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Real-World Justification for Use of CT Angiography in Free Flap Breast Reconstruction
James Boehmler, Fred Durden, Ergun Kocak, Pankaj Tiwari
Ohio State University
2012-01-30
Presenter: James Boehmler
Affidavit:
Director Name:
Author Category: Attending
Presentation Category: Clinical
Abstract Category: Breast (Aesthetic and Recon.)
How does this presentation meet the established conference educational objectives?
This presentation will give an update to the rationale and benefits of CT angiography in the planning of free flap breast reconstruction.
How will your presentation be used by practicing physicians in the audience?
By elucidated secondary benefits of CT angiography in the planning of free flap breast reconstruction, the physician will have the tools to better and more efficiently treat his patients while avoiding certain "traps" or complications which might be elucidated by the CT angiogram.
Preoperative perforator imaging has become increasingly common prior to free flap breast reconstruction. CT angiograms (CTA) allow for subcutaneous and intramuscular visualization of the vascular anatomy of the deep inferior epigastric (DIE) and superficial inferior epigastric (SIE) systems. Despite the potential benefits of CTA (including faster perforator identification and dissection, increased use of DIEP and SIEA flaps, and overall cost savings), there is still controversy about the regular utilization of CTA in breast reconstruction. In this study, a 5-year retrospective analysis was performed of all patients undergoing free flap breast reconstruction at a single institution to identify situations where the data obtained from CTA definitively changed the operative plan. In the analysis, it was discovered that CTA presented several scenarios which significantly altered the operative plan prior to surgery: 1) inadequate or absent flow identified from DIE source vessels; 2) inadequate infra-umbilical perforators which required elevation of the skin paddle design to incorporate supra-umbilical perforators; 3) significant SIEA visualized on CTA requiring lower skin paddle design to incorporate SIE system; 4) diagnosis of previously unknown metastatic bone and visceral bone cancer leading to cancellation of surgery and further cancer management. In each of these scenarios, the CTA was instrumental in either changing the operative plan or identifying potential microsurgical disasters that were successfully averted. Although routine CTA for breast reconstruction is a valuable tool to increase operative efficiency, it was determined that its additional, and potentially greater, value is in identifying potential anatomic and medical problems prophylactically.
