Strategies for Recognizing and Managing Intraoperative Venous Congestion in Abdominally Based Autologous Breast Reconstruction

Abstract

Therapeutic, IV.

Anatomical features associated with venous congestion in DIEP flap using CT angiography with three-dimensional reconstruction

“…Other common strategies include the anastomosis of the SIEV to a second internal mammary vein, to an internal mammary perforator, or end-to-side to one of the DIEVs of the flap. [10,25,26] Less popular options include the anastomosis of the SIEV to the thoracoacromial vein, to the contralateral intermammary vein (which may need a vein graft), or to the toracodorsal vein (which may prevent the use of a latissimus dorsi as a rescue surgery in case the DIEP flap fails), among others. Notwithstanding, carrying out a second venous anastomosis is timeconsuming, which represents the main drawback of this procedure, taking between 30 to 90 min.…”

“…[10][11][12] However, the origin remains to be elucidated. Some triggering factors have been proposed: diameter of the SIEV larger than 1.5 mm, [6,13] absence of communications of both SIEVs crossing the abdominal midline, [6,13] absence of direct communications by perforators between the SIEV and the deep inferior epigastric vein (DIEV), [6] number of perforators of the flap, [5] and subcutaneous tissue thickness.…”

Double Venous System Drainage in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

“…[3][4][5][6][7] Anatomic studies have shown that the deep inferior epigastric vein (DIEV) connects with the superficial inferior epigastric vein (SIEV) through a system of choke vessels within the flap. [8] In numerous studies, the superficial venous system has been used to adequately decongest the flap in cases where venous congestion was clinically observed [9][10][11][12][13]. We have found that routinely anastomosing both the superficial and deep venous systems has resulted in significantly fewer operative take-backs and decreased venous complications with use of the DIEP flap.…”

A Case of Cold Urticaria Mistaken as Congestion Status during Breast Reconstruction with Deep Inferior Epigastric Perforator Free Flap Coverage.

“…The main causes of venous congestion are venous thrombosis, inadequate venous drainage, inadequate perforator selection, and anatomic superficial venous system dominance with insufficient communicating veins to the deep system [4][5][6]. In contrast, cold urticaria prevalence is not well determined and has an estimated incidence rate of 0.05% [3].…”

“…The incidence of venous congestion status in DIEP and transverse rectus abdominis myocutaneous flaps for breast reconstruction is not rare, ranging from 2 to 20% [4][5][6]. The main causes of venous congestion are venous thrombosis, inadequate venous drainage, inadequate perforator selection, and anatomic superficial venous system dominance with insufficient communicating veins to the deep system [4][5][6].…”