Differential visualization of arterial and venous flow in deep inferior epigastric perforator imaging with vector-flow perforator Phase Contrast Angiography (pPCA)

Abstract

Perforator flaps are commonly used in reconstructive surgery, with decreased donor site morbidity and increased flexibility in flap design cited as advantages over traditional techniques. 1. Lee BT Lin SJ Bar-Meir ED et al. Pedicled perforator flaps: a new principle in reconstructive surgery. Plast Reconstr Surg. 2010; 125: 201-208 Crossref PubMed Scopus (25) Google Scholar Vascular imaging is often obtained preoperatively in order to facilitate flap design and execution. 2. Garvey PB Selber JC Madewell JE et al. A prospective study of preoperative computed tomographic angiography for head and neck reconstruction with anterolateral thigh flaps. Plast Reconstr Surg. 2011; 127: 1505-1514 Crossref PubMed Scopus (35) Google Scholar , 3. Kim H Lim SY Pyon JK et al. Preoperative computed tomographic angiography of both donor and recipient sites for microsurgical breast reconstruction. Plast Reconstr Surg. 2012; 130: 11e-20e Crossref PubMed Scopus (34) Google Scholar Computed tomographic angiography (CTA) is widely used in a variety of different perforator flaps, but possesses a number of drawbacks. CTA utilizes ionizing radiation, which is of particular concern to the patient population receiving perforator flap surgery as many of them are young and with greater than usual susceptibility to radiation induced neoplasia due to risk factors such as BRCA gene mutations and Li-Fraumeni Syndrome. The average radiation dose of an abdominal CT is 8 mSv, which is equivalent to 2.6 years of natural background radiation. 4. Mettler Jr, FA Huda W Yoshizumi TT et al. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology. 2008; 248: 254-263 Crossref PubMed Scopus (1450) Google Scholar In addition, CTA requires the administration of exogenous iodine-based contrast medium, which has potential adverse effects including nephrotoxicity and anaphylaxis. Lastly, CTA predominately delineates arterial anatomy, whereas both arteries and veins are of interest in perforator flap surgery. To address these limitations, we developed a novel imaging technique, perforator Phase Contrast Angiography (pPCA), which does not require use of ionizing radiation or exogenous contrast medium. In an earlier publication, we reported an initial application of pPCA to deep inferior epigastric artery perforator (DIEP) imaging and assessed its performance against CTA. 5. Yang X Miller MJ Friel HT et al. Perforator phase contrast angiography of deep inferior epigastric perforators: a better preoperative imaging tool for flap surgery than computed tomographic angiography?. Invest Radiol. 2017; 52: 334-342 Google Scholar In this communication, we describe a further refinement of the pPCA technique that provides the ability to differentiate between arteries and veins, which is likely to be of potential use to reconstructive microsurgeons in both clinical practice and research.