Persistent median artery of the forearm
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The persistent median artery of the forearm is an accessory artery that arises from the ulnar artery in the proximal forearm and is a persistent embryological remnant of the axial artery that usually regresses by eight weeks gestation 4.
It is present in ~10% (range 2.2-23%) of the population.
It is unilateral ~67% of the time and is associated with anomalous median nerves ~70% (range 63-80%) of the time - most commonly bifid median nerves followed by high division of the median nerve. The persistent median artery is contained within the epineurium of the normal or bifid median nerve.
The persistent median artery is located on the ulnar aspect of the normal median nerve but if the median nerve is bifid the persistent median artery is located between the two nerve bundles.
In early embryonic development, the median artery is the major supply to the forearm and hand. As the radial and ulnar arteries develop, the median artery usually regresses, only remaining as a tiny vessel accompanying the median nerve within the carpal tunnel, which is not normally visible on imaging. Occasionally, the median artery fails to regress and remains as a large vessel into maturity 6.
The persistent median artery can be a cause of carpal tunnel syndrome and is important to recognize if imaging is performed pre-operatively as it may be damaged during surgery. If it is not recognized intra-operatively due to tourniquet use subsequent damage may be a cause of post-operative bleeding.