Concordance between preoperative computed tomography angiographic mapping and intraoperative perforator selection for deep inferior epigastric artery perforator flap breast reconstructions

Vivian B. Boer, Jan J. van Wingerden, Carolien F. Wever, Joost J. Kardux, Michiel R. Beets, Hester J. van der Zaag-Loonen, Willem J. Theuvenet


Background: Preoperative imaging for perforator identification prior to a deep inferior epigastric artery perforator (DIEP) flap elevation for breast reconstruction has many advantages. Currently, computed tomography (CT) angiography provides good visualization of the perforators and their course, and is thus the imaging technique of choice. The primary aim of this study was to determine the concordance between the perforators identified preoperatively and the perforators ultimately selected intraoperatively, with a standardized protocol, in a single institution. Secondly, we wanted to compare our results with those of other, similar studies and, thirdly, to identify those factors that may lead to a higher concordance.
Methods: A retrospective review was undertaken of a case series of 49 consecutive patients undergoing unilateral autologous breast reconstruction with a DIEP flap at the Gelre Hospital, in the Netherlands, over a 4-year period from 2013 to 2017. The preoperative identification and selection of perforator number and location with the aid of CT angiography scanning were compared to the intraoperative findings and preference.
Results: Our study revealed a concordance of 67.3% between one or more perforators advised preoperatively by the radiologist and chosen intraoperatively by the surgeon. We identified significant differences in our protocol compared to others.
Conclusions: The study confirmed the benefit to both the patient and the surgeon when preoperative CT angiography is used. Scanning protocols may vary considerably and should thus be carefully scrutinized before future comparisons are made. Based on this study, the scanning range, method of selecting perforators and timing of image acquisition may have to be optimized for future prospective clinical trials.