Evaluation of anatomy and variations of superficial palmar arch and upper extremity arteries with CT angiography

CT Angiography of the Upper Extremities: Review of Acute Arterial Entities

Historically, evaluation of the upper extremity vasculature was performed using digital subtraction angiography. With the advancement of cross-sectional imaging and submillimeter isotropic data acquisition, CT angiography (CTA) has become an excellent noninvasive diagnostic tool for evaluation of the vasculature of the upper extremities. CTA allows quick evaluation of vessel patency and irregularity and achievement of the anatomic detail needed in preoperative planning. When interpreting CTA of the upper extremities, radiologists must be familiar with the normal vascular anatomy, common vascular anomalies, and pitfalls or artifacts that may mimic or mask abnormality. In this review, the authors provide an overview of the utility of CTA of the upper extremities. Also discussed are CTA techniques and the use of several newer technologies including dual-energy and photon-counting detector CT. The utility of CTA in patients with upper extremity trauma is explored, with a focus on assessing vascular injury. Other vascular abnormalities including infection, acute limb ischemia, and vasculitis are discussed. It is imperative for radiologists to be accustomed to CTA of the upper extremities in diagnosing acute vascular abnormalities and to recognize common pitfalls and mimics of these abnormalities. ©RSNA, 2025 Supplemental material is available for this article.

Superficial palmar branch of radial artery flap for digital skin reconstruction: anatomical study and clinical applications

BACKGROUND

This study investigates the anatomy of the superficial palmar branch of the radial artery (SUPBRA) for palmar skin reconstruction. It aims to detail SUPBRA's anatomical features for hand/finger reconstruction and pinpoint reference points for efficient harvesting.

MATERIALS AND METHODS

Nineteen male hand specimens (aged 18-70 years), fixed in 10% formalin, were dissected to study the anatomy of SUPBRA island flap. All measurements such as the external diameter of the SUPBRA, its bifurcation point from the radial artery, length of the SUPBRA pedicle, accompanied by venae comitantes, the number and location of perforators were used analyzed. Two flap techniques based on SUPBRA, the mid-palmar axis and wrist line axis, were studied. SUPBRA flap designs were used in three hand injury cases.

RESULTS

The distance from SUPBRA's origin to the styloid process averaged 9.4 ± 1.1 mm, and its mean diameter was 2.4 ± 1.5 mm. It has not been encountered a pattern with a narrow diameter of 1.1 mm or less, which is considered hypoplastic and unsuitable for a flap due to inadequate nourishment, in SUPBRA. Mean length of the SUPBRA pedicle was 31.0 ± 6.3 mm. The SUPBRA was typically accompanied by two vena comitantes. The location of the musculocutaneous perforators, approximately 10 mm distal to the scaphoid tubercle, suggests that when the SUPBRA flap is designed transversely along the distal wrist crease, the direct cutaneous perforators will play a crucial role in providing adequate blood supply to the flap as a pedicle. Flap sizes ranged from 1.5 × 3.0 mm to 2.5 × 6.5 mm. To obtain a longer pedicle, the flap was designed with a long-skin pattern along the long-axis direction, and the accompanying veins were dissected proximally to the radial artery. All cases confirmed the SUPBRA flap's viability for microvascular anastomosis in the thenar regions.

CONCLUSION

SUPBRA flap isa valuable option for hand and finger reconstruction,. providing detailed anatomical insights, including its external diameter, bifurcation point from the radial artery, flap length, presence of venae comitantes, and the number and locations of perforators. This flap is particularly suitable for reconstructing palmar defects of the radial digits, palm, and first webspace, and its arterial dimensions and lengths make it well-suited for microvascular anastomosis.

A Unique Case of Vascular Variations in the Upper Limbs: A Brachioradial Artery and Bilateral Persistent Median Arteries With Incomplete Superficial Palmar Arches

Numerous vascular variations were observed in the upper limbs of a 109-year-old female donor to the Gift Body Program of Saint Louis University School of Medicine. Variations in the right upper limb included the presence of a brachioradial artery (BRA), persistent median artery (PMA), and an ulnar-dominant incomplete type B superficial palmar arch (SPA). In the left upper limb, the brachial artery bifurcated normally into the ulnar artery (UA) and radial artery (RA). However, a more developed palmar type of PMA was observed, replacing much of the palmar circulation typically supplied by the superficial palmar branch of the RA, which existed only as a small branch anastomosing with the PMA to form a rare arcus medianoradialis-type SPA. Both PMAs arose from their respective UAs distal to the origin of the common interosseous arteries. The left PMA pierced the median nerve (MN) as it descended the forearm. The extent of these variations together presents a unique case of vascularity in the upper limbs. Knowledge of these variations is pertinent to MN compression pathologies as well as procedures involving the upper limb.

Upper limb computed tomography (CT) angiography in the emergency department

A range of abnormalities may acutely affect the upper limb (UL) extremity vasculature including trauma, peripheral vascular disease, and inflammatory conditions. Significant technical advances in computed tomography angiography (CTA) have led to the widespread adoption of this noninvasive modality for rapid evaluation of UL arterial abnormalities in the emergency department setting. A key advantage of CTA over traditional digital subtraction angiography (DSA) is the ability to evaluate concurrent osseous and soft tissue injuries. Accurate identification of pathology requires knowledge of normal UL arterial anatomy in addition to a high-quality study, which may be achieved with a robust CTA protocol. We describe the spectrum of imaging findings on upper limb CTA associated with various acute presentations. Traumatic vascular injuries may occur secondary to penetrating and blunt aetiologies appearing on CTA as contrast extravasation, pooling, pseudoaneurysm, occlusion, and arteriovenous fistula. Peripheral vascular disease manifests as atherosclerotic plaques with thready downstream opacification, and these may precipitate acute thromboembolic events. Inflammatory conditions affecting the UL vasculature includes large and small vessel vasculitides characterised by arterial mural thickening. The use of modalities, including ultrasound and magnetic resonance angiography (MRA), should be considered for further characterisation where appropriate.

Anatomical variations of the superficial palmar arch in human fetuses

The superficial palmar arch is an important anatomical structure that contributes to the arterial supply of the palmar side of the hand in the upper extremity. However, there is limited information on the embryological morphological structure of the superficial palmar arch in the literature. We studied the types of the superficial palmar arch and determined their variations by dissecting 80 upper extremities of 40 formalin-fixed human fetuses (19 males, 21 females) 18-37 weeks of age. The types and variations of the superficial palmar arch were examined, and the median artery was imaged. The superficial palmar arch type was complete in 58 hands (72.5%) and incomplete in 22 hands (27.5%). The complete group consisted of type A (47.5%), type B (16.25%), type C (3.75%), type D (1.25%), and type E (3.75%). On the other hand, the incomplete group consisted of type F (15%), type G (8.75%), type H (2.5%), and type I (1.25%). A median artery that originated from the ulnar artery and passed through the carpal tunnel during its course was detected in two hands (2.5%). Knowledge of the superficial palmar arch variations will contribute to hand microsurgery particularly in vascular graft and free flap application interventions for arterial bleeding in the palmar region.

Variations in Superficial Palmar Arch: Case Series with Clinico-anatomical Perspective

The superficial palmar arch (SPA) is an important anastomotic network primarily formed by the superficial branch of the ulnar artery with one of the superficial branches of the radial artery. SPA variations were observed in three out of 20 cadaveric hand specimens. Two cases of unilateral incomplete SPA and the third case of a unilateral ulnar-to-median complete SPA were recorded. The incomplete SPA was located superficial to the flexor digitorum tendons and deep to the palmar aponeurosis. SPA in the remaining 17 hands was anatomically normal, with major contributions from the superficial palmar branch of the ulnar artery and minor contributions from the superficial palmar branch of the radial artery. These variations are clinically important, especially during procedures like arterial blood sampling, cardiac catheterization, and hemodialysis. Thus, anatomical variabilities in this region may cause complications with vascular occlusion if not ascertained before the procedure.

Use of multidetector computed tomography angiography of upper limb circulation in patients undergoing coronary artery bypass grafting surgery

OBJECTIVE

This study aimed to evaluate the bilateral forehand circulation using a 64-channel multidetector computed tomography (MDCT) as a noninvasive method to define criteria for an upper extremity arterial anatomy and pathology prior to the use of arterial conduits.

MATERIALS AND METHODS

Fifty-five patients with coronary artery disease who underwent total arterial coronary artery bypass grafting (CABG) were randomly selected for this prospective study. MDCT angiography was performed for 110 examinations of forearm and hand arterial anatomy. Prior to MDCT, Allen tests were performed in all patients with a normal result, except four. Thirteen patients had diabetes mellitus (DM), 8 had peripheral artery occlusive disease, and 19 had a history of smoking.

RESULTS

All arteries, including axillary, ulnar artery (UA) and radial artery (RA), were clearly visualized in all patients. Upper extremity anatomical and pathological results were examined in 16 patients (29.1%). Severely calcified RA and/or UA were found in 6 patients who had a moderate renal failure. Nearly total occlusion of the RA was detected in another two patients. Focal intimal RA calcification was recorded in 1 female and 3 male patients. Ten patients who had severe calcification or intimal sclerosis of the upper extremity arteries had DM. The remaining patients had normal forehand arterial circulation. A persistent median artery with the absence of radial and ulnar arteries and a high bifurcation of RA from the brachial artery was detected as an anatomic variation in seven patients (12.7%).

CONCLUSIONS

The major advantages of MDCT angiography are its non-invasiveness and the ability to detect calcific subadventitial plaques, which are difficult to diagnose using conventional angiography. MDCT may be used as a safe and non-invasive method to assess RA and UA prior to harvesting the upper limb artery. Preoperative imaging of forehand arteries is a means to avoid unnecessary forearm exploration or the use of an unsuitable arterial conduit in CABG operations, especially in patients with DM and moderate renal impairment.

High-resolution, non-contrast-enhanced magnetic resonance angiography of the wrist, hand and digital arteries using optimized implementation of Cartesian quiescent interval slice selective (QISS) at 1.5 T

PURPOSE

Non-contrast-enhanced (CE) magnetic resonance angiography (MRA) techniques are of considerable interest for diagnosing vascular diseases in the upper extremities owing to the possibility of repeated examinations, sufficient coverage of the measurement volume, and because possible side effects of administering iodine- or gadolinium-based contrast agents and radiation exposure can be avoided. The aim of this study was to investigate the feasibility of an optimized electrocardiogram (ECG) triggered Cartesian quiescent interval slice selective (QISS) technique for MRA of hand arteries.

MATERIAL AND METHODS

Both hands of 20 healthy volunteers (HVs) were examined using an optimized QISS-MRA pulse sequence at 1.5 Tesla. The wrist and hand arterial trees were divided into 36 segments. Cross-sectional areas (CSA) of all arterial segments were measured. For the technical evaluation of the pulse sequence, the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were computed and six imaging artifacts were graded. Two experienced observers used an ordinal scoring system to assess the image quality of each arterial segment. Interobserver agreement was determined.

RESULTS

The median CSA was 7.3 mm2 in the ulnar and radial artery, 3.2 mm2 in the four common digital arteries, and 1.5 mm2 in five proper digital arteries. The median SNR and CNR of the third common proper arteries were 45.9 and 20.3, respectively. None of the arterial segments were contaminated by venous enhancement. The image quality of arterial segments for both hands was considered as diagnostic in 87.2% of all 1440 segments. An interobserver agreement of 0.67 for both hands was determined for image quality of arterial segments using a five-grade scoring system. Optimized QISS-MRA allows as the first MRA technique the classification of superficial palmar arch (SPA) and deep palmar arch (DPA) variants. 5 new SPA and 6 new DPA variants could be classified using QISS-MRA in comparison with previous studies using CE computed tomography angiography and using fixed cadaver hands.

CONCLUSIONS

By using this optimized 2D Cartesian QISS-MRA protocol, contrast agent-free angiography of the wrist and hand arteries provided a high in-plane spatial resolution and an excellent visualization of small digital arteries.

Superficial palmar branch of the radial artery in a fibromuscular tunnel: a case report

The radial artery usually passes on the radial side of the wrist lateral to the wrist to enter the anatomical snuff box and dorsum of the hand. If the radial artery passes anterior to the wrist, it usually enters the carpal tunnel, and in such cases, it may lead to the compression of the median nerve within the carpal tunnel. During the routine dissection, we found a case of the unusual radial arterial branch that passed anterior to the wrist yet outside the carpal tunnel. The artery passed within a tunnel formed by the fibromuscular fibers of thenar muscles arising from the anterior aspect of the transverse carpal ligament. Knowledge of the course and distribution of the variant superficial palmar branch of radial artery are of importance to the surgeons operating around the wrist, radiologist interpreting angiograms, and orthopedists managing trauma to the wrist.

CT and MR imaging of the upper extremity vasculature: pearls, pitfalls, and challenges

Imaging is needed for diagnosis, treatment planning, and follow-up of patients with pathologies affecting upper extremity vasculature. With growth and evolution of imaging modalities [especially CT angiography (CTA) and MR angiography (MRA)], there is need to recognize the advantages and disadvantages of various modalities and obtain the best possible imaging diagnostic test. Understanding various limitations and pitfalls as well as the best practices to minimize and manage these pitfalls is very important for the diagnosis. This article reviews the upper extremity arterial vascular anatomy, discusses the CTA and MRA imaging, various pitfalls, and challenges and discuss imaging manifestations of upper extremity arterial pathologies.

Incomplete superficial palmar arch and bilateral persistent median artery

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Possible anatomical variations of the vascular supply for the hand.

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Screen patients for the presence of persistent median artery.

Introduction

The superficial palmar arch (SPA) is a major source of blood supply to much of the hand and is conventionally formed by the anastomosis of the ulnar artery with the superficial branch of the radial artery. The SPA has been classified into complete or incomplete based on the presence or absence of anastomosis between the arteries contributing to the formation of this palmar arch.

Case report

Reported here is a unilateral presentation of incomplete superficial palmar arch. The ulnar artery (UA) gave off one proper palmar digital artery, which supplied the ulnar side of the little finger, and two common palmar digital arteries, which supplied the little, ring, and the middle finger. The superficial palmar branch of the radial artery gave off a proper palmar digital artery to the thumb, and two common palmar digital arteries, which supplied the thumb, index, and middle fingers. Apart from the presence of the incomplete SPA, persistent median arteries were also observed bilaterally in this cadaver.

Discussion

The prevalence of incomplete SPA has been reported to vary between 3.6–54.76%. To the best of our knowledge, this is the first case report describing an incomplete palmar arch and bilateral persistent median artery in a cadaver.

Conclusion

Patients should be screened for the presence of complete or incomplete SPA before harvesting the radial artery either for myocardial revascularization or for radial artery forearm flap to prevent ischemic complications in the hand.

Persistent Median Artery as an Unusual Finding in the Carpal Tunnel: Its Contribution to the Blood Supply of the Hand and Clinical Significance

BACKGROUND Knowledge of the variable relation of the persistent median artery (PMA) to the median nerve and its contribution to the formation of the superficial palmar arch is of great clinical significance. This study presents a proposal of specific variables which might be introduced to characterize the PMA in the wrist region. MATERIAL AND METHODS One hundred and twenty-five randomly selected, isolated upper limbs fixed in 10% formalin solution were subjected to anatomical dissection. RESULTS Of the 125 upper limbs, PMA was found in 5 specimens (4% of the total number of limbs). In the carpal tunnel, the artery occupied the anterolateral position (2 cases), the anterior position (2 cases) or the anteromedial position (1 case) in relation to the median nerve. Two types of superficial palmar arches with significant contributions from the PMA were observed in the studied material: complete medio-ulnar arch and an incomplete arch without a connection between the territories of the ulnar and median arteries. The mean ratio of the diameter of the PMA to the diameter of ulnar artery at the level of the wrist was 0.59 (min.=0.38, max=0.83, SD=0.19). CONCLUSIONS Orthopedic and hand surgeons should be aware of the probability of occurrence of the PMA in both planning and conducting surgeries within the wrist region and within the carpal tunnel, as this anomalous vessel might present significant contributions to the arterial blood supply of the hand and might potentially play an important role in the presence of notable clinical symptoms and presentations.

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

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.

A rare anatomic variation of the superficial palmar branch of the radial artery causing pain

Background

The superficial palmar branch of the radial artery (SPBRA) normally pierces through the thenar muscles and unites with the ulnar artery to form the superficial palmar arch. Rarely, a subcutaneous course of the SPBRA is described in which the artery lies superficial to the thenar muscles.

Case report

We report about a 17-year-old female patient with pain at the thenar eminence due to a unique course of the SPBRA. Duplex sonography and magnetic resonance angiography revealed a subcutaneous course of the artery over the thenar muscles. Arterial transposition by splitting of the abductor pollicis brevis muscle was performed. At 12-month follow-up, the patient is still free of symptoms. Duplex sonography confirmed patency of the SPBRA.

Conclusion

While a subcutaneous course of the SPBRA has been described before, we present an adolescent patient with this anatomical variation causing pain. Our specifically tailored treatment strategy consisting of arterial transposition by splitting of the abductor pollicis brevis muscle was efficient and feasible in our patient and hand surgeons should be aware of this anatomical variation.