A Further Strategy for Managing Intraoperative Venous Congestion in Abdominally Based Autologous Breast Reconstruction

Abstract

Sir:FigureWe read with great interest the recent article by Dr. Sbitany and colleagues regarding the strategies for recognizing and managing intraoperatively the abdominal free flap venous congestion in breast reconstruction.1 As the authors highlighted, intraoperative venous congestion is multifactorial and, when not technically related (selection of inadequate perforator and/or unreliable venous anastomosis), depends mainly on the anatomical dominance of the superficial venous system. The authors reported a series of 1201 patients who underwent abdomen-based autogenous breast reconstruction without any preoperative imaging perforator assessment. Among these, 11 cases exhibited intraoperative venous congestion without evidence of venous thrombosis. Of these, 10 were transverse rectus abdominis musculocutaneous flaps and one was a deep inferior epigastric artery perforator (DIEP) flap. The presence of an engorged superficial inferior epigastric vein (SIEV) along with brisk bleeding when declamped, and flow-through anastomosis on the strip test and on Doppler ultrasound imaging, emphasized that congestion was attributable to the dominance of the superficial venous system that was not adequately drained by the deep system. Their suspicions were confirmed intraoperatively, as the congestion resolved after the ipsilateral SIEV was connected. As described in the past by Rohde and Keller in 2005,2 they anastomose the SIEV to the deep system by creating a superficial-to-deep venous loop within the flap. The venous drainage into the contralateral deep inferior epigastric vein is ensured by the H-communications naturally present between the two retrograde internal mammary veins.3 The technique described represents a valid alternative to more tedious procedures, such as using distant recipient veins. We share with Sbitany et al. recognition of the method for superficial venous congestion. However, by using preoperative imaging such as multidetector-row computed tomography, we do study the superficial venous flap hemodynamics, by evaluating both the midline venous communication and the deep-to-superficial venous system communications at the level of the selected perforator.4 By enhancing the preoperative perforator selection process, it is possible to reduce the rate of venous congestion resulting from the inadequate choice of perforator. When superficial venous congestion occurs, we routinely supercharge the venous outflow by anastomosing the SIEV to the homolateral internal mammary vein. Depending on how the deep inferior epigastric artery and vein and SIEV naturally accommodate once the flap is positioned on the chest wall for microanastomosis, we anastomose the deep inferior epigastric artery and vein and the SIEV, respectively, to the antegrade and retrograde internal mammary vessels or vice versa (Fig. 1).Fig. 1: Intraoperative photograph of a three-zone DIEP flap transferred to the chest wall for delayed breast reconstruction. The anastomoses are completed. The deep inferior epigastric artery and vein (DIEA/V) have been anastomosed to the antegrade limb of the internal mammary vessels (AIMV). Because of intraoperative superficial venous congestion, the flap has been venous supercharged by anastomosing the contralateral superficial epigastric vein (SIEV) to the retrograde internal mammary vein (RIMVein). After the latter anastomosis, the congestion resolved.This is an easier, faster, and reliable way of anastomosing the SIEV.5 The retrograde internal mammary vessels are ready for use after the preparation of the internal mammary vessels; thus, no further vessel dissection is needed. Both the artery and the vein have a good caliber, which makes the anastomosis easier and more reliable. Being at the same level of the main anastomosis (i.e., with deep inferior epigastric artery and vein), the flap insetting is not spoiled. According to our experience, retrograde internal mammary vessels (work in progress) should be taken into consideration as further reliable recipient vessels in autologous breast reconstruction for both flap pedicle anastomosis and venous supercharging. Marzia Salgarello, M.D. Giuseppe Visconti, M.D. Department of Plastic and Reconstructive Surgery Liliana Barone-Adesi, M.D. Breast Unit, Catholic University of Sacro Cuore, University Hospital A. Gemelli, Rome, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.