5 Arteriography

10.1055/b-0034-77587

5 Arteriography

Helmberger, T., Schmitt, R.

A number of vascular variants are found in the forearm and hand, especially constitutional differences in the palmar arch resulting from a dominant radial or ulnar arterial supply. Indications for imaging of arteries in the forearm and hand are circulatory disturbances, inflammatory vascular diseases such as obliterating thrombangitis and traumatic vascular lesions, and the presurgical evaluation of congenital anomalies of the hand and vascularized soft-tissue tumors (especially hemangiomas). Catheter angiography with transfemoral or transbrachial accessneedle angiography is an invasive procedure. Advantages of these methods are the high spatial resolution with demonstration of even the smallest vessels, as well as functional recording of the blood flow. Contrast-enhanced magnetic resonance (MR) angiography differentiates between high-resolution and temporal-resolution techniques. Three-dimensional data sets can provide multiplanar maximal-intensity-projection (MIP) angiograms, whereas temporal-resolution data sets can only provide MIP images in the acquisition plane.

Anatomy and Variants of Hand Arteries

Forearm Arteries

The ulnar artery originates directly from the brachial artery. In the forearm, the arteria interossea communis, whose dorsal branch provides part of the arterial circulation of the back of the hand, branches off from it. In rare cases, there is a persisting median artery, which can join the superficial palmar arch. The ulnar artery divides into a superficial and a deep palmar arch in Guyon’s canal.

The radial artery originates in 80–85% of the cases from the brachial artery in the elbow. In the remaining 15–20%, it branches off high up from the brachial artery or the axillary artery, which can cause misinterpretation when the brachial artery is punctured. In theperiphery, the radial artery passes dorsally and crosses the trapezium and the base of the first metacarpal. In 96% of the cases, it runs along the palmar side of the hand in interdigital space I–rarely in II–or, after dividing into an accessory vessel, in interdigital spaces I and II. Next to the junction with the superficial and deep palmar arches, the main branches of the princeps pollicis artery and the radialis indicis artery, as well as the dorsal carpal network (to the rete carpi dorsalis) branch off from the radial artery in the periphery.

Fig. 5.1 **Diagram of the arterial palmar arch.** Filling of the superficial palmar arch by the ulnar artery. Communication with the radial artery over the superficial branch of the radial artery. The deep palmar arch is filled by the radial artery. Anastomosis with the ulnar artery via the deep branch of the ulnar artery. Abbreviations: ADC = aa. digitales communes; APPO = a. princeps pollicis; APP = arcus palmaris profundus; APS = arcus palmaris superficialis; AR = a. radialis; ARI = a. radialis indicis; AU = a. ulnaris; RPAU = rete profundus a. ulnaris; RSAR = rete superficialis a. radialis.

Arteries in the Palm

The palmar arteries represent a complex system of collaterals, which consists mainly of two palmar arches ( Fig. 5.1 ).

The superficial palmar arch is mainly fed by the ulnar artery. After passing through Guyon’s canal, the ulnar artery joins the superficial palmar arch, which ends superficially in relation to the flexor tendons of the fingers and the branches of the median nerve in the middle of the palm. The superficial palmar arch is closed in 42% of cases and anastomoses via its superficial radial branch with the radial artery. In 58% of cases, the arch is congenitally open. On the radial side of the hand, the common digital arteries originate from the superficial palmar arch, which projects onto the middle of the metacarpals in angiograms.
The deep palmar arch is fed primarily by the radial artery in 97% of the cases. Before reaching the deep palmar arch, however, the radial artery takes a dorsal detour by leaving the flexor side of the forearm at the level of the anatomical snuff box, and, after passing a short distance through metacarpal space I/II, returns to the palmar side. The deep palmar arch lies on top of the interosseous muscles and between the two heads of the adductor pollicis muscle deep in the middle of the palmar compartment. In 95% of cases, it is congenitally closed by an anastomosis with the deep network of the ulnar artery. In angiography, the deep palmar arch projects on the bases of the metacarpals, running proximal to the superficial arch. The princeps pollicis artery, radial indicis artery, and smaller palmar metacarpal arteries originate from the deep palmar arch.

Table 5.1 and Figure 5.2 summarize the arterial variants in the hand.

Figures 5.3 and 5.4 show examples of the arterial variations as depicted in angiograms.

Table 5.1 Variations in the arterial palmar arch (according to Lippert and Pabst)
Superficial palmar arch with closed arc
Radioulnar	Normal textbook case	35%	Fig. 5.2a
Medianoulnar	Persisting median artery	4%	Fig. 5.2b
Radiomedianoulnar	Persisting median artery	1%	Fig. 5.2c
Profundoulnar	Anastomosis with the deep palmar arch	2%	Fig. 5.2d
Superficial palmar arch with open arc
Ulnar	All common palmar digital arteries from the ulnar artery	37%	Fig. 5.2e
Ulnoradial	Common palmar digital artery I originates from the radial artery, the rest from the ulnar artery	31%	Fig. 5.2f
Radioulnar	Common palmar digital arteries I and II originate from the radial artery, III and IV from the ulnar artery	3%	Fig. 5.2g
Radiomedianoulnar	Common palmar digital artery II originates from the median artery	1%	Fig. 5.2h
Medianoulnar	Common palmar digital arteries I and II originate from the median artery, III and IV from the ulnar artery	4%	Fig. 5.2i
Deep palmar arch
Radioulnar		79%	Fig. 5.2j
Radioulnar	Two deep ulnar branches	13%	Fig. 5.2k
Radiomedianoulnar	Median artery also involved	5%	Fig. 5.2l
Open arc		3%	Fig. 5.2m

Fig. 5.2a-q **The most common variants of the hand and finger arteries** (modified according to Lippert and Pabst). **a-d** Variants with closed superficial palmar arch. **e-i** Variants with open superficial palmar arch. **j-m** Variants of the deep palmar arch. **n-q** Variants of the common and proper palmar digital arteries. Anatomical courses of vascular variants are described in more detail in **Tables 5.1** and **5.2** .

Fig. 5.3 **Variants with aplasia of the deep palmar arch.** The deep palmar arch is not visualized in arterial DSA. A normal superficial palmar arch is seen (arrow), as well as the metacarpal palmar arteries (m) and the common (c) and proper (p) palmar digital arteries.

Fig. 5.4 **Intra-arterial DSA of a persistent median artery.** Medianoulnar vascular supply of the hand combined with a persistent median artery (arrows). The radial artery is not present, and the deep palmar arch is hypoplastic.

Arteries of the Finger

In accordance with the wealth of variations in the palmar arch, the palmar metacarpal arteries, the common palmar digital arteries, and the properdigital arteries can have different sources of vascular supply ( Fig. 5.5 ). The most common vascular variants are summarized in Table 5.2 .

Fig. 5.5 **Normal DSA findings of the common and proper palmar digital arteries.**

Table 5.2 Variations in the arteries (Aa.) of the fingers (according to Lippert and Pabst)
Aa. digitales palmares communes	Originate from the superficial palmar arch	77%	Fig. 5.2n
Arteries of the thumb	Originate from both palmar arches Originate entirely from the deep palmar arch as the main artery of the thumb	10% 11%	Fig. 5.2o Fig. 5.2p
Arteries of the thumb and index finger	Originate from the deep palmar arch	2%	Fig. 5.2q
Communications between Aa. digitales palmares communes and Aa. metacarpae palmares	No communications Communicates via the proper palmar digital arteries	60% 30%