomosis was also characterized by a tortuous course.
In all three cases, the presence of a recurrent radial artery
was observed, which branched directly off this anastomosis.
Moreover, an accessory recurrent radial artery was found in
both male limbs, originating from the posteromedial aspect
of the “normal” brachial artery (Figure 4(a)): 31 mm and 26
mm above the cubital crossover in the right and left male
limbs. No accessory recurrent radial artery was observed in
Figure 3: Dominant type of cubital crossover. Anterior view of the
the female limb (Figure 4(b)).
cubital fossa, right upper limb. This type of anastomosis between
The minimal type of cubital crossover was observed in
the brachioradial and “normal” brachial artery is characterized by
a greater diameter than the brachial segment of the brachiora- two cases (18.2% of brachioradial arteries; 1.7% of all tested
dial artery. The brachioradial artery is present, but hypoplastic. limbs): one left male limb and one right female (Figure 5(a)).
BA: brachial artery; hBRA: hypoplastic brachial segment of the In this variant, no differences were found in the diameter
brachioradial artery; MN: median nerve; RA: radial artery. White of the brachioradial artery above and beneath the cubital
arrowheads show the cubital crossover. crossover. However, in both cases, the diameter of the
BioMed Research International 5

IUCA
BA

RN

BRA
BA RRA
aRRA *
MN
BRA
RRA

SBRN

AIA UA

(a) (b)

Figure 4: Balanced type of cubital crossover. This type of the anastomosis is characterized by the similar diameter to that of the brachioradial
artery. (a) Anterior view of the cubital fossa, right male upper limb. The cubital crossover (marked by white arrowheads) runs anterior to
the distal biceps tendon. (b) Anterior view of the cubital fossa, right female upper limb. In this case the cubital crossover (marked by white
arrowheads) runs posterior to the distal biceps tendon. AIA: anterior interosseous artery; aRRA: accessory radial recurrent artery; BA: brachial
artery; BRA: brachioradial artery; IUCA: inferior ulnar collateral artery; MN: median nerve; RA: radial artery; RRA: radial recurrent artery;
SBRN: superficial branch of the radial nerve; UA: ulnar artery.

MN

BA
aRRA
BRA
BA
RRA

RRA
BRA

(a) (b)
Figure 5: Two variants of the cubital crossover. (a) Minimal type of the cubital crossover (marked by white arrowheads). Anterior view of the
cubital fossa, right female upper limb. (b) Absence of the cubital crossover. Anterior view of the cubital fossa, left female upper limb. In this
case, two separate, unanastomosed arterial trunks ran within the cubital fossa. aRRA: accessory radial recurrent artery; BA: brachial artery;
BRA: brachioradial artery; MN: median nerve; RRA: radial recurrent artery.
6 BioMed Research International

Table 2: Comparison between the diameters of the ulnar and radial or brachioradial arteries at the level of the wrist.

The diameters of the typical radial and ulnar arteries at the level of the wrist
Radial artery [mm] Ulnar artery [mm]
Minimal Maximal Standard Minimal Maximal Standard
Mean Median Mean Median
value value deviation value value deviation
Male limbs 3.14 3.2 2.5 4.11 0.43 2.7 2.6 2.15 3.24 0.34
Female limbs 2.75 2.63 2.15 3.28 0.37 2.69 2.68 2.1 3.11 0.27
Total 2.95 2.98 2.15 4.1 0.43 2.69 2.64 2.1 3.24 0.31
The diameters of the brachioradial and ulnar arteries at the level of the wrist
Brachioradial artery [mm] Ulnar artery [mm]
Minimal Maximal Standard Minimal Maximal Standard
Mean Median Mean Median
value value deviation value value deviation
Male limbs 3.18 3.03 2.74 4.12 0.52 3.15 3.12 2,87 3.45 0.2
Female limb 3.02 3.08 2.02 3.65 0.57 2.85 2.86 2.03 3.43 0.49
Total 3.1 3.03 2.02 4.12 0.53 3 3.08 2.03 3.45 0.39

anastomosis decreased from 1.84 mm to 1.41 mm in the male

upper limb and from 1.92 mm to 1.12 mm in the female upper PL
limb just after the origin of the radial recurrent artery. The
presence of an accessory recurrent radial artery was observed RA
in one female limb (diameter 1.71 mm, 13 mm above the SPB
origin of the cubital crossover): the artery originated from the
UN
brachioradial artery (Figure 5(a)).
UA
The cubital crossover was found to be absent in 45.4% of
brachioradial arteries: in two male limbs (one right, one left)
and in three female limbs (two left, one right) (Figure 5(b)).
SPA
In these limbs, the radial recurrent artery originated from
the brachioradial artery below the intercondylar line of the
humerus (Figure 5(b)). An accessory recurrent radial artery
was observed only in one of these cases (one female left limb).
This artery originated from the “normal” brachial artery.
In summary, the variations related to the origin of the
recurrent radial arteries observed in the examined upper
limbs branched off the “normal” (typical) radial artery in
81.6% of cases (98/120), the posterior radioulnar division
(called “trifurcation of the brachial artery”) in 9.2% (11/120),
Figure 6: The most frequent variant of superficial palmar arch
directly from the brachioradial artery in 5% (6/120), and the observed on the limbs showing a high origin to the radial artery
cubital crossover in 4.2% (5/120). The accessory radial artery (brachioradial artery). This type may be classified as a complete
was noted in 28 cases (28/120 = 23.3%), including four of the radioulnar arch in which a well-developed superficial palmar branch
11 limbs (36.4%) with a brachioradial artery. of radial (or, respectively, brachioradial) artery contributes to the
radial half of the arch. SPA: superficial palmar arch; SPB: superficial
palmar branch arising from the brachioradial artery; PL: tendon of
3.4. Contribution of Radial or Brachioradial Arteries to Forma-
palmaris longus muscle; RA: radial artery; UA: ulnar artery; UN:
tion of the Superficial Palmar Arch. Two basic types of super- ulnar nerve.
ficial palmar arch were observed in the examined specimens.
The first major type was a complete radioulnar arch, in which
a well-developed superficial palmar branch of radial (or,
respectively, brachioradial) artery contributed to the radial
half of the arch (Figure 6). This type was revealed in eight artery. This type was observed in three of the limbs with a
of the upper limbs with a brachioradial artery present (8/11; brachioradial artery (3/11; 27.3%) and in 51 (51/109; 46.8%)
72.7%) and in 41 upper limbs (41/109; 37.6%) in which a in which a “normal” radial artery was found; the remaining
“normal” radial artery was found. A significant difference limbs with a “normal” radial artery possessed rarer variants
was found between the limbs with a “typical” radial artery of an incomplete superficial palmar arch (17/109). Table 2
and those with a brachioradial artery with regard to the compares the diameters of the radial, brachioradial, and ulnar
occurrence of a superficial palmar arch (p < 0.05). The second arteries at the level of the wrist. No significant differences
major type received its full contribution from the ulnar were found between the limbs with “normal” radial artery
BioMed Research International 7

RA BRA

BA

IA
MA
UA
BA

(a) (b)

Figure 7: Schematic representation of the arterial remodeling in the developing upper limb between Carnegie stages 17 and 18. (a) Stage 17.
Before this stage, the brachial artery branches into the capillary network allowing for the formation of different blood flow pathways. (b) Stage
18. The definitive origin of the radial artery is established at this stage. Also at this stage, the cubital crossover (black arrowheads) between the
brachioradial and “normal” brachial artery may be formed in the place of typical origin of the radial artery (both typical origin and high origin
of the radial artery have been marked by dotted lines). BA: brachial artery; BRA: brachioradial artery; IA: interosseous artery; MA: median
artery; RA: radial artery; UA: ulnar artery. This figure is a modification of the drawing taken from Wysiadecki et al. (2017) under the terms
of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium.

and the limbs with the brachioradial artery with regard to the 4.2. A Review of the Variations of the Brachioradial Artery.
formation of the deep palmar arch. The prevalence of the high origin of the radial artery (bra-
chioradial artery) according to different authors varies from
4. Discussion 4.67% to 15.6% [7, 8, 10, 12, 14, 21, 22, 36, 37]. The frequency of
the brachioradial artery given by selected authors is presented
4.1. Embryological Background. Classical theories of develop- in Table 3. This variation was observed most often unilaterally
ment of upper limb arteries assumed that a gradual sprouting [11–13, 21, 22, 45]. However, the identified dependence of the
of arterial trunks takes place from a primitive axial artery occurrence of the brachioradial artery in relation to gender
[20, 38]. In turn, Rodrı́guez-Baeza et al. [22] propose a model and the side of the body varies between studies. In a study
based on the assumption that during normal morphogenesis, carried out on 750 upper limbs, McCormack et al. [10] found
the upper limb arteries are formed by the union of superficial a radial artery with a high origin originating from the brachial
and deep pathways, implying that the superficial brachial artery in 57 right and 37 left upper limbs and from the
artery is a consistent embryonic vessel. New models of the axillary artery in 14 left and two right upper limbs. Rodrı́guez-
development of the upper limb arteries assume that the Niedenführ et al. [12] noted this variant more frequently
definitive arterial pattern of the upper limb is formed as in women and on the right side. In the present study, no
a result of the isolation of main arterial trunks within the statistically significant differences were observed in the prev-
primitive capillary plexus [12, 13, 39–41]. The dominant vas- alence of the brachioradial artery with regard to gender or
cular channels differentiate as a result of capillary remodeling side of the body. However, the origin from the axillary artery
(Figure 7). It can be assumed that such remodeling may give was observed only in two right male upper limbs.
rise to anatomic variations in the arterial pattern, including The brachioradial artery may take the origin from all parts
the presence of atypical high origin of the radial artery. of the axillary artery or, more commonly, it branches off the
The cubital crossover may be considered as remnant medial circumference of the brachial artery [7, 8, 10, 12–14, 21,
of the connection between the primitive axial and super- 22, 36, 37, 45]. The frequency of the origin of brachioradial
ficial brachial arteries at the level of typical origin of the artery from the axillary or brachial artery recorded in the
radial artery [12, 13, 15, 17, 22, 40, 41]. Different types of studies of other authors is presented in Table 3. According to
this anastomosis as well as numerous variations of radial Nasr [11], the mean distance between the intercondylar line
and radial recurrent arteries can indicate various possible of the humerus and the normal origin of RA was 38.7 ± 9.5
directions of rearrangements occurring at early stages of fetal mm in male cadavers and 36.5 ± 8.5 mm in female cadavers.
development (Figures 7 and 8). In rare cases, two arteries In the present study, the brachioradial artery usually arose
(superficial brachial and brachial) may create an arterial between 126 mm and 260 mm above the intercondylar line
complex (like an island pattern) at the level of the radial neck, of the humerus (mean 178 mm, ± 44 mm).
which ends in a division into radial and ulnar arteries [42] A cubital crossover is an anastomotic artery running in
(Figure 8(d)). Thus, an analysis of anatomical variations can a variable manner between the brachioradial and “normal”
contribute to a better understanding of the mechanisms that brachial artery (Figures 8(b), 8(c), and 8(e)). Such “loop-
guide the morphogenesis of arteries [43]. Furthermore, many like” formations were observed by Tiedemann [46], who
additional regulators, including genes, molecular signals, and was the first to systematically describe variations of the
hemodynamic forces, may play an important role in the upper limb arteries and then by Adachi [7] in his classical
formation of the definitive arterial pattern [40, 41, 44]. studies. Docimo et al. [47] describe such anastomosis as
8 BioMed Research International

BA hBRA BA BRA BA
BRA BA BRA BA BRA BA

RRA aRRA
RRA RRA
RRA URA URA
RRA

MB
CIA CIA CIA CIA CIA CIA

RA UA RA UA UA UA UA UA

(a) (b) (c) (d) (e) (f)

Figure 8: Selected anatomical variations of the cubital crossover (marked by black arrowheads) between the brachioradial and “normal”
brachial artery. (a) Typical course of the radial artery. (b) Dominant type of cubital crossover with hypoplastic preanastomotic part of
brachioradial artery. (c) Balanced type. (d) Arterial island (described by Piagkou et al. [42]). (e) Minimal type. (f) No anastomosis between
the brachioradial and “normal” brachial artery within the cubital fossa. aRRA: accessory radial recurrent artery; BA: brachial artery; BRA:
brachioradial artery; CIA: common interosseous artery; hBRA: hypoplastic preanastomotic part of brachioradial artery; MB: muscular branch;
RA: radial artery; RRA: radial recurrent artery; UA: ulnar artery; URA: ulnar recurrent artery.

“arterio-arterial malformation between a high origin radial radioulnar division (5.4%), brachioradial artery (7.8%), bra-
artery and brachial artery” within the cubital fossa. In a study chial artery (7.2%), ulno-interosseous trunk (2.7%), or even
conducted by McCormack et al. [10], the cubital crossover the interosseous trunk (0.3%). Our present findings indicate
was found in 17.8% of the limbs with a high origin of the radial the recurrent radial artery branched off the “normal” (typical)
artery, with only 5 cases (4.7% of limbs with the brachioradial radial artery in 81.6% of limbs, the posterior radioulnar
artery; 26.3% of specimens with the anastomosis) in which division in 9.2%, directly from the brachioradial artery in
a cubital anastomosis passed posterior to the distal biceps 5%, and the cubital crossover in 4.2%. McCormack et al. [10]
tendon. In turn, in a study of 384 upper limbs, Rodrı́guez- found the radial recurrent artery to arise from the cubital
Niedenführ et al. [12] observed cubital anastomosis in 14 out crossover in 10 out of 14 cases possessing this type of union.
of 53 limbs (26.4%) with brachioradial artery. The anastomo- However, Rodrı́guez-Niedenführ et al. [12] found that when
sis adopted a “rectilinear form” in four cases (two in front the brachioradial artery was present, the radial recurrent
and two behind the distal biceps tendon) and a “sling-like artery took origin from it in 46% of cases, from the “normal”
loop morphology” in 10 cases (six in front and four behind brachial artery in 34%, and from the cubital crossover in 20%.
the distal biceps tendon). A very prominent anastomosis In our study, when the brachioradial artery was present, the
with slender preanastomotic part of the radial artery of recurrent radial artery directly branched off the brachioradial
high origin (Figure 8(b)) was observed by McCormack et artery in 54.6% of cases (6/11) or the cubital crossover in
al. [10] in 4.7% of limbs with the high origin of the radial 45.4% of cases (5/11). Similar observations apply to those
artery, where 26.3% of specimens were with the anastomosis. cases in which the accessory recurrent radial artery occurs.
A similar hypoplastic proximal (preanastomotic) segment Vazquez et al. [18] found the accessory recurrent radial artery
of the brachioradial artery was described by von Haller to be present in 103 (31%) out of 332 upper limbs, wherein the
as vasa aberrantia [48]. The present study distinguishes accessory recurrent radial artery always (100%) branched off
three types of cubital crossover (i.e., “cubital connection”) the brachial artery, above the typical level of the origin of the
based on its diameter: dominant in one case (Figure 8(b)), radial artery, running posterior to the distal biceps tendon.
balanced in three cases (Figure 8(c)), and minimal in two Rodrı́guez-Niedenführ et al. [12] describe the occurrence of
cases (Figure 8(e)). In our research, the cubital crossover was the accessory radial artery in 12 cases (22.6%) where the
absent in five out of 11 (45,4%) upper limbs with brachioradial brachioradial artery was present. In the present study, the
artery (Figure 8(f)). accessory radial artery was identified in four out of 11 cases
Major anatomical variations of the upper limb arteries (36.4%) where the brachioradial artery was also present.
often coexist with the variations of radial recurrent arteries
[18]. According to Vazquez et al. [18] the radial recurrent ar- 4.3. Clinical Importance. Since the radial artery is often used
tery takes its origin most frequently from the radial in vascular, plastic, and reconstructive surgery [2, 3] and
artery (64,8%), posterior radioulnar division (9%), anterior routinely used for puncture and cannulation [32, 33, 35],
BioMed Research International 9

Table 3: Frequency of the brachioradial artery given by selected authors.

Frequency
Author, year of study Sample (No. of
limbs) Origin from axillary Origin from brachial All cases of the
artery artery brachioradial artery
Quain, 1844 [36] 30% of brachioradial 70% of brachioradial 12.4% of total amount
429
arteries arteries of upper limbs
2.2% (9/410) 4.9% (20/410)
Adachi, 1928 [7] 410 (31% of brachioradial (69% of brachioradial 7% of all limbs
arteries) arteries)
14.27% of all
McCormack et al., 1953 [10] 2.13% of total / 11.5 % 12.14 % of total / 65.5 specimens – 77% of
750
of variations % of variations all variations of upper
limb arteries
Wathersby, 1956 [14] 408 - - 15.6%
Keen, 1961 [21] 284 - - 5.9%
82 patients with
1.22% of all patients 8.54% of all patients
Karlsson and Niechajev, 1982 [8] demonstrated 97.5% of the cases in
(12.5% of (12.5% of
anatomy of the whole angiographic studies
brachioradial arteries) brachioradial arteries)
upper extremity
100 angiographic 1% of all cases / 12.5% 7% of all cases / 87.5%
Uglietta and Kadir, 1989 [37] 8% of all examined
studies of the upper of brachioradial of brachioradial
cases
limb arteries arteries
0.67% of total /
Rodrı́guez-Baeza et al., 1995 [22] 4% of total / 85.72% of
150 14.28% of 4.67%
brachioradial arteries
brachioradial arteries
13.8% of total amount
Rodrı́guez-Niedenführ et al., 2001 [12] 3.1% of total (23% of 3.1% of total (23% of of upper limbs and
384
brachioradial arteries) brachioradial arteries) 20.3% out of 192
cadavers
1% of total
Nasr, 2012 [11] 8% of total amount of
100 (1 out of 8 7% of total
upper limbs
brachioradial arteries)
1.67% of all upper 7.5% limbs subjected
Our present findings 9.2% of total amount
120 limbs and 18% of to autopsy; 82% of
of upper limbs
brachioradial arteries brachioradial arteries

knowledge of its variations can be of great clinical signifi- artery occurred. The presence of atypical arterial patterns
cance. Transradial access can be hindered by the presence in the upper limb can be predicted based on the Color
of an unusual origin and course of the vessel [26, 34]. It has Doppler ultrasonography, which facilitate the assessment of
been recently noted that the presence of a high origin of the the origin, course, variations, and locations of both arteries
radial artery (namely, the brachioradial artery) “considerably and accompanying veins [53, 54].
contributed to the development of tortuosity”, which can
increase the risk of failure of transradial catheterization [49]. 5. Conclusions
Anatomical variations of both radial and recurrent radial
arteries may also influence the safety and success rate of The brachioradial artery has several anatomical variations.
plastic and reconstructive surgery. The presence of a recur- Although it typically originates from the brachial artery, it
rent radial artery may be useful in the radial forearm free can also, less frequently, originate from the axillary artery.
flap surgeries. Hamahata et al. [16] stated that anastomosis An anastomosis can frequently be observed between the
using radial recurrent artery vessels is recommended as a brachioradial and “normal” brachial arteries in the cubital
strategy in free radial forearm transplantation for salvage fossa, known as a “cubital crossover” or “cubital connection”.
operations. The superficial palmar branch of the radial artery A cubital crossover was observed in three variations classified
can be also used in plastic and reconstructive surgery as as dominant, balanced, or minimal depending on the diame-
the radial artery superficial palmar branch perforator flap ter. A complete radioulnar arch, in which a well-developed
[50–52]. Our present findings indicate that the prominent superficial palmar branch contributed to the radial half of
superficial palmar branch contributed to the formation of the arch, was observed more often when the brachioradial
superficial palmar arch more often when the brachioradial artery was present as a variant. Orthopedic, hand, and plastic
10 BioMed Research International

surgeons should be aware of anatomic variations of the radial [12] M. Rodrı́guez-Niedenführ, T. Vázquez, L. Nearn, B. Ferreira, I.
artery both in planning and in conducting surgeries of the Parkin, and J. R. Sañudo, “Variations of the arterial pattern in
upper limb. the upper limb revisited: a morphological and statistical study,
with a review of the literature,” Journal of Anatomy, vol. 199, no.
5, pp. 547–566, 2001.
Data Availability [13] M. Rodrı́guez-Niedenführ, T. Vázquez, I. G. Parkin, and J. R.
Sañudo, “Arterial patterns of the human upper limb: Update of
The data used to support the findings of this study are anatomical variations and embryological development,” Euro-
available from the corresponding author upon request. pean Journal of Anatomy, vol. 7, no. 1, pp. 21–28, 2003.
[14] H. T. Weathersby, “Anomalies of brachial and antebrachial arter-
Conflicts of Interest ies of surgical significance,” Southern Medical Journal, vol. 49,
no. 1, pp. 46–49, 1956.
The authors declare that they have no conflicts of interest. [15] G. Wysiadecki, M. Polguj, R. Haładaj, and M. Topol, “Low origin
of the radial artery: a case study including a review of literature
and proposal of an embryological explanation,” Anatomical
Acknowledgments Science International, vol. 92, no. 2, pp. 293–298, 2017.
[16] A. Hamahata, H. Nakazawa, M. Takeuchi, and H. Sakurai, “Use-
The authors wish to express their gratitude to all those who
fulness of radial recurrent artery in transplant of radial forearm
donated their bodies to medical science. Publication of the flap: An anatomical and clinical study,” Journal of Reconstructive
article is funded by Medical University of Lodz. Microsurgery, vol. 28, no. 3, pp. 195–198, 2012.
[17] M. Rodrı́guez-Niedenführ, J. R. Sañudo, T. Vázquez, L. Nearn,
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