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

Davis, Christopher R.; Jones, Lyn; Tillett, Rachel; Richards, Helen; Wilson, Sandra

doi:10.1002/micr.30367

Cited by 27 publications

(28 citation statements)

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“…After thorough evaluation of all the articles retrieved on the subject of venous superdrainage, we have come down to 11 studies on various functional factors, [6][7][8][9][10][11][12][13][14][15][16] 18 studies reporting on the results of a single center on hydraulic constructs, 2,5,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] one review of the literature, 33 six studies on treatment algorithms, 1,15,[34][35][36][37] and one meta-analysis 38 (►Table 1).…”

Section: Resultsmentioning

confidence: 99%

Different Hydraulic Constructs to Optimize the Venous Drainage of DIEP Flaps in Breast Reconstruction: Decisional Algorithm and Review of the Literature

Pignatti

Giorgini

Miralles

et al. 2020

J Reconstr Microsurg

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Background Venous congestion is the most common perfusion-related complication of deep inferior epigastric artery perforator (DIEP) flap. Several hydraulic constructs can be created for venous superdrainage in case of flap venous engorgement or as a preventive measure. These can be classified based on the choice of the draining vein of the flap, either a second deep inferior epigastric vein (DIEV) or a superficial inferior epigastric vein (SIEV), and of the recipient vein, either a vein of the chest or the DIEV. Methods We conducted a comprehensive systematic literature review in Medline, Scopus, EMBASE, Cochrane Library, and Google Scholar to find publications that reported on venous congestion in DIEP flap. The keywords used were DIEP Flap, breast reconstruction, venous congestion, supercharging, superdrainage, SIEV, and DIEV. Results Based on the studies found in the literature, we developed an algorithm to guide the surgeon's decision when choosing the veins for the superdrainage anastomosis. Conclusion Several alternatives for venous anastomosis in superdrainage are available. We propose an algorithm to simplify the choice. The use of the ipsilateral SIEV to be connected to a vein of the chest appears to be advantageous. The anatomical position that allows the easiest anastomosis dictates which chest vein to favor.

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Section: Resultsmentioning

confidence: 99%

Different Hydraulic Constructs to Optimize the Venous Drainage of DIEP Flaps in Breast Reconstruction: Decisional Algorithm and Review of the Literature

Pignatti

Giorgini

Miralles

et al. 2020

J Reconstr Microsurg

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“…Before surgery, radiological examination like CTA or MRA is recommended if possible. Studies have shown that preoperative CTA can identify atypical venous connections between deep and super cial systems that increase the risk of postoperative congestion ve-fold (28). Identifying atypical venous connections maximizes the chances of ap survival and minimizes complications.…”

Section: Discussionmentioning

confidence: 99%

The role of intermittent negative pressure wound therapy combined with a mesh incision in the salvage of perforator flap with venous congestion, a case report

Xie

et al. 2020

Preprint

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Background: The application of perforator flap is becoming wide. The most common postoperative complication is venous congestion but traditional treatments’ effect is limited. A new method called negative pressure wound therapy(NPWT) was introduced to improve wound healing. Many scholars have tried this method with continuous mode and achieved good outcomes. In this paper, we tried a different mode(intermittent) of negative pressure wound therapy on congested perforator flaps after a mesh incision, and we expected this paper could provide information for follow-up clinical research.Case presentation: A retrospective research of 6 patients (6 perforator flaps) who had been suffered from venous congestion from June, 2016 to June, 2019 was performed. All flaps were treated by intermittent negative pressure wound therapy after a mesh incision. Among 6 flaps, 4 of them were totally survived while the other 2 of them were mostly survived.Conclusions: Intermittent negative pressure wound therapy combined with a mesh incision can be a safe option to rescue perforator flaps with venous congestion. This technique has a certain success rate and clinical application value.

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“…From previous literature including a magnetic resonance angiography-guided anatomical study and a cadaveric study, a minimum of one and a maximum of three venae communicantes (normal) were noted in each hemiabdomen. However, Davis et al (2019) reported an absence of connections (Type II) in five cases (12.5%) among 40 patients. This anatomic discordance between Davis et al (2019) and previous studies might originate from the inherent nature of a study design based on reanalysis of harvested perforator only, limitation of CTA resolution, and a small sample size.…”

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confidence: 95%

“…However, Davis et al (2019) reported an absence of connections (Type II) in five cases (12.5%) among 40 patients. This anatomic discordance between Davis et al (2019) and previous studies might originate from the inherent nature of a study design based on reanalysis of harvested perforator only, limitation of CTA resolution, and a small sample size. Furthermore, the authors suggested that patients with absent connections were good candidates for DIEP flaps, and that such flaps would be even safer than flaps with atypical connecting vessels.…”

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confidence: 95%

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

Kim

Mun

2019

Microsurgery

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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.

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

Cited by 27 publications

References 50 publications

Different Hydraulic Constructs to Optimize the Venous Drainage of DIEP Flaps in Breast Reconstruction: Decisional Algorithm and Review of the Literature

Different Hydraulic Constructs to Optimize the Venous Drainage of DIEP Flaps in Breast Reconstruction: Decisional Algorithm and Review of the Literature

The role of intermittent negative pressure wound therapy combined with a mesh incision in the salvage of perforator flap with venous congestion, a case report

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

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