Clinical utility of CT angiography in DIEP breast reconstruction

CT angiography has become the gold-standard imaging modality prior to DIEP flap breast reconstructions. Recent studies show excellent correlation between CTA and operative perforator location, but not their clinical significance. This study seeks to specifically evaluate the clinical utility of CTA in DIEP free flaps.

Preoperative CT angiography of the deep inferior epigastric system was obtained in 52 sequential DIEP free flaps involving 37 patients with dominant perforators marked by radiologist. Planned and used perforators were documented by the surgeon before and after the operation.

A total of 62 out of 76 planned perforators were ultimately used (82%). Of those not used, 71% were abandoned due to inadequacy of preoperative CT. An additional 38 perforators were used that were not part of the initial preoperative plan, 60% of which were added due to inadequacy of the preoperative CT for planning. In total 23/52 flaps (44%) involved intraoperative changes due to features not appreciated on preoperative CT.

CTA mapping of perforators prior to DIEP flap surgery increases surgeon confidence and reduces operative time; however, there are still a significant number of changes made based on clinical judgment. This study highlights the importance of surgeon review of CTA images. Caution is warranted in reliance on CTA mapping, and significant perforators should not be sacrificed until the anticipated perforator(s) have been exposed and evaluated.

Level 3.