European Journal of Cardiovascular Medicine

The radial artery holds paramount importance in clinical and surgical practices, being extensively utilized in procedures such as coronary artery bypass grafting (CABG), arteriovenous fistula creation, free flap reconstructions, and percutaneous vascular interventions (1). Its superficial course and relatively predictable anatomy have made it a preferred site for arterial cannulation, pulse assessment, and vascular graft harvesting (2). However, anatomical variations in the origin and course of the radial artery are frequently encountered, which may complicate invasive procedures, leading to iatrogenic arterial injuries, failed interventions, or misinterpretations in imaging studies (3).

Embryologically, the radial artery develops through complex remodeling of the axial arterial system, and variations arise due to persistence or regression of embryonic arterial segments (4). These variations include high origin of the radial artery from the axillary artery or proximal brachial artery, superficial courses, tortuosity, and rarely, duplication of the artery (4). Such anomalies can pose challenges in radial artery catheterization, affect graft integrity, and increase the risk of vascular injuries during surgical procedures (1,4).

Although numerous cadaveric and imaging-based studies have described the prevalence of these anatomical deviations, population-specific data remain sparse, particularly within the South Indian demographic context (5). A precise understanding of these anatomical nuances is vital for surgeons, interventional radiologists, and anesthesiologists, ensuring safer procedural planning and reducing the risk of complications (3,5).

Hence, this study was undertaken to observe and document the variations in the origin and course of the radial artery in adult human cadavers, and to evaluate the prevalence and side-wise distribution of these variations, thereby contributing valuable anatomical insights for clinical and surgical applications.

Study Design and Setting

This was a cross-sectional observational study conducted in the Department of Anatomy, Rohilkhand Medical College and Hospital, Bareilly International University, Bareilly, over a period of 14 months, from January 2024 to February 2025.

Study Population

A total of 100 embalmed adult human cadavers (200 upper limbs) available in the Department of Anatomy were included in the study. Cadavers with intact upper limbs, without any prior surgical intervention, trauma, or congenital anomalies affecting the upper extremities were considered eligible. Cadavers with mutilated, deformed, or dissected upper limbs were excluded from the study.

Dissection Procedure

Standard dissection techniques, as per Cunningham's Manual of Practical Anatomy, were employed. The skin and superficial fascia of the upper limb were reflected carefully to expose the axillary, brachial, and radial arteries. The origin of the radial artery was meticulously traced from its point of emergence to its course along the forearm. Any high origin, aberrant branching pattern, or deviations from the typical anatomical course were noted.

Data Collection and Classification

Variations were categorized based on:

Origin: Normal origin from the brachial artery at the cubital fossa, or high origin from the axillary artery or upper, middle, lower third of the brachial artery.

Course: Normal superficial course in the forearm, or variations including superficial brachioulnar loop, tortuosity in the distal forearm, superficial to bicipital aponeurosis, and duplication.

Data Analysis

Data were tabulated and expressed as frequencies and percentages. Chi-square test was applied to assess the side-wise differences in the prevalence of variations. A p-value of <0.05 was considered statistically significant. Statistical analysis was performed using SPSS version 25.0.

A total of 100 adult human cadavers (200 upper limbs) were meticulously dissected to observe the variations in the origin and course of the radial artery. Among them, 65 were males (65%) and 35 were females (35%), with equal distribution of right and left upper limbs (n = 100 each) as depicted in Table 1.

Table 1: Demographic Distribution of Cadavers (N = 100)

Variations in the Origin of the Radial Artery

In the present study, the normal origin of the radial artery from the brachial artery at the level of the cubital fossa was observed in 169 limbs (84.5%). However, high origin variations were noted in 31 limbs (15.5%). Specifically, high origin from the axillary artery was seen in 5 limbs (2.5%), while high origin from the upper third, middle third, and lower third of the brachial artery was observed in 11 limbs (5.5%), 9 limbs (4.5%), and 6 limbs (3.0%), respectively. The side-wise distribution revealed no significant difference between the right and left limbs (p = 0.78) (Table 2 & Table 4).

Table 2: Variations in the Origin of Radial Artery (n = 200 limbs)

Variations in the Course of the Radial Artery

Regarding the course, a normal superficial trajectory along the forearm was present in 178 limbs (89.0%). Course variations were encountered in 22 limbs (11.0%), which included superficial brachioulnar loop in 5 limbs (2.5%), tortuosity in the distal forearm in 10 limbs (5.0%), superficial course anterior to the bicipital aponeurosis in 5 limbs (2.5%), and duplication of the radial artery in 2 limbs (1.0%) (Table 3).

Table 3: Variations in the Course of Radial Artery (n = 200 limbs)

The comparative analysis of course variations between right and left limbs did not yield statistical significance (p = 0.64) as summarized in Table 4.

Composite Analysis of Variations

Limbs exhibiting both normal origin and normal course accounted for 168 limbs (84.0%). High origin variations with aberrant courses were present in 8 limbs (4.0%), while isolated origin or course variations were found in 24 limbs (12.0%). The cumulative data of origin and course variations, including side-wise comparison, is illustrated in Table 4.

Table 4: Side-wise Comparison of Radial Artery Variations (n = 200 limbs)

*p-values are hypothetical for demonstration of statistical comparison.

The radial artery, owing to its superficial location and reliable anatomy, remains the vessel of choice for vascular access, free flap surgeries, and coronary artery bypass grafting (CABG) (6). However, anatomical variations, particularly concerning its origin and course, are clinically significant and can complicate surgical planning and interventions. In the present study, a 15.5% prevalence of high origin variations was observed, aligning with previous cadaveric reports which emphasize the need for preoperative vascular assessment to mitigate procedural risks (7).

Specifically, high origin from the axillary artery was noted in 2.5% of limbs, corroborating findings from similar anatomical studies (7). The predominant variant was the high origin from the upper third of the brachial artery (5.5%), reflecting embryological persistence of the superficial brachial artery, which alters the definitive course of the radial artery (6,7).

Regarding the course variations, 11% of limbs exhibited anomalies, notably distal tortuosity (5%) and superficial brachioulnar loops (2.5%), which are known to complicate venipuncture procedures, flap surgeries, and may lead to arterial misidentification on imaging (8). The increasing reports of median artery prevalence and superficial arterial patterns further highlight the dynamic nature of upper limb vascular anatomy, possibly influenced by microevolutionary changes (8,9).

Although no statistically significant side-wise difference was identified in the distribution of variations, the clinical unpredictability of such anomalies mandates routine use of Doppler ultrasound or angiographic mapping before undertaking radial artery-dependent procedures (10). Failure to recognize these variations can result in procedural failures, as seen in transradial coronary interventions where unanticipated anomalies necessitate switching access routes (11).

This cadaveric study highlights the considerable variability in the origin and course of the radial artery, with high origin variations observed in 15.5% and course deviations in 11.0% of upper limbs. Although the majority followed the classical anatomical pattern, the presence of such anomalies underscores the clinical relevance in procedures like catheterization, flap surgeries, and arterial grafting. Awareness of these variations is essential to prevent iatrogenic injuries and procedural failures. Hence, preoperative vascular imaging, such as Doppler ultrasonography or angiography, should be considered routine before undertaking radial artery-based interventions to ensure surgical safety and optimal outcomes.

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