The arterial anatomy of the upper limb has long attracted attention due to its relevance in anatomical education, comparative morphology, and a broad range of clinical and surgical procedures [1]. Conventionally, the brachial artery is described as the continuation of the axillary artery distal to the lower border of teres major, descending along the medial aspect of the arm, giving off muscular branches, the profunda brachii artery, superior and inferior ulnar collateral arteries, and terminating in the cubital fossa by dividing into the radial and ulnar arteries [2]. However, deviations from this classical pattern are not uncommon, and multiple forms of brachial artery variation have been reported in cadaveric, radiological, embryological, and operative studies [3–8].

Brachial artery variations include, but are not limited to, superficial brachial artery, high bifurcation into radial and ulnar arteries, brachioradial artery patterns, atypical origin of the profunda brachii, trifurcation, accessory branches, duplicated segments, tortuosity, and persistent embryonic channels [9–13]. These variants arise from complex remodeling of the embryonic vascular plexus of the limb bud, influenced by persistence, regression, and hemodynamic dominance of specific arterial channels during development [14–18]. Classical embryological work and later reinterpretations support the concept that the definitive brachial artery emerges from selective enlargement and involution of superficial and deep vascular pathways [17].

The clinical implications of brachial artery variations are increasingly significant in the modern era of endovascular and minimally invasive medicine. The brachial artery is routinely encountered during arterial cannulation, coronary angiography, arteriovenous fistula planning, trauma exploration, flap reconstruction, orthopedic fixation, humeral fracture management, catheter-based interventions, and ultrasound-guided regional anesthesia [19–28]. Superficial arterial courses may predispose to inadvertent intra-arterial injection, hemorrhage, pseudoaneurysm, or misidentification as superficial veins [29]. High bifurcation may complicate transradial access, alter catheter trajectories, reduce vessel caliber, or increase spasm risk [30]. In trauma or reconstructive surgery, aberrant branching may affect collateral circulation, flap perfusion, or operative dissection planes [31– 33].

Although multiple narrative reviews and regional cadaveric series have discussed upper-limb arterial variations, the available evidence remains fragmented [34–36]. Existing reports differ substantially in terminology, classification systems, sample units, detection modalities, and population composition, limiting direct comparison [37–39]. Furthermore, many older reports predate current imaging techniques or do not distinguish between isolated and combined variants. The increasing use of high-resolution Doppler ultrasonography, CT angiography, MR angiography, and digital subtraction angiography now provides an opportunity to compare anatomical and imaging-based prevalence more rigorously [40–43].

A focused synthesis of brachial artery variations is particularly warranted because this vessel occupies a transitional anatomical zone between the axillary and forearm arteries, where embryological persistence and branching diversity may be especially pronounced [44]. Unlike broader upper-limb arterial reviews, a dedicated meta-analysis centered on the brachial artery can provide clinically actionable estimates for procedural planning, risk counseling, and anatomy curricula [45].

Therefore, the present study aimed to systematically review and meta-analyze published studies from 2000 to 2025 to determine the pooled prevalence of any brachial artery variations, the relative frequency of major morphological patterns, variation distribution by study type, geography, and laterality, and the clinical implications of these variants across medical and surgical disciplines.

MATERIAL AND METHODS

Study design and reporting

This systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) statement. The methodology was designed for prevalence synthesis of anatomical variations, incorporating principles recommended for observational evidence synthesis and anatomical meta-analyses [46].

Protocol and eligibility framework

A predefined protocol was developed before study selection. The review question was structured using a modified CoCoPop framework (Condition, Context, Population) for prevalence studies [47]:

• Condition: Brachial artery anatomical variations
• Context: Cadaveric, radiologic, surgical, or interventional evaluation
• Population: Human upper limbs/participants evaluated between 2000 and 2025

Information sources and search strategy

A systematic search was performed in the following databases:

• PubMed/MEDLINE
• Scopus
• Embase
• Web of Science
• Google Scholar
• ScienceDirect
• Regional indexing sources (where accessible)
• Manual reference screening of relevant articles

The search covered studies published from January 1, 2000, to March 31, 2025.

Example search string (PubMed / MEDLINE)

("brachial artery"[Title/Abstract] OR "arteria brachialis"[Title/Abstract]) AND (variation OR anomal OR variant OR "high bifurcation" OR "superficial brachial artery" OR "aberrant branching" OR trifurcation OR morphology OR branching pattern). Equivalent Boolean adaptations were used for other databases.

Inclusion criteria

Studies were included if they:

1. Were published between 2000 and 2025
2. Were original human studies
3. Reported brachial artery branching pattern, course, termination, or related anatomical variation
4. Included cadaveric dissection, imaging, angiographic, surgical, or operative data
5. Reported sufficient data to determine prevalence, frequency, or case distribution
6. Were published in English or had sufficient extractable English

Exclusion criteria

Studies were excluded if they:

1. Were published before 2000
2. Were case reports with isolated anecdotal findings only (unless embedded in larger case series),
3. Focused exclusively on axillary or forearm arteries without extractable brachial artery data
4. Were reviews, editorials, conference abstracts without full text, letters, or expert opinions
5. Used duplicated populations or overlapping datasets without unique extractable information
6. Reported purely traumatic lesions without anatomical variation

Study selection

All identified records were exported into a reference manager and deduplicated. Two reviewers independently screened titles and abstracts, followed by full-text review of potentially eligible studies. Disagreements were resolved by consensus and, where necessary, by consultation with a third reviewer.

Data extraction

The following variables were extracted:

• First author and publication year
• Country/region
• Study design
• Study setting
• Sample type (cadaveric, CTA/MRA, Doppler, angiography, surgical)
• Number of upper limbs/participants
• Sex distribution (if available)
• Laterality (right/left/bilateral)
• Classification of brachial artery variation
• Frequency of each variant
• Prevalence of any variation
• Clinical context or procedural implications
• Methodological quality/risk of bias indicators

Classification of brachial artery variations

For synthesis, variants were grouped into the following categories:

1. Superficial brachial artery (SBA)
2. High bifurcation of brachial artery (HBBA)
3. Trifurcation / atypical terminal branching
4. Aberrant origin of profunda brachii or collateral branches
5. Accessory or duplicated brachial channels
6. Combined/complex variants

Where studies used inconsistent terminology, reported patterns were reclassified into the above harmonized categories based on morphological descriptions [4,6].

Quality assessment / risk of bias

Methodological quality was assessed using a modified prevalence appraisal approach adapted for anatomical observational studies [47–49]. Domains included:

• Sampling clarity
• Anatomical definition of variation
• Dissection/imaging adequacy
• Completeness of reporting
• Bilateral limb accounting
• Selection bias
• Statistical clarity

Studies were categorized as:

• Low risk of bias
• Moderate risk of bias
• High risk of bias

Statistical analysis

Meta-analysis of prevalence was performed using a random-effects model (DerSimonian-Laird framework with variance stabilization for proportions where appropriate) due to anticipated clinical and methodological heterogeneity. Pooled prevalence estimates were reported with 95% confidence intervals (CIs). Heterogeneity was assessed using I² and Cochran’s Q. Preplanned subgroup analyses included:

• Cadaveric imaging-based studies
• Asia Europe vs. Africa vs. Americas
• Sample size (<200 ≥200 upper limbs)
• Unilateral bilateral reporting
• Study quality categories

Sensitivity analyses were conceptually performed by excluding high-risk studies and small-sample studies. Publication bias was assessed qualitatively by funnel asymmetry and, where applicable, by Egger-type small- study effect consideration for prevalence meta-analysis.

RESULTS

Study selection

The database search identified 1,126 records. After removal of 284 duplicates, 842 records underwent title/abstract screening. Of these, 728 records were excluded for irrelevance. 114 full-text articles were assessed for eligibility. After full-text review, 66 articles were excluded for the following reasons:

• Not focused on brachial artery-specific data (n = 21)
• Ineligible publication type (review/case report/editorial) (n = 16)
• Overlapping or duplicate datasets (n = 9)
• Published outside the 2000–2025 window (n = 8)
• Insufficient extractable prevalence data (n = 12)

Ultimately, 48 studies were included in the qualitative synthesis and quantitative synthesis (meta-analysis).

Study characteristics

The 48 included studies were published between 2000 and 2025 and represented data from Asia, Europe, Africa, North America, and South America. The combined dataset included 12,684 upper limbs. Of the included studies:

• 31 were cadaveric dissection studies,
• 11 were imaging-based studies (CTA/MRA/Doppler/angiography),
• 6 were mixed surgical or operative

Geographically:

• Asia: 22 studies
• Europe: 11 studies
• Africa: 7 studies
• North America: 5 studies
• South America: 3 studies

The median study size was 224 upper limbs (range: 48–910).

Overall pooled prevalence of any brachial artery variation

Across all 48 studies, the pooled prevalence of any brachial artery variation was: 18.7% (95% CI: 15.2%–22.6%), with substantial heterogeneity (I² = 88.4%, p < 0.001). This suggests that approximately 1 in 5 upper limbs demonstrates a clinically relevant deviation from the classical brachial artery pattern.

Pattern-specific prevalence

The pooled prevalence of major variation patterns was as follows:

• Superficial brachial artery (SBA): 4% (95% CI: 5.8%–9.2%)
• High bifurcation of brachial artery (HBBA): 8% (95% CI: 4.2%–7.7%)
• Trifurcation / atypical terminal branching: 1% (95% CI: 1.2%–3.3%)
• Aberrant profunda brachii / collateral branch origin: 9% (95% CI: 1.0%–3.0%)
• Accessory/duplicated brachial channels: 2% (95% CI: 0.6%–2.0%)
• Combined/complex variants: 5% (95% CI: 0.8%–2.4%)

PRISMA 2020 flow diagram

Flow diagram showing the identification, screening, eligibility assessment, and inclusion of studies in the systematic review and meta-analysis of brachial artery variations (2000–2025). A total of 1,126 records were identified, 284 duplicates were removed, 842 records were screened, 114 full-text articles were assessed for eligibility, and 48 studies were included in both the qualitative and quantitative synthesis.

Figure 1: PRISMA 2020 flow diagram of study selection

Subgroup analyses

By study type

Cadaveric studies (31 studies; 8,962 limbs): 20.9% (95% CI: 16.8%–25.3%)

• Imaging studies (11 studies; 2,874 limbs): 14.8% (95% CI: 9%–19.1%)
• Surgical/operative series (6 studies; 848 limbs): 16.3% (95% CI: 1% 22.3%)

By continent

• Asia: 8% (95% CI: 16.4%–25.6%)
• Europe: 2% (95% CI: 11.8%–21.2%)
• Africa: 4% (95% CI: 15.1%–28.4%)
• North America: 7% (95% CI: 9.1%–21.4%)
• South America: 5% (95% CI: 10.8%–25.5%)

By sample size

• <200 limbs: 1% (95% CI: 17.1%–27.6%)
• ≥200 limbs: 9% (95% CI: 13.2%–21.0%)

Laterality

Among studies reporting laterality explicitly (n = 29 studies):

• Right-sided prevalence: 6%
• Left-sided prevalence: 8%
• Bilateral variations in the same individual/specimen: 3%

No statistically robust side dominance was consistently demonstrated, although several studies suggested slightly higher right-sided superficial arterial patterns [12,37].

Quality assessment

Of the 48 studies:

• 18 studies were judged low risk of bias
• 24 studies were moderate risk of bias
• 6 studies were high risk of bias

Common limitations included:

• Non-random convenience sampling,
• Incomplete laterality reporting,
• Inconsistent classification terminology,
• Lack of sex-stratified analysis,
• Unclear handling of combined

Excluding high-risk studies yielded a pooled prevalence of 17.9% (95% CI: 14.6%–21.6%), indicating relative robustness of the main estimate.

Clinical implications

The reported clinical consequences across the included literature clustered into the following domains:

1. Vascular access and catheterization
   • Difficulty in transbrachial or transradial navigation
   • Failure of guidewire progression
   • Unexpected vessel caliber reduction
   • Increased arterial spasm risk [24,26]
2. Regional anesthesia
   • Altered relationship to median nerve and basilic vein
   • Risk of intravascular injection during peripheral nerve blocks
   • Need for ultrasound-based vessel identification [22]
3. Venipuncture / injection hazards
   • Superficial arterial course mistaken for veins
   • Inadvertent intra-arterial drug injection
   • Hematoma, ischemia, thrombosis [21,23]
4. Trauma and orthopedic surgery
   • Unusual injury patterns in humeral fractures
   • Risk during external fixation or open reduction
   • Variable collateral circulation [27]
5. Reconstructive and vascular surgery
   • Flap perfusion unpredictability
   • AV fistula planning challenges
   • Need for preoperative vascular mapping [31–33]

Table 1: Characteristics of included studies (n = 48)

Table 2: Summary of pooled prevalence estimates

Table 3: Subgroup analysis of overall prevalence of any brachial artery variation

Table 4: Laterality and bilateral occurrence (studies with extractable data only)

Table 5: Methodological quality / risk of bias summary

Table 6: Clinical implications of brachial artery variations

DISCUSSION

This systematic review and meta-analysis of 48 studies published between 2000 and 2025 demonstrates that brachial artery variations are common, with an overall pooled prevalence of 18.7%. This indicates that nearly one in five upper limbs exhibits a deviation from the classic anatomical description. Among the identified patterns, superficial brachial artery (7.4%) and high bifurcation of the brachial artery (5.8%) emerged as the dominant variants.

These findings reinforce the long-standing anatomical concept that the upper-limb arterial tree is highly variable, particularly at the transition zone between the axillary artery and forearm vessels [17]. The prevalence observed in the present review is broadly consistent with the cumulative impression of prior narrative anatomical literature, but this study offers a more focused and clinically applicable estimate centered specifically on the brachial artery [34–36].

The embryological basis of brachial artery variation is complex and likely reflects persistence or regression of superficial and deep arterial channels during limb bud vascular remodeling [14]. The superficial brachial artery is often interpreted as persistence of a superficial embryonic channel that may normally regress or become incorporated into the definitive radial or brachial pathways [16,17]. Similarly, high bifurcation may reflect premature division or persistence of a proximal radial/ulnar arterial origin, resulting in altered branching topology within the arm [17,23].

This developmental perspective is important because it explains why multiple variant patterns may coexist in the same limb, including superficial course, high radial origin, and atypical collateral branching. The combined/complex variant prevalence of 1.5% in the present review likely underestimates the true frequency, as many studies lacked detailed pattern stratification.

Cadaveric studies demonstrated a higher pooled prevalence than imaging studies (20.9% vs. 14.8%). Several factors may explain this difference:

1. Greater morphological resolution in dissection allows direct visualization of fine accessory branches and subtle course deviations.
2. Imaging studies may prioritize clinically significant or lumen-dominant branches and underreport small- caliber variants.
3. Retrospective imaging studies may be affected by slice thickness, contrast timing, reporting bias, and indication bias.
4. Cadaveric series often use bilateral specimen accounting, increasing detection opportunities [35,38].

This divergence highlights the importance of integrating both cadaveric and imaging evidence rather than assuming direct equivalence.

Broader upper-limb arterial variation literature often emphasizes radial artery anomalies, superficial ulnar artery, and brachioradial patterns [34,36]. However, the present study shows that when the brachial artery itself is specifically interrogated, clinically relevant variants are far from rare. The pooled prevalence of high bifurcation and superficial brachial artery suggests that the brachial artery should be regarded as a frequent site of clinically meaningful variation rather than a largely stable conduit. Several prior authors have noted that terminology differs substantially across studies, especially regarding ‘high origin of radial artery’, ‘brachioradial artery,’ ‘superficial brachial artery,’ and ‘high bifurcation’ [9,17]. This inconsistency likely contributed to the substantial heterogeneity observed in our pooled analyses. A standardized international classification for upper-limb arterial variation would improve comparability and reduce misclassification in future meta-analyses.

The rise of transradial and transbrachial access in interventional cardiology, neuroradiology, and peripheral vascular procedures makes knowledge of proximal upper-limb arterial anatomy increasingly critical [24,26]. High brachial bifurcation may reduce the diameter of individual forearm branches, alter catheter support, and increase spasm or tortuosity-related access failure [15,35]. Superficial or duplicated channels may create misleading trajectories on angiography or complicate sheath placement [20,24].

Ultrasound-guided upper-limb blocks rely on predictable relationships between the brachial artery, median nerve, basilic vein, and fascial planes. A superficial or aberrant brachial artery may alter expected landmarks, increasing the risk of intravascular injection or incomplete block if the operator relies on classical anatomy alone [22]. This is particularly relevant in brachial plexus approaches near the arm and cubital fossa. One of the most important practical implications of a superficial brachial artery is the risk of mistaking the artery for a superficial vein, particularly in the medial arm or cubital region [21,23]. Inadvertent intra-arterial injection may result in vasospasm, thrombosis, ischemic pain, tissue necrosis, or distal embolic complications. This hazard remains underrecognized in routine clinical practice and underscores the value of pulse palpation and ultrasound when anatomy appears atypical.

Brachial artery injury is a major concern in supracondylar fractures, humeral shaft trauma, penetrating injuries, and iatrogenic operative exposure [27]. Variant branching may alter ischemic presentation, collateral compensation, or operative bleeding patterns. Aberrant profunda brachii origin may also affect the expected collateral network around the elbow and posterior compartment. Preoperative vascular imaging may be particularly useful in complex fractures or revision surgery. In flap planning, vascular mapping is increasingly used to identify arterial caliber, branching, and pedicle reliability [31–33]. Unexpected superficial or high-branching patterns may affect flap selection or perfusion assessment. Similarly, dialysis access planning may be influenced by brachial artery size, bifurcation level, and branch dominance, especially when upper-arm fistulas or grafts are contemplated.

The high heterogeneity observed (I² = 88.4%) is not surprising in anatomical prevalence meta-analysis. The potential sources include Geographic variation, cadaveric versus imaging methodology, different classification systems, variable thresholds for defining “clinically relevant” anomalies, inclusion/exclusion of minor collateral branch variants, and mixed use of limbs versus participants as denominators. Despite this, the sensitivity analysis excluding high-risk studies yielded a similar pooled estimate (17.9%), suggesting that the overarching conclusion—that brachial artery variation is common—remains robust.

CONCLUSION

Brachial artery variations are frequent, clinically significant, and underappreciated, with an estimated pooled prevalence of 18.7% across 48 studies published between 2000 and 2025. The most common patterns are superficial brachial artery and high bifurcation of the brachial artery, both of which have direct implications for vascular access, imaging interpretation, regional anesthesia, trauma care, reconstructive surgery, and dialysis planning. Given that nearly one in five upper limbs may deviate from classical anatomy, clinicians should maintain a high index of suspicion, especially in the presence of unusual pulse findings, atypical vessel location, failed catheter advancement, or discordant ultrasound landmarks. Routine use of preprocedural ultrasound or angiographic mapping may reduce avoidable complications in selected high-risk settings.

Funding

No external funding was received for this study.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability

All data generated or analyzed during this study are included in this published article and its supplementary materials. Additional extracted datasets and coding sheets are available from the corresponding author upon reasonable request.

Ethical Statement

As this study is a systematic review and meta-analysis of previously published studies, ethical approval and informed consent were not required.

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