Preoperative Imaging for DIEA Perforator Flaps: A Comparative Study of Computed Tomographic Angiography and Doppler Ultrasound

TLDR

Abdominal donor‑site flaps such as TRAM and DIEA perforator flaps are standard in breast reconstruction, but variable vascular anatomy makes preoperative imaging essential, and computed tomographic angiography has recently been proposed as a noninvasive alternative to Doppler sonography. This study formally compares preoperative Doppler ultrasound with computed tomographic angiography for imaging the deep inferior epigastric artery in eight consecutive patients undergoing DIEA perforator flap breast reconstruction. All imaging and surgical procedures were performed at a single institution by the same surgeons and radiology team, allowing a direct comparison that showed CT angiography superior to Doppler in delineating the DIEA course, branching pattern, and perforators. Computed tomographic angiography proved highly specific (100 %) and significantly more sensitive than Doppler ultrasound for mapping DIEA perforators (p = 0.0078), accurately identified the superficial epigastric system, was faster, eliminated interobserver variability, and led the authors to discontinue the study after eight patients, confirming its value for preoperative donor‑site vascular assessment in TRAM and DIEA perforator flaps.

Abstract

Abdominal donor-site flaps, including the transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric artery (DIEA) perforator flaps, are standard in autologous breast reconstruction. With significant variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential for preoperative planning and reducing intraoperative error. Doppler and color duplex sonography have been used with varying results, and the quest continues for optimal preoperative assessment. Computed tomographic angiography has recently been proposed as a noninvasive modality for this purpose. This is the first study to formally compare preoperative Doppler ultrasound with computed tomographic angiography for imaging the DIEA.Eight consecutive patients undergoing DIEA perforator flap surgery for breast reconstruction underwent both computed tomographic angiography and Doppler ultrasound preoperatively. All investigations and procedures were performed at the same institution with the same primary and assisting surgeons and the same radiology team.Computed tomographic angiography was superior to Doppler ultrasound at identifying the course of the DIEA and its branching pattern, and in visualizing its perforators. Preoperative computed tomographic angiography was highly specific (100 percent) and more sensitive in mapping and visualizing perforators (p = 0.0078). It was also proficient at identifying the superficial epigastric arterial system and for effectively displaying the results intraoperatively. It was substantially quicker and removed the interobserver error associated with Doppler ultrasonography. The study was ceased after eight patients because of the overwhelming benefit of computed tomographic angiography over Doppler ultrasonography.Computed tomographic angiography is a valuable imaging modality for the preoperative assessment of the donor-site vascular supply for TRAM and DIEA perforator flaps.