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J Reconstr Microsurg 2018; 34(06): 404-412
DOI: 10.1055/s-0038-1626695
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Algorithmic Approach for Intraoperative Salvage of Venous Congestion in DIEP Flaps

Erica L. Bartlett
1   Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
,
Dmitry Zavlin
2   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
,
Zachery K. Menn
2   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
,
Aldona J. Spiegel
2   Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
› Author Affiliations
Further Information

Publication History

06 September 2017

14 December 2017

Publication Date:
16 February 2018 (online)

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Abstract

Background Flap congestion is a frequently described intraoperative complication during autologous breast reconstruction with abdominal perforator flaps, which, if not addressed, can lead to detrimental results such as flap failure. Here, we describe our institution's algorithm of intraoperative salvage of congested flaps and present their outcomes.

Patients and Methods All patient charts from 2002 to 2016 of a single plastic surgeon were reviewed for patients who underwent deep inferior epigastric perforator flap breast reconstruction resulting in 602 patients and 831 flaps. Of those, 38 women (6.3%) with 40 congested flaps (4.8%) were included in this study. Based on the algorithm guiding the selection of additional venous anastomosis, the patients' surgical details, outcomes, as well as their demographic characteristics are evaluated.

Results Average age and body mass index of our cohort were 47.0 ± 8.0 years and 26.1 ± 3.9, respectively. Ten patients (26.3%) were current or former smokers while 20 (52.6%) required external radiation. Thirty-two congested flaps (80.0%) were predominantly salvaged with a superficial inferior epigastric vein (SIEV)-to-deep inferior epigastric vein (comitante) anastomosis. An SIEV-to-internal mammary vein comitante anastomosis was the second favorite option (5 flaps, 12.5%). Five patients suffered minor complications within a mean follow-up of 18.8 ± 12.3 months without flap failure, bleeding, or infection.

Conclusions Venous flap congestion is an uncommon intraoperative intricacy during free tissue transfer for autologous breast reconstruction. Our proposed algorithm primarily recommends adding an additional venous anastomosis between the superficial and deep drainage system and results and favorable outcomes without major complications.

Keywords

venous congestion - anastomosis - free tissue transfer - breast reconstruction

Presentation

Parts of this manuscript were presented at the annual meeting of the Texas Society of Plastic Surgeons taking place in Ft. Worth, Texas (September 15–17, 2017).


Ethical Considerations

The work described in this manuscript was approved by our institutional review board (Protocol number Pro00011704: “Observational Research in the Department of Plastic and Reconstructive Surgery”). The authors adhered to the Declaration of Helsinki at all times.


Letter to this article:

Anterograde Flow Rerouting in Venous Supercharged DIEP FlapJ Reconstr Microsurg 2018; 34(06): e5-e5
DOI: 10.1055/s-0039-1700557

 

  • References

  • 1 Knox ADC, Ho AL, Leung L. , et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: a 12-year clinical retrospective study and literature review. Plast Reconstr Surg 2016; 138 (01) 16-28
    CrossrefPubMedGoogle Scholar
  • 2 Atisha DM, Rushing CN, Samsa GP. , et al. A national snapshot of satisfaction with breast cancer procedures. Ann Surg Oncol 2015; 22 (02) 361-369
    CrossrefPubMedGoogle Scholar
  • 3 Hutcheson HA, Hartrampf Jr CR. Breast reconstruction using abdominal tissue. Plast Surg Nurs 1986; 6 (03) 97-104
    CrossrefPubMedGoogle Scholar
  • 4 Mennie JC, Mohanna P-N, O'Donoghue JM, Rainsbury R, Cromwell DA. Donor-site hernia repair in abdominal flap breast reconstruction: a population-based cohort study of 7929 patients. Plast Reconstr Surg 2015; 136 (01) 1-9
    PubMedGoogle Scholar
  • 5 Ochoa O, Chrysopoulo M, Nastala C, Ledoux P, Pisano S. Abdominal wall stability and flap complications after deep inferior epigastric perforator flap breast reconstruction: does body mass index make a difference? Analysis of 418 patients and 639 flaps. Plast Reconstr Surg 2012; 130 (01) 21e-33e
    CrossrefPubMedGoogle Scholar
  • 6 Atisha D, Alderman AK. A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction. Ann Plast Surg 2009; 63 (02) 222-230
    CrossrefPubMedGoogle Scholar
  • 7 Galanis C, Nguyen P, Koh J, Roostaeian J, Festekjian J, Crisera C. Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg 2014; 134 (01) 20-27
    PubMedGoogle Scholar
  • 8 Garvey PB, Buchel EW, Pockaj BA, Casey WJ, Gray RJ, Samson TD. The DIEP and pedicled TRAM: a comparison of outcomes. Plast Reconstr Surg 2005; 116 (Supplement): 208-210
    CrossrefPubMedGoogle Scholar
  • 9 Blondeel PN, Arnstein M, Verstraete K. , et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000; 106 (06) 1295-1299
    CrossrefPubMedGoogle Scholar
  • 10 Niranjan NS, Khandwala AR, Mackenzie DM. Venous augmentation of the free TRAM flap. Br J Plast Surg 2001; 54 (04) 335-337
    CrossrefPubMedGoogle Scholar
  • 11 Sbitany H, Mirzabeigi MN, Kovach SJ, Wu LC, Serletti JM. Strategies for recognizing and managing intraoperative venous congestion in abdominally based autologous breast reconstruction. Plast Reconstr Surg 2012; 129 (04) 809-815
    CrossrefPubMedGoogle Scholar
  • 12 Kim D-Y, Lee TJ, Kim EK, Yun J, Eom JS. Intraoperative venous congestion in free transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator flaps during breast reconstruction: a systematic review. Plast Surg (Oakv) 2015; 23 (04) 255-259
    PubMedGoogle Scholar
  • 13 Imanishi N, Nakajima H, Minabe T, Chang H, Aiso S. Anatomical relationship between arteries and veins in the paraumbilical region. Br J Plast Surg 2003; 56 (06) 552-556
    CrossrefPubMedGoogle Scholar
  • 14 Rozen WM, Pan W-R, Le Roux CM, Taylor GI, Ashton MW. The venous anatomy of the anterior abdominal wall: an anatomical and clinical study. Plast Reconstr Surg 2009; 124 (03) 848-853
    CrossrefPubMedGoogle Scholar
  • 15 Smit JM, Audolfsson T, Whitaker IS, Werker PM, Acosta R, Liss AG. Measuring the pressure in the superficial inferior epigastric vein to monitor for venous congestion in deep inferior epigastric artery perforator breast reconstructions: a pilot study. J Reconstr Microsurg 2010; 26 (02) 103-107
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Civelek B, Kargi E, Aköz T, Sensöz O. Turbocharge or supercharge?. Plast Reconstr Surg 1998; 102 (04) 1303
    CrossrefPubMedGoogle Scholar
  • 17 Semple JL. Retrograde microvascular augmentation (turbocharging) of a single-pedicle TRAM flap through a deep inferior epigastric arterial and venous loop. Plast Reconstr Surg 1994; 93 (01) 109-117
    CrossrefPubMedGoogle Scholar
  • 18 Wechselberger G, Schoeller T, Bauer T, Ninkovic M, Otto A, Ninkovic M. Venous superdrainage in deep inferior epigastric perforator flap breast reconstruction. Plast Reconstr Surg 2001; 108 (01) 162-166
    CrossrefPubMedGoogle Scholar
  • 19 Ali R, Bernier C, Lin YT. , et al. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. Ann Plast Surg 2010; 65 (04) 398-406
    CrossrefPubMedGoogle Scholar
  • 20 Schaverien MV, Ludman CN, Neil-Dwyer J. , et al. Relationship between venous congestion and intraflap venous anatomy in DIEP flaps using contrast-enhanced magnetic resonance angiography. Plast Reconstr Surg 2010; 126 (02) 385-392
    CrossrefPubMedGoogle Scholar
  • 21 Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous territories (venosomes) of the human body: experimental study and clinical implications. Plast Reconstr Surg 1990; 86 (02) 185-213
    CrossrefPubMedGoogle Scholar
  • 22 Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984; 73 (01) 1-16
    CrossrefPubMedGoogle Scholar
  • 23 Carramenha e Costa MA, Carriquiry C, Vasconez LO, Grotting JC, Herrera RH, Windle BH. An anatomic study of the venous drainage of the transverse rectus abdominis musculocutaneous flap. Plast Reconstr Surg 1987; 79 (02) 208-217
    CrossrefPubMedGoogle Scholar
  • 24 Hester Jr TR, Nahai F, Beegle PE, Bostwick III J. Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery. Plast Reconstr Surg 1984; 74 (05) 657-670
    CrossrefPubMedGoogle Scholar
  • 25 Schaverien M, Saint-Cyr M, Arbique G, Brown SA. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg 2008; 121 (06) 1909-1919
    CrossrefPubMedGoogle Scholar
  • 26 Minqiang X, Lanhua M, Jie L, Dali M, Jinguo L. The value of multidetector-row CT angiography for pre-operative planning of breast reconstruction with deep inferior epigastric arterial perforator flaps. Br J Radiol 2010; 83 (985) 40-43
    CrossrefPubMedGoogle Scholar
  • 27 Eom JS, Sun SH, Lee TJ. Selection of the recipient veins for additional anastomosis of the superficial inferior epigastric vein in breast reconstruction with free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator flaps. Ann Plast Surg 2011; 67 (05) 505-509
    CrossrefPubMedGoogle Scholar
  • 28 Xin Q, Luan J, Mu H, Mu L. Augmentation of venous drainage in deep inferior epigastric perforator flap breast reconstruction: efficacy and advancement. J Reconstr Microsurg 2012; 28 (05) 313-318
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Ochoa O, Pisano S, Chrysopoulo M, Ledoux P, Arishita G, Nastala C. Salvage of intraoperative deep inferior epigastric perforator flap venous congestion with augmentation of venous outflow: flap morbidity and review of the literature. Plast Reconstr Surg Glob Open 2013; 1 (07) e52
    CrossrefPubMedGoogle Scholar
  • 30 Rothenberger J, Amr A, Schiefer J, Schaller H-E, Rahmanian-Schwarz A. A quantitative analysis of the venous outflow of the deep inferior epigastric flap (DIEP) based on the perforator veins and the efficiency of superficial inferior epigastric vein (SIEV) supercharging. J Plast Reconstr Aesthet Surg 2013; 66 (01) 67-72
    CrossrefPubMedGoogle Scholar
  • 31 Boutros SG. Double venous system drainage in deep inferior epigastric perforator flap breast reconstruction: a single-surgeon experience. Plast Reconstr Surg 2013; 131 (04) 671-676
    CrossrefPubMedGoogle Scholar
  • 32 Sojitra NM, Vandevoort M, Ghali S, Fabre G. Two new techniques for correcting venous congestion in the free DIEP flap for breast reconstruction: an analysis of venous augmentation in 581 DIEP flaps. Plast Reconstr Surg 2010; 125 (02) 72e-74e
    CrossrefPubMedGoogle Scholar
  • 33 Liu TS, Ashjian P, Festekjian J. Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis. Ann Plast Surg 2007; 59 (02) 214-217
    CrossrefPubMedGoogle Scholar
  • 34 Rohde C, Keller A. Novel technique for venous augmentation in a free deep inferior epigastric perforator flap. Ann Plast Surg 2005; 55 (05) 528-530
    CrossrefPubMedGoogle Scholar
  • 35 Tutor EG, Auba C, Benito A, Rábago G, Kreutler W. Easy venous superdrainage in DIEP flap breast reconstruction through the intercostal branch. J Reconstr Microsurg 2002; 18 (07) 595-598
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 La Padula S, Hersant B, Noel W. , et al. Use of the retrograde limb of the internal mammary vein to avoid venous congestion in DIEP flap breast reconstruction: Further evidences of a reliable and time-sparing procedure. Microsurgery 2016; 36 (06) 447-452
    CrossrefPubMedGoogle Scholar
  • 37 Guzzetti T, Thione A. The basilic vein: an alternative drainage of DIEP flap in severe venous congestion. Microsurgery 2008; 28 (07) 555-558
    CrossrefPubMedGoogle Scholar
  • 38 Kerr-Valentic MA, Gottlieb LJ, Agarwal JP. The retrograde limb of the internal mammary vein: an additional outflow option in DIEP flap breast reconstruction. Plast Reconstr Surg 2009; 124 (03) 717-721
    CrossrefPubMedGoogle Scholar
  • 39 Razzano S, Figus A, Marongiu F, Haywood R. Contralateral DIEV as an interpositional vein graft for venous supercharge in the salvage of a congested DIEP flap. Microsurgery 2016; 36 (03) 263-264
    CrossrefPubMedGoogle Scholar
  • 40 Wongtriratanachai P, Martin AM, Chaiyasate K. DIEP flap salvage by cannula venesection of the superficial inferior epigastric vein. Eur J Plast Surg 2016; 39 (02) 151-154
    CrossrefPubMedGoogle Scholar
  • 41 Figus A, Mosahebi A, Ramakrishnan V. Microcirculation in DIEP flaps: a study of the haemodynamics using laser Doppler flowmetry and lightguide reflectance spectrophotometry. J Plast Reconstr Aesthet Surg 2006; 59 (06) 604-612 , discussion 613
    CrossrefPubMedGoogle Scholar
  • 42 Lundberg J, Mark H. Avoidance of complications after the use of deep inferior epigastric perforator flaps for reconstruction of the breast. Scand J Plast Reconstr Surg Hand Surg 2006; 40 (02) 79-81
    CrossrefPubMedGoogle Scholar
  • 43 Enajat M, Rozen WM, Whitaker IS, Smit JM, Acosta R. A single center comparison of one versus two venous anastomoses in 564 consecutive DIEP flaps: investigating the effect on venous congestion and flap survival. Microsurgery 2010; 30 (03) 185-191
    CrossrefPubMedGoogle Scholar
  • 44 Tran NV, Buchel EW, Convery PA. Microvascular complications of DIEP flaps. Plast Reconstr Surg 2007; 119 (05) 1397-1405 , discussion 1406–1408
    CrossrefPubMedGoogle Scholar
  • 45 Minqiang X, Jie L, Dali M, Lanhua M. Hemodynamic effect of different kinds of venous augmentation in a pig transmidline flap model of DIEP flap. J Reconstr Microsurg 2013; 29 (06) 379-386
    Article in Thieme ConnectPubMedGoogle Scholar