Valves of the common brachial vein: anatomical study

Abstracts

CONTEXTO: Boa parte das insuficiências venosas é devida à incompetência de suas válvulas. Como uma das alternativas cirúrgicas, temos os enxertos venosos valvulados no segmento insuficiente. OBJETIVO: Descrever a anatomia das válvulas da veia braquial comum. MÉTODOS: Foram selecionados 30 cadáveres do sexo masculino, independentemente de raça, que tinham seus membros superiores articulados ao tronco. Os mesmos estavam formolizados e foram mantidos em conservação com solução de formol a 10%. Utilizamos como critério de exclusão a existência de desarticulação de um dos membros ou de alterações deformantes em topografia das estruturas estudadas. RESULTADOS: O número total de válvulas identificadas foi de 28 em membro superior direito e de 33 em membro superior esquerdo, sendo 15 no segmento proximal direito e 21 no segmento proximal esquerdo. Mais de 91% das válvulas foram do tipo bicúspide e parietal. CONCLUSÃO: Conclui-se que a veia braquial comum apresenta freqüentemente válvulas do tipo bicúspide e parietal.

Anatomia; cadáver; insuficiência venosa; varizes; transplante

ORIGINAL ARTICLE

Valves of the common brachial vein: anatomical study

Carlos Adriano Silva dos Santos^I; Luiz Francisco Poli de Figueiredo^II; Luiz Carlos Buarque de Gusmão^III; Guilherme Benjamin Brandão Pitta^IV; Fausto Miranda Jr.^V

^IVascular surgeon, Hospital–Escola Dr. José Carneiro, Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brazil

^IIDoutor. Associate professor, Department of Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil

^IIIDoutor. Associate professor, Department of Morphology, Universidade Federal de Alagoas (UFAL), Maceió, AL, Brazil

^IVDoutor. Associate professor, Department of Surgery, UNCISAL, Maceió, AL, Brazil

^VFull professor, Department of Surgery, UNIFESP, São Paulo, SP, Brazil

^{Correspondence}

ABSTRACT

BACKGROUND: A great part of venous insufficiencies is due to valve incompetence. Valved venous grafts in the insufficient segment are a surgical alternative.

OBJECTIVE: To describe the anatomy of the common brachial vein valves.

METHODS: We used 30 male corpses of varied races with their upper limbs articulated to the trunk. They were preserved in formol and fixed in a 10% formol solution. Exclusion criteria were presence of disarticulation in one limb or deforming alterations in the topography of assessed structures.

RESULTS: The total number of identified valves was 28 in the right arm and 33 in the left arm, 15 of them in the right proximal segment and 21 in the left proximal segment. More than 91% of the valves were bicuspid and parietal.

CONCLUSION: We conclude that the common brachial vein often presents bicuspid and parietal valves.

Keywords: Anatomy, cadaver, venous insufficiency, varicose veins, transplantation.

Introduction

Clinical manifestations such as pain in the legs, edema, varicose veins, pigmentations and ulcers reflect an advanced degree of venous insufficiency largely represented by reflux in the venous system.^1,2 These manifestations are usually associated with valve incompetence in the ascending aortic blood flow. There are several surgical proposals to repair these incompetent valves. The most traditional are represented by valve transplantations, valve segmental transpositions and valvuloplasties (internal and external).^2–10

As an attempt to repair an incompetent venous segment in which there is reflux, a portion of another vein with competent valves and that assures lack of reflux in that segment can be used; these are called valved venous grafts. In these cases, upper limb veins are mostly used, such as basilic, brachial and axillary veins.¹¹ Choice of donor vein is made according to diameter and number of valves present in the chosen segment. Although frequently used in these cases, the common brachial vein (CBV) is seldom mentioned in medical routine.

CBV can be defined as a vein formed from the junction of the medial brachial vein with the lateral brachial vein. Its origin is in the arm, presenting valves and representing an important route of collateral circulation of the upper limb, connecting the arm to the axilla, and can be useful in surgeries to treat chronic venous insufficiency.^12–16

This study aims at describing the anatomy of CBV valves in human corpses.

Methods

This study was approved by the Research Ethics Committee of Universidade Estadual de Ciências da Saúde de Alagoas and Universidade Federal de Alagoas.

It is a descriptive, macroscopic study of human corpses preserved in formaldehyde. Our sample consisted of 30 corpses with their upper limbs articulated to the trunk.

Inclusion criteria were adult male corpses that, independent of race, were preserved in formol and that presented upper limbs articulated to the trunk. Exclusion criteria were presence of deforming alterations in lower limbs (such as mass), previous use of some of the vessels anatomically related to assessed structures, bone fracture and laceration affecting the structures that form the vascular and nervous content of the arm.

Dissection technique consisted of placing the corpse in a supine position with abducted lower limb (approximately 90 °) and performing a longitudinal incision at the medial aspects of the limb, from the axilla to the medial epicondyle of the humerus.

To better identify CBV, we divided the arm into three portions (proximal, medial and distal). These segments were equidistant from each other, limited from a line drawn between epicondyles of the humerus (distally) and another line drawn from the inferior border of the teres major muscle (proximally). The space between these two limits was divided by three, and the result corresponded to segment length.

After dissection, we tried to identify the level in which the CBV was formed and its continuity along the upper limb.

For the variable valve, we used the z test with two samples for averages (using the software Microsoft Excel^® 2003, Redmond, WA, USA). For the variables CBV frequency and continuity, we used the signal test. P value was equal or lower than 5% (a< 5%) to reject the null hypothesis.

Results

CBV was present in 73% (22/30) of the corpses under investigation, with 95% confidence interval (IC95%) ranging from 57 to 89% and p = 0.0081 and was therefore significant. Of the corpses that had CBV, 10 (45%) had their origin in the left arm, nine (41%) in the right arm and three (14%) in both arms. Its mean length was 136 mm (IC95% 118–154) in the right side and 102 mm (IC95% 73–131) in the left side; difference between limbs was not significant (p = 0.064). The largest diameter was seen in the proximal third of the CBV, 5.4 mm (IC95% 4.8–6.0) in the right side and 4.3 mm (IC95% 3.8–4.8) in the left side; difference between limbs was not significant (p = 0.26).

CBV in the right arm was identified in 12 corpses, in a total of 28 valves: one in the distal third, 12 in the medial third and 15 in the proximal third; 26 were bicuspid and two were unicuspid (Table 1). The number of valves per right CBV was one in the distal third, zero to two in the medial third (most frequent number of one valve) and zero to three in the proximal third (most frequent number of one valve) (Figure 1).

Click to enlarge

In the left arm, 13 corpses had CBV, in a total of 33 valves; two in the distal third, 10 in the medial third and 21 in the proximal third (Figure 2). Of these, 32 were bicuspid and one was unicuspid (Figure 3). The number of valves per CBV was zero to two in the distal third, zero to two in the medial third (most frequent number of two valves) and zero to three in the proximal third (most frequent number of two valves).

The CBV presents a route closely associated with the brachial artery (BA). The possibilities of CBV distribution in relation to BA are presented as a stylized illustration, in a tomographic view that corresponds to a cross–sectional view, taking as level an intermediate point of each arm segment (Figures ⁴, ⁵ and ⁶).

The CBV confluence was into the basilic vein in 18% (4/22) of the corpses, and the proximal segment was the destination of choice. In 82% (18/22) of cases, the confluence of the CBV was into the axillary vein (Table 2).

Discussion

Searching for alternatives in vascular surgery comprehends searching for knowledge in classical anatomy. Structures that have been unknown so far gain new perspectives based on a more detailed study.

The CBV can be cited as a famous unknown, going unnoticed in most dissections. It does not even belong to the anatomical terminology,¹⁷ which fails to identify this vein, only naming it brachial vein, and not clarifying whether it is lateral, medial or common. The existence of the CBV associated with discrete available bibliographic information (almost always in classical anatomy books that cannot even be found in large libraries, being considered rarities) has drawn our attention and motivated us to prepare a more advanced study on this vein.

However, in our study, the CBV was characterized for being a vein present in most corpses (73%), with not very long mean extension: 136 mm to the right side and 102 mm to the left side; its largest mean diameter is 5.4 mm in the right side and 4.3 in the left side.

Authors such as Gerard,¹² Salvi,¹³ Hollinshead & Rose,¹⁴ Gusmão & Prates,¹⁵ Nicolas,¹⁸ Paturet¹⁹ and Moore²⁰ described the presence of CBV quite differently. A constant statement was that this vein originates from the junction of the medial and lateral brachial veins, without providing details on the segment in which the vein is originated or whether occurrence is more prevalent in a particular arm. There is no description of the frequency with which this vein is present either. Tandler²¹ claims that the CBV is formed in a varied arm height. Latarjet & Ruiz Liard²² report that the lateral and medial brachial veins form the CBV in the superior aspect of the arm. Santos & Gusmão,¹⁶ besides mentioning CBV formation, report that this vein was found in 25% of corpses in their sample and that its origin was more prevalent in the medial third of the arm, describing the right side as prevalent in the occurrence of CBV.

Nicolas¹⁸ was the only author who described some morphometric parameters of the CBV, claiming that these veins have large diameters and may reach 8 mm.

However, the results found in our study as to number of valves emphasize that, in the proximal third of the CBV, there was a higher number of valves, and their presence is frequent in all CBV segments. Most of these valves were bicuspid and parietal.

Nicolas¹⁸ reported that brachial veins (lateral, medial and common) have between five and 15 valves in total. Paturet¹⁹ described that brachial veins have around six to 12 valves in total. The authors did not mention the number of valves per thirds or the total of valves in the CBV exclusively. Moore²⁰ and Tandler²¹ reported that brachial veins have many valves. We agree with Nicolas,¹⁸ Paturet,¹⁹ Moore²⁰ and Tandler²¹ as to the fact of presence of valves in brachial veins. The only problem is that there are no conditions of comparing CBV valves exclusively, since those authors did not individually cite the valves per brachial vein.

However, we observed that CBV presented close relationship with BA, and such relationship was present since the distal segment; therefore, it is the most important identification structure of this vein. During surgical access to CBV, due to this proximity, it was possible to identify the BA pulsatility as a reference point to the CBV. The data found corroborate what we had¹⁶ previously published in a study on the basilic vein, in which we stressed the anatomical relationship of the CBV with the BA.

Another important factor was that most CBV continued in the axilla, and few were limited to the arm and, even in some cases, the proximal segment was the destination of choice. These results allows us to agree with authors such as Hollinshead & Rose,¹⁴ Gusmão & Prates¹⁵ and Santos & Gusmão¹⁶ when they claim that the CBV confluence can be into the axillary vein, which represents its main destination.

Based on the data obtained and presented in this study, we can conclude that the CBV often presents bicuspid and parietal valves, mostly located in the proximal segment of this vein. This constant presence of valves in a vein with good diameter encourages us to cite CBV as an alternative in the search for valves to treat chronic venous insufficiency.

References

Manuscript received November 8, 2006, accepted February 21, 2007.

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Publication Dates

• Publication in this collection
  19 July 2007
• Date of issue
  Mar 2007

History

• Received
  08 Nov 2006
• Accepted
  21 Feb 2007