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.

Full text

Original Article
Patterns of the superficial veins of
the cubital fossa: A meta-analysis
Kaissar Yammine
1
and Mirela Eric
´
2
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 pre-
ferred sites for venipuncture, transfusion, infusion, car-
diac 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 pat-
tern 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 identifi-
cation 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
1
The Center for Evidence-Based Anatomy, Sport and Orthopedic
Research, and the Foot & Hand Clinic, Beirut, Lebanon
2
Department of Anatomy, Faculty of Medicine, University of Novi Sad,
Serbia
Corresponding author:
Mirela Eric
´, Department of Anatomy, Faculty of Medicine, University of
Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia.
Email: mirela.eric@gmail.com, mirela.eric@mf.uns.ac.rs
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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 promin-
ent superficial vein in the body, and is visible or palp-
able 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
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 fre-
quency 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
C B
MAV
MBV
MCV
C B
C
MAV
MBV
MCV
Type 1
(M or Y)
C B
MAV
MCuV
Type 2
(N or H)
C B
MAV
Type 3
(I or O)
C
B
MAV
Type 4
C B
MAV
MCuV
MCuV
Type 5
C B
Type 6 Type 7
C B
MAV
B
C
AC
MBV
MCV
Type 8
MCV
C B
MAV
MBV
C B
MAV
MCuV
C
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).
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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, AccuVein
6
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 cubi-
tal fossa for clinical procedures such as venipuncture,
transfusion, infusion, cardiac catheterization, or place-
ment 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 superfi-
cial 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 path-
ways 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 Studies
36
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 combin-
ation 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 web-
sites 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.perse
´e.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 identi
fied. 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 investi-
gations) 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 preva-
lence of the superficial veins pattern types in the cubital
region. Secondary outcomes were set to be the preva-
lence 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 non-
standard 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 per-
formed using StatsDirect v2.7.8 (Altrincham, United
Kingdom). Proportion meta-analysis was used to cal-
culate the pooled prevalence estimate (PPE), and odds
ratio (OR) meta-analysis was used to establish potential
associations with other variables such as gender, lat-
erality 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 amen-
able to meta-analysis. We examined heterogeneity
amongst studies using I
2
statistics; whenever I
2
>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 dif-
ferent 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).
Yammine and Eric
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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, respect-
ively. The true prevalence results reported in all other
studies are given in Tables 2 and 3.
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 sig-
nificantly 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 signifi-
cantly higher occurrence of type 2 when compared to
Electronic and hand
search database
98 hits
86 abstract checking
51 not relevant
35 full-text
retrieved 14 excluded:
-2 describing CV
anatomy
-6 with no full-text
-1 describing veins’
valves
-3 no paern reporng
-1 in Spanish
-1 in Chinese
21 relevant studies
27 studies meeng
inclusion criteria
Reference checking:
addional 6 relevant
studies
12 duplicates
Figure 2. Flowchart of the search strategy.
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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 Newton
27
Clinical Australian (British origin) Adults 300 300 0 600 300 300
Charles
23
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 Shaharuddin
16
Clinical Malaysian 18–65 266 170 96 532 266 266
Halim and Abdi
44
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 Poradnik
45
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
Okamoto
25
Clinical Japanese Adults 100 100 0 200 100 100
Singh
17
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
Vasudha
22
Cadaveric and Clinical Indians Adults 25 12 13 50 25 25
Vuc
ˇinic
´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
Yammine and Eric
´5
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Table 2. Prevalence of types 1 to 4.
Studies
Sample
size
(subjects)
Sample
size
(arms)
Type 1 Type 2 Type 3 Type 4
OMF RL OMF RL OMF R L OMF 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
Newton
27
300 600 96
(16)
––––498
(83)
––––4
(0.7)
––– –2
(0.3)
––––
Charles
23
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)
Charles
23
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
481
(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
Shaharuddin
16
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 Abdi
44
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
Poradnik
45
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)
(continued)
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Table 2. Continued
Studies
Sample
size
(subjects)
Sample
size
(arms)
Type 1 Type 2 Type 3 Type 4
OMF RL OMF RL OMF R L OMF R L
Mikuni et al.
5
NR 128 1
(0.78)
––––104
(82)
––––9
(7.0)
––– –– ––––
Okamoto
25
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)
Singh
17
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)
Vasudha
22
25 cadavers 50 2
(4)
––––44
(88)
––––2
(4)
––– –2
(4)
––––
100 subjects 200 4
(2)
––––196
(98)
––––0
(0)
––– –0
(0)
––––
Vuc
ˇinic
´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.
a
Crude prevalence values.
Yammine and Eric
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Table 3. Prevalence of types 5 to 8.
Studies
Sample
size
(arms)
Type 5 Type 6 Type 7 Type 8
OMFRLO M F RLOMFRLOMFR L
AlBustami et al.
7a
528 2 (0.8) 2 (1.5) 0 (0) – – 28 (11.2) 13 (9.8) 15 (11.4) – – – – – – – – – – – –
Charles
23
120
(White)
3
(2.5)
3
(2.5)
2
(3.3)
1
(1.7)
– – – ––– ––– – – – – – –
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
Shaharuddin
16
532 1
(0.6)
1
(0.6)
0
(0)
––26
(4.9)
22
(6.5)
4
(2.0)
–– – – – – – – – – – –
Halim and Abdi
44
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
Poradnik
45
80 – – – – – – – – – – – – – - – 6
(7.5)
––3
(7.5)
3
(7.5)
Mikuni et al.
5
128 – – – – – – – – – – – – – – – 14
(11)
––– –
Okamoto
25
200 17
(8.5)
––7
(7)
10
(10)
– – – ––– ––– – –––– –
(continued)
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other ancestries; no overlapping in confidence intervals.
Type 3 was significantly more frequent in Malay popu-
lation whereas type 4 in Indian ancestry. The number of
studies reporting types 4 to 8 was not amenable to sen-
sitivity, 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.
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 sensitiv-
ity 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 signifi-
cant 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, AccuVein
6
, helical computed tom-
ography,
30
or reflective near-infrared technology
49
might provide more accurate findings but these meth-
ods 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 pat-
tern. 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 dif-
ferent 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
Table 3. Continued
Studies
Sample
size
(arms)
Type 5 Type 6 Type 7 Type 8
O MFRLO M F RLOMFRLOMFR L
Singh
17
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)
Vuc
ˇinic
´et al.
28
338 10
(2.95)
10
(3.70)
05
(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.
a
Crude prevalence values.
Yammine and Eric
´9
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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
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
Ty p e 7
No. of
studies
No. of
elbows
Ty p e 8
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 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%
10 Phlebology 0(0)
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in cubital region in humans and subsequently could
assist medical and health allied professionals in per-
forming safer venipuncture, venesection, or venous sur-
gery 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.
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 pub-
lished studies.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Guarantor
None.
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