Conventional CT versus Dedicated CT Angiography in DIEP Flap Planning: A Feasibility Study.

Alessandro Cina,Paolo Belli,Gianluca Franceschini,Riccardo Manfredi,Elena Jane Mason,Giulia Macrì,Giuseppe Visconti,Marzia Salgarello,Liliana Barone Adesi,Anna D’Angelo,Sara Mercogliano,Pierluigi Barbieri,Sabatino D’Archi,Cristina Grippo

doi:10.3390/jpm11040277

Abstract

The deep inferior epigastric perforator (DIEP) flap is used with increasing frequency in post-mastectomy breast reconstruction. Preoperative mapping with CT angiography (CTa) is crucial in reducing surgical complications and optimizing surgical techniques. Our study’s goal was to investigate the accuracy of conventional CT (cCT), performed during disease staging, compared to CTa in preoperative DIEP flap planning. In this retrospective, single-center study, we enrolled patients scheduled for mastectomy and DIEP flap breast reconstruction, subjected to cCT within 24 months after CTa. We included 35 patients in the study. cCT accuracy was 95% (CI 0.80–0.98) in assessing the three largest perforators, 100% (CI 0.89–100) in assessing the dominant perforator, 93% (CI 0.71–0.94) in assessing the perforator intramuscular course, and 90.6% (CI 0.79–0.98) in assessing superficial venous communications. Superficial inferior epigastric artery (SIEA) caliber was recognized in 90% of cases (CI 0.84–0.99), with an excellent assessment of superficial inferior epigastric vein (SIEV) integrity (96% of cases, CI 0.84–0.99), and a lower accuracy in the evaluation of deep inferior epigastric artery (DIEA) branching type (85% of cases, CI 0.69–0.93). The mean X-ray dose spared would have been 788 ± 255 mGy/cm. Our study shows that cCT is as accurate as CTa in DIEP flap surgery planning.

Highlights

The Superficial inferior epigastric artery (SIEA) caliber was correctly assessed by conventional CT (cCT) in 90% of cases (CI 0.84–0.99). cCT was less accurate in the evaluation of deep inferior epigastric artery (DIEA) branching type (85% of cases, CI 0.69–0.93), but had an excellent assessment of the integrity of superficial inferior epigastric vein (SIEV) (96% of cases, CI 0.84–0.99)
The results of our study show that cCT, performed routinely during breast cancer disease staging, is as accurate as CT angiography (CTa) in obtaining information required for deep inferior epigastric perforator (DIEP) flap planning
Our results show an excellent diagnostic accuracy of cCT in identifying the three largest perforators, the perforator intramuscular course, SCVs, the dominant perforator, SIEA caliber, and SIEV integrity. cCT was less accurate in the evaluation of DIEA branching type, probably because of lower contrast resolution during the venous phase, different contrast medium injection speed, and the cranial-caudal direction of acquisition

Summary

Introduction

The deep inferior epigastric perforator (DIEP) flap is, nowadays, considered the “gold standard” in autologous breast reconstruction [1]. Subcutaneous tissue and skin are transferred from the abdomen to the thorax in order to guarantee a more natural appearance of the reconstructed breast, compared to heterologous approach [2,3] (Figures 1 and 2). A low donor site morbidity with an aesthetical abdomen improvement is an important factor for choosing DIEP flap in autologous breast reconstruction. The inconsistent anatomy of the abdominal perforators leads to a more challenging and time-consuming technique compared to a (muscle sparing) Transverse Rectus Abdominis Muscle (TRAM) flap [4,5]

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Conclusion