Actually, a duplicated axillary vein is a more common occurrence practically than theoretically. There is no literature to suggest the guideline for extent of axillary dissection in such cases. Nor is there any data on incidence of lymphedema. But I reviewed the anatomical basis of a duplicated axillary vein and that gave me some clue as to the extent of axillary dissection which i now follow in my clinical practice. Axillary vein normally is formed as a result of the union of the basilic vein and the vennae commitantes of the brachial artery. In a duplicated state, the vennae commitantes fuse to form the antero-inferior axillary vein and the basilic continues as the postero-superior axillary vein.Nodes along the basilic vein are known to drain lymph solely from the upper limb outer half and hence do not contribute to lymphatic clearance for the breast. it thus stands to reason that the anteroinferior axillary vein should be treated as the main axillary vein in the duplicated state and the tissue in between left alone. Its an excellent question and any further comments would be welcome

Thank you very much for the prompt reply sir! I have also read the articles pertaining to the variations in the anatomy of axillary vein and we follow the same principle which you have pointed out. We even came across some patients with duplicated axillary veins while doing ARM and found that some blue nodes were either in the inter-venous tissue or above the superior branch.

Dear Rohan,

in fact embryologically Pranjal is completely right; however also in normal anatomy there are crosslinks of lymphatic channels between the lymphatic drainage of the breast and the arm - thus being responsible for a certain persentage of lymphedema even in strictly infraaxillary lymphadenectomy - this is also true vice versa.

As a consequence the node resection should rather be oriented at the physiological border lamella between the lymphatic compartments than at the anatomical landmarks of the doubled axillary vein. In most cases there is a clear layer between the main trunc draining the arm and the main trunc draining the breast and chest wall as it is usually in a single axillary vein, too. The probability of spread along the main truncs is markedly higher compared to the crosslinks, so that in minor involvment of axillary nodes positive nodes will usually not appear in the common trunc of the arm.

Try to identify this physiological border during your coming preparations and form your own opinion.

Yours Rainer

My literature search says that there is no communication between arm and breast lymphatics  and they are separate. Any correction ,please?