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1. UNIVERSITI KUALA LUMPUR
ROYAL COLLEGE OF MEDICINE PERAK
SPECIAL STUDY MODULE (SSM)
A cross-sectional study on the anatomical variations of the
superficial veins of the upper limb among the preclinical medical
students in UniKL-RCMP
Group members : HANAFI BIN ABDUL HAMID
: AMIR AFIF BIN SUHAIMI
: MUHAMMAD NAZMI BIN NOOH
: MUHAMAD AFIF IKHWAN BIN MOHD FUAT
Group number : GROUP NUMBER FIVE (5)
Supervisor : Dr. SAN SAN THWIN*
Co-Supervisor : Dr. MYINT MYINT SOE**
Department : *Department of Anatomy Universiti Kuala Lumpur Royal College of
Medicine Perak
** Department of Public Health Universiti Kuala Lumpur Royal College
of Medicine Perak

2. Date : 23rd
November 2009
Table of Content pages
a) Abstract 3
b) Introduction 4-5
c) Objectives 6
d) Hypothesis 7
e) Methodology 8-11
f) Result 12-17
g) Discussion 18-19
h) Conclusion 19
i) References 19
j) Acknowledgment 20
STUDIES ON VARIATIONS OF SUPERFICIAL VEINS OF UPPER LIMB
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3. HANAFI B. ABDUL HAMID, AMIR AFIF B.SUHAIMI, MUHAMAD NAZMI B.NOOH,
MUHAMAD AFIF IKHWAN B.MOHD FUAT
Department of Anatomy Universiti Kuala Lumpur Royal College of Medicine Perak
ABSTRACT
Objectives
The aim of the study was to observe and describe the distribution of anatomical variations of the
superficial veins of the upper limb among preclinical medical students in UniKL-RCMP.
Methods
Our sample was composed of 180 preclinical medical students of UniKL-RCMP aged from 18 to
27 years old. We had applied the tourniquet or blood pressure cuff applied around the right and
left arm of the respondent and we asked him/her to perform repeated flexion and extension of
forearm to help distend the veins. The pattern of the veins seen had been drawn onto a survey
form.
Result
Based on our analysis, the commonest type of anastomosis seen is Y type with 52.2% on the
right cubital fossa and 50.6% on the left cubital fossa. H type of anastomosis observed is 25% on
the right and 20.6% on the left cubital fossa. I type/no anastomosis was observed in 22.8% and
28.9% on the right and left cubital fossa respectively.
Conclusion
In our study of variation of anastomosis of superficial veins of upper limb, we found that the
majority of our subjects, from 50.6% to 52.2% have Y type of anastomosis on both left and right
cubital fossa respectively, followed by H type of anastomosis from 20.6% to 25.0% on both left
and right cubital fossa respectively. I type or no anastomosis was found in 22.8% to 28.9% on
right and left cubital fossa respectively.
Keywords
Superficial veins, right upper limb, left upper limb, Y type, H type, no anastomosis, cubital fossa.
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4. INTRODUCTION
Venous drainage of the upper limb can be classified as superficial and deep veins. Superficial
veins of upper limb are located in the superficial fascia of the upper limb. They are mainly
composed of cephalic vein and basilic vein. The cephalic vein lies on the lateral side of biceps
brachii, drains into axillary vein on infraclavicular fossa. The basilic vein lies on the medial side
of biceps brachii, drains into axillary vein together with venae comitantes in the deep fascia.
There are some variations of the superficial veins in the cubital fossa, either the presence of
median cubital vein (H type) or median antebrachial vein (Y type) or the I type when no
anastomoses. In this study, we observed the variations of superficial veins of cubital fossa on
both side.
The superficial veins are clinically important and are used for venipuncture for blood collection
and blood donation, as well as for health screening and testing, intravenous transfusion for the
emergency treatment of hypovolemic shock. The median basilic vein or basilic vein is commonly
used in central venous catheterization, and the basilic vein and cephalic vein can be used for
arteriovenous fistula (brachiobasilic or brachiocephalic fistula) for the hemodialysis purpose.
The arteriovenous shunting between cephalic vein and radial artery is recommended conduit
bypass (pre-bypass) of the upper limb to increase the diameter and strengthen the venous wall in
bypass surgery of lower extremities.
While there is much clinical relevance associated with the superficial veins of the cubital fossa,
no published literature is found on the anatomical variations of superficial veins of the upper
limb among Malaysian population. Thus, this study attempts to examine and describe the pattern,
branches and variations of the superficial veins of both upper limbs of the cubital fossa among
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5. the preclinical students of the medical degree program of UniKL-Royal college of Medicine
Perak.
There are two methods which can be employed to do this research. The first method is to apply a
blood pressure cuff or tourniquet at the right and left arm of the respondents. Then, they are
asked to perform repeated flexion and extension simultaneously to make the vein become
prominent. After that, the pattern of the anastomosis is drawn onto a blank form. The second
method is by dissecting cadavers at autopsy and observing the pattern of the superficial veins of
upper limb. This technique had been done by Ryszard Jasiński and Elżbieta Poradnik in their
research using 40 dead bodies.
Since as medical students conducting an elective research project in a short period of time, and
without access to the required number of cadavers to dissect, we have chosen to do the first
method of applying tourniquet and mapping the visualized superficial veins and their
anastomoses.
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6. OBJECTIVES
Main objective:
To observe and describe the distribution of anatomical variations of the superficial veins of the
upper limb among preclinical medical students in UniKL-RCMP
Specific objectives:
1. To describe the study population by socio-demographic characteristics; age, gender and
ethnicity
2. To describe the study population by the presence or absence of the following superficial
veins; basilic vein, median basilic vein, cephalic vein, median cephalic vein, median vein,
and the median cubital vein of forearm
3. To describe the distribution of type of anastomosis observed between superficial veins of
the cubital fossa whether Y type, H type or absence of anastomosis.
4. To describe the study population by sets of venous pattern; Y type on both right and left
arm (YY), H type on both right and left arm (HH), no anastomosis on both right and left
arm (II), and mixture of venous pattern (YH, YI, IY, HY, HI, IH).
5. To explore relationship between type of anastomosis and socio demographic variables
such as gender and ethnicity.
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7. Hypotheses:
In exploring association; the type of anastomosis either H, Y and I type will be the dependent
variable and independent variable will be like socio demographic variables, gender and ethnicity.
Hypothesis:
Question 1: Is there any association between type of anastomosis and gender?
H0: There is no association between type of anastomosis and gender
H1: There is an association between type of anastomosis and gender
Question 2: Is there any association between type of anastomosis and ethnicity?
H0: There is no association between type of anastomosis and ethnicity
H1: There is an association between type of anastomosis and ethnicity
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8. METHODOLOGY
Study design
The study is designed as a descriptive cross-sectional survey involving a simple examination of
the superficial veins of cubital fossa among preclinical students of UniKL-RCMP.
Study field
The study was conducted in UniKL-Royal College of Medicine Perak starting from 2nd
November till 20th
November 2009.
Sample size and sampling procedure.
For sample size calculation, the estimated prevalence of H type of anastomosis is 50 percent and
if the worst acceptable prevalence at 95% confidence interval is set at 40 percent, the minimum
required sample size is 96. To do a subgroup analysis by other variables we have doubled the
required sample size and have decided to study a sample size of 192.
Since the total number of students registered in the current preclinical years is 194, we chosen all
preclinical students into the study to fulfill our sample size requirement.
Inclusion criteria
All Phase 1A and Phase 1B students currently registered in the Medical Degree Program of
UniKL-RCMP who give their consent to participate are taken into the study.
Exclusion criteria
All preclinical medical students who could not be reached and contacted to participate are not
included without any exclusion criteria.
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9. Study variables and operational definition
The study variables are as follows;
1. Socio demographic variables
• Age
• Gender
• Ethnicity
2. Presence or absence of superficial veins of cubital fossa
• Basilic vein
• Cephalic vein
• Median Basilic vein
• Median Cephalic vein
• Median vein
• Medial Cubital vein
3. Type of anastomosis of superficial veins
• H type
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10. • Y type
• I type / absence of anastomosis
Type of study variables, definition and measurement scale
Study Variable Type Operational Definition Scale
Socio-demographic
Variable
1. Age
2. Gender
3. Ethnicity
Qualitative /
numerical
Qualitative /
categorical
Qualitative /
categorical
Age in completed years as
stated by respondent
Gender as stated by
respondent
Ethnicity as stated by
respondent
Numeric continous
age in completed
years last birthday
Nominal
• Male
• Female
Nomimal
• Malay
• Chinese
• Indian
Superficial Vein
1. Basilic vein
2. Cephalic
vein
3. Median
basilic vein
4. Median
cephalic
vein
5. Median vein
Qualitative /
categorical
Presence or absence as
observed under
examination
Nominal
• Present
• Absent
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11. 6. Median
cubital vein
Type of
Anastomosis
1. H type
2. Y type
3. I type
Qualitative /
categorical
Type of anastomoses
observe under examination
Nominal
H type : Yes
: No
Y type : Yes
: No
I type : Yes
: No
Method of data collection and data collection instrument
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12. Data had been collected from interview with the respondents to obtain the necessary socio-
demographic information on age, gender and ethnicity. A simple examination had been
performed to observe and to draw the visualized superficial veins of the upper limb on both
sides.
A data collection form given in Appendix 1 had been used to record the necessary socio-
demographic data and to map the observed pattern of superficial veins of upper limb on right and
left sides.
Technique of examination of superficial veins.
1) First, the tourniquet or blood pressure cuff applied around the right and left arm of the
respondent. Then, we asked him/her to perform repeated flexion and extension of
forearm to help distend the veins.
2) When the superficial veins become prominent and visible, we sketch a drawing of
superficial veins, the branching and type of anastomosis seen on the data collection
sheet as shown in appendix 1.
Statistical Tests
All information collected are coded and entered into computer and analyzed using SPSS
software version 15.0. Data had been cleaned and checked before analysis.
A univariate analysis was done to describe the study population in percentage and proportion by
socio-demographic composition, and to describe the presence or absence of superficial veins and
type of anastomosis seen.
A bivariate cross tabulation had been done to explore possible association between the type of
variations seen in superficial veins and socio-demographic variables. A Chi Square test has been
performed to determine statistical significance of any association found.
RESULT
The respond rate of a total of 194 preclinical medical students, all those who could be reached a
total of 180 and consented to participate were included in study with a response rate of 92%. The
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13. Male
29%
Female
71%
Distributionof Study
Populationby Gender
remaining 14 students could not be reached even after three attempt of home visit to their
residential homes, could not be included in the study.
The results of the study were based on the analysis of 180 preclinical medical students of the
UniKL Royal College of Medicine Perak.
Socio Demographic Characteristic
The mean age of the study population is 20.11 years with a standard deviation of 1.56 years, and
ranging between 18 to 27 years.
Figure 1 shows the percentage distribution of the study population by gender. From 180 students
of our sample, 128 of them are female with percentage of 71%, and 52 of them are male with
percentage of 29%.
Figure 1. Study Population by gender distribution.
Figure 2 shows the percentage distribution of the study population by ethnicity. Malays comprise
the highest population with 153 students (85%), followed by Indians with 19 students (10.6%)
and Chinese with 8 students (10.6%).
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14. 85%
4.4%
10.6%
Distributionof Study
Populationby Ethnicity
Malay
Chinese
Indian
Figure 2. Study Population by Ethnicity Distribution
Superficial Veins on Upper Limbs
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15. Our finding on analysis of the study population by the presence of the following superficial
veins; basilic vein, median basilic vein, cephalic vein, median cephalic vein, median vein, and
the median cubital vein of forearm is shown in figure 3.
Figure 3 shows the percentages of the study population by presence of superficial veins on right
and left upper limbs. On the right upper limb, the basilic and cephalic veins are observed in
99.4% and 98.3% of subjects. The median basilic, median cephalic, and median veins are
observed in 52.2% subjects and the median cubital vein is seen in 25% subjects only.
On the left upper limb, the basilic and cephalic veins are observed in 98.9% and 98.3% of
subjects. The median basilic, median cephalic, median veins are observed in 50.6% of subjects.
The median cubital vein is observed in 21.1% subjects only.
Figure 3 Study Population by presence of Superficial Veins on Right and Left Upper Limbs
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16. Types of Anastomosis of Superficial veins of the Cubital Fossa
The results of analysis by types of anastomosis observed between superficial veins of the cubital
fossa whether Y type, H type or absence of anastomosis/I type is shown in figure 4.
The commonest type of anastomosis seen is Y type with 52.2% on the right cubital fossa and
51.1% on the left cubital fossa. H types of anastomosis observed is 25% of subjects on the right
cubital fossa and in 20.6% of subjects on the left cubital fossa. I type/no anastomosis was
observed in 22.8% and 28.9% on the right and left cubital fossa respectively.
52.2%
25%
22.8%
Right Cubital Fossa
Y type
H type
I type
50.6%
20.6%
28.9%
Left Cubital Fossa
Y type
H type
I type
Figure 4 Types of Anastomosis of Superficial Veins Observed in Right and Left Cubital Fossa of Upper Limb
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17. The result analyzed by sets of venous pattern; Y type on both right and left arm (YY), H type on
both right and left arm (HH), no anastomosis on both right and left arm (II), and mixture of
venous pattern (YH, YI, IY, HY, HI, IH) is shown in figure 5.
The commonest set of venous pattern seen is the mixture of venous pattern (YH, YI, IY, HY, HI,
IH) with 46.67%. The YY set of venous pattern was observed in 32.2% of subjects, HH set of
venous pattern was observed in 7.8% and II set of venous pattern was observed in 13.3%.
Figure 5 Study Population by Set of Venous Pattern.
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18. Relationship between type of anastomosis and socio demographic variables.
According to our objective no 5, we have attempted to explore relationship between type of
anastomosis of the superficial vein and socio demographic variables, by doing cross tabulations
and Chi-Square tests of significance.
• Gender and Y type on right cubital fossa, p = 0.010
• Gender and Y type on left cubital fossa, p = 0.426
• Gender and H type on right cubital fossa, p = 1.000
• Gender and H type on left cubital fossa, p = 0.347
• Gender and I type on right cubital fossa, p = 0.002
• Gender and I type on left cubital fossa, p = 0.068
• Ethnicity and Y type on right cubital fossa, p = 0.480
• Ethnicity and Y type on left cubital fossa, p = 0.731
• Ethnicity and H type on right cubital fossa, p = 0.628
• Ethnicity and H type on left cubital fossa, p = 0.847
• Ethnicity and I type on right cubital fossa, p = 0.741
• Ethnicity and I type on left cubital fossa, p = 0.398
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19. DISCUSSION
Most of the students in our population have Basilic and Cephalic Veins because they are the
easily found. The previous study done by Berry et al showed that, the frequency of people having
Basilic Vein is smaller compared to those of the Cephalic Vein.
From the results, the first hypothesis is accepted for certain conditions; there are possible
associations between gender with Y-type of anastomosis and absent of anastomosis (I-type) in
right cubital fossa.
Frequency of male students to have Y-type pattern of anastomosis is higher than female students.
Y-type anastomosis characterizes the individual with strong body build and with average length
of limbs5
especially in male students. Thus, according to χ2
-test, the p-value for possible
association between genders with Y-type anastomosis on the right cubital fossa is significant (p-
value=0.010, <0.050). Most of the female students came with absent of anastomosis or I-type
anastomosis in right cubital fossa compared to the male students, with significant p-value (p-
value=0.002, <0.050). This means that there is possible association between genders with absent
(I-type) of anastomosis in right cubital fossa. For H-type anastomosis in right cubital fossa, the
p-value is not significant (p-value=0.628, >0.050) because the probability for male and female
students having H-type anastomosis on right cubital fossa is equal. Thus, there is no possible
association between genders with H-type pattern of anastomosis on right cubital fossa.
There are no possible associations for all type of anastomosis in left cubital fossa because all the
p-values are not significant (all p-values more than 0.050) according to gender.
There are no possible associations between ethnicity with pattern of anastomosis in both cubital
fossae. We cannot associate all type of anastomoses with ethnicity because there is biased in
Malay ethnic compared to Chinese and Indian. Thus, all the p-values derived from χ2
-test are not
significant (more than 0.050).
From this study, we can conclude that, there are associations between genders for Y-type and
absent type (I-type) of anastomosis in right cubital fossa; and the relationship between ethnicity
with pattern of venous anastomosis is not relevant. This is a limitation in our study, which can be
improved by modify the sample population which represents the population in Malaysia.
According to the previous study done by Berry et al 8
, showed that the frequency of H-type
anastomosis is the highest followed by Y-type pattern and absent (I-type) of anastomosis.
Compared to the present study, the frequency of Y-type pattern is the highest followed by absent
(I-type) of anastomosis and H-type venous pattern.
The similar study done by Jasinski et al stated that, there are 4 different venous sets of both
Cubital Fossae (Y-Y, H-H, I-I and mixture of venous sets). The highest frequency is H-H type,
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20. followed by Y-Y type, mix type and I-I type. The present study showed that the highest
frequency is mix type, followed by Y-Y type, I-I type and H-H type. The difference in frequency
of the present study and the study done by Jasinski et al, is believed to be due to the sample size
and gender in particular population. Jasinski et al study use 40 respondents as sample size which
all of them are males deceased from diseases of cardiovascular and nervous systems5
.
CONCLUSION
In our study of variation of anastomosis of superficial veins of upper limb, we found that the
majority of our subjects, from 50.6% to 52.2% have Y type of anastomosis on both left and right
cubital fossa respectively, followed by H type of anastomosis from 20.6% to 25.0% on both left
and right cubital fossa respectively. I type or no anastomosis was found in 22.8% to 28.9% on
right and left cubital fossa respectively.
REFERENCES
1. Snell R.S: Clinical Anatomy by Regions, 8th
ed. Lippincott William & Wilkins, 2008
2. Fitzgerald J.T, et al. (February 2004) Outcomes of Upper Arm Arteriovenous Fistulas for
Maintenance Hemodialysis Access. Archive of Surgery, 139(2), page 201
3.Stefanov G, et al. (2007) Arterialized cephalic vein as a femoropopliteal bypass graft: A case
report. International Journal of Angiology, 16(4), page 146-148
4.Kouji (K) Y, et al. (2008) Cubital fossa venipuncture sites based on anatomical variations and
relationships of cutaneous veins and nerve. Journal of Clinical anatomy (New York), 21(4), page
307-313
5.Jasiński R, et al. (2003) Superficial venous anastomosis in the human upper extremity — a
post-mortem study. Folia Morphol., 62(3), page 191-199
6. Netter F.H: Atlas of Human Anatomy, 4th
ed. Saunders, 2006
7. Drake R.L, Vogl W, Mitchell A.W.M: Gray’s Anatomy for Students, Elsevier Churchill
Livingstone, 2005
8. Berry R.J.A., and H.A.S. Newton (1908): A Study of Superficial Veins.
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21. ACKNOWLEDGEMENT
We thank to our supervisor, Dr. San San Thwin and our co-supervisor Dr. Myint Myint Soe for
their invaluable assistance, guidance and advice throughout the elective period. We also thank to
our friends who had helping us to collect the data and also to all the volunteers who cooperated
and helped us in this project.
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