Preoperative Angio-CT preliminary study of the TRAM flap after selective vascular delay

The pedicled TRAM (pTRAM) flap is one of the best options for autologous breast reconstruction, but vascular complications reported in the standard versions are about 30%. To reduce complication rate, especially in high-risk patients, surgical delay has been suggested. Individual precise preoperative location and evaluation of perforating vessels and of variations of the diameter of the deep superior epigastric artery (DSEA) are highly desirable for improving surgical strategy. Previous reports using color duplex scanning, although generally confirming the validity of the delay maneuver, have showed several pitfalls. The aim of this report was to demonstrate the usefulness of multidetector computed tomography angiography (MDCTA) for preoperative planning in patients undergoing pTRAM flap breast reconstruction after selective vascular delay.

Three patients were considered for breast reconstruction with the pTRAM flap. An MDCTA was performed before and after selective delay to locate the muscle perforators and to show increase in DSEA diameter. Axial images, multiplanar reconstruction, and 3D volume images were analyzed.

Accurate identification of the main perforators was achieved. Location, course, and anatomic variations of DSEA were reported. The average increase in diameter of the DSEA was 29.3%.

Preoperative planning of pTRAM flap with MDCTA allows surgeons to visualize and locate the dominant perforators and to select the best DSEA. Consequently, the choice between the homolateral or contralateral rectus muscle is facilitated. The high sensitivity and specificity and the ease of interpreting data have made MDCTA a highly promising diagnostic tool for planning a pTRAM flap.