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Preoperative Analysis of Venous Anatomy Before Deep Inferior Epigastric Perforator Free-Flap Breast Reconstruction Using Ferumoxytol-enhanced Magnetic Resonance Angiography

Dortch, John MD*; Forte, Antonio J. MD*; Bolan, Candice MD; Kandel, Pujan MD*; Perdikis, Galen MD*

doi: 10.1097/SAP.0000000000001421
Microsurgery: PDF Only

Background Venous congestion after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is a complication that may be partially attributable to variations in venous abdominal wall anatomy. In previous work, we have shown that ferumoxytol may be used as a bloodpool contrast agent to perform high-resolution venous imaging. Our current aim was to use this technology to perform a detailed analysis of the venous anatomy among patients undergoing DIEP flap breast reconstruction.

Methods All patients undergoing DIEP flap reconstruction with preoperative ferumoxytol-enhanced magnetic resonance angiography (FE-MRA) were retrospectively reviewed. A detailed anatomic analysis of each abdominal wall on FE-MRA was performed before review of operative findings. Statistical analysis was used to determine venous characteristics associated with superficial inferior epigastric vein (SIEV) augmentation.

Results From 2012 to 2016, 59 patients underwent preoperative FE-MRA. This resulted in imaging for 118 hemiabdomen and 99 flaps. Superficial-deep communication was identified in 117 of 118 hemiabdomen. Fifty (93%) of 59 patients had greater than 1-mm venous communication of the superficial system across midline. Reconstructed breasts were based on dominant medial row perforators in 82 (83%) of 99 flaps. The mean diameters of the SIEV and dominant venous perforator were 3.8 and 2.8 mm, respectively. Anatomic characteristics associated with SIEV augmentation included SIEV diameter (P = 0.01), dominant perforator diameter (P = 0.04), and the ratio between these 2 variables (P = 0.001).

Conclusions Ferumoxytol-enhanced magnetic resonance angiography provides excellent imaging of the venous system. Anatomic characteristics such as the diameter of the SIEV and the diameter of the dominant perforator may be useful in determining which flaps require venous augmentation using the SIEV.

From the Departments of *Surgery and

Radiology, Mayo Clinic Florida, Jacksonville, FL.

Received October 25, 2017, and accepted for publication, after revision January 2, 2018.

Conflicts of interest and sources of funding: none declared.

Reprints: Galen Perdikis, MD, 4500 San Pablo Rd, Davis 3N, Jacksonville, FL. E-mail:

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