JOURNAL OF INTERNATIONAL ACADEMIC RESEARCH FOR MULTIDISCIPLINARY Impact Factor 1.625, ISSN: , Volume 3, Issue 6, July 2015

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1 UNILATERAL VARIANT BRANCHING PATTERN OF FEMORAL ARTERY- A CASE REPORT BLESSYMOL JOSEPH 1 ELIASWONDIMYIRDAW 2 MANOJ KOLLUKKAD 3 TIGABUDERBEWENDALEW 4 1 Senior lecturer, Department of Anatomy, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia 2 Lecturer, Department of Anatomy, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia 3 Lecturer, Department of Anatomy, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia 4 Lecturer, Department of Anatomy, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia ABSTRACT This report describes an extremely rare arterial variation in terms of the anatomical, clinical, and embryological basis. During the routine cadaveric dissection, a variant branch of the femoral artery was detected in the right lower extremity of a 55 years old adult Ethiopian male cadaver. The branching pattern of the femoral artery and profundafemoris artery are subject to considerable anatomical variations. Variations in the branching pattern of femoral artery can be explained on the basis of abnormal development of the arterial network of the lower limb in the embryo.developmental arrests at different stages may lead to anatomical variations related to branches of femoral artery. Ignorance of such variations can lead to fatal intraoperative haemorrhage and incapacitating sensory and motor deficit hence a proper knowledge of the origin and branches of the femoral artery are important for anatomists, clinicians and surgeons in various procedures. The femoral artery is commonly used for various diagnostic and therapeutic purposes in cardiovascular diseases. KEYWORDS: Femoral artery, profundafemoris artery, femoral triangle, midinguinal point, external iliac artery INTRODUCTION The femoral artery [FA] is a continuation of the external iliac artery distal to the inguinal ligament, is the primaryartery of the lower limb. It enters the femoral triangle deep to the midpoint of the inguinal ligament. The pulsations of the femoral artery are palpable within the triangle because of its relatively superficial position [Moore et al., 2014].It then descends along the anteromedial part of the thigh in the femoral triangle, enters and passes through the adductor (subsartorial) canal, and becomes the popliteal artery as it passes through an opening in adductor magnus near the junction of the middle and distal thirds of the thigh. Its first three or four centimetres are enclosed, with the femoral vein, in the femoral sheath. The femoral artery gives off several branches in the proximal thigh, including the 424

2 superficial epigastric [SEA], superficial circumflex iliac [SCIA], superficial external pudendal [SEPA], deep external pudendal[depa] and profundafemoris arteries (deep femoral arery) [PFA]. It gives off the descending genicular artery within the adductor canal. In clinical parlance, the part of the femoral artery proximal to the origin of profundafemoris is often termed the common femoral artery [CFA], while that distal to the origin of the profunda is termed the superficial femoral artery [SFA].Rarely, the femoral artery divides, distal to the origin of the PFA, into two trunks that reunite near the adductor opening. It may be replaced by the inferior gluteal artery, accompanying the sciatic nerve to the popliteal fossa and representing a persistence of the original axial artery [Standring, 2005]. As the pharyngeal arches form during the fourth and fifth weeks, they are supplied by arteries-the pharyngeal arch arteries-that arise from the aortic sac and terminate in the dorsal aortas.each limb is supplied by an axis artery that is derived from intersegmental arteriesbranches of the dorsal aorta. The axis artery of the lower limb is derived from fifth lumbar intersegmental artery, runs on the posterior aspect of the lower limb. It forms inferior gluteal artery, part of popliteal artery above the popliteus muscle, distal part of peroneal artery, and part of plantar arch. The femoral artery appears as an entirely new vessel formed on the ventral aspect of thigh. It develops a connection with the external iliac artery above and poplitealartery below. The external iliac artery is an offshoot of the axial artery. [Sing, 2012]. Case report During the dissection classes for the medical undergraduates, a variant branching pattern of femoral artery was observed in a middle aged male, formalin fixed cadaver, at the Department of Anatomy, Hawassa University. At a distance of 2.5cm from the midinguinal point an unnamed new arterial branch arose from the medial part of right femoral artery. The diameter of the latter was approximately 8mm.This variant branch coursed downwards and medially in front of the femoral vein and then passed between the pectin us and adductor long us where it ends by giving off muscular branches to pectin us, adductor long us and adductor brevis as it lies on the adductor brevis. This variation was unilateral (Figure1).The superficial external pudendal artery arose anterolaterally from femoral artery, a little above to the origin of this variantartery. The Profundafemoris artery took its origin as usual from the femoral artery, at a distance of 5 cm from the midinguinal point. The deep external pudendal artery originated from the femoral artery about2.5cm distal to the origin of this variant artery. The rest of the course and distribution of the femoral artery was as usual. The course and 425

3 distribution of obturator artery was found to be normal (Figure 2). On the left side, the femoral artery showed a normal pattern. Figure1: picture depicting the variant branching pattern of right femoral artery.[fa-femoral artery, SCIA-superficial circumflex iliac artery, SEA-superficial epigastric artery, SEPAsuperficial external pudendal artery, DEPA-deep external pudendal artery, PFAprofundafemorisartery, LCFA-lateral circumflexfemoral artery, - unnamed variant branch of FA. Figure 2: picture showing the relations of right femoral artery. [ FN- femoral nerve, FAfemoral artery, FV- femoral vein, OA-obturator artery, ON- obturator nerve, PFA- profundafemoris artery, - unnamed variant branch of FA. 426

4 Discussion Arterial variations of the lower limb have been widely described in various studies.the present study reports an extremely rare case where a large unnamed arterial branch took its origin from the medial aspect of right femoral artery at a distance of 2.5cm from the midinguinal point. While dissecting the femoral triangle, this variant artery was confused as the medial origin of profundafemoris artery. But on detailed analysis it was clear as a new branch. The profundafemoris artery took its origin as usual from the femoral artery, at a distance of 5 cm from the midinguinal point. Variations in the branching pattern of FA can be explained on the basis of abnormal development of the arterial network of the lower limb in the embryo. Standring et al. (2008), reported the developmental anatomic characteristics of the lower limb arteries. The axis artery of lower limb is derived from the fifth lumber intersegmental artery. It is seen as the branch of internal iliac artery and runs on the dorsal aspect of the thigh. The femoral artery passes along the ventral surface of the thigh, opening a new channel to the lower limb. It arises from a capillary plexus that is connected proximally with the femoral branches of the external iliac artery and distally with the axis artery. It is generally accepted that increase of blood flow in these capillaries determines the final mature arterial pattern. Thus, the most appropriate channels enlarge while others contract and disappear. Arey et al. (1965), described that in the 6-mm human embryo, the sciatic artery provides the major blood supply to the lower limb bud. It is a dorsal branch of the umbilical artery. Between the 6- and 33-mm stages, the iliac artery system, which gives rise to the femoral artery system, develops from the umbilical artery, and the sciatic artery regresses. By the 33- mm stage, the development of the arterial system of the lower extremity is complete. The embryologic femoral artery is composed of multiple vascular channels known as the femoral arterial plexus. These small vascular channels unite and form the superficial and profunda femoral arteries. Keen (1961), conveyed that developmental arrests at different stages may lead to anatomical variations related to branches of femoral artery. Vasculature development in the lower limb is preceded by morphological and molecular changes that occur in the limb mesenchyme, therefore variations in vascular pattern are often recorded. It was reported that femoral artery is commonly used for arterial catheterization as it can be readily accessed. Thereby it is used for investigation of any arterial system in the body and for various clinical procedures like coronary angioplasty. The femoral artery at the femoral 427

5 triangle is directly opened at the origin of the profundafemoris artery for femoral embolectomy in lower limb arterial thromboembolism(kirk R.M, 2000).It is also crucial to know the arterial anatomic characteristics of the lower extremity before proceeding with any interventional or surgical procedure. Clinically, minor anatomic variations involving the superficial femoral artery may not cause serious problems, whereas major anatomic variations may pose difficulties during a surgical procedure (Aksoy et al., 2002). Pradipet al.(2015),dissected 51 human femoral triangles from 26 (18 male and 08 female) human cadavers and femoral artery and its branches were dissected and studied. In this study, the largest femoral artery ( mm2 cross sectional area) was noted in the left femoral artery of male cadaver. The smallest femoral artery (45.86 mm2 cross sectional area) was noted in left side of male cadaver. There was no significant difference found in estimated diameter of femoral artery between male and female. That does not correlate with the study of Sandgren (1999) and Lewis (1986), who measured the femoral artery diameter in living subjects with Eco tracking B-Mode ultrasound method and found differences in male and female femoral artery diameter. External circumference, diameter and cross sectional area of the femoral artery is important for various devices (e.g. Arterial catheter) manufacturing, required in clinical procedures. Normally, the profundafemorisarises laterally from the femoralartery (sometimes medial or rarelyposterior) about 3.5 cm distal to the inguinal ligament. The profundafemoris originated above the inguinalligament in 1 out of 431 cases, halfan inch below the inguinal ligamentin 3.01% of cases, and deep to inguinal ligament in 1.6% of cases (Sabnis A.S, 2013). In the present case, it arose from the femoralartery about 5 cm below the midinguinalpoint. Uzel et al. (2008), have studied 110 inguinal regions and found that the LCFA arose from profundafemoris artery in 85 cases (77.3%), from the femoral artery in 21 cases (19.1%). In aortoiliac occlusive diseases, bypass to the PFA orfa has emerged as a suitable mode of treatment. But in patients with total occlusion of femoral artery as well as profundafemoris artery, bypass to the LCFA was found to be successful (Chauhan, P. et al, 2015). Hence, knowledge of course and branching pattern of LCFA is extremely important in management of patients with multilevel occlusive diseases of iliac and femoral arteries(gradman, 1992). Marcucci G et al.(2010), revealed that variations of the great saphenous vein, femoral artery and vein is quite rare and, despite being asymptomatic can lead to technical difficulties increasing the risk of major intra operative complications. The knowledge of this anomaly seems to be important and its detection is usually intra operative. Gautier E et al., (2000) 428

6 opined that precise knowledge of the anatomy of medial femoral circumflex artery is essential when performing both trochanteric and intertrochanteric osteotomies and is also helpful to avoid iatrogenic vascular necrosis ofthe head of femur in reconstructive surgery of the hip and fixation of acetabular fractures through the posteriorapproach. Femoral arteriography is the main line of investigation in peripheral occlusive arterial diseases and in the diagnosis of suspected congenital anomalies. As the femoral arteries are commonly used for these procedures, the internal diameter and as well as the origin of the profundafemoris artery and its branches in front of the thigh are of clinical significance in the procedures of Judkins and Seldinger techniques used for diagnosis (Davidson et al, 2005). Conclusion To the best of our knowledge, the sevariations in the present case are unique and the first of its kind in the literature. So this knowledge is of great help to clinicians and surgeons to avoid any arterial or venous complications during surgery. Knowledge of the femoral artery and its branches is important for not only surgeons, but also for physicians, anatomists and all types of clinical practitioners in medicine because it is important in various clinical examinations, clinical procedures and surgical interventions. There foreanatomical and embryological knowledge of the branching pattern of the femoral artery and its branches is very important. Variations in the branches of femoral artery must be considered. Extensive study is required to find out the variations in femoral artery branches. References 1. Aksoy M, Barbaros U, Genc FA, Kurtoglu M.(2002). Duplication of superficial femoral and poplitealartery. EJVES Extra; 4: Arey LB (1965). Developmental Anatomy. 7th ed.philadelphia, PA: WB Saunders Co, Pradip C, Alpa C, Monika A, Ashish R, Ankit A, SureshR (2015). Femoral artery and its branches in femoral triangle: A cadaveric study in Rajkot.International Journal of Research in Biosciences, Vol. 4 Issue 1, p: (55-59). 4. Davidson C.J., Bonon R.(2005). Cardiac Catheterization, Edited by Zipes, Liby et al, Braunwald s Heart Diseases A Textbook of Cardiovascular Medicine, 7th Edn. Vol. I. Pennsylvania, USA. Elseveier Saunders, Gautier E, Ganz K, Krugel N, Gill T, GanzR (2000).Anatomy ofthe medial femoral circumflex artery and its surgical implications, J Bone Joint Surg Br, 82(5): Gradman WS (1992). Bypass to the lateral circumflex femoral artery. Ann Vascular Surgery; 6: [PMID: DOI: / BF ]. 7. Keen JA (1961). A study of the arterial variations in the limbs,with special reference to symmetry of vascular patterns. Amer Journal of Anatomy ;108: [PMID: DOI: /aja ] 8. Kirk R.M. (2000).General Surgical Operations. 4th Ed. In Churchill Livingston, Lewis P., Psaila J.V., Davies W.T., McCarthy K., Woodcock J.P (1986). Measurement of volume flow in the human common femoral artery using a duplex ultrasound system,ultrasound in Medicine &Biology, 10 (12),

7 10. Marcucci G, Antonelli R, Accrocca F, Siani A. (2010). A rare anomaly of the femoral vessels: complete transposition of the femoral artery and vein. Interactive CardioVascular and Thoracic Surgery,11: Moore, K.L., Dally, A. F., Agur, A. M. R. (2014). Clinically Oriented Anatomy.7th edn. Lippincott:Williams& Wilkins, p: Sabnis AS (2013). Anatomical variations of profundafemories Artery. J Clin Res Lett.,4(1): Sandgren T., Sonesson B., Ahlgren A.R., Lanne T.(1999). The diameter of common femoral artery in healthy human: Influence of sex, age and body size, Journal of vascular Surgery, 29, Singh,V. (2012). Development of blood vessels.srivastava,r.,&dutta, S. (Eds.).The text book of Clinical Embryology(19, ). New Delhi, Elsevier. 15. Standring S (2005). Grays anatomy, 39th edn.philadelphia, PA: Elsevier Churchill Livingstone, p : Standring S, Borley NR, Collins P, Crossman AR,Gatzoulis MA, Healy JC, et al (2008), Editors. Development of the pelvic girdle and lower limb. In Gray's Anatomy. 40th Ed. London: Churchill Livingstone; P Uzel M, TanyeliE,Yildirim M (2008). Anatomical study of the origin of Lateral circumflex femoral artery in Turkish population.folia Morphology, vol. 67, no 4,