Using an anomalous brachial artery as an alternative choice of arteriovenous shunt feeding artery
Sir,
Anatomical anomalies of the upper extremity arterial system caused by aberrant embryological development are not rare, and most of them are reported in cadaver studies [13]. In recent years, angiography has provided an alternative tool for uncovering these embryological variants. It is important for surgeons and nephrologists to be aware of the possible arterial variations, because using anomalous arteries to establish arteriovenous access could be considered a viable alternative in some instances. To the best of our knowledge, this is the first case report of a patient undergoing maintenance haemodialysis via arteriovenous graft (AVG) with an anomalous brachial artery as the feeding artery.
Case. A 68-year-old man was an end-stage renal disease patient undergoing haemodialysis for the last 15 years. The present vascular access was a polytetrafluoroethylene graft placed in his right arm 3 years ago. After placement, no numbness or paraesthaesia was noted and access function was optimal. However, recently decreased blood flow and increased venous pressure were found at the access site. Surgical thrombectomy was performed smoothly and palpable thrill was restored. He underwent an immediate postoperative angiography to evaluate the residual stenosis. Retrograde brachial arteriography was performed at the cubital fossa level and initially failed to show an AVG. Another set of angiography studies performed via the AVG clarified the course of the feeding artery (Figure 1) and showed multiple stenotic lesions in the distal part of the AVG. Retrograde brachial arteriography at the axillary level demonstrated that the feeding artery originated from the axillary artery and was measured as 7 mm in diameter. He underwent successful percutaneous transluminal angioplasty with a 5*20 SMASH balloon (Boston Scientific). At 2 months follow-up, the dialysis course was rather smooth and the thrill was prominent.

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Fig. 1. Light microscopic histological findings of the skin biopsy specimen from the cutaneous nodule of the right leg. The biopsy specimen showed an inflammatory infiltration containing PAS-positive micro-organisms (arrows). Magnification, x200. PAS stain.
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Comment. Anomalies of the upper extremity arterial vasculature occur in 920% of the general population in cadaver studies [4,5]. Although the number of reported cases is small, the prevalence of anomalous arteries is high enough to warrant their use in clinical practice. Anomalous arteries are not as easily identified as a brachial artery (as we discovered in our case), but the superficial brachial artery usually has the same caliber as that of the main one and hence is suitable as a feeding artery for arteriovenous access. Easy accessibility, normal vessel caliber, and adequate blood flow qualify its use in arteriovenous shunt. Although aberrant vasculature caused ischaemic complications in patients undergoing radial or ulnar artery flap [6], our patient experienced neither ischaemia nor paresthaesia with adequate arterial inflow. In conclusion, if the brachial artery is neither optimal nor available, the anomalous vessel may be a viable alternative for establishing arteriovenous access.
Conflict of interest statement. None declared.
Hung-Yuan Chen1,
Yen-Hung Lin2,
Vin-Cent Wu2,
I-Jung Tsai3,
Kwan-Dun Wu1 and
Juey-Jen Hwang1,2
1 Department of Internal Medicine3
Department of Pediatrics
National Taiwan University Hospital
National Taiwan University
College of Medicine
Taipei, Taiwan2
Department of Internal Medicine
National Taiwan University Hospital Yun-Lin Branch
Douliou, Taiwan
Email: juey{at}ha.mc.ntu.edu.tw
References
- Ciervo A, Kahn M, Pangilinan AJ, Dardik H. Absence of the brachial artery: report of a rare human variation and review of upper extremity arterial anomalies. J Vasc Surg 2001; 33: 191194[CrossRef][ISI][Medline]
- Cavdar S, Zeybek A, Bayramicli M. Rare variation of the axillary artery. Clin Anat 2000; 13: 6668[CrossRef][ISI][Medline]
- Polkinghorne KR, McDonald SP, Marshall MR, Atkins RC, Kerr PG. Vascular access practice patterns in the New Zealand hemodialysis population. Am J Kidney Dis 2004; 43: 696704[CrossRef][ISI][Medline]
- Uglieta J, Kadir S. Arteriographic study of variants arterial anatomy of the upper extremities. Cardiovasc Intervent Radiol 1989; 12: 145148[ISI][Medline]
- McConnack I, Cauldwell E, Anson B. Brachial and antebrachial patterns: a study of 750 extremities. Surg Gynecol Obstet 1953; 96: 4354[ISI][Medline]
- Fatah MJ, Nancarrow JD, Murray DS. Raising the radial artery forearm flap: the superficial ulnar artery trap. Br J Plast Surg 1985; 38: 394395[CrossRef][ISI][Medline]