INTRODUCTION
The nature of the human body inspires from the dawn of mankind to the present day. Despite new alternative methods, the anatomical dissection still remains the golden standard in the study of the anatomy of the human body [7]. Searching of new patterns or variations of structures of the human body is the most important challenge for every anatomist [10, 12]. Former postulates of clinicians addressed to anatomists, encouraging them to continue exploration of human body, have not lost their relevance [6, 8, 12].
Variations in the venous pattern of the upper limb are very common. Conventional textbooks describe the anatomy of the venous system of the upper limb as two layouts [11]. The first one is called superficial or superfascial and the second one — deep or subfascial. These are not independent systems, but the existing anastomoses between them provide blood flow from the superficial to the deep system, which ultimately delivers blood to the heart. The superficial system is represented by two main veins: the basilic vein and cephalic vein. At the level of the forearm and arm both these veins run along the inner and lateral side of the upper limb. Finally, in the middle of the arm, the basilic vein connects to one of the brachial veins and the cephalic vein joins the axillary vein in the deltopectoral triangle. The deep system consists of veins accompanying the arteries, whose names come from the accompanying arteries. Usually, in this system, there are two veins which run along one artery, except of the axillary and subclavian vein [7, 9]. The number of anatomical variants of the veins of the upper limb seems countless. There are reports of new discovered variants of the veins of the upper limb constantly. Continuous update increases the number of anatomical variants of the veins of the upper limb. Updating these patterns is especially important in vascular procedures [6, 7].
CASE REPORT
During preparation of one of the upper limbs for the educational purposes an unusual pattern of superficial and deep veins system was noticed.
As can be seen on the photography of the left upper limb was observed the unusual pattern of the basilic and cephalic vein (Fig. 1). Basically, the cephalic and basilic vein runs up along both side of forearm. Then, both veins enter the arm, avoiding the area of the cubital fossa but in our case they ran directly to the elbow pit where unexpected they both fused to form one of two main brachial veins. For this publication it was called superficial brachial vein. As can be seen on Figure 1 the second brachial vein has been formed fully separately by the veins of the deep system.
According to classical textbooks both brachial veins, near the armpit should join together to create singular axillary vein. As can be seen, each of brachial veins ran separately along the whole arm up to the axillary cavity. They both became axillary veins and ran, still separately, upwards. The axillary vein, which was formed by the superficial brachial vein, was named the accessory axillary vein.
One has an irresistible impression when looking at the photograph that the blood flowing from the upper limb rolls along two independent vessel systems. One system runs superficially, independently of the arteries, up to the axillary cavity, the other one is located deeper and accompanies the arteries of the upper limb. This pattern of blood circulation in the upper limbs seems to be unique and has not been published so far.
The work was approved by the Local Ethics Committee of Pomeranian Medical University in Szczecin.
DISCUSSION
The traditional anatomy texts offer a lot of description of the upper arm veins and are particularly abundant in regards to their variations [6, 8, 12].
Bardeleben [2] was one of the first authors to provide a systematic nomenclature of the veins of the upper limbs and their topography. He also described about 36 varieties. However, in none of them was a description similar to the presented case [2]. Also the detailed classification of the superficial and deep upper limb veins is given by Vazquez et al. [14]; however, among these 11 variants there is also no description similar to the presented case.
Although the literature describes some types of anatomical variants of the veins of the upper limb, we have established that this pattern has not yet been published [1, 6, 8–10]. It has been found a report which describes an anatomical variant of the basilic and cephalic vein that is slightly similar to our case. But in their case the deep system was joined with the superficial system in the cubital fossa [11]. The occurrence of accessory axillary vein is estimated quite high, over 50%. Charpy [3] was the first to describe this variability, but there were no similar descriptions to the presented case. Similarly, Gusmao and Prates [5] in their observations noted that the basic branches forming the accessory axillary vein originated from the deep vessel system, which sometimes received the branches from the superficial system. The authors did not encounter the accessory axillary vein formed exclusively by the veins from superficial system [5]. Unlike the basilic vein, which is characterized by some topographic instability, many reports indicate a fairly stable course of the cephalic vein [10, 12]. However, several variants of the cephalic vein have been already described. Del Sol et al. [4] and Ukoha et al. [13] in their research indicated six pattern varieties of the vein course in the area of the ulnar fossa; however, none of the given variants was similar to ours. It may be another proof that variability of the cephalic vein is not a rare phenomenon, as it is supposed to be [1, 10, 12]. Some authors have emphasized the importance of identifying some variants of cephalic vein for surgical procedures, especially vascular or orthopaedic [8, 10].
They especially point out some procedures, such as creation of arteriovenous fistulas, where transposition of veins in some variants could increase the risk of complications [1, 8]. Some authors suggest vein mapping before surgery to minimise the risk of some complications resulting from unexpected variants [1].
The presence of two large veins in the axillary cavity was demonstrated by ultrasound examination in patients undergoing vascular procedures. The authors regarded one of these veins as the accessory axillary vein. At this point, should be emphasized the importance of radiologic tools in anatomical exploration on the living. However, the authors concluded that anatomical dissection should be the basis for transferring the new anatomical pattern to other descriptions, e.g. radiological.
The above conclusion can be seen when editing radiological or surgical atlases. Therefore, cross-sectional studies should be still continued.
CONCLUSIONS
The catalogue of patterns of the upper limb venous system seems to be unlimited and should therefore be constantly updated. During each vascular surgery the probability of anatomical and topographic variability of the venous system of the upper limb should be taken into account.
Acknowledgements
Special thanks to Mr. J. Smolenski for help in the dissecting works.