Complete Absence of the Deep Inferior Epigastric Artery: An Increasingly Detected Anomaly Detected with the Use of Advanced Imaging Technologies

In this journal, we recently reported the congenital absence of the deep inferior epigastric artery (DIEA) in a patient undergoing preoperative imaging prior to DIEA perforator flap surgery.[1] This anomaly was present in the absence of previous abdominal surgery and was fortuitously detected prior to any surgery on this vessel being undertaken. At the time, this was the first such reported case of this variant; however, since then a subsequent case has been reported, and we would like to share a third such case.

Matteucci et al[2] recently presented a case in which the DIEA was absent, detected intraoperatively during DIEA harvest, and confirmed postoperatively with the use of magnetic resonance imaging. Although the anomaly in that case did not impair flap harvest, the potential for poor outcomes was made evident by the authors. We have recently encountered a third case of this anomaly, in which a unilaterally absent DIEA was detected preoperatively with the use of computed tomographic angiography (CTA). This case differs from the other two cases in that it was caused by a previous surgical mishap.

In this case, a patient underwent preoperative CTA as our standard preoperative assessment for breast reconstruction. She had a history of a laparoscopic gynecologic procedure being converted to an open procedure due to excessive bleeding, and she had a midline laparotomy scar as well as scars on her abdomen consistent with the laparoscopy. CTA revealed occlusion of the right DIEA (Fig. [1]) beneath one of the laparoscopic scars; the likely explanation being that the DIEA was damaged and clipped as a result of the previous surgery. Again in this case, there was collateral flow into the abdominal wall perforators (Fig. [2]) from the ipsilateral deep superior epigastric artery. As in our previous case, the flap was raised on the contralateral DIEA, and there were no postoperative complications.

Figure 1 Preoperative computed tomographic angiogram of the abdominal wall vasculature, showing occlusion of the deep inferior epigastric artery on the right. This occurred deep to a laparoscopy scar, with a surgical clip in the abdominal wall demonstrated.

Figure 2 Preoperative computed tomographic angiogram of the abdominal wall vasculature, demonstrating the presence of cutaneous perforators (arrows).

The unilateral absence of a right DIEA in both of our cases was associated with two other findings: compensatory filling by the deep superior epigastric arteries of perforators usually supplied by the DIEA, and a large superficial inferior epigastric artery on both sides.

Our experiences with the initial case prompted a review of 150 previous CTAs of the abdominal wall, which revealed no further instances of this anomaly. Since then, we have performed ~50 more CTAs (400 hemiabdominal walls in total), with only the two mentioned cases demonstrating an absent DIEA. It appears that the incidence of this anomaly is very low, probably even lower than the 0.25% of hemiabdominal walls thus scanned.

CTA has proven to be a technique that has many advantages, including shorter operating times and ease of dissection due to the preoperative selection of perforators. It also allows for planning in cases like these where aberrant anatomy could cause significant intraoperative problems to the surgeon.

REFERENCES

• 1 Rozen W M, Houseman N D, Ashton M W. The absent inferior epigastric artery: a unique anomaly and implications for deep inferior epigastric artery perforator flaps.  J Reconstr Microsurg. 2009;  25 289-293
• 2 Matteucci P, Stanley P R, Bates J, Riaz M. Complete absence of lower rectus abdominus muscle and deep inferior epigastric artery complicating free DIEP flap breast reconstruction.  J Plast Reconstr Aesthet Surg. 2009;  62 e112-e113