Preoperative CT angiography reduces surgery time in perforator flap reconstruction

Smit, Jeroen M.; Dimopoulou, Angeliki; Liss, Anders G.; Zeebregts, Clark J.; Kildal, Morten; Whitaker, Iain S.; Magnusson, Anders; Acosta, Rafael

doi:10.1016/j.bjps.2007.12.090

Cited by 165 publications

(139 citation statements)

References 11 publications

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“…Although all of these variations are rare, the importance for a particular patient in such cases, particularly an absent DIEA, is substantial. As such, the use of preoperative imaging is of value in predicting anatomical variations and contributes to previous studies that have shown such imaging to significantly improve surgical outcomes (Rozen et al, 2008a;Smit et al, 2008;Uppal et al, 2008).…”

Section: Discussionmentioning

confidence: 90%

The branching pattern of the deep inferior epigastric artery revisited in‐vivo: A new classification based on CT angiography

2009

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The deep inferior epigastric artery (DIEA) is a reliable pedicle in the design of DIEA perforator flaps, with variations in its anatomy infrequent. Previous studies describing its branching pattern have all been based on cadaveric anatomy and described the following three branching patterns: Type 1 (single trunk), Type 2 (bifurcating trunk), and Type 3 (trifurcating trunk). The increased use of preoperative imaging, particularly with computed tomographic angiography (CTA), has enabled visualization of the DIEA and its branches in vivo, providing a functional view of this anatomy. We undertook a study of 250 patients (500 hemiabdominal walls) undergoing preoperative CTA before DIEA perforator flaps for breast reconstruction. The branching pattern of the DIEA and correlation to the contralateral hemiabdominal wall were assessed. The branching patterns of the DIEA were found to be different in vivo compared with cadaveric studies, with a higher than previously reported incidence of Type 1 patterns and lower than reported incidence of Type 3 patterns, and that some patterns exist which were not included within the previous nomenclature (namely, Type 0 or absent DIEA and Type 4 or four-trunk DIEA). There was also shown to be no overall concordance in the branching patterns of the DIEA between contralateral sides of the same abdominal wall; however, there was shown to be a statistically significant concordance in cases of a Type 1 DIEA (51% concordance, P = 0.04). As such, a new modification to the classification system for the branching pattern of the DIEA is presented based on imaging findings.

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Section: Discussionmentioning

confidence: 90%

The branching pattern of the deep inferior epigastric artery revisited in‐vivo: A new classification based on CT angiography

2009

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“…Although CTA has become increasingly utilized prior to all cases of perforator flap surgery, as a tool to evaluating ''normal'' individual variability and anatomical variation (Rozen et al, 2008c), this study has shown that variation may be even more pronounced in cases of previous surgery. Although CTA is associated with radiation exposure and a risk of uncommon complications, it has been shown in multiple international studies to significantly improve operative outcomes in abdominal free flap surgery (Rozen et al, 2008a;Smit et al, 2008;Uppal et al, 2008;Casey et al, 2009), and this paper further contributes to these benefits.…”

Section: Discussionmentioning

confidence: 84%

The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: A cadaveric and clinical study with clinical implications

et al. 2009

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The anterior abdominal wall integument is frequently used in a range of reconstructive flaps. These tissues are supplied by the deep and superficial inferior epigastric arteries (DIEA and SIEAs) and the deep and superficial superior epigastric arteries (DSEA and SSEAs). Previous abdominal wall surgery alters this vascular anatomy and may influence flap design. One hundred and sixty-eight patients underwent abdominal wall computed tomographic angiography (CTA) for preoperative imaging. Fifty-eight of these patients had undergone previous abdominal surgery, and were assessed for scar pattern and relationship to the course and distribution of all major axial vessels and perforators. Two cadaveric abdominal wall specimens with midline abdominal scars underwent contrast injection of the DIEAs and DSEAs, with subsequent CTA. The course and distribution of all cutaneous vessels were assessed. In all clinical and cadaveric cases, the vasculature of the abdominal wall had been altered by previous surgery. In the clinical cases, vascular architecture was universally altered in the region of the scar, often modifying the filling patterns of the abdominal wall and occasionally precluding the use of an abdominal wall flap. In both cadaveric specimens, regions of non-filling were evident upon contrast injection, highlighting the angiosomes not supplied by the DIEA or DSEA. Previous abdominal wall surgery necessarily alters the vascular architecture of the abdominal wall, and may alter the source vessels supplying cutaneous tissues. CTA was useful in identifying and delineating these changes, and may be used as a preoperative tool in this role.

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“…Some studies have argued that the cost of the CTA is justified by the savings acquired by a reduction in operating time (16,17). However, overall, the literature is inconclusive regarding whether findings of faster operating times are truly significant (19).…”

Section: Discussionmentioning

confidence: 99%

“…In previous work, the superiority of CTA compared with Doppler US with respect to providing detailed anatomical data (2,4,5,15) reduced surgical time (16,17), and fewer complications have been reported (2,4,5,15). In a prospective study of 30 abdominal flap breast reconstructions, Scott et al (5) demonstrated that colour Doppler US was only able to predict 66.3% of dominant DIEP vessels identified by CTA.…”

Section: Discussionmentioning

confidence: 99%

Computed tomography-based preoperative vascular imaging in autologous breast reconstruction: A Canadian perspective

Symonette

Gan

2013

Canadian Journal of Plastic Surgery

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There appears to be increased use of computed tomography angiography (CTA) in the preoperative planning of autologous perforator flap breast reconstruction. Despite the advantages of providing superior anatomical detail, concerns regarding cost and radiation exposure of this technique remain. In the current study, a paper-based survey was distributed to 44 plastic surgeons with a special interest in breast reconstruction at 19 different centres across Canada to collect their perspectives and practice characteristics with respect to the use of CTA as a preoperative imaging modality in breast reconstruction. The response rate of the survey was 75%. The majority of respondents commonly use perforator flap breast reconstruction and CTA in their breast reconstruction practice. Surgeons identified particular benefits of CTA in patients who had previously undergone abdominal surgery. However, more than one-half of the overall cohort was concerned about radiation exposure associated with CTA. A review of the literature suggests that it may be worthwhile to reduce the unnecessary risks of additional radiation exposure to the breast cancer population. A prospective study may help to better define the group of patients in whom CTA will provide optimal benefits in terms of reducing perioperative microvascular morbidity.

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Preoperative CT angiography reduces surgery time in perforator flap reconstruction

Cited by 165 publications

References 11 publications

The branching pattern of the deep inferior epigastric artery revisited in‐vivo: A new classification based on CT angiography

The branching pattern of the deep inferior epigastric artery revisited in‐vivo: A new classification based on CT angiography

The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: A cadaveric and clinical study with clinical implications

Computed tomography-based preoperative vascular imaging in autologous breast reconstruction: A Canadian perspective

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