Comments on “Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging”

Abstract

Comments on "Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging"Dear Editor:We read the article by Davis, Jones, Tillett, Richards, and Wilson (2019) with great interest. Venous congestion is a major concern when performing deep inferior epigastric perforator (DIEP) flap reconstruction and previous studies related to this subject primarily focused on the intraoperative or postoperative management or salvage of congested flaps (Bartlett, Zavlin, Menn, & Spiegel, 2018). Venous congestion in DIEP flaps is affected by a number of factors including surgical technique and anatomic impediments to adequate venous drainage, such as insufficient venous perforator caliber, inadequate communication between the superficial and deep systems, and absent communication of venous collaterals across the midline, and thus it may be difficult to identify specific causative factors that can help predict its occurrence (Dortch, Forte, Bolan, Kandel, & Perdikis, 2018). The notable work performed by Davis et al. (2019) was the prediction of venous congestion complications based on preoperative computed tomographic angiography (CTA) findings.Despite a few limitations, including the retrospective study design and small number of patients, the presence of atypical connections between the superficial and deep venous system on preoperative CT was found to increase the risk of venous congestion of DIEP flaps fivefold. Although further study on multivariate analysis is a better knowledge of surgical anatomy maximizes the benefits of the procedure while minimize the potential risks. We welcome the authors' suggestion to extend the CT scan field to the thorax, which we have also recommended to reinforce the role of preoperative CTA including volumetric planning (Kim et al., 2012). The role of CTA in DIEP flap surgery has expanded and evolved, and more data and information are available. We commend the authors' effort to quantify the risk of venous congestion using analysis of CTA data, which emphasized the importance of preoperative CTA-based DIEP flap planning.