Patterns of the superficial veins of the cubital fossa: A meta-analysis

Abstract

Background

The aim of this systematic review is to quantitatively synthesize evidence on the prevalence of superficial vein patterns in the cubital region.

Method

A systematic literature search was conducted through a number of electronic databases. We identified 27 studies, including 9924 arms, which met the inclusion criteria.

Results

Meta-analysis showed that “N” shaped arrangement type was the commonest pattern (≈44–60%) followed by “M” shaped arrangement (≈20–25%). The prevalence of “M” type and “M”-like type was significantly higher in males, whereas females showed a significant predominance of “I” or “O” type. No significant differences in various pattern types were found for laterality. The frequency of “M” type is significantly lesser in Indian and Japanese populations, but they have significantly higher frequency of “N” type. In Malay population, “I” or “O” type was significantly higher, while the brachial CV was poorly developed or missing significantly in Indian population.

Conclusion

This evidence-based clinical anatomy review contributes to our anatomical knowledge regarding the true prevalence of pattern types of the superficial veins in cubital region in humans and, subsequently, might help in performing safer venous access and more direct approaches to these veins, especially under emergency conditions.

Keywords

Cubital fossa cephalic vein basilic vein patterns meta-analysis

Introduction

The cubital fossa and its superficial veins are highly relevant to daily clinical practice. Because those veins lie superficially in the subcutaneous tissue and not paired with any artery, they are easy to view and access.^1,2 The main superficial veins of the cubital fossa, include the cephalic, basilic, median cubital, and median antebrachial vein and are the most preferred sites for venipuncture, transfusion, infusion, cardiac catheterization, or placement of dialysis access.^3–5 However, their arrangement and prevalence are highly variable, so is their proximity to the adjacent arteries and nerves; therefore, knowledge of their anatomy pattern is a pre-requisite for successful interventions and safe practice.^6,7

Anatomy

The cephalic vein (CV) begins usually over the “anatomical snuff-box” from the radial end of the dorsal venous network.¹ It curves around the radial side of the forearm and ascends along the lateral aspect of the arm within the superficial fascia.⁸ Two fascia layers are surrounding the CV and basilic vein (BV) similarly to the saphenous vein of the lower limb. This venous compartment could be criteria for identification of those veins, to differentiate them from the deep veins as well as from the superficial network of the upper limb, which is useful in daily practice.⁹ Distal to the elbow, the median cubital vein (MCV) diverges proximomedially to reach the BV.¹⁰ The CV ascends superficially to a groove between the brachioradialis and biceps, crosses anteriorly the lateral cutaneous nerve of the forearm, continues lateral to biceps and then between pectoralis major and deltoid.^1,2,11 The BV drains the ulnar end of the dorsal venous network of the hand.¹² It ascends posteromedially in the forearm then continues anteriorly at the elbow where it is joined by the MCV.¹³ The BV ascends superficial to and then between biceps and pronator teres muscles and it is crossed by branches of the medial cutaneous nerve of the forearm.¹⁴ The MCV connects the CV with the BV across the cubital fossa. It is usually the most prominent superficial vein in the body, and is visible or palpable when all other veins are hidden by fat or collapsed during a shock.^14,15 The palmar venous plexus is drained by the median antebrachial vein (MAV). This vein ascends anteriorly in the forearm and ends in the MCV, the BV, or into both.^1,10

Pattern classification and prevalence

Six types are usually reported in the literature: four major and two minor (Figure 1).^7,16–19 The “M” (or “Y” or classical) shaped arrangement called type 1 is a pattern where a dominant MAV continues with two terminal branches, the MCV and the median basilic vein (MBV), joining CV and CB, respectively.^1,10 The prevalence range of type 1 is reported to be 0.78–54.13%.^5,20 The “N” (or “H”) shaped arrangement or embryonal type (type 2) is a pattern where a poorly developed MAV ends into the MCV which connects CV and BV in the cubital region with a prevalence ranging from 9% to 98%.^21,22 The “I” or “O” type (type 3) presents with no communicating branch between CV and BV with a prevalence ranging from 1.1% to 37%.^6,18 Type 4 is a pattern where the CV drains into BV, and MAV drains into CV or BV below the cubital fossa while the CV is poor developed or missing; prevalence of this type ranges between 1.6% and 32%.^23,24 In rare instances, the MCV is doubled (type 5) with a frequency of 0.6–8.5%.^16,25

Figure 1.

Pattern types of superficial cubital veins (C – cephalic vein, B – basilic vein, MAV – median antebrachial vein, MCV – median cephalic vein, MBV – median basilic vein, MCuV – median cubital vein).

Type 6 is a pattern where the CV and BV are joined by an arched vein, with a proximally oriented concavity into which two or more veins are drained from the forearm^7,26; its prevalence ranges between 2% and 10.6%.^7,27

Few authors identified two additional types. The “M”-like type (type 7) where MCV does not link to CV or when the CV is divided into MCV and MBV. In that case MCV drains into the accessory CV. Prevalence of this type ranges between 5.2% and 30%.^19,26 Type 8 is very rarely described in literature; it includes nonclassifiable patterns such as an absent antebrachial BV or a doubled brachial CV with a frequency of 0.88–29.6%.^26,28

Clinical procedures used to detect patterns

Tourniquet application when combined with active movements of the hand (opening and closing of the fist) is the most frequent method used to make the superficial veins of the cubital fossa more prominent. Investigators used different techniques. Other methods have been used recently such as duplex ultrasound,²⁹ venous illuminator, AccuVein⁶ and helical computed tomography.³⁰

Clinical relevance

Due to their numerous variations, it is important to master the anatomy of the superficial veins of the cubital fossa for clinical procedures such as venipuncture, transfusion, infusion, cardiac catheterization, or placement of dialysis access. Additionally, arteries and nerves that lie near or below these superficial veins could be at risk for missed punctures. The medial and lateral antebrachial cutaneous nerves which lie superficial to BV, CV, MCV, and MBV in the cubital region are susceptible to injury during phlebotomy.^31–35

On the other hand, different vein patterns existing in the cubital fossa can provide collateral venous pathways in the case of occlusion.^8,34

The aim of this systematic review is to quantitatively synthesize evidence on existence and prevalence of the superficial vein patterns at the antecubital region.

Methods

A modified checklist of the MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies³⁶ and the Checklist for Anatomical Reviews and Meta-Analysis (CARMA) served as the framework for this review.³⁷

Search strategy and identification of studies

A systematic literature search was conducted through a number of electronic databases such as Medline, Embase, Scielo, EBSCO, and Google Scholar from inception to February 2016, using the Boolean combination of broad terms such as [(vena OR vein) AND (fossa cubiti OR cubital fossa)] to locate the maximum number of relevant articles. We also searched the websites of the following journals: Anatomical Record, Anatomical Sciences International, Annals of Anatomy, Clinical Anatomy, European Journal of Anatomy, Folia Morphologica, Journal of Anatomy, Journal of Vascular Access, Journal of Vascular Surgery, International Journal of Morphology, Okajimas Folia Anatomica (Japan), and Surgical and Radiological Anatomy. Electronic databases such as the Digital Collections of the National Library of Medicine, www.persée.fr, and www.gallica.fr were also searched for old manuscripts. All included articles were citation-tracked using Google Scholar to ensure that all relevant articles were identified. Duplicates were deleted.

Criteria for study selection

Literature concerning the morphology and prevalence of the superficial veins pattern types of the cubital region in cadavers and living subjects (clinical investigations) is infrequent, so all published or unpublished studies reporting pattern types and their prevalence rates were included in the review. Studies were required to report the ethnic origin of the studied populations and at least the primary outcome which is the prevalence of the superficial veins pattern types in the cubital region. Secondary outcomes were set to be the prevalence rates of different pattern types in relation to gender and body side. The criteria used for inclusion and exclusion were considered as a quality checklist for our prevalence review. To ensure unbiased selection of included studies, abstracts from conferences were not included. No restriction was imposed on date, language or age; however, only those written in English, French, and German were included. Titles and abstracts were initially screened and full-text articles were obtained when at least one primary outcome was thought to be reported. We excluded all studies which described nonstandard classifications and therefore were not reliable.

Data extraction and analysis

Data extracted included sample size, sample details, type of investigation, and the results. Analysis was performed using StatsDirect v2.7.8 (Altrincham, United Kingdom). Proportion meta-analysis was used to calculate the pooled prevalence estimate (PPE), and odds ratio (OR) meta-analysis was used to establish potential associations with other variables such as gender, laterality or side. To test our overall results, we conducted sensitivity analysis on studies with samples above 100 elbows. Subgroup analysis related to ancestry and types of investigation were performed as well. Descriptive analysis was conducted when the data was not amenable to meta-analysis. We examined heterogeneity amongst studies using I² statistics; whenever I²> 50%, the random-effect estimate was reported.

Results

Search results

The electronic search yielded 98 hits. Twelve duplicates were identified and removed. The initial 86 abstracts checking revealed 35 potentially relevant studies and full manuscripts were obtained. Twenty-one studies met the inclusion criteria and 14 were excluded for different reasons (Figure 2). The reference checking yielded another six relevant studies. In total 27 studies (32 sub-studies) with a total of 9924 arms were included in the meta-analysis (Table 1).

Figure 2.

Flowchart of the search strategy.

Table 1.

Characteristics of the included studies.

Studies	Study type	Population	Age	Sample size (subjects)	Male	Female	Sample size (arms)	Right	Left
Abdul Hamid et al.³⁸	Clinical	Malaysian	20.1 ± 1.5	180	52	128	360	180	180
AlBustami et al.⁷	Clinical	Jordanian	18–25	264	132	132	528	264	264
Baptista-Silva et al.³⁹	Cadaver	Brazilian	47.8 ± 16.9	13	13	0	26	13	13
Berry and Newton²⁷	Clinical	Australian (British origin)	Adults	300	300	0	600	300	300
Charles²³	Cadaver	White and Black American	Adults	122 (60 Caucasian and 62 Black)	122	0	244	122	122
Corzo Gomez et al.¹⁸	Clinical	Colombian	18–46	400	200	200	800	400	400
Corzo Gomez et al.¹⁹	Clinical	Colombian	18–68	885	438	447	1770	885	885
Da Silva et al.⁴⁰	Cadaver	Brazilian	Adults	4	4	0	8	4	4
Del Sol et al.⁴¹	Cadaver	Brazilian	0–1	20	10	10	40	20	20
Del Sol et al.⁴²	Clinical	Chilean (multiple ethnicities)	17–24	200	114	86	400	200	200
Del Sol et al.⁴³	Clinical	Chilean (Mapuche ethniciy)	15–84	150	30	120	300	150	150
Dharap and Shaharuddin¹⁶	Clinical	Malaysian	18–65	266	170	96	532	266	266
Halim and Abdi⁴⁴	Clinical & cadaveric	Indian	>18	268 (68 living, 200 cadavers)	NR	NR	536
Hamzah et al.²⁹	Clinical (Ultrasound)	Malaysian (Malays, Chinese & Indians)	>18	300 (100 for each ethnicity)	150	150	600	300	300
Jasinski and Poradnik⁴⁵	Cadaveric	Polish	22–92	40	40	0	80	40	40
Lee et al.⁶	Clinical	Korean	21–87	200	120	80	353	174	179
Mikuni et al.⁵	Cadaveric	Japanese	NR	NR	NR	NR	128	NR	NR
Okamoto²⁵	Clinical	Japanese	Adults	100	100	0	200	100	100
Singh¹⁷	Clinical	Nigerian	Adults	300	200	100	600	300	300
Singh et al.²¹	Clinical	Nigerian	Adults	200	NR	NR	400	200	200
Sohier et al.^46,47	Cadaveric	West African	Adults	NR	NR	NR	55	NR	NR
Thoma et al.⁴⁸	Surgical	Canadian	Adults	40	NR	NR	40	NR	NR
Ukoha et al.²⁶	Clinical	Nigerian	20–27	135	100	35	270	135	135
Vasudha²²	Cadaveric and Clinical	Indians	Adults	25	12	13	50	25	25
Vučinić et al.²⁸	Clinical	Serbs	18–20	169	135	34	338	169	169
Wasfi et al.²⁰	Clinical	Iraqi	Adults	300	200	100	600	300	300
Yamada et al.⁴	Cadaveric	Japanese	66–102	40	15	25	66	34	32

Meta-analytical prevalence results of Types 1 to 8

Only the study of AlBustami et al.⁷ reported crude prevalence values of 17.4%, 63.6%, 13.2%, 9.4%, 0.8%, and 10.6% for types 1, 2, 3, 4, 5, and 6, respectively. The true prevalence results reported in all other studies are given in Tables 2 and 3.

Table 2.

Prevalence of types 1 to 4.

Studies	Sample size (subjects)	Sample size (arms)	Type 1					Type 2					Type 3					Type 4
Studies	Sample size (subjects)	Sample size (arms)	O	M	F	R	L	O	M	F	R	L	O	M	F	R	L	O	M	F	R	L
Abdul Hamid et al.³⁸	180	360	185 (51.4)	–	–	94 (52.2)	91 (50.6)	92 (25.5)	–	–	45 (25)	37 (20.6)	93 (25.8)	–	–	41 (22.8)	52 (28.9)	–	–	–	–	–
AlBustami et al.⁷	264	528	45 ^a (17.4)	24 (18.2)	22 (16.6)	–	–	168 ^a (63.6)	68 (51.5)	60 (45.4)	–	–	35 ^a (13.2)	18 (13.6)	17 (12.8)	–	–	25 ^a (9.4)	7 (5.3)	18 (13.6)	–	–
Baptista- Silva et al.³⁹	13	26	6 (23.1)	–	–	–	–	18 (69.2)	–	–	–	–	1 (3.8)	–	–	–	–	–	–	–	–	–
Berry and Newton²⁷	300	600	96 (16)	–	–	–	–	498 (83)	–	–	–	–	4 (0.7)	–	–	–	–	2 (0.3)	–	–	–	–
Charles²³	60 (Caucasian)	120	33 (27.5)	33 (27.5)	–	17 (28.3)	16 (26.7)	81 (67.5)	81 (67.5)	–	40 (66.7)	41 (68.3)	2 (3.3)	2 (3.3)	–	0 (0)	2 (3.3)	1 (1.7)	1 (1.7)	–	1 (1.7)	0 (0)
Charles²³	62 (Black)	124	15 (12)	15 (12)	–	8 (12.9)	7 (11.3)	85 (68.5)	85 (68.5)	–	43 (69.4)	42 (67.8)	18 (11)	18 (11)	–	9 (14.5)	9 (14.5)	3 (4.8)	3(4.8)	–	0 (0)	3(4.8)
Corzo Gomez et al.¹⁸	400	800	31 (4)	11 (2)	20 (5)	15 (4)	16 (5)	190 (24)	112 (28)	78 (19)	89 (22)	101 (25)	297 (37)	81 (21)	216 (54)	141 (35)	156 (39)	92 (12)	74 (18)	18 (4)	54 (13)	38 (9)
Corzo Gomez et al.¹⁹	885	1770	146 (8)	73 (8)	73 (8)	79 (9)	67 (7)	348 (19)	228 (26)	120 (14)	148 (17)	200 (23)	451 (26)	84 (10)	367 (41)	235 (27)	216 (24)	177 (10)	123 (14)	54 (6)	82 (9)	95 (11)
Da Silva et al.⁴⁰	4	8	1 (12.5)	–	–	–	–	3 (37.5)	–	–	–	–	0 (0)	–	–	–	–	2 (25)	–	–	–	–
Del Sol et al.⁴¹	20	40	12 (30)	–	–	–	–	12 (30)	–	–	–	–	10 (25)	–	–	–	–	4 (10)	–	–	–	–
Del Sol et al.⁴²	200	400	145 (36.2)	–	–	–	–	115 (28.7)	–	–	–	–	69 (17.2)	–	–	–	–	59 (14.7)	–	–	–	–
Del Sol et al.⁴³	150	300	116 (38.7)	29 (48.3)	87 (36.2)	63 (42)	53 (35.3)	85 (28.3)	14 (23.3)	71 (29.6)	47 (31.3)	38 (25.3)	72 (24)	13 (21.7)	59 (24.6)	29 (19.3)	43 (28.7)	13 (4.3)	1 (1.7)	12 (5)	5 (3.4)	8 (5.3)
Dharap and Shaharuddin¹⁶	266	532	86 (32.3)	64 (18.8)	22 (11.5)	–	–	362 (68)	212 (62.4)	150 (78.2)	–	–	44 (8.3)	30 (8.8)	14 (7.3)	–	–	12 (2.2)	10 (2.9)	2 (1)	–	–
Halim and Abdi⁴⁴	268	536	35 (6.5)	–	–	–	–	353 (65.9)	–	–	–	–	32 (6)	–	–	–	–	105 (19.5)	–	–	–	–
Hamzah et al.²⁹	300 (Total)	600	162 (27)	80 (53.3)	82 (54.7)	79 (52.7)	83 (55.3)	344 (57.3)	173 (57.6)	171 (57)	176 (58.7)	168 (56)	32 (5.3)	13 (4.3)	19 (6.3)	14 (4.7)	18 (6)	27 (4.5)	14 (4.7)	13 (4.3)	14 (4.3)	13 (4.3)
Hamzah et al.²⁹	100 (Malay)	200	39 (19.5)	–	–	18 (18)	21 (21)	120 (60)	–	–	64 (64)	56 (56)	19 (9.5)	–	–	8 (8)	11 (11)	9 (4.5)	–	–	5 (5)	4 (4)
Hamzah et al.²⁹	100 (Chinese)	200	78 (39)	–	–	38 (38)	40 (40)	94 (47)	–	–	47 (47)	47 (47)	8 (4)	–	–	4 (4)	4 (4)	9 (4.5)	–	–	4 (4)	5 (5)
Hamzah et al.²⁹	100 (Indian)	200	43 (21.5)	–	–	21 (21)	22 (22)	132 (66)	–	–	67 (67)	65 (65)	5 (2.5)	–	–	2 (2)	3 (3)	9 (4.5)	–	–	5 (5)	4 (4)
Jasinski and Poradnik⁴⁵	40	80	26 (32.5)	–	–	12 (30)	14 (35)	35 (43.7)	–	–	18 (45)	17 (42.5)	0 (0)	–	(4.5)	–	–	13 (16.2)	–	–	7 (17.5)	6 (15)
Lee et al.⁶	200	353	165 (46.7)	108 (49.3)	57 (42.5)	85 (47.5)	80 (46)	177 (50.1)	102 (46.6)	75 (56)	88 (49.2)	89 (51.1)	4 (1.1)	3 (1.4)	1 (0.7)	2 (1.1)	2 (1.1)	7 (2)	6 (2.7)	1 (0.7)	4 (2.2)	3 (1.7)
Mikuni et al.⁵	NR	128	1 (0.78)	–	–	–	–	104 (82)	–	–	–	–	9 (7.0)	–	–	–	–	–	–	–	–	–
Okamoto²⁵	100	200	2 (1)	–	–	2 (1)	0 (0)	154 (77)	–	–	82 (82)	72 (72)	29 (14.5)	–	–	11 (11)	18 (18)	9 (4.5)	–	–	2 (2)	7 (7)
Singh¹⁷	300	600	156 (26)	96 (24)	60 (30)	–	–	346 (57.7)	248 (62)	98 (49)	–	–	48 (8)	28 (7)	20 (10)	–	–	–	–	–	–	–
Singh et al.²¹	200	400	160 (40)	–	–	–	–	36 (9)	–	–	–	–	80 (20)	–	–	–	–	80 (20)	–	–	–	–
Sohier et al.^46,47		55	21 (38.1)	–	–	–	–	34 (62)	–	–	–	–	0 (0)	–	–	–	–	–	–	–	–	–
Thoma et al.⁴⁸	40	40	8 (20)	–	–	–	–	17 (43)	–	–	–	–	0 (0)	–	–	–	–	–	–	–	–	–
Ukoha et al.²⁶	135	270	75 (27.8)	57 (28.5)	18 (25.7)	39 (28.9)	36 (26.7)	76 (28.2)	57 (28.5)	19 (27.2)	31 (22.9)	45 (33.3)	11 (4.1)	5 (2.5)	6 (8.6)	6 (4.4)	5 (3.7)	14 (5.2)	7 (3.5)	7 (10)	6 (4.4)	8 (5.4)
Vasudha²²	25 cadavers	50	2 (4)	–	–	–	–	44 (88)	–	–	–	–	2 (4)	–	–	–	–	2 (4)	–	–	–	–
Vasudha²²	100 subjects	200	4 (2)	–	–	–	–	196 (98)	–	–	–	–	0 (0)	–	–	–	–	0 (0)	–	–	–	–
Vučinić et al.²⁸	169	338	177 (52.4)	150 (55.5)	27 (39.7)	91 (53.8)	86 (50.9)	125 (37)	87 (32.2)	38 (55.8)	60 (35.5)	65 (38.5)	17 (5)	14 (5.18)	3 (4.41)	9 (5.32)	8 (4.73)	6 (1.8)	6 (2.2)	0 (0)	3 (1.7)	3 (1.7)
Wasfi et al.²⁰	300	600	336 (56)	239 (59.7)	97 (48.5)	166 (55.3)	170 (56.7)	99 (16.5)	64 (16)	35 (17.5)	49 (16.3)	50 (16.6)	79 (13.1)	46 (11.5)	33 (16.5)	40 (13.33)	39 (13)	37 (6.2)	24 (6)	13 (6.5)	18 (6)	17 (5.6)
Yamada et al.⁴	40	66	25 (41.7)	–	–	–	–	34 (56.7)	–	–	–	–	0 (0)	–	–	–	–	1 (1.7)	–	–	–	–

The values between parentheses are the percentage values.

O: overall; M: male; F: female; R: right; L: left.

Crude prevalence values.

Table 3.

Prevalence of types 5 to 8.

Studies	Sample size (arms)	Type 5					Type 6					Type 7					Type 8
Studies	Sample size (arms)	O	M	F	R	L	O	M	F	R	L	O	M	F	R	L	O	M	F	R	L
AlBustami et al.^7 a	528	2 (0.8)	2 (1.5)	0 (0)	–	–	28 (11.2)	13 (9.8)	15 (11.4)	–	–	–	–	–	–	–	–	–	–	–	–
Charles²³	120 (White)	3 (2.5)	3 (2.5)		2 (3.3)	1 (1.7)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–
Charles²³	124 (Black)	3 (2.4)	3 (2.4)		2 (3.2)	1 (1.6)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–
Corzo Gomez et al.¹⁸	800	–	–	–	–	–	–	–	–	–	–	114 (14)	79 (20)	35 (10)	58 (15)	56 (14)	76 (9)	43 (11)	33 (8)	43 (11)	33 (8)
Corzo Gomez et al.¹⁹	1770	–	–	–	–	–	–	–	–	–	–	524 (30)	307 (35)	217 (24)	286 (32)	238 (27)	124 (7)	61 (7)	63 (7)	55 (6)	69 (8)
Da Silva et al.⁴⁰	8	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	2 (25)	–	–	–	–
Del sol et al.⁴¹	40	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	2 (5)	–	–	–	–
Del sol et al.⁴²	400	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	12 (3)	–	–	–	–
Del sol et al.⁴³	300	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	14 (4.7)	–	–	6 (4.0)	8 (5.3)
Dharap and Shaharuddin¹⁶	532	1 (0.6)	1 (0.6)	0 (0)	–	–	26 (4.9)	22 (6.5)	4 (2.0)	–	–	–	–	–	–	–	–	–	–	–	–
Halim and Abdi⁴⁴	536	9 (1.6)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	2 (0.4)	–	–	–	–
Hamzah et al.²⁹	600 (Total)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	35 (12)	20 (13)	15 (10)	–	–
	200 (Malay)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	13 (6.5)	–	–	5 (5)	8 (8)
	200 (Chinese)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	11 (5.5)	–	–	7 (7)	4 (4)
	200 (Indian)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	11 (5.5)	–	–	5 (5)	6 (6)
Jasinski and Poradnik⁴⁵	80	–	–	–	–	–	–	–	–	–	–	–	–	–	-	–	6 (7.5)	–	–	3 (7.5)	3 (7.5)
Mikuni et al.⁵	128	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	14 (11)	–	–	–	–
Okamoto²⁵	200	17 (8.5)	–	–	7 (7)	10 (10)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–
Singh¹⁷	600	17 (3)	16 (4)	12 (6)	–	–	22 (3.6)	12 (3)	10 (5)	–	–	–	–	–	–	–	–	–	–	–	–
Singh et al.²¹	400	8 (2)	–	–	–	–	–	–	–	–	–	32 (8)	–	–	–	–	4 (1)	–	–	–	–
Thoma et al.⁴⁸	40	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–	15 (37)	–	–	–	–
Ukoha et al.²⁶	270	–	–	–	–	–	–	–	–	–	–	14 (5.2)	13 (6.5)	1 (1.4)	9 (6.67)	5 (3.70)	80 (29.6)	61 (30.5)	19 (26.8)	44 (32.59)	36 (26.67)
Vučinić et al.²⁸	338	10 (2.95)	10 (3.70)	0	5 (2.95)	5 (2.95)	–	–	–	–	–	–	–	–	–	–	–	–	–	–	–
Wasfi et al.²⁰	600	–	–	–	–	–	25 (4.2)	13 (3.2)	12 (6)	12 (4)	13 (4.3)	–	–	–	–	–	24 (4)	14 (3.5)	10 (5)	13 (4.33)	11 (3.37)

The values between parentheses are the percentage values.

O: overall; M: male; F: female; R: right; L: left.

Crude prevalence values.

Type 2 was the commonest pattern (≈44–60%) followed by type 1 (≈20–25%), then type 7 (≈13%), type 3 (≈4–11%), type 8 (8%), type 6 (4.5%), type 4 (≈3–4%), and type 5 (2.4%). Types 1 and 7 were significantly more prevalent in men and type 3 more prevalent in women while no sex-based significance was found for all other types. No significant difference was found between right and left sides and that for all types. The Indian and Japanese populations showed significantly lesser frequencies of type 1 and significantly higher occurrence of type 2 when compared to other ancestries; no overlapping in confidence intervals. Type 3 was significantly more frequent in Malay population whereas type 4 in Indian ancestry. The number of studies reporting types 4 to 8 was not amenable to sensitivity, subgroup or ethnicity-based analysis.

The overall, sensitivity analyses, subgroup analyses, sex-based, side-based and ethnicity-based meta-analytical results are shown in detail in Tables 4 and 5.

Table 4.

Meta-analytical results type 1 to 4.

Prevalence (P) or Odds ratio (OR)	No. of studies	No. of elbows	Type 1			Type 2			Type 3			Type 4
Prevalence (P) or Odds ratio (OR)	No. of studies	No. of elbows	PPE/OR	CI (p)	I ²	PPE/OR	CI (p)	I ²	PPE/OR	CI (p)	I ²	PPE/OR	CI (p)	I ²
Overall (P)	26	9596	21%	0.200–0.216	98.6%	51%	0.405–0.612	99%	8%	0.045–0.120	97.7%	4.2%	0.023–0.066	96.2%
Sensitivity analysis (P)	20	9,231	22.4%	0.152–0.304	98.8%	49.8%	0.376–0.619	99.3%	10%	0.058–0.152	98.3%	4%	0.019–0.068	97.2%
Clinical (P)	16	8,323	25.3%	0.161–0.357	99%	44.4%	0.312–0.580	99.4%	11%	0.059–0.171	98.5%	4%	0.018–0.70	97.2%
Cadaveric (P)	10	737	20.5%	0.113–0.315	91.3%	60%	0.493–0.703	88%	4%	0.012–0.084	83%	3.3%	0.010–0.068	77.5%
Sex-based P (OR)	10	3466 (M) 2724 (F)	1.2	1.045–1.375 (0.01)	61.8%	1.0	0.702–1.424 (0.8)	87.5%	0.54	0.307–0.964 (0.001)	89.7%	1.5	0.828–2.94 (0.1)	76.6%
Side-based P (OR)	9	2981 (R) 2981 (L)	1.07	0.938 - 1.222 (0.3)	0%	1.07	0.938–1.222 (0.3)	0%	0.93	0.808–1.06 (0.7)	0%	0.97	0.788–1.21 (0.8)	1.1%
Ethnicity-based P
African (P)	5	1449	28.2%	0.198–0.372	91.7%	37.4%	0.115–0.681	99.2%	8.3%	0.031–0.155	94%	3.6%	0.0006–0.14	98%
Caucasian (P)	5	1178	29.4%	0.140–0.477	91.7%	55.6%	0.374–0.784	98.3%	1.7%	0.002–0.046	84.8%	3%	0.003–0.081	92%
Indian (P)	3	986	7.7%	0.019–0.167	93.8%	81.6%	0.601–0.960	98%	2.7%	0.003–0.072	89%	5.4%	0.003–0.189	97.4%
Japanese (P)	3	394	8.2%	0.0001–0.311	91.7%	71%	0.556–0.843	89.6%	6%	0.005–0.168	91.1%	2%	0.0006–0.062	79%
Malay (P)	3	1092	28%	0.09–0.525	98.5%	51%	0.239–0.777	98.8%	13.8%	0.048–0.264	96.3%	1.7%	0.0007–0.054	91.3%
South American (P)	7	3344	20.8%	0.094–0.354	98.4%	29%	0.232–0.349	87.9%	22%	0.158–0.290	92.3%	10%	0.072–0.131	77.9%

PPE: pooled prevalence value

Table 5.

Meta-analytical results of types 5 to 8.

Prevalence (P) or Odds ratio (OR)	No. of studies	No. of elbows	Type 5			No. of studies	No. of elbows	Type 6			No. of studies	No. of elbows	Type 7			No. of studies	No. of elbows	Type 8
Prevalence (P) or Odds ratio (OR)	No. of studies	No. of elbows	PPE/OR	CI (p)	I ²	No. of studies	No. of elbows	PPE/OR	CI (p)	I ²	No. of studies	No. of elbows	PPE/OR	CI (p)	I ²	No. of studies	No. of elbows	PPE/OR	CI (p)	I ²
Overall P	8	3378	2.4%	0.011 – 0.042	87.8%	4	2260	4.5%	0.037–0.054	0%	4	3240	13.2%	0.044–0.258	98.6%	8	5932	8%	0.047–0.120	95.8%
Sex-based P (OR)	4	769 (M) 494 (F)	1.5	0.344–1.640 (0.6)	29.8%	4	834 (M) 560 (F)	0.9	0.430–1.905 (0.8)	65%	3	738 (M) 682 (F)	2.65	2.094–3.354 (0.0001)	0%	5	1088 (M) 932 (F)	1.1	0.868–1.434 (0.4)	0%
Side-based P (OR)	3	391 (R) 391 (L)	0.9	0.454–1.190 (0.8)	0%	–	–	–	–	-	3	1420 (R) 1420 (L)	1.25	1.046–1.50 (0.01)	0%	7	2210 (R) 2210 (L)	1.02	0.815–1.273 (0.8)	0%

Discussion

Our findings showed that the commonest pattern was the embryonal “N” type 2 followed by type 1 whether the investigation was clinical or cadaveric. The sensitivity analyses showed some further differences; when compared to the clinical results, the cadaveric estimates demonstrated lesser type 1 and a higher frequency of type 2 (20.5% vs. 20.3% and 60% vs. 44.4%). However, the cadaveric studies were small sample-sized compared to the clinical studies. While no significant differences were found for laterality, the gender difference in relation to type “M” and “’I’’ along with the clear association between pattern type and ethnicity would highly suggest a genetic base to the observed pattern frequencies.

One of the possible limitations with regard to our clinical results is that the pattern type was determined by different techniques. Investigation techniques for venous visualization such as duplex ultrasound,²⁹ venous illuminator, AccuVein⁶, helical computed tomography,³⁰ or reflective near-infrared technology⁴⁹ might provide more accurate findings but these methods are more expensive and require time. In addition, the application of the tourniquet and the applied amount of pressure were not always reported and this might cause inaccuracy in reporting. It is worthy to note that different genetic and hydrodynamic factors could play an important role in the observed vein pattern. For instance, in obese people, the superficial veins of the cubital fossa may not always be clearly visible. In fact, one study stated the values of body mass index of their subjects.²⁸ Additionally, no previous quantitative review has been reported in the literature to which results of this meta-analysis could be compared.

Lastly, it has been reported that the lateral half of the MCV near the cephalic vein and the upper part of the CV in the cubital fossa seems to be relatively safe for venipuncture.^4,5 However, due to the focused scope of our study, such could not be confirmed. A more accurate knowledge of the venous pattern type in different ethnicities could reduce nerve injuries when approaching those veins.

In sum, this evidence-based clinical anatomy review contributes to our anatomical knowledge regarding the true prevalence of pattern types of the superficial veins in cubital region in humans and subsequently could assist medical and health allied professionals in performing safer venipuncture, venesection, or venous surgery at this site. Awareness of the gender and ethnicity differences, common and uncommon cubital venous patterns might help in performing more direct approaches to these veins, especially under emergency conditions.

Footnotes

Contributorship

None.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

None, because this paper represents a meta-analysis of published studies.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Guarantor

None.

References

Standring

. Gray’s anatomy, 41st ed. Edinburg: Elsevier Churchill Livingstone, 2016.

Snell

. Clinical anatomy by regions, 9th ed. Baltimore: Lippincott Williams & Wilkins, 2012.

Kiray

Ergür

Tayefi

. Anatomical evaluation of the superficial veins of the upper extremity as graft donor source in microvascular reconstructions: A cadaveric study. Acta Orthop Traumatol Turc 2013; 47: 405–410.

Yamada

Katsuda

. Cubital fossa venipuncture sites based on anatomical variations and relationships of cutaneous veins and nerves. Clin Anat 2008; 21: 307–313.

Mikuni

Chiba

Tonosaki

. Topographical anatomy of superficial veins, cutaneous nerves, and arteries at venipuncture sites in the cubital fossa. Anat Sci Int 2013; 88: 46–57.

Lee

Kim

. Variations of the cubital superficial vein investigated by using the intravenous illuminator. Anat Cell Biol 2015; 48: 62–65.

AlBustami

Altarawneh

Rababah

. Pattern of superficial venous arrangement in the cubital fossa of adult Jordanians. J Med J 2014; 48: 269–274.

Shenoy

. Surgical anatomy of upper arm: What is needed for AVF planning. J Vasc Access 2009; 10: 223–232.

Lemasle

. Il existe également des compartiments pour les troncs veineux collecteurs du member supérieur!. J Mal Vasc 2010; 35: 332–333.

10.

Moore

Upper limb. In: Moore

Dalley

(eds). Clinically oriented anatomy, 5th ed. Baltimore: Lippincot Williams, 2006, pp. 726–884.

11.

Singh

. Textbook of anatomy upper limb and thorax (Volume 1), 2nd ed. New Delhi: Elsevier, 2014.

12.

Feneis

Dauber

. Pocket atlas of human anatomy, 4th ed. Stuttgart, New York: Thieme, 2000.

13.

Singh

. Textbook of anatomy, 5th ed. New Delhi, Panama City, London: Jaypee Brothers, 2011.

14.

Singh

. Clinical and surgical anatomy, 2nd ed. New Delhi: Elsevier, 2007.

15.

Faiz

Moffat

. Anatomy at a glance, Oxford: Blackwell Science, 2002.

16.

Dharap

Shaharuddin

. Patterns of superficial veins of the cubital fossa in Malays. Med J Malaysia 1994; 49: 239–241.

17.

Singh

. Patterns of superficial veins of the cubital fossa in Nigerian subjects. Acta Anat (Basel) 1982; 112: 217–219.

18.

Corzo

GEG

Gómez

DOL

Niño

MME

. Distribution pattern of the veins of the cubital fossa in a sample of people born in Bucaramanga. Colombia. Int J Morphol 2010; 28: 1011–1018.

19.

Corzo

GEG

Gómez

DOL

Niño

MME

. Distribution pattern of the veins of the cubital fossa in a sample of people born in the Department of Santander, Colombia. Int J Morphol 2014; 32: 221–226.

20.

Wasfi

Dabbagh

AlAthari

. Biostatistical study on the arrangement of the superficial veins of the cubital fossa in Iraqis. Acta Anat (Basel) 1986; 126: 183–186.

21.

Singh

Ekandem

Bose

. A study of the superficial veins of the cubital fossa in Nigerian subjects. Acta Anat (Basel) 1982; 114: 317–320.

22.

Vasudha

. A study on superficial veins of upper limb. NJCA 2013; 2: 204–208.

23.

Charles

. On the arrangement of the superficial veins of the cubital fossa in American White and American Negro males. Anat Rec 1932; 54: 9–14.

24.

Sun

. Applied anatomical study of PICC with veins of upper limb approach. J Nurs (China) 2011; 18: 8–11.

25.

Okamoto

. A study of the superficial veins in the superior extremity of live Japanese. Anat Rec 1922; 23: 323–331.

26.

Ukoha

Oranusi

Okafor

. Patterns of superficial venous arrangement in the cubital fossa of adult Nigerians. Niger J Clin Pract 2013; 16: 104–109.

27.

Berry

Newton

HAS

. A study of the superficial veins of the superior extremity in 300 living subjects. Anat Anz 1908; 33: 591–601.

28.

Vučinić

Erić

Macanović

. Patterns of superficial veins of the middle upper extremity in Caucasian population. J Vasc Access 2016; 17: 87–92.

29.

Hamzah

Ramasamy

Adnan

. Pattern of superficial venous of the cubital fossa among volunteers in a tertiary hospital. Trop Med Surg 2014; 2: 164–164.

30.

Del Sol

Lillo

Lobos

. Study of the veins of the cubital fossa byhelical computed tomography and its clinical application. Int J Morphol 2012; 30: 64–69.

31.

Horowitz

. Peripheral nerve injury and causalgia secondary to routine venipuncture. Neurology 1994; 44: 962–964.

32.

Berry

. Venipuncture nerve injuries. Lancet 1977; 1: 1236–1237.

33.

Newman

Waxman

. Blood donation-related neurologic needle injury: Evaluation of 2 years’ worth of data from a large blood center. Transfusion (Paris) 1996; 36: 213–215.

34.

Horowitz

. Venipuncture-induced causalgia: Anatomic relations of upper extremity superficial veins and nerves, and clinical considerations. Transfusion (Paris) 2000; 40: 1036–1040.

35.

Newman

. Venipuncture nerve injuries after whole-blood donation. Transfusion (Paris) 2001; 41: 571–572.

36.

Stroup

Berlin

Morton

. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–2012.

37.

Yammine

. Evidence-based anatomy. Clin Anat 2014; 27: 847–852.

38.

Abdul Hamid HB, Suhaimi BAA, Nooh BMN, et al. A cross-sectional study on the anatomical variations of the superficial veins of the upper limb among the preclinical medical students in UniKL-RCMP. Report, University of Kuala Lumpur, Royal College of Medicine Perak, Malaysia, November 2009.

39.

Baptista-Silva

JCC

Dias

Cricenti

. Anatomy of the basilic vein in the arm and its importance for surgery. Braz J Morphol Sci 2003; 20: 171–175.

40.

Da Silva

Pereira

Albuquerque

. Morphological study of the medial cubital vein. Arq Ciênc Saúde UNIPAR, Umuarama 2013; 17: 37–42.

41.

Del Sol

De Angelis

Bolini

PDA

. Formacoes venosas de fossa cubital crianca. Pediatr Mod 1988; 23: 225–231.

42.

Del Sol

Wustner

Fritz

. Types of vein formations in the cubital fossa of Chilean youth. Rev Chil Technol Med 1990; 13: 646–649.

43.

Del Sol

Lagos Mardones

Torres Bustos

. Venous formations in the cubital fossa of Mapuche. Bioscopy study. Int J Morph 2007; 25: 885–894.

44.

Halim

Abdi

. Superficial venous patterns in the cubital region of Indians. Anat Rec 1974; 178: 631–636.

45.

Jasiński

Poradnik

. Superficial venous anastomosis in the human upper extremity — a post-mortem study. Folia Morphol 2003; 62: 191–199.

46.

Sohier

Fustac

Laffont

. Superficial veins of the elbow in the West African. Bull Soc Med Afrique Noire 1962; 7: 107–111.

47.

Sohier

Fustac

Laffont

. Superficial veins in the antecubital fossa of the West African. Bull Assoc Anat 1964; 720: 1230–1235.

48.

Thoma

Archibald

Jackson

. Surgical patterns of venous drainage of the free forearm flap in head and neck reconstruction. Plast Reconstr Surg 1994; 93: 54–59.

49.

Schears

Pennington

. Innovation in vascular access: Near-infrared technology revolutionizes visualization of blood vessels, Memphis: Christie Medical Holdings Inc., 2008.