Introduction

The arcuate artery (AA) is usually a branch of the dorsalis pedis artery (DPA) that arises anterior to the lateral tarsal artery in the proximal foot at the tarsometatarsal joint. It passes laterally along the bases of the lateral four metatarsals, deep in the tendon of the extensor digitorum brevis. At the lateral aspect of the foot, it anastomoses with the lateral tarsal artery to form an arterial loop. It gives off the second through fourth dorsal metatarsal arteries which course between the toes, and each divides into two dorsal digital branches for the adjacent toe (1,2). Knowledge of the anatomical pattern of the arcuate artery is important for several reasons. First, it is critical during harvesting and application of myocutaneous flaps on the dorsum of the foot. Second, the distal part of the foot may constitute donor material for reconstructing the hand (3,4). Third, it minimizes inadvertent injury during diagnostic and interventional procedures (5). Fourth, it is an important component in the description and classification of the dorsalis pedis artery (6). Lastly, it is important for understanding the concept and application of “topographical” or angiosome-guided bypasses to foot ischemic wounds (7) and endovascular “wound directed” revascularization (8), for assessing and judging the anatomical distribution of angiosomes, and collateral circulation in macro- and microcirculation (9). Several variations involving origin, course and branching have been reported (1,4,10-13). High origin has also been reported in several studies (6,12,14,15). Low origin/ location, however, is seldom reported.

 

Case Report

During routine dissection of the dorsalis pedis artery in a Kenyan cadaver, we encountered a right foot with an arcuate artery that branched from the dorsalis pedis at the metatarsophalangeal joint and then gave the 2nd, 3rd and 4th digital arteries directly (Figs. 1 and 2). In the same specimen, the 2nd dorsal metatarsal artery branched from the DPA directly. The 3rd and 4th dorsal metatarsals were not seen. In the left foot however, the AA branched from the DPA at the tarsometatarsal joint and passed beneath the extensor digitorum brevis where it gave out the 2nd, 3rd and 4th dorsal metatarsal arteries (Figs. 1 and 2).

Click to view Figure 1

Click to view Figure 2

The point of origin of this unusual AA was measured from the base of the first metatarsal bone. The points of origin of the digital arteries were measured from the bases of the 2nd, 3rd and 4th metatarsals respectively and tabulated. Both measurements used a vernier calliper (Table 1). Photographs were also taken with the help of a camera (Carl Zeiss, 12.1 megapixels). To compare the morphometric values of the results, average values of the same parameters were taken in specimen with the common course and branching of the dorsalis pedis artery.

Click to view Table 1

 

Discussion

The pattern of arcuate artery observed is unique in two respects: first, the artery originated as a branch of the dorsalis pedis in the distal 3rd of the foot; second, the branching pattern varied with conventional descriptions. Data from the USA (16) reported that the DPA may originate at the cuneonavicular joint other than its common point of origin at the tarsometatarsal joint. In our results, the AA originated in the distal 3rd of the foot, 6.9 cm from the base of the 1st metatarsal bone. This was significantly lower than the average 2.7 cm that was recorded in Kenyan cadavers. Though literature has a few cases of the AA originating distal to the tarsometatarsal joint, none is from Africa. High origin arcuate artery has however been reported in India (8). The lateral and medial malleolar arteries were also noted to originate lower (4.1 cm, 3.63 cm respectively from the base of 2nd metatarsal bone) than the average results recorded from the same setting (3.5 cm, 3.54 cm respectively from the base of the 2nd metatarsal bone). Regarding its branching pattern, the arcuate artery usually gives off the 2nd, 3rd and 4th dorsal metatarsal arteries. In other instances, it may give the 2nd and 3rd dorsal metatarsal arteries only, or the 2nd metatarsal artery solely. In cases where it does not give any of the metatarsal arteries, these vessels have been shown to originate from the lateral tarsal artery (17). Of interest, in the Indian population where a high origin arcuate artery was noted, the dorsalis pedis artery continued as the anterior tibial artery, which divided into medial and lateral branches. The medial branch continued as the 1st dorsal metatarsal artery supplying the 1st intermetatarsal space while the lateral branch behaved like an arcuate artery giving off the 2nd, 3rd and 4th dorsal metatarsal arteries (8). In our case however, the arcuate artery did not give out the dorsal metatarsal arteries but instead gave out the digital arteries directly. Unfortunately, there is paucity of data from previous literature for comparison. It is plausible that the individual whose body was dissected was at risk of ischemia of the 2nd to the 4th toes following kinking of the dorsal digital arteries. This is because the vessels were given off at a joint—the metatarsal phalangeal joint. In our case, though, owing to lack of clinical information on the individual, it is difficult to confirm this. The case observed occurred probably owing to genetic factors that affected the embryology of the vessel. Variant arterial anatomy of the foot is important for vascular surgeons during reconstruction as well as in flap selection from the DPA, AA or the dorsal metatarsal arteries. Though rare, this case is relevant and should be considered in procedures involving the DPA, the AA or its branches.

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Conclusion

The arcuate artery may be located in the distal 3rd of the foot and have unusual branching pattern. Care should be taken during diagnostic and interventional procedures

 

References

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