Epigastric artery

Ko SF, Lin H, Ng SH, Lee TY, Wan YL (2002) Postpartum hemorrhage with concurrent massive inferior epigastric artery bleeding after cesarean delivery. Am J Obstet Gynecol 187 243-244... 

Anatomic Considerations The internal pudendal artery, a terminal branch of the anterior division of the internal iliac artery supplies the external genitalia. With extension to inguinal and iliac lymph nodes, additional supply originates from the obturator branch of the internal iliac artery, the inferior epigastric artery from the external iliac artery and the superficial epigastric artery and the superficial and deep external pudendal branches of the common femoral arteries. 

In our opinion, the anastomosis according to the Sharlip technique is the best solution because it envisages a retrograde revascularization of the cavernous artery through the common penile trunk. For this reason we usually anastomosed the epigastric artery on the dorsal artery of the penis end-to-end in the proximal direction (Fig. 15.1). This technique has been associated with the most success and the fewest complications (Wespes et al. 2003). 

Fig. 15.1. Penile arterial revascularization. Photograph showing the isolated epigastric artery before anastomosis with the dorsal artery at the root of the penis...

Fig. 16.14. Complicated dorsal vein arterialization. Arteriography shows the inferior epigastric artery (open arrow) connected to the deep dorsal vein (arrowhead) and marked hyperemia of the glans (curved arrow) requiring reoperation with ligation of the distal portion of the arterialized vein...

The arterial axis is first palpated to evaluate the quality of its wall. Arterial and venous dissection is limited to segments to be used for anastomoses. In most cases, the renal vein is attached to the external iliac vein. The arterial anastomosis is more variable end-to-side to the external iliac, most often above the venous implantation, or to the primary iliac artery sometimes end-to-end to the hypogastric artery, when taken from a living donor, because the graft s artery does not have an aortic patch. All these sites can be used in combination when multiple arteries are reimplanted, even the epigastric artery for the small isolated polar branches. 

Adverse effects include bradycardia, nausea, vomiting, epigastric discomfort, dizziness, fatigue, tiredness, skin rash, leg pain, cold extremities because of peripheral arterial insufficiency. 

A 55-year-old woman with a history of chronic pancreatitis developed epigastric pain and melena and was found to have a splenic artery pseudoaneurysm expanding a pseudocyst. She was given an intravenous bolus of octreotide followed by an infusion of 50 micrograms/ hour. A CT scan subsequently suggested thrombosis of the pseudoaneurysm, with segmental splenic infarction. Nine months later the pseudoaneurysm had recanalized. 

Acute and chronic cholecystitis has been reported after floxuridine hepatic artery infusion (3). Chemotherapy in this patient was associated with persistent epigastric pain with radiation to the back which was not accompanied by any fever or white blood cell elevation. Cholecystectomy showed a shrunken, thickened fibrotic gallbladder that was filled with thick, pasty, hemorrhagic material. There were no gallstones. 

Superior mesenteric artery (SMA) syndrome is an uncommon but well recognized clinical entity characterized by compression of the third, or transverse, portion of the duodenum against the aorta by the SMA, resulting in chronic, intermittent or acute complete or partial duodenal obstruction. Clinical symptoms are chronic upper abdominal symptoms such as epigastric pain, nausea, vomiting (bilious or partially digested food), postprandial discomfort and sometimes subacute small bowel obstruction. The stomach can be massively dilated and perforation has been described (Carty et al. 2005 Parker 2003). 

Planning CT additional arterial phase scan necessary in selected cases for differentiation of small arteries along access path (e.g., internal mammary artery, epigastric vessels)... 

Some teams systematically implant the first graft on the right because of the more superficial iliac vessels others prefer implanting a right kidney on the left and left kidney on the right so that the renal pelvis and ureter are placed anteriorly, thereby facilitating subsequent nephrostomy should it be necessary. Epigastric vessels are dissected and conserved should reimplantation of a polar artery be required. 

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