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Ruiz-Moya et al. Assessment of DIEP flap using CTA with 3D reconstruction

new information concerning the identification of the controversial anatomical features associated with venous congestion in DIEP
flaps. CTA and 3D virtual reconstruction were useful tools for evaluating the abdominal wall anatomy and for planning DIEP breast
surgery, but neither for predicting nor preventing the diffuse congestive phenomenon.

INTRODUCTION diameter of the SIEV, and another one indicated a
[8]
higher chance of congestion in DIEP flaps based on
Since the deep inferior epigastric artery perforator just one perforator without direct communication with
(DIEP) flap was used for the first time for breast the SIEV. [7]
reconstruction by Allen and Treece, it has been
[1]
adopted as the gold standard for autologous breast The routine use of preoperative imaging to assess the
reconstruction, overtaking other popular autologous microvascular anatomy of the anterior abdominal wall
[15]
methods such as the latissimus dorsi flap and the helps to achieve optimal outcomes. Preoperative
transverse rectus abdominis myocutaneous flap. The planning of DIEP flaps with computed tomographic
amount of available tissue, the low abdominal morbidity, angiography (CTA) followed by three-dimensional
the ability of replacing like-for-like, and the good (3D) reconstruction has proved to be an effective
aesthetic results, are the most notable advantages of technique to map the abdominal vascular anatomy,
this technique that have contributed to its widespread allowing a better tracking of the perforators, including
use. The success rate is high, with a flap loss rate their size, location and course, so as to shorten the
[2]
under 3% according to the review by Lie et al. on operative time and number of complications. [16,17] On
[3]
more than 17,000 DIEP flaps. the other hand, little is known about the anatomical
features related with the postoperative diffuse venous
The main arterial inflow is provided by the deep congestion and how new imaging technologies are
inferior epigastric artery (DIEA), while the main able to identify aspects that can threaten the perfusion
venous drainage is provided by the superficial inferior of the DIEP flap.
epigastric vein (SIEV). Although the arterial component
of the flap has been widely documented, [4,5] the venous This study aimed to evaluate the anatomical features
system has not been as thoroughly studied. When that could preoperatively predict the potential
a DIEP flap is dissected, a redirection of the venous venous congestion of DIEP flaps, using 3D virtual
outflow occurs from the dominant superficial system reconstructions from CTA.
to the deep system. This redistribution could favor
venous congestion in some of the flaps, leading to METHODS
the most common vascular complication, the diffuse
venous congestion of the DIEP flap, neither caused by This retrospective case-control study included
pedicle-related issues (such as venous thrombosis or 210 consecutive DIEP breast reconstructions in
kinking) nor by technical errors (for example, deficient which a CTA was performed prior to surgery. These
suture or avulsion of the pedicle). [6,7] This phenomenon flaps were carried out consecutively by the same
is observed in 2-10.9% of cases [7-9] and it may cause surgeon (D. Sicilia-Castro) in the Department of
partial or total flap loss if unsolved. In fact, up to 40% Plastic and Reconstructive Surgery of the Virgen del
of total DIEP flap necrosis are associated with venous Rocio University Hospital in Seville, Spain, between
problems. Paradoxically, the mechanisms behind January 2004 and January 2016. All patients were
[3]
this complication remain unclear and have not been prophylactically administered low molecular weight
clarified yet. heparin every 24 h postoperatively, in a dose of 40 mg
of enoxaparin, and flaps were assessed clinically and
Several strategies exist to overcome such complication with a hand-held Doppler probe hourly during the first
of DIEP flap diffuse venous congestion. [10-12] However, 48 h, and every 2 h during the next 48 h. All patients
the origin remains to be elucidated. Some triggering signed informed consent to be included in the study.
factors have been proposed: diameter of the SIEV
larger than 1.5 mm, [6,13] absence of communications Cases were defined as DIEP flaps preoperatively
of both SIEVs crossing the abdominal midline, [6,13] planned with CTA and 3D virtual reconstruction, which
absence of direct communications by perforators exhibited diffuse venous congestion intraoperatively
between the SIEV and the deep inferior epigastric after ligating the SIEV, not due to pedicle-related
vein (DIEV), number of perforators of the flap, issues (venous thrombosis, twisting or kinking) or to
[5]
[6]
and subcutaneous tissue thickness. Nevertheless, technical failures (deficient suture or venous avulsion
[14]
scarce evidence has been reported to date as only during manipulation). Controls were defined as DIEP
one study was able to refuse the correlation with the flaps preoperatively planned with CTA and 3D virtual
128 Plastic and Aesthetic Research ¦ Volume 4 ¦ August 21, 2017