Charting Variant Vascular Pathways in Musculoskeletal Imaging: Clinical and Surgical Implications

Variant vascular pathways often present a challenge to a radiologist interpreting routine musculoskeletal imaging studies. In this article, the authors focus on the prevalence, anatomic landmarks for both normal and variant anatomy, clinical significance of the aberrant vasculature and anatomic associations, and potential risks of surgical complications. In the upper extremity, the persistent median artery and high division of the radial artery, known as the brachioradial artery, threaten median neuropathy or upper extremity ischemia. Pelvic trauma cases should be scrutinized for corona mortis, an anastomotic vessel draping around the superior pubic ramus, that threatens severe, even fatal, hemorrhage if lacerated from superior pubic rami fractures or during acetabular fixation. In the posterior thigh, the persistent sciatic artery can be the supplemental or dominant vascular supply to the leg, which when thrombosed risks limb-threatening arterial insufficiency. The relatively fixed course of the aberrant anterior tibial artery between the popliteus muscle and posterior tibial cortex places it at risk in several orthopedic procedures, predominately those involving anterior to posterior instrumentation, and can have severe clinical repercussions including compartment syndrome, limb ischemia necessitating amputation, and hemorrhage. The peroneal arteria magna, referring to a dominant peroneal artery providing the sole vascular supply to the foot, is at risk for traumatic or iatrogenic aneurysm or pseudoaneurysm formation or ischemia if lacerated. Both common and uncommon variants are important to recognize for potential immediate or remote surgical intervention and treatment.