Journal of Ayurveda and Integrated Medical Sciences

Introduction

The brachial artery is a major artery of arm and continuation of the axillary artery. It begins at the lower border of the teres major muscle and ends at the level of the neck of the radius in deeper part of cubital fossa by dividing into radial and ulnar arteries. The brachial artery is superficial throughout its course and covered by skin and superficial fascia. It lies medial to the humerus in upper part but gradually spirals anterior to it until it lies midway between the humeral epicondyles. Anteriorly it is related to medial cutaneous nerve of fore arm in upper part, crossed by median nerve in middle part and crossed by bicipital aponeurosis in lower part. Posteriorly it is related to triceps muscle coracobrachialis muscle and brachialis muscle from above downward. Medially it is related to ulnar nerve and basalic vein in upper part and median nerve in lower part. Laterally it is related to coracobrachialis, biceps brachia muscle and median nerve. The brachial artery gives origin to profunda brachii, superior ulnar collateral and inferior ulnar collateral, nutrient, muscular, radial, and ulnar arteries.^[1]

The brachial artery variations were observed in its course, branching pattern and division but the variations of Brachial Artery division are common and have been documented by many researches. The division of Brachial Artery can be determined with reference to imaginary line joining the medial and lateral epicondyles of Humerus. The bifurcation of brachial artery above this line is terminated as high division of brachial artery.^[2] According to Anson 15% of individuals have high origin of radial artery and may arise as high as the axillary artery but most commonly it arises from the proximal one third of the arm.^[3] The course, termination and precise knowledge of variations of brachial artery is an important aspect in the clinical practice of Physician, Vascular surgeons, and Radiologist. Higher division of brachial artery is one of the common variations ranging from 15% to 20% of population. It divides more proximally in the arm into radial and ulnar artery (Proper Brachial Artery).

Case Report

The present study was carried in a middle-aged formalin embalmed male cadaver during routine dissection of upper limb by Ayurvedic

wrist. Radial artery measures approximately 46 cms from its origin to the wrist. In the fore arm and hand the radial artery were found to be normal in course and branching pattern.

Proper brachial artery is thick in calibre and extends from lower border of the teres major to the neck of the radius their after continue as ulnar artery in the forearm. In the arm proper Brachial Artery descends downwards along with the medial border of biceps brachii muscle and lateral to the radial artery. In the cubital fossa proper Brachial Artery passes deep to the pronator teres muscle and continues as ulnar artery. Proper Brachial Artery gives following branches in the arm.

1. The profounda brachi artery was originated from proper brachial artery just 1 cm above the origin of radial artery and runs posteriolaterally in radial groove of humerus.

2. Superior Ulnar collateral artery was originated from proper brachial artery just 2.5 cms below the origin of radial artery.

3. Inferior Ulnar collateral artery was originated from proper brachial artery just 3.5 cms below the origin of radial artery.

Observations in Left Upper Limb

The brachial artery bifurcated into medial and lateral branches 4cm distal to the lower border of teres major muscle. The medial branch is known as radial artery and the lateral branch is known as Proper Brachial Artery both arteries descend downwards parallel to each other.

The radial artery was originated from brachial artery 4 cm below the lower border of teres major as medial superficial branch and descends downwards along with the median nerve in the arm. The course of the radial artery is similar to the right upper limb. Radial artery measures approximately 42cms from its origin to the wrist. In the fore arm and hand the radial artery were found to be normal in course and branching pattern.

Left Proper brachial artery and its branching pattern is almost similar to the right one with following slight difference.

1. The profound brachi artery was originated from proper brachial artery just half centimetre below the origin of radial artery and runs posteriolaterally in radial groove of humerus.

Puspalata M also reported a case of bilateral high division of brachial artery into radial and ulnar artery. The radial artery passes downwards and laterally and ulnar artery passes downwards and medially in arm and passes deep to the ulnar head of pronator teres muscle in cubital fossa.

The radial artery graft is considered the second option after the left internal mammary artery graft in coronary artery bypass grafting, because the diameter of the Radial Artery is approximately equal to that of coronary artery but when Radial Artery arising at a high level in the arm sometimes have smaller diameter which cannot be used for coronary artery grafting. The coronary artery bypass graft (CABG) surgery is the treatment of choice for multivessel coronary artery disease.^[12] The radial artery graft is easy to harvest and can be bypassed to reach the major coronary arteries and also multiple studies have shown better patency rate and survival with radial artery graft as compared to saphenous vein graft. Carpentier and his colleagues in 1973 first introduced the radial artery graft^[13] but within a few years, it was banned because of the high rate of occlusion. Acar and colleagues reintroduced it in 1992 after discovering patent radial graft on an angiogram. With modification in surgical technique and utilization of antispasmodic agents, the radial artery graft patency rate is more than 90% at both one year and five years.^[14]

Wen-yuan Li and his colleagues conducted study to establish the relationship between blood pressure measured on the brachial artery and blood pressure assessed on the radial artery in the right arm. The brachial artery blood pressure was significantly lower than the radial artery blood pressure. The difference between the two values varied from 13 to 18 mmHg in systolic Blood Pressure, diastolic Blood Pressure and mean blood pressure respectively.^[15] In our case report we found that radial artery lies superficial to the ulnar artery (Proper Brachial Artery) in the cubital fossa hence in such cases while recording the BP we are doing auscultation of radial artery that suggest for misdiagnosis of Blood Pressure.

Acharya Sushruta known as father of Indian surgery explained that two Avedhyasira and Bahvi Marma in relation to surgical anatomy of arm. Avedhya Sira means the vessel should not puncher or cut during surgical or parasurgical procedures. Acharya Sushuta explained two Avedya Sira

Callander’s Surgical Anatomy. Arm or Brachial region. 3rd Edn. W.B. Saunder’s Co. Philadelphia; 1952; pp. 762-764.

4. Lippert H, Pabst R. Arterial variations in man. Munich, Bergman, 1985; pp. 66-77.

5. Bidarkotimath S, Avadhani R, Kumar A. Primary pattern of arteries of upper limb with relevance to their variations. Int J Morphol. 2011; 29(4): 1422-1428.

6. Bergman RA, Thompson SA, Afifi AK, Saadeh FA. Compendium of human anatomic variation, 1988, Urban & Schwarzenberg, Baltimore.

7. Anson BJ, Morris M. Human Anatomy in the cardiovascular system - Arteries and veins. Thoms, M. Edr. McGraw Hill Book Co. New York; 1966; pp. 708-724.

8. De Garis CF, Swartley WB. The axillary artery in white and Negro stocks. Am J Anat. 1928; 41:353-97.

9. Chandrika Teli et al. High division and variation in brachial artery branching pattern. J Dent Med Sci. 2013; 3(6):68-70.

10. Madhyastha S, Nayak SR, Krishnamurthy A, D'Costa S, Jose AA, Bhat KMR. Case report of high origin of radial, ulnar, and profunda brachii arteries, its clinical implications and review of the literature. J Vasc Bras. 2009; 8:374-78.

11. Puspalatha M, Haq I. Bilateral high divisions of the brachial artery - a case report. Anat Karnataka. 2010; 4(1):59-61.

12. Benedetto U, Gaudino M, Ng C, Biondi-Zoccai G, D'Ascenzo F, Frati G, Girardi LN, Angelini GD, Taggart DP. Coronary surgery is superior to drug-eluting stents in multivessel disease. Int J Cardiol. 2016 May 01;210:19-24.

13. Carpentier A, Guermonprez JL, Deloche A, Frechette C, DuBost C. The aorta-to-coronary radial artery bypass graft. A technique avoiding pathological changes in grafts. Ann Thorac Surg. 1973 Aug;16(2):111-21.

14. Acar C, Jebara VA, Portoghese M, Beyssen B, Pagny JY, Grare P, Chachques JC, Fabiani JN, Deloche A, Guermonprez JL. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg. 1992 Oct;54(4):652-9; discussion 659-60.