| 1. Aubry S, Pauchot J, Kastler A, Laurent O, Tropet Y, Runge M. Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery. Skeletal Radiol. 2013;42(3):319-327. |
Review/Other-Dx |
N/A |
To discuss advantages and drawbacks of current imaging modalities for mapping the course of perforating vessels in the planning of DIEP flap surgery, and to present state-of-the-art imaging techniques. |
No results in abstract. |
4 |
| 2. Karunanithy N, Rose V, Lim AK, Mitchell A. CT angiography of inferior epigastric and gluteal perforating arteries before free flap breast reconstruction. Radiographics. 2011;31(5):1307-1319. |
Review/Other-Dx |
N/A |
To familiarize readers with the acquisition and interpretation of CT angiograms so that they can relay to the surgical team information that is relevant for preoperative planning. |
CT angiography is a valuable tool that can enhance the precision of preoperative planning for perforator free flap breast reconstruction. Knowledge of the relevant anatomy, surgical technique, and protocols for acquiring and interpreting CT angiograms can help reduce procedure time and lead to better outcomes. |
4 |
| 3. Chernyak V, Rozenblit AM, Greenspun DT, et al. Breast reconstruction with deep inferior epigastric artery perforator flap: 3.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall perforators. Radiology. 2009;250(2):417-424. |
Observational-Dx |
19 Patients |
To prospectively evaluate 3.0-T gadolinium-enhanced magnetic resonance (MR) imaging for localization of inferior epigastric artery (IEA) perforators before reconstructive breast surgery involving a deep inferior epigastric perforator (DIEP) flap. |
There were 30 surgical flaps, and 11 (58%) of the 19 patients underwent bilateral flap dissection. At surgery, 122 perforators were localized, and 118 (97%) of these perforators—with a mean diameter of 1.1 mm (range, 0.8–1.6 mm)—had been identified at preoperative MR imaging. Thirty perforators with a mean diameter of 1.4 mm (range, 1.0–1.6 mm) were labeled as the best at MR imaging. Thirty-three perforators were harvested intraoperatively, and all of these had been localized preoperatively. Twenty-eight (85%) of these 33 perforators were labeled as the best at MR imaging. |
3 |
| 4. Tseng CY, Lipa JE. Perforator flaps in breast reconstruction. Clin Plast Surg. 2010;37(4):641-654, vi-ii. |
Review/Other-Dx |
N/A |
To review pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes. |
No results in abstract. |
4 |
| 5. Hijjawi JB, Blondeel PN. Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging. J Reconstr Microsurg. 2010;26(1):11-20. |
Review/Other-Dx |
N/A |
To describe the advantages of MDCT over color duplex imaging in perforator flap breast reconstruction. |
No results. |
4 |
| 6. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/body-cta.pdf. |
Review/Other-Dx |
N/A |
Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. |
No abstract available. |
4 |
| 7. Casey WJ, 3rd, Chew RT, Rebecca AM, Smith AA, Collins JM, Pockaj BA. Advantages of preoperative computed tomography in deep inferior epigastric artery perforator flap breast reconstruction. Plast Reconstr Surg. 2009;123(4):1148-1155. |
Observational-Dx |
213 cases |
To compare the outcomes of DIEAP and superficial inferior epigastric artery (SIEA) breast reconstruction both before and after the routine use of preoperative computed tomography to determine the advantages that this imaging technique can provide. |
Two hundred eighty-seven flaps were performed on 213 patients. There were 139 unilateral and 74 bilateral reconstructions, with 168 flaps performed immediately after mastectomy and 119 flaps performed in a delayed setting. One hundred one flaps were performed with computed tomographic imaging, whereas 186 flaps followed hand-held Doppler interrogation alone. Mean follow-up was 24 months. The use of computed tomography had a beneficial impact on operative times (unilateral, 370 versus 459 minutes; bilateral, 515 versus 657 minutes; p < 0.05), number of perforators included (1.5 versus 1.9; p < 0.05), and abdominal bulges (1 percent versus 9.1 percent; p < 0.05). Anastomotic complications (6.9 percent versus 8.1 percent), failure rates (2 percent versus 3.8 percent), fat necrosis (10.9 percent versus 13.4 percent), and abdominal wounds (11.8 percent versus 16.6 percent) were not found to be significantly different. Computed tomography did identify three cases of deep inferior epigastric vessel ligation from previous operations, which compromised these as suitable source vessels. |
2 |
| 8. Gacto-Sanchez P, Sicilia-Castro D, Gomez-Cia T, et al. Computed tomographic angiography with VirSSPA three-dimensional software for perforator navigation improves perioperative outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg. 2010;125(1):24-31. |
Observational-Tx |
70 patients |
To reduce surgery time and the number of complications. |
The use of VirSSPA preoperative planning correlated with operative times reduced by a mean of 2 hours 8 minutes. In addition, a statistically significant reduction (>45 percent) in the incidence of any flap-related complications was observed in patients undergoing preoperative computed tomographic angiography-guided VirSSPA reconstruction and a decrease above 50 percent in overall donor-site morbidity. The use of computed tomographic angiography-guided VirSSPA three-dimensional reconstruction was found to be a protective factor against developing any kind of complication after DIEP flap surgery (odds ratio, 0.03; 95 percent confidence interval, 0.006 to 0.15). |
1 |
| 9. Ghattaura A, Henton J, Jallali N, et al. One hundred cases of abdominal-based free flaps in breast reconstruction. The impact of preoperative computed tomographic angiography. J Plast Reconstr Aesthet Surg. 63(10):1597-601, 2010 Oct. |
Observational-Dx |
100 cases |
To examine the impact of CTA imaging on our practise and also to discuss the process of image acquisition. |
Following use of CTA, fewer superficial inferior epigastric artery (SIEA) flaps were performed (18% vs. 0%), although the number of DIEP and muscle-sparing transverse rectus abdominis myocutaneous (MS TRAM) flaps remained similar. There was an increased use of single perforators in the CTA group than in the non-CTA group (48% vs. 18%) as well as increased numbers of medial-row perforators (65% vs. 32%). Unilateral reconstructions were performed 1h faster in the CTA group (489min vs. 566min). Finally, hernia rates decreased from 6% in the non-CTA group to 0% in the CTA group. |
3 |
| 10. Keys KA, Louie O, Said HK, Neligan PC, Mathes DW. Clinical utility of CT angiography in DIEP breast reconstruction. J Plast Reconstr Aesthet Surg. 2013;66(3):e61-65. |
Observational-Dx |
52 sequential DIEP free flaps in 37 patients |
To specifically evaluate the clinical utility of CTA in DIEP free flaps. |
A total of 62 out of 76 planned perforators were ultimately used (82%). Of those not used, 71% were abandoned due to inadequacy of preoperative CT. An additional 38 perforators were used that were not part of the initial preoperative plan, 60% of which were added due to inadequacy of the preoperative CT for planning. In total 23/52 flaps (44%) involved intraoperative changes due to features not appreciated on preoperative CT. |
3 |
| 11. Malhotra A, Chhaya N, Nsiah-Sarbeng P, Mosahebi A. CT-guided deep inferior epigastric perforator (DIEP) flap localization -- better for the patient, the surgeon, and the hospital. Clin Radiol. 2013;68(2):131-138. |
Observational-Dx |
100 CTA patients and 100 US patients |
To define the clinical benefits to the patient of preoperative imaging planning for deep inferior epigastric perforator (DIEP) flap reconstruction. |
There were statistically significant improvements in mean operative duration (p < 0.05), intra-operative blood loss (p < 0.05), shorter mean inpatient stay (p < 0.05) for the CTA planning versus the ultrasound planning of DIEP flap reconstruction. |
2 |
| 12. Masia J, Kosutic D, Clavero JA, Larranaga J, Vives L, Pons G. Preoperative computed tomographic angiogram for deep inferior epigastric artery perforator flap breast reconstruction. J Reconstr Microsurg. 2010;26(1):21-28. |
Observational-Dx |
357 patients |
To review our 5-year experience with the technique we developed based on our previous research confirming accuracy of a computed tomographic (CT) angiogram (multidetector row computed tomography [MDCT]) in preoperative planning of abdominal perforator flap surgery. |
Exact correlation between surgical and radiological results was found in the first 36 cases. A significant reduction in average operating time and postoperative complications was noted in the following 321 patients. |
2 |
| 13. Masia J, Larranaga J, Clavero JA, Vives L, Pons G, Pons JM. The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases. Ann Plast Surg. 2008;60(1):29-36. |
Observational-Dx |
162 patients |
To describe the working method, establish an actuation algorithm, and reach new conclusions which may be of considerable use for breast reconstruction surgery using autologous tissue. |
In the first 36 cases, an absolute correlation was observed between the radiologic information and intraoperative findings. In the following 126 cases, surgery time and the rate of postoperative complications decreased significantly. The multidetector scanner provides valuable preoperative information enabling identification of the most suitable perforator in view of its caliber, location, course, and anatomic relationships. |
3 |
| 14. Minqiang X, Lanhua M, Jie L, Dali M, Jinguo L. The value of multidetector-row CT angiography for pre-operative planning of breast reconstruction with deep inferior epigastric arterial perforator flaps. Br J Radiol. 2010;83(985):40-43. |
Observational-Tx |
44 patients |
To describe the benefits of this method for preoperative planning before breast reconstruction with DIEP flaps. |
The pre-operative redesign ratio was 22.7% in the test group and 0% in the control group. The intra-operative method change ratio was 0% in the test group and 13.6% in the control group. The mean time spent on flap harvest was 2.8 +/- 0.2 h in the test group and 4.4 +/- 0.2 h in the control group (p<0.05). The flap complication rate was 1/22 in the test group and 3/22 in the control group (p _ 0.04). |
4 |
| 15. Molina AR, Jones ME, Hazari A, Francis I, Nduka C. Correlating the deep inferior epigastric artery branching pattern with type of abdominal free flap performed in a series of 145 breast reconstruction patients. Ann R Coll Surg Engl. 2012;94(7):493-495. |
Review/Other-Dx |
145 Patients |
To evaluate the distribution of the different DIEA branching patterns in abdominal free flap breast reconstruction patients who had undergone pre-operative CTA |
Some 150 breast reconstructions were performed in 145 patients. There were 67 DIEP flaps, 69 MS-2 transverse rectus abdominis myocutaneous (TRAM) flaps and 14 MS-1 TRAM flaps (where MS-1 spares the lateral muscle and MS-2 spares both lateral and medial segments). Proportionally more DIEP flaps were performed in patients with a type 2 branching pattern. There was one flap loss (0.67%). |
4 |
| 16. Lam DL, Mitsumori LM, Neligan PC, Warren BH, Shuman WP, Dubinsky TJ. Pre-operative CT angiography and three-dimensional image post processing for deep inferior epigastric perforator flap breast reconstructive surgery. Br J Radiol. 2012;85(1020):e1293-1297. |
Review/Other-Dx |
N/A |
To review the arterial anatomy of the anterior abdominal wall, describe the features used to select a perforator artery for DIEP flap surgery and present a CT scanning and image post-processing protocol. |
No results in abstract. |
4 |
| 17. Scott JR, Liu D, Said H, Neligan PC, Mathes DW. Computed tomographic angiography in planning abdomen-based microsurgical breast reconstruction: a comparison with color duplex ultrasound. Plast Reconstr Surg. 2010;125(2):446-453. |
Review/Other-Dx |
22 Patients |
To compare the accuracy of computed tomography angiography in locating clinically useful abdominal wall perforators with that of duplex ultrasound. |
Computed tomography angiography preoperatively identified 83 of the largest perforators, while only 55 of these large perforators (66.3 percent) were preoperatively identified on ultrasound. No superficial inferior epigastric arteries were identified by ultrasound. However, in all eight breast reconstructions performed with the superficial inferior epigastric system, the superficial inferior epigastric arteries were identified preoperatively as adequate size for microsurgical transfers, with an average diameter of 1.6 mm. |
4 |
| 18. Teunis T, Heerma van Voss MR, Kon M, van Maurik JF. CT-angiography prior to DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurgery. 2013;33(6):496-502. |
Meta-analysis |
8 studies |
To evaluate flap loss after preoperative CTA and Doppler US in DIEP-flap breast reconstruction. |
From 678 studies, eight were selected for appraisal. Six case–control studies were included in the final analysis. Pooled analysis showed CTA resulted in a significant reduction in partial necrosis (odds ratio/OR 0.15; 95% confidence interval/CI 0.07–0.32, P<0.0001) and decreased flap loss (OR 0.28; 95% CI 0.10–0.79, P50.02). |
M |
| 19. Hummelink S, Hoogeveen YL, Schultze Kool LJ, Ulrich DJO. A New and Innovative Method of Preoperatively Planning and Projecting Vascular Anatomy in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial. Plast Reconstr Surg. 143(6):1151e-1158e, 2019 06. |
Experimental-Dx |
60 adults (projection method = 33; Doppler method = 27) |
To investigate whether the preoperative projection of a virtual three-dimensional plan based on computed tomographic angiography onto the abdomen leads to more correctly identified perforator locations and less operative time spent on dissecting the free flap compared to the commonly used Doppler ultrasound planning method. |
Sixty patients provided 69 DIEP flaps for analysis. The projection method is capable preoperatively of displaying significantly more perforators compared to the Doppler method (61.7 ± 7.3 percent versus 41.2 ± 8.2 percent, respectively; p = 0.020)). During the procedure, flap harvest time is decreased by 19 minutes (136 ± 7 minutes versus 155 ± 7 minutes; p = 0.012). Complications were comparable across both groups. |
3 |
| 20. Ngaage LM, Hamed R, Oni G, et al. The Role of CT Angiography in Assessing Deep Inferior Epigastric Perforator Flap Patency in Patients With Pre-existing Abdominal Scars. J Surg Res. 235:58-65, 2019 03. |
Observational-Dx |
106 patients |
To investigate CTA utility in predicting the most clinically useful DIEA perforators in scarred abdomens. |
A hundred and six patients with preoperative CTAs underwent 132 FFBRs, 44% (58) from scarred and 56% (74) from virgin abdomens. All flap transfers were successful. Concordance between perforators identified by CTA preoperatively and those selected by the surgeon intraoperatively was 95% (scarred 93%; non-scarred 96%, P = 0.470). There was a significant difference in the proportion of single-perforator flaps between the two groups (scarred 46%; non-scarred 28%, P = 0.041). "Scarred" flaps were heavier (789 vs 676 g, P = 0.0244) than those harvested from virgin abdomens. |
3 |
| 21. Haddock NT, Dumestre DO, Teotia SS. Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging. Plast Reconstr Surg. 146(4):719-723, 2020 10. |
Observational-Dx |
27 blinded patients; 33 unblinded patients |
To compare operative times for specific portions of DIEP flap harvest with and without preoperative computed tomographic angiography imaging. |
Times were recorded in 60 DIEP flaps (27 blinded and 33 unblinded). The nonblinded group was more efficient in all categories: time to first perforator identification (28.6 minutes versus 17.8 minutes; p < 0.0001), time to perforator decision-making (23.1 minutes versus 5.6 minutes; p < 0.0001), time to flap harvest (128 minutes versus 80 minutes; p < 0.0001), and total operative time (417 minutes versus 353 minutes; p < 0.001). Perforator location was not different between groups. Blinded intraoperative decisions correlated with preoperative imaging in 74 percent of flaps. More perforators were included in the blinded flaps compared to the nonblinded flaps (2.3 versus 1.4; p < 0.001). |
1 |
| 22. Kim SY, Lee KT, Mun GH. Computed Tomographic Angiography-Based Planning of Bipedicled DIEP Flaps with Intraflap Crossover Anastomosis: An Anatomical and Clinical Study. Plast Reconstr Surg. 138(3):409e-18e, 2016 Sep. |
Observational-Dx |
38 patients |
To investigate anatomical characteristics of intramuscular DIEA branches in detail using computed tomographic angiography, focusing on the branching pattern, topography, and vessel size. |
Three intramuscular DIEA branching patterns with distinct branch point topography, branch diameters, and superior continuations cranial to sizable perforators were observed. In the prospective clinical study, a primary pedicle with a recipient branch for intraflap crossover anastomosis could be specified preoperatively using computed tomographic angiography-based anatomical data of the pedicles, including size of DIEA branches or their superior continuation and size of perforators. In all cases, the bipedicle configuration was easily achieved as planned on computed tomographic angiography, and secure perfusion of the entire flap was achieved. |
3 |
| 23. Myung Y, Choi B, Yim SJ, et al. The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations. Surg Radiol Anat. 40(8):873-879, 2018 Aug. |
Observational-Dx |
184 patients |
To analyze the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap. |
CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29 mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22 mm) than in the non-operation group (9.86 mm). |
3 |
| 24. O'Malley RB, Robinson TJ, Kozlow JH, Liu PS. Computed Tomography Angiography for Preoperative Thoracoabdominal Flap Planning. [Review]. Radiol Clin North Am. 54(1):131-45, 2016 Jan. |
Review/Other-Dx |
N/A |
To discuss the use of CTA for preoperative thoracoabdominal flap planning. |
No results provided. |
4 |
| 25. Rozen WM, Ashton MW, Grinsell D. The branching pattern of the deep inferior epigastric artery revisited in-vivo: a new classification based on CT angiography. Clin Anat. 2010;23(1):87-92. |
Observational-Dx |
250 patients |
To re-evaluate the classification system. |
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. |
3 |
| 26. Suffee T, Pigneur F, Rahmouni A, Bosc R. Best choice of perforator vessel in autologous breast reconstruction: Virtual reality navigation vs radiologist analysis. A prospective study. J Plast Surg Hand Surg. 49(6):333-8, 2015. |
Observational-Dx |
30 patients |
To demonstrate the concordance between the preoperative choice of the best perforator vessel by the radiologist using CTA and the surgeon using the VirSSPA software. |
Best perforator concordance was 33% between the radiologist and the surgeon. The perforator used for reconstruction was chosen by the radiologist in 16 cases (53%) and in 10 cases (33%) by the surgeon. In only nine cases was the same perforator chosen by both of them. Distances of the best perforator from the umbilicus measured by VirSSPA showed an error margin varying from 1-47 mm from the real distances measured by CTA. The Pearson product-moment correlation coefficient was found to be 0.0235 (p = 0.94), reflecting a non-linear relationship. |
1 |
| 27. Wong KK, Stubbs E, McRae M, McRae M, CTA in preoperative planning for DIEP breast reconstruction: what the reconstructive surgeon wants to know. A modified Delphi study. Clin Radiol. 74(12):973.e15-973.e26, 2019 Dec. |
Review/Other-Dx |
N/A |
To gather expert reconstructive surgical opinion to define and rank the surgically most important anatomy and provide guidance for report content to radiologists when reading a preoperative computed tomography angiography (CTA). |
Response rates were 62%, 77%, and 69% for each of the three survey rounds, respectively. The panel identified that the most important perforator characteristics in selecting the optimal perforator are diameter of the vein, perforator location within the flap, and diameter of the artery, respectively. The stated preference was for perforators located below the umbilicus. If no suitable perforator was located below the umbilicus, the panel would consider perforators up to 2 cm above the umbilicus. The most important considerations for the preoperative radiology planning report are: the size of the perforator vein, perforator location relative to landmarks, and the size of the perforator artery. |
4 |
| 28. Rozen WM, Ashton MW. Improving outcomes in autologous breast reconstruction. Aesthetic Plast Surg. 2009;33(3):327-335. |
Review/Other-Dx |
N/A |
To review ways to maximize operative success and minimize the risk of complications. |
Deep inferior epigastric artery perforator (DIEP) flaps, the current mainstay in choice of autologous reconstruction, provide generally good outcomes. However, improvements in outcomes can still be achieved with a better understanding of individual anatomy. Perforator size, location, intramuscular and subcutaneous course, and association with motor nerves are all factors that can significantly affect operative technique, length of operation, and operative outcomes. With significant variation between individuals, preoperative imaging has become an essential element of DIEP flap surgery. Computed tomography angiography (CTA) is currently the gold standard but evolving techniques such as magnetic resonance angiography (MRA) and image-guided stereotaxy are rapidly contributing to improved outcomes. |
4 |
| 29. Nanidis TG, Ridha H, Jallali N. The use of computed tomography for the estimation of DIEP flap weights in breast reconstruction: a simple mathematical formula. J Plast Reconstr Aesthet Surg. 2014;67(10):1352-1356. |
Observational-Dx |
17 Patients |
To develop a simple, yet reliable method of calculating the deep inferior epigastric artery perforator flap weight using the routine preoperative computed tomography angiogram (CTA) scan. |
In the retrospective group 17 DIEP flaps in 17 patients were analyzed. Average predicted flap weight was 667 g (range 293-1254). The average actual flap weight was 657 g (range 300-1290) giving an average percentage error of 6.8% (p-value for weight difference 0.53). In the prospective group 15 DIEP flaps in 15 patients were analyzed. Average predicted flap weight was 618 g (range 320-925). The average actual flap weight was 624 g (range 356-970) giving an average percentage error of 6.38% (p-value for weight difference 0.57). |
3 |
| 30. Pennington DG, Rome P, Kitchener P. Predicting results of DIEP flap reconstruction: the flap viability index. J Plast Reconstr Aesthet Surg. 2012;65(11):1490-1495. |
Observational-Dx |
45 Patients |
To develop a mathematical tool to predict the risks of partial flap necrosis utilising pre-operative measurements and to discover the maximum survival weight of flaps based on internal diameters of perforators. |
At operation, perforator positions correlated well with CTA measurements. Seven flaps (14%) sustained some partial fat or skin necrosis. There was no significant difference in mean perforator internal diameter between 59 chosen medial perforators (mean 1.66 mm) and lateral perforators (mean 1.61 mm.p Z 0.284). Mean weight for 50 flaps was 618 gm. There was no significant difference between the weights of flaps with no necrosis and those with some. Comparing 43 flaps with no necrosis and 7 with some partial skin or fat necrosis, there were no significant differences for perforator numbers per flap (p Z 0.45) nor for mean vertical distance of perforators from flap equator (p Z 0.26). There was a marginal advantage for perforators closer to the midline (p Z 0.048) and a significant advantage for larger perforators as predicted by the FVI (p Z 0.037). |
3 |
| 31. Davis CR, Jones L, Tillett RL, Richards H, Wilson SM. Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging. Microsurgery. 39(1):24-31, 2019 Jan. |
Observational-Dx |
202 patients |
To correlate preoperative computed tomography angiography (CTA) findings with postoperative venous congestion to predict patients at risk of congestion. |
Two hundred and forty DIEP flaps were performed in 202 patients over the 4-year study. Venous congestion affected 15 flaps (6.3%). Preoperative CTA showed significantly more atypical venous connections between deep and superficial systems in congested flaps compared to controls (66.7% vs. 8%; P < .0001), with a positive predictive value of 83%. Atypical connections were narrow, tortuous, or incomplete. Patients with congestion-free flaps had more normal connections (80% vs. 26.7%; P < .001) and more cranial perforators (P = .02). Similar CTA findings between groups included perforator size and lateral position, superficial inferior epigastric vein size, crossing of midline, and absent connections (P > .05). |
2 |
| 32. Wagels M, Pillay R, Saylor A, Vrtik L, Senewiratne S. Predicting venous insufficiency in flaps raised on the deep inferior epigastric system using computed tomography (CT) angiography. J Plast Reconstr Aesthet Surg. 68(12):e200-2, 2015 Dec. |
Review/Other-Dx |
98 patients |
To conduct a retrospective cohort study of flap raised on the deep inferior epigastric system (DIES) at our institution in order to identify CTA signs that might predict venous congestion in these flaps. |
98 consecutive patients who had 124 DIES flaps raised from 2008 to 2012 were studied. Of these 124 flaps, four (3.2%) developed venous congestion. Our results showed that a Superficial Inferior Epigastric Vein (SIEV) that is larger than the DIEV at origin is highly predictive of congestion (5.2 vs 3.5 mm, p = 0.007). The findings of an axial non-arborising superficial system (96.7% vs 0, p < 0.001), without connection to deep system perforators (38.1 vs 88.8%, p < 0.001) and a type I pedicle were also predictive (75 vs 64.2%, p = 0.22). |
4 |
| 33. Han HH, Kang MK, Choe J, et al. Estimation of Contralateral Perfusion in the DIEP Flap by Scoring the Midline-Crossing Vessels in Computed Tomographic Angiography. Plast Reconstr Surg. 145(4):697e-705e, 2020 04. |
Observational-Dx |
94 patients |
To determine whether contralateral perfusion is related to blood vessel status across the midline. |
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). |
3 |
| 34. Ohkuma R, Mohan R, Baltodano PA, et al. Abdominally based free flap planning in breast reconstruction with computed tomographic angiography: systematic review and meta-analysis. Plast Reconstr Surg. 2014;133(3):483-494. |
Meta-analysis |
13 Studies |
To systematically assess breast reconstruction outcomes after abdominally based free flaps planned with preoperative computed tomographic angiography versus Doppler ultrasonography. |
A total of 13 studies met inclusion criteria. Preoperative computed tomographic angiography was associated with significantly fewer flap-related complications (relative risk, 0.87; 95 percent CI, 0.78 to 0.97), reduced donor-site morbidity (relative risk, 0.84; 95 percent CI, 0.76 to 0.94), and shorter reconstruction operative time by 87.7 minutes (mean difference, 87.7 minutes; 95 percent CI, 78.3 to 97.1 minutes). |
M |
| 35. Agrawal MD, Thimmappa ND, Vasile JV, et al. Autologous breast reconstruction: preoperative magnetic resonance angiography for perforator flap vessel mapping. J Reconstr Microsurg. 31(1):1-11, 2015 Jan. |
Review/Other-Dx |
400 MRA examinations |
To present our experience with magnetic resonance angiography (MRA) for perforator vessel mapping including MRA technique and interpretation. |
In our practice, anterior abdominal wall tissue is the most commonly used donor site for perforator flap breast reconstruction and deep inferior epigastric artery perforators are the most commonly used vascular pedicle. A thigh flap, based on the profunda femoral artery perforator has become the second most used flap at our institution. In addition, MRA imaging also showed evidence of metastatic disease in 4% of our patient subset. |
4 |
| 36. Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, Benito A, Dominguez PD, Zubieta JL. Preoperative planning of DIEP and SGAP flaps: preliminary experience with magnetic resonance angiography using 3-tesla equipment and blood-pool contrast medium. J Plast Reconstr Aesthet Surg. 2010;63(2):298-304. |
Review/Other-Dx |
10 Patients |
To show the usefulness of angio- MR, using a 3-T equipment and blood-pool contrast medium, for preoperative planning for DIEP and SGAP flaps. |
Angio-MR showed all the main perforator vessels later observed during the surgical procedure with a very good location concordance, but missed one main perforator vessels in each of two patients. In all patients undergoing SGAP flaps, an accurate identification of the main perforator vessels was achieved. Angio-MR clearly showed the intramuscular course of the perforator vessels for DIEP and SGAP flaps. Exact correlation between angio-MR and surgical findings was observed. |
4 |
| 37. Chong LW, Lakshminarayan R, Akali A. Utilisation of contrast-enhanced magnetic resonance angiography in the assessment of deep inferior epigastric artery perforator flap for breast reconstruction surgery. Clin Radiol. 74(6):445-449, 2019 06. |
Observational-Dx |
93 perforators |
To identify and characterise the ideal-sized (defined as at least 2.7 mm based on the experience of plastic surgeons at Hull Royal Infirmary) perforators using magnetic resonance angiography (MRA).To evaluate a presumption that perforators on the left are generally larger than on the right. |
Ninety-three ideal-sized perforators were identified (diameter of 2.8-4.2 mm). Fifty-one of these were located on the left, and 42 on the right. The left perforators were indeed larger than the right (Wilcoxon's test, p=0.017). Most of the perforators were found in the superior region and medial rows. Additionally, lateral row perforators were observed to have a shorter intramuscular course. |
4 |
| 38. Cina A, Salgarello M, Barone-Adesi L, Rinaldi P, Bonomo L. Planning breast reconstruction with deep inferior epigastric artery perforating vessels: multidetector CT angiography versus color Doppler US. Radiology. 2010;255(3):979-987. |
Observational-Dx |
45 patients |
To evaluate the accuracy of multidetector computed tomographic (CT) angiography versus color Doppler ultrasonography (US) for perforating artery identification, intramuscular course of perforator vessel assessment, and superficial venous communication detection before a deep inferior epigastric perforator (DIEP) procedure for breast reconstruction. |
The accuracy for identifying dominant perforator arteries was 97% for color Doppler US and 91% for CT angiography. Perforator arteries suitable for surgery were identified in 90% of cases with color Doppler US and in 95% of cases with CT angiography. For measurement of perforator calibers, surgical findings were similar to color Doppler US measurements (P = .33) but were significantly different than CT measurements (P < .0001). The accuracies for intramuscular course of perforator vessel assessment and superficial venous communication detection were 95% and 97% for CT and 84% and 80% for color Doppler US, respectively. In our population, the absence of superficial venous communication was associated with a risk for flap morbidity (P = .009). |
2 |
| 39. Greenspun D, Vasile J, Levine JL, et al. Anatomic imaging of abdominal perforator flaps without ionizing radiation: seeing is believing with magnetic resonance imaging angiography. J Reconstr Microsurg. 2010;26(1):37-44. |
Observational-Dx |
31 Patients |
To detail our initial experience with MRA for preoperative imaging of abdominal perforator vessels used for breast reconstruction. |
Fifty abdominal flaps were successfully transferred in 31 patients. All perforators visualized on MRA were found at surgery (0% false-positive). In two flaps, preoperative MRA failed to demonstrate significantly sized lateral row perforators vessels that were used for tissue transfer (4% false-negative rate). In both of these flaps, the signal from the patient’s buttock fat was inadequately suppressed and obscured the signal from the lateral portion of the abdomen. |
3 |
| 40. Kurlander DE, Brown MS, Iglesias RA, Gulani V, Soltanian HT. Mapping the superficial inferior epigastric system and its connection to the deep system: An MRA analysis. J Plast Reconstr Aesthet Surg. 69(2):221-6, 2016 Feb. |
Observational-Dx |
53 patients (106 hemiabdomens) |
To investigate preoperative imaging of patients undergoing free-flap breast reconstruction by a single surgeon between 2008 and 2013. |
This analysis included 53 patients (106 hemiabdomens). A total of 80 (75%) hemiabdomens were categorized as having simple and 10 (9%) as complex branching patterns. A total of 16 (15%) hemiabdomens had no identifiable vessels. At least one superficial-to-deep connection was found among 89 hemiabdomens (84%). Superficial systems crossing the midline were found in 14 patients (26%). |
4 |
| 41. Masia J, Kosutic D, Cervelli D, Clavero JA, Monill JM, Pons G. In search of the ideal method in perforator mapping: noncontrast magnetic resonance imaging. J Reconstr Microsurg. 2010;26(1):29-35. |
Observational-Dx |
162 Patients |
To evaluate our results after 3 years of using the multidetector scanner and to characterize the anatomic findings. |
In the first 36 cases, an absolute correlation was observed between the radiologic information and intraoperative findings. In the following 126 cases, surgery time and the rate of postoperative complications decreased significantly. During the evaluation of the radiologic image for each of the 162 patients studied, at least 1 appropriate perforator was identified as suitable for surgery. An average of 2.3 perforators on each hemiabdomen was found useful for surgery. In 4.9% of cases, only 1 perforator vessel was found to meet selection criteria because abdominal tissue was scarce; supraumbilical perforators could not be chosen since abdominal wall closure might be compromised. Only 1 suitable infraumbilical perforator was found in these patients. Its location and study by means of radiologic imaging contributed significantly to the success of the surgical procedure. |
3 |
| 42. Versluis B, Tuinder S, Boetes C, et al. Equilibrium-phase high spatial resolution contrast-enhanced MR angiography at 1.5T in preoperative imaging for perforator flap breast reconstruction. PLoS One. 2013;8(8):e71286. |
Observational-Dx |
23 Patients |
To evaluate the accuracy of equilibrium-phase high spatial resolution (EP) contrast-enhanced magnetic resonance angiography (CE-MRA) at 1.5T using a blood pool contrast agent for the preoperative evaluation of deep inferior epigastric artery perforator branches (DIEP), and to compare image quality with conventional first-pass CE-MRA. |
There was 100% agreement between EP CE-MRA and surgical findings in identifying the single best perforator branch. All EP acquisitions were of diagnostic quality, whereas in 10 patients the quality of the first-pass acquisition was qualified as non-diagnostic. Both signal- and contrast-to-noise ratios were significantly higher for EP imaging in comparison with first-pass acquisitions (p,0.01). |
2 |
| 43. Wade RG, Watford J, Wormald JCR, Bramhall RJ, Figus A. Perforator mapping reduces the operative time of DIEP flap breast reconstruction: A systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography. J Plast Reconstr Aesthet Surg. 71(4):468-477, 2018 04. |
Meta-analysis |
14 articles |
To investigate the hypothesis that preoperative perforator mapping by ultrasound, CTA or MRA prior to DIEP flap breast reconstruction, reduces operating time. |
Fourteen articles were included. Preoperative perforator mapping by CTA or MRA significantly reduced operating time (mean reduction of 54 minutes [95% CI 3, 105], p = 0.04), when directly compared to DIEP flap breast reconstruction with no perforator mapping. Further, perforator mapping by CTA was superior to ultrasound, as CTA saved more time in theatre (mean reduction of 58 minutes [95% CI 25, 91], p < 0.001) and was associated with a lower risk of partial flap failure (RR 0.15 [95% CI 0.04, 0.6], p = 0.007). All studies were at risk of methodological bias and the quality of the evidence was very low. |
Inadequate |
| 44. Kiely J, Kumar M, Wade RG. The accuracy of different modalities of perforator mapping for unilateral DIEP flap breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021;74:945-56. |
Meta-analysis |
21 articles with 1146 women |
To evaluate the accuracy of different modalities for locating perforators for unipedicled DIEP flap breast reconstruction. |
Six methods were described; handheld doppler, colour doppler (duplex) ultrasonography, computed tomography angiography, magnetic resonance angiography (MRA), direct infrared thermography with and without doppler. Meta-analysis revealed 94% (95% CI 88-99%) of DIEPs identified as the 'dominant perforator' on imaging were chosen as dominant perforators intraoperatively. Colour doppler (Duplex) ultrasonography had the lowest agreement (mean 74% [95% CI 67-81%]) whilst MRA had the highest agreement (mean 97% [95% CI 86-100%]). There was no statistically significant difference in the performance of different tests. All studies were subject to bias as the operators had knowledge of the index test prior to conducting the reference standard. |
Good |
| 45. Cina A, Barone-Adesi L, Rinaldi P, et al. Planning deep inferior epigastric perforator flaps for breast reconstruction: a comparison between multidetector computed tomography and magnetic resonance angiography. Eur Radiol. 2013;23(8):2333-2343. |
Observational-Dx |
23 Patients |
To prospectively evaluate the accuracy of both techniques in identifying perforator vessels, measuring their calibre and IMC, assessing DVC between perforators and the superficial venous network, SVC between the right and left hemiabdomen and DIEA branching type, in patients undergoing DIEP flap breast reconstruction. |
Accuracy in identifying dominant perforators was 91.3 % for both techniques and mean error in calibre measurement 1.18 +/- 0.35 mm for CTA and 1.63 +/- 0.39 mm for MRA. Accuracy in assessing perforator IMCs was 97.1 % for CTA and 88.4 % for MRA, DVC 94.4 % for both techniques, SVC 91.3 % as well, and DIEA branching type 100 % for CTA and 91.3 % for MRA. Image acquisition and interpretation time was 21 +/- 3 min for CTA (35 +/- 5 min for MRA). |
2 |
| 46. Klasson S, Svensson H, Malm K, Wasselius J, Velander P. Preoperative CT angiography versus Doppler ultrasound mapping of abdominal perforator in DIEP breast reconstructions: A randomized prospective study. J Plast Reconstr Aesthet Surg. 68(6):782-6, 2015 Jun. |
Experimental-Dx |
CTA group = 32 patients; US group = 31 patients |
To examine the difference in surgery time and complication rate when Doppler ultrasound (US) is used for the preoperative mapping of perforators in comparison with computer tomography angiography (CTA). |
Women who were candidates for breast reconstruction using the deep inferior epigastric perforator (DIEP) free flap were enrolled in a prospective randomized study. The operating time was 249 ± 62 min (mean ± SD) in the CTA group (n = 32) and 255 min ± 75 in the US group (n = 31)--hence a difference of 6 min on average. No flaps were lost. Sixteen complications occurred in 15 patients: seven in the CTA group and nine in the US group. |
1 |
| 47. Mijuskovic B, Tremp M, Heimer MM, et al. Color Doppler ultrasound and computed tomographic angiography for perforator mapping in DIEP flap breast reconstruction revisited: A cohort study. J Plast Reconstr Aesthet Surg. 72(10):1632-1639, 2019 Oct. |
Observational-Dx |
98 patients |
To revisit the role of Color Doppler Ultrasound (CDU) by comparing the reliability of CDU and Computed Tomographic Angiography (CTA) in predicting intraoperative perforator selection. |
We identified 98 patients who received 125 DIEP flap surgeries. A significantly stronger correlation was found between CDU and intraoperative findings of perforator detection and size (p<0.0001) and selection (r = 0.9987, CI 0.9981-0.9991, p < 0.0001 and r = 0.01, CI -0.18-0.2, p = 0.91, respectively), when compared with CTA data. If none of the preoperative imaging studies matched intraoperative perforator selection, an association with a higher incidence of flap loss (Odds ratio 4.483, CI 0.5068-39.65, p = 0.2171) was found. |
3 |
| 48. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. |
Review/Other-Dx |
N/A |
To provide evidence-based guidelines on exposure of patients to ionizing radiation. |
No abstract available. |
4 |
