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OLGU SUNUMU/CASE REPORT Gülhane Tıp Derg 2012; 54: 323-325 © Gülhane Askeri Tıp Akademisi 2012 doi:10.5455/gulhane.30580 Common origin of the medial circumflex femoral and inferior epigastric arteries from the femoral artery Selda Yıldız (*), Fatih Yazar (*) SUMMARY Classically, the inferior epigastric artery is a branch of the external iliac artery before it becomes the femoral artery. It may arise from different origin and this kind of differences was important for vascular attempts of this region. Variation of these arteries carries weight for reconstruction of perine, scrotum, head (especially maxilla) and neck. We believe that; the proper and efficient demonstration of this variation will add important contribution to our knowledge. A variation of the inferior epigastric artery was observed during routine dissection of a 74-year-old male cadaver. In our case, inferior epigastric artery appeared as a common trunk with medial circumflex femoral artery, which leaves femoral artery. This case of common origin of the medial circumflex femoral and inferior epigastric arteries from the femoral artery is different from comparing with rare cases from the literature. Knowledge about anatomical variations regarding origins of the femoral artery proximal branches should keep in mind and is important for clinicians in the interventional radiology. Key words: Inferior epigastric artery, medial circumflex femoral artery ÖZET Arteria femoralis’den ayrılan arteria epigastrica inferior ve arteria circumflexa femoris medialis’in ortak orijini Klasik olarak a.epigastrica inferior, a.iliaca externa’nın a.femoralis olmadan önceki dalıdır. Değişik noktalardan köken alabilir ve bu tür farklılıklar bu bölgenin vasküler girişimleri için önemlidir. Bu arterlerin varyasyonu perine, scrotum, baş (özellikle maxilla) ve boyun rekonstrüksiyonunda önemlidir. Biz bu varyasyonun tam ve etkin olarak gösterilmesinin bilgilerimize önemli katkı sağlıyacağını düşünüyoruz. Yetmişdört yaşındaki erkek kadavranın rutin disseksiyonu sırasında a.epigastrica inferior varyasyonuna rastlandı. A.epigastrica inferior, a.circumflexa femoris medialis ile birlikte a.femoralis’den ayrılan ortak bir kök olarak izleniyordu. Literatürdeki nadir olgularla karşılaştırıldığında a.circumflexa femoris medialis’in ve a.epigastrica inferior’un a.femoralis’den ortak orijinli ayrılışı farklılık gösterir. A.femoralis’in proximal dallarının varyatif orijinleri girişimsel radyolojide klinisyenler için önemlidir ve akılda tutulmalıdır. Anahtar kelimeler: A.epigastrica inferior, a.circumflexa femoris medialis Introduction The femoral artery is a continuation of the external iliac artery. The femoral artery gives off several branches in the proximal thigh, including the superficial epigastric, superficial circumflex iliac, superficial external pudendal, deep external pudendal and profunda femoris arteries. The medial and the lateral circumflex femoral arteries usually originates from the the profunda femoris, but sometimes originates from the femoral artery. Classically, the inferior epigastric artery (IEA) is a branch of the external iliac artery before it becomes the femoral artery. It may arise from the femoral artery or from the external iliac artery in common with the obturator artery(1). Preparatory ligation of the IEA is often performed for myo(cutaneous) flaps using the mid or lower rectus abdominis based on the superior epigastric artery to allow expansion of the superior arterial flow to improve viability of the flap. Branches anastomose with terminal branches of the lower six posterior intercostal arteries posterior to rectus abdominis at the lateral border close to the sheath. The artery is an important inferomedial relation of the deep inguinal ring, and may be damaged during extensive medial dissection of the deep ring during hernia repair, particularly when this is performed in the preperitoneal plane. The vas deferens in the male, or round ligament in the female, wind laterally round it. It has the following branches: the cremasteric artery, a pubic branch, and muscular and cutaneous branches(1). Importance of variation of these arteries for reconstruction of perine, scrotum, head (especially maxilla) and neck is cited in literature(2,3,4,5). *Gulhane Military Medical Academy, Department of Anatomy Reprint request: Dr. Selda Yıldız, Gulhane Military Medical Academy, Department of Anatomy, Etlik-06018, Ankara, Turkey E-mail: [email protected] Date submitted: August 02, 2011 Date accepted: September 08, 2011 Online publication date: December 26, 2012 Case Report In our case it was detected that in 74 years old male cadaver, IEA appeared as a common trunk with me323 dial circumflex femoral artery (MCFA), which leaves femoral artery (Figs. 1). This common trunk was separated from femoral artery medially and 6.9 mm distally from the mid point of inguinal ligament. The trunk was separated into two branches after 7 mm while MCFA showed a normal course and branching pattern, IEA moved towards supero-medial, passed under the inguinal ligament and extends to the anterior wall of the abdomen in rectus sheath along with the inferior epigastric vein. Lateral circumflex femoral artery, which was the other branch of the femoral artery, was separated from the lateral side of femoral artery and 30.22 mm distally from the mid point of inguinal ligament. Deep femoral artery was separated from postero-lateral side of the femoral artery and 59.7 mm distally from the middle point of inguinal ligament. Discussion Adachi(6), stated that the IEA and MCFA arise from the external iliac and deep femoral arteries, respectively. In addition to this; the IEA and obturator ar- Figure 1. Anterior view of the femoral region and related structures. 1; inferior epigastric artery, 2; medial circumflex femoral artery, *; common trunk, IL; inguinal ligament, IPM; iliopsoas muscle, SM; sartorius muscle, FA; femoral artery, FV; femoral vein, 3; lateral circumflex femoral artery, 4; deep femoral artery. 324 • December 2012 • Gulhane Med J tery arising with a common origin is a well-known and relatively frequent anomaly, occurring in 20– 30% of cadavers(7,8). Seldom, there are also some cases about IEA originating from the MCFA(9), the deep femoral artery (10) or a common trunk together with the IEA, which is extremely rare(11). In a large number of investigations including angiographies the femoral artery was mentioned as preferred and easily accessible to catheterization. Knowledge about anatomical variations regarding origins of the femoral artery proximal branches should keep in mind and is important for clinicians in the interventional radiology(12). The extended deep inferior epigastric perforator artery flap had been described in 1983. For head and neck reconstruction, Masià J et all. have been used a variation of this flap, namely a perforator free flap of the deep inferior epigastric system with a superolateral extension of the skin paddle. The extended deep inferior epigastric perforator flap is reliable, has a safe vascular supply, and has a long pedicle. Its versatility makes it suitable for reconstruction of moderate to large head and neck reconstruction(4). Zhang YX et all. evaluated the efficacy of the distinct free flaps in reconstruction of different types of maxillectomy defects(5). Coskunfirat et all. mentioned that the medial circumflex femoral artery perforator flap is a good option with its good mobility, thinness for scrotal contour, possibility for muscle preservation, and direct closure of the donor site for scrotal reconstruction(2). Reconstruction using six local medial circumflex femoral artery perforator flaps was undertaken in five male patients with complex penoscrotal or perineal wounds by Karsidag et all(3). Variations in the origin of the profunda femoris artery, lateral circumflex femoral artery and MCFA are commonly observed. This case of common origin of the MCFA and IEA from the femoral artery is different, comparing with rare cases from the literature. The proper and efficient demonstration and evaluation of this variation and its figure will add important contribution to the literature. References 1. Standring S, ed. Gray’s Anatomy. 40th Ed., Chapter 61, Edinburg, Churchill Livingstone. 2008; 1056-1059. Yıldız et al. 2. Coskunfirat OK, Uslu A, Cinpolat A, Bektas G. Superiority of Medial Circumflex Femoral Artery Perforator Flap in Scrotal Reconstruction. Ann Plast Surg. 2011 Feb; 21. 3. Karsidag S, Akcal A, Sirvan SS, Guney S, Ugurlu K. Perineoscrotal reconstruction using a medial circumflex femoral artery perforator flap. Microsurgery. 2011 Feb; 31(2): 116-21. 4. Masià J, Sommario M, Cervelli D, Vega C, León X, Pons G. Extended deep inferior epigastric artery perforator flap for head and neck reconstruction: A clinical experience with 100 patients. Head Neck. 2011 Sep; 33(9): 1328-34. 5. Zhang YX, Zhang B, Li DZ, Xu ZG, Tang PZ. Microvascular free flap reconstructive options in patients with different types of maxillectomy defects]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2011 May; 46(5): 368-72. 6. Adachi B. Das Arteriensystem der Japaner, band 2. Kyoto, Kenkyusha. 1928; 111. Volume 54 • Issue 4 7. Lippert H, Pabst R. Arterial variations in man: classification and frequency. Munchen, J.F. Bergman Verlag. 1985; 54. 8. Sanudo JR, Roig M, Rodrıguez A, Ferreira B, Domenech JM. Rare origin of the obturator, inferior epigastric and medial circumflex femoral arteries from a common trunk. J Anat. 1993; 183: 161-163. 9. Vazquez MT, Murillo J, Maranillo E, Parkin I, Sanudo J. Patterns of the circumflex femoral arteries revisited. Clin Anat. 2007; 20(2): 180-185. 10.Tanyeli E, Yildirim M, Uzel M, Vural F. Deep femoral artery with four variations: a case report. Surg Radiol Anat. 2006; 28(2): 211-213. 11. Kopuz C, Yildirim M, Öztürk A, Malazgirt Z. Rare origin of the inferior epigastric and medial circumflex femoral arteries arising from a common trunk. Eur J Plast Surg. 2000; 23: 438–440. 12. Siddharth P, Smith NL, Mason RA, Giron F. Variational anatomy of the deep femoral artery, Anat Rec. 1985; 212(2): 206–209. Common origin of the inferior epigastric artery • 325