The superior epigastric artery is the terminal continuation of the internal thoracic artery, descending behind the rectus abdominis muscle within its sheath after passing through the diaphragm at the posterior part of the costal margin. It anastomoses with the inferior epigastric artery from the external iliac system at the level of the umbilicus, creating a continuous vertical anastomotic channel that can sustain the rectus abdominis as a pedicled flap.
| Origin | Internal thoracic artery, as a terminal branch in the sixth intercostal space |
|---|---|
| Course | Descends between the sternal and costal attachments of the diaphragm into the rectus sheath, running behind rectus abdominis to anastomose with the inferior epigastric artery around the umbilicus |
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The superior epigastric artery is the pedicle for superiorly based rectus abdominis myocutaneous flaps (TRAM flap, Rubens flap) used in breast reconstruction and abdominal wall repair. Knowledge of its course within the rectus sheath is essential for safe rectus abdominis harvest. The superior and inferior epigastric anastomosis at the umbilicus is important collateral circulation in aortoiliac occlusive disease. The vessel is ligated with the ITA during CABG harvesting when the bifurcation is distal to the intended conduit length.
The zone 4 of the pedicled TRAM flap, furthest from the superior epigastric artery pedicle, is at highest risk of fat necrosis due to the tenuous blood supply through the anastomosis with the inferior epigastric system, an important consideration in planning the extent of skin and fat harvest.
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