Davis Christopher R, Jones Lyn, Tillett Rachel L, Richards Helen, Wilson Sherif M
Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom.
Department of Plastic Surgery, Southmead Hospital, Bristol, United Kingdom.
Microsurgery. 2019 Jan;39(1):24-31. doi: 10.1002/micr.30367. Epub 2018 Sep 5.
Venous congestion is the principle cause of flap failure after microsurgical breast reconstruction. We aim to correlate preoperative computed tomography angiography (CTA) findings with postoperative venous congestion to predict patients at risk of congestion.
All patients undergoing deep inferior epigastric perforator (DIEP) breast reconstruction between August 2009 and August 2013 underwent preoperative CTA and prospectively entered the study. Patients with postoperative venous congestion were matched with a similar cohort of complication-free patients. Preoperative CTAs were randomized and re-interpreted by a radiologist, blinded to the subsequent clinical outcome. Inter-group comparisons were performed.
Two hundred and forty DIEP flaps were performed in 202 patients over the 4-year study. Venous congestion affected 15 flaps (6.3%). Preoperative CTA showed significantly more atypical venous connections between deep and superficial systems in congested flaps compared to controls (66.7% vs. 8%; P < .0001), with a positive predictive value of 83%. Atypical connections were narrow, tortuous, or incomplete. Patients with congestion-free flaps had more normal connections (80% vs. 26.7%; P < .001) and more cranial perforators (P = .02). Similar CTA findings between groups included perforator size and lateral position, superficial inferior epigastric vein size, crossing of midline, and absent connections (P > .05).
Preoperative CTA identifies atypical venous connections between deep and superficial systems that increase the risk of postoperative DIEP congestion five-fold. Identifying atypical venous connections maximizes the chances of flap survival and minimizes complications for patients considering DIEP breast reconstruction.
静脉淤血是显微外科乳房重建术后皮瓣坏死的主要原因。我们旨在将术前计算机断层血管造影（CTA）结果与术后静脉淤血情况相关联，以预测有淤血风险的患者。
2009年8月至2013年8月期间所有接受腹壁下深动脉穿支（DIEP）乳房重建的患者均接受了术前CTA检查，并前瞻性地纳入本研究。术后出现静脉淤血的患者与一组类似的无并发症患者进行匹配。术前CTA随机分组后由一位对后续临床结果不知情的放射科医生重新解读。进行组间比较。
在为期4年的研究中，202例患者共进行了240例DIEP皮瓣移植。15例皮瓣（6.3%）出现静脉淤血。与对照组相比，术前CTA显示淤血皮瓣的深浅静脉系统之间非典型静脉连接明显更多（66.7%对8%；P <.0001），阳性预测值为83%。非典型连接狭窄、迂曲或不完整。无淤血皮瓣的患者有更多正常连接（80%对26.7%；P <.001）和更多的头侧穿支（P =.02）。两组间相似的CTA表现包括穿支大小和外侧位置、腹壁浅静脉大小、中线交叉情况以及无连接情况（P >.05）。
术前CTA可识别深浅静脉系统之间的非典型静脉连接，这些连接会使术后DIEP淤血风险增加五倍。识别非典型静脉连接可最大程度提高皮瓣存活几率，并将考虑进行DIEP乳房重建患者的并发症降至最低。
