High bifurcation of the brachial artery and its implications for arteriovenous fistula construction

Abstract

To the Editor, We read the article by Acharya et al.[1] describing a case of high bifurcation of the brachial artery (HBBA) with interest. The brachial artery usually bifurcates into its terminal branches, the radial and ulnar arteries, slightly distal to the elbow joint. However, it is not uncommon for this bifurcation to occur proximally. The reported prevalence of HBBA is 12.3%.[2] HBBA is associated with a higher incidence of the failure of arteriovenous fistula creation.[3] The functional patency rate of arteriovenous fistulae at 12 months created in patients with HBBA is less (53.4%) than the normal brachial artery (74.5%).[3] Moreover, the superficial radial artery, which is associated with the HBBA, may pose a high risk for iatrogenic cannulation injuries, particularly in patients undergoing hemodialysis.[4] Even though the vascular mapping is recommended before the arteriovenous fistula creation, it is not uncommon to perform this procedure based on anatomical landmarks,[5] particularly in resource-poor settings. Thus, we intended to assess the prevalence of HBBA in Sri Lanka. This study was approved by the institutional ethics review committee. We randomly selected 20 cadavers (10 males and 10 females) with no history of trauma involving upper limbs, vascular instrumentation, or arteriovenous fistula creation. We dissected 20 upper limbs and measured the length of a line drawn perpendicularly from the intercondylar line to the brachial artery bifurcation using a Vernier caliper. We also measured the length of the brachial artery from the lower border of the teres major to its bifurcation using a measuring tape. The mean length of the brachial artery was 23.3 (range: 15.4–29.3, standard deviation [SD] = 3.7) cm. One cadaveric female left upper limb demonstrated HBBA 4.8 cm proximal to the level of the intercondylar line [Figure 1]. The mean distance from the intercondylar line to the bifurcation of the brachial artery was 3.7 cm (range: 4.8 cm proximal to the intercondylar line to 6.1 cm distal to the line, SD = 2.3). We did not observe previously reported other common anatomical variations of the brachial artery, such as the superficial brachial artery, accessory brachial artery, brachioradial artery, or brachioulnar artery.Figure 1: High bifurcation of the brachial artery in a female cadaver. The point of bifurcation is indicated by the blue arrow. The intercondylar line is shown by the dashed lineIn conclusion, we report that HBBA in our population is not uncommon. Since a significant proportion of the population may have an HBBA, vascular mapping is essential before arteriovenous access creation. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.