Estimation of Contralateral Perfusion in the DIEP Flap by Scoring the Midline-Crossing Vessels in Computed Tomographic Angiography

Abstract

Background: In deep inferior epigastric perforator flap surgery, the amount of perfusion achievable in the contralateral side over a midline is unclear. Predicting contralateral perfusion preoperatively using computed tomographic angiography will allow efficient breast reconstruction with decreased complications. The authors used computed tomographic angiography to determine whether contralateral perfusion is related to blood vessel status across the midline. Methods: Preoperative computed tomographic angiography scans and intraoperative perfusion in patients who underwent breast reconstruction with a deep inferior epigastric perforator flap between January of 2018 and July of 2018 were checked prospectively. A vessel scoring system was prepared according to vessel density across the flap midline on the scan (grade 0, no visible vessels; grade 1, visible vessels with disconnection or could not be judged as grade 0 or 2; grade 2, definite vessels). Intraoperative flap perfusion was confirmed with indocyanine green angiography. Postoperative fat necrosis was analyzed using ultrasonography. Results: Ninety-four patients were analyzed. Mean maximal contralateral perfusion length was as follows: grade 0, 7.50 ± 1.89 cm; grade 1, 7.93 ± 2.01 cm; and grade 2, 10.14 ± 2.29 cm. Grade 2 had a statistically significantly greater contralateral perfusion length than grade 0 (p < 0.001) and grade 1 (p < 0.001). Fat necrosis occurred in 27.3 percent (grade 0), 19.1 percent (grade 1), and 8 percent (grade 2), which was statistically significant (p = 0.035). Conclusions: A definite vessel connection across the midline (as in grade 2) in preoperative computed tomographic angiography indicates that contralateral perfusion will be sufficiently achieved. This vessel scoring system would be helpful in predicting flap perfusion and planning the surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

The Influence of Flow Velocity in the Feeding Vessel on Flap Perfusion in Deep Inferior Epigastric Artery Perforator Flap

“…Up to 12.5 mg of ICG was injected when the signal was considered weak based on our previously reported protocol. 6 All ICG angiographic images were acquired in the arterial phase to ensure consistency in measurements. After intravenous ICG injection, the sound of the saturation monitor changed after 50 to 70 seconds of dwell time, which is when the oximetry desaturation occurs because of the ICG 15 or when ICG is believed to enter the systemic circulation during imaging.…”

“…Up to 12.5 mg of ICG was injected when the signal was considered weak based on our previously reported protocol. 6 All ICG angiographic images were acquired in the arterial phase to ensure consistency in measurements. After intravenous Fig.…”

“…Up to 12.5 mg of ICG was injected when the signal was considered weak based on our previously reported protocol. 6 All ICG angiographic images were acquired in the arterial phase to ensure consistency in Fig. 1 The method for measuring peak flow velocity in the vessel intraoperatively, using the duplex color doppler and ICG angiography with infrared camera.…”

“…5 Another study also mentioned the utility of CT angiography to check the midline-crossing perforator and its relationship with contralateral perfusion. 6 Losken et al estimated the perfusion of each zone by intraoperative indocyanine green (ICG) angiography. 7 In some studies, perfusion was assessed by thermogenic imaging on the abdominal flap after induced hypothermia.…”

A Systematic Review and Meta-Analysis of Microvascular Stacked and Conjoined-Flap Breast Reconstruction

“…Fat necrosis is influenced by multiple factors, both extrinsic, such as smoking and radiation, as well as intrinsic, based on flap physiology. [39][40][41] Perforator number, quality, row, and angiosomal branching patterns 22,[42][43][44] all play an important role in determining the area and relative degree of perfusion of harvested tissue. In cases of abdominally-based reconstruction, SC flaps may be able to improve perfusion of Holm Zone III 45 reliant on choke vessels crossing the midline.…”