Use Of Preoperative Computed Tomography Angiography Research Articles

Encountering Peritoneo-Cutaneous Perforators in Microsurgical DIEP Flap Breast Reconstruction.

The vascular anatomy of the deep inferior epigastric artery perforator (DIEP) flap has been well studied in the planning for autologous breast reconstruction. Preoperative imaging with computed tomography angiography (CTA) provides accurate assessment of this vascular anatomy, which varies widely across patients. Several papers to date have described their encounter with an anomalous "epiperitoneal" or "peritoneo-cutaneous" perforator during flap harvest, a perforator that pierces the posterior rectus sheath from a peritoneal origin, to traverse rectus abdominis and supply the DIEP flap integument. In the course of over 3,000 CTA assessments of the vascular anatomy of the abdominal wall, we have encountered dominant peritoneo-cutaneous perforators in 1% of cases, and smaller perforators seen in many more cases, approaching 5% of cases. With increasing sensitivity of imaging, we also describe a unique case of multiple large bilateral peritoneo-cutaneous perforators, and present these findings in the context of DIEP flap harvest. It is critical to recognize these peritoneo-cutaneous perforators preoperatively to avoid mistaking them for a DIEP during the raising of a DIEP flap. The routine use of preoperative CTA enables the safe identification of individual vascular anatomy, including significant peritoneo-cutaneous perforators.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time.

Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes. A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively. Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction. CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

Localization of the Dominant Deep Inferior Epigastric Artery Perforator by Computed Tomography Angiogram

The deep inferior epigastric artery perforator (DIEP) free flap is the optimal autogenous reconstructive technique in many patients undergoing postmastectomy. Our aim was to evaluate the standard DIEP free flap design in relation to the dominant perforating vessels using computed tomography angiography (CTA). We retrospectively reviewed CTAs from 75 patients who had undergone perforator flap reconstruction within the past year. Locations of the largest perforator with a minimum diameter of 2.0 mm piercing the anterior rectus fascia were recorded. Of 150 hemiabdomens reviewed, 146 (97.3%) had a dominant perforator. The median location for the dominant perforator was 3.3 cm lateral and 0.9 cm below the umbilicus. One hundred twenty-one (83%) of the dominant perforators arose within 3 cm of the umbilicus. One hundred one (69%) arose at or below the level of the umbilicus. Forty-five (31%) arose above the level of the umbilicus. Thirteen (9%) arose more than 2 cm above the umbilicus. The standard DIEP flap design incorporates most of the dominant perforating vessels. However, a significant number of perforators arise at or above the umbilicus, which would be near the edge or out of the standard design of the DIEP. Our findings support the use of preoperative CTA in the evaluation of patients undergoing DIEP free flap reconstruction. Modification of flap design to include the dominant perforating vessels should be considered when the dominant vessel is outside the standard design of the DIEP.

Evaluation of preoperative computed tomography angiography in association with conventional angiography versus computed tomography angiography only, in the endovascular treatment of aortic diseases

Objective To evaluate the association of conventional angiography (AG) with computed tomography angiography (CTA) as compared with CTA only, preoperatively, in the treatment of aortic diseases. Materials and Methods Retrospective study involving patients submitted to endovascular treatment of aortic diseases, in the period from January 2009 to July 2010, with use of preoperative CTA + conventional AG or CTA only. The patients were divided into two groups, namely: G1 – thoracic aortic diseases; and G2 – abdominal aortic diseases. G1 was subdivided into 1A (preoperative AG + CTA) and 1B (preoperative CTA). G2 was subdivided into 2C (CTA + AG) and 2D (CTA only). Results The authors evaluated 156 patients. In subgroups 1A and 1B, the rate of technical success was, respectively, 100% and 94.7% (p = 1.0); and the rate of therapeutic success was, respectively, 81% and 58% (p = 0.13). A higher number of complications were observed in subgroup 1B (p = 0.057). The accuracy in the calculation of the prosthesis was higher in subgroup 1A (p = 0.065). In their turn, the rate of technical success in subgroups 2C and 2D was, respectively, 92.3% and 98.6% (p = 0.17). The rate of therapeutic success was 73% and 98.6% (p = 0.79). Conclusion Preoperative conventional AG should be reserved for cases where CTA cannot provide all the information in the planning of a therapeutic intervention.

Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction?

Breast reconstruction is increasingly performed with the use of the abdominal wall donor site, with potential complications including donor site morbidity and impaired flap viability. As a tool for selecting the optimal perforators which will ultimately supply the flap, preoperative imaging with computed tomography angiography (CTA) has become increasingly popular. Potential benefits include reduced intramuscular dissection, with faster and safer dissection, reduced donor site morbidity and improved flap vascularity and survival. Despite the potential for improvements in operative outcome, any benefits are yet to be established. A cohort study of 104 breast reconstructions in 88 patients was conducted. All patients underwent breast reconstruction based on an abdominal wall free flap. Of these, 40 patients undergoing preoperative imaging with CTA and 48 patients not undergoing CTA were included, with all CTAs undertaken at a single institution. Length of operation, length of stay, and operative complications were assessed. An evaluation of operative stress was achieved with the use of visual analogue scales (VAS) administered to the surgeons. The use of CTA was associated with decreased operating time (mean: 77 min for bilateral cases), significantly decreased complications related to flap viability (particularly partial flap loss), and a statistically significant reduction in donor site morbidity. Psychometric testing of surgeons revealed a statistically significant decrease in operative stress (41% decrease) with the use of preoperative CTA. The use of CTA for preoperative imaging in breast reconstruction is associated with improved operative outcomes.