What information do surgeons need from a Deep Inferior Epigastric Perforator (DIEP) flap Computed Tomography Angiography (CTA)?

Critical Information for Surgeons from DIEP Flap CTA Imaging

For optimal DIEP flap outcomes, radiologists must provide surgeons with detailed information about perforator location, size, and intramuscular course, with perforators ranked based on these characteristics to guide surgical decision-making. 1

Essential Information to Include in DIEP Flap CTA Reports

1. Perforator Vessel Details

• Location: Precise position where perforators pierce the anterior rectus sheath in relation to the umbilicus (using the umbilicus as a fixed reference point) 1
• Size/Caliber: Diameter measurements of perforators, with priority given to largest calibers (>1mm) due to their influence on flap viability 1, 2
• Intramuscular Course: Length and complexity of the intramuscular segment, with shorter courses being preferable for easier dissection 1

2. Ranking of Perforators

• Create a prioritized list of perforators based on:
  • Caliber (larger is better)
  • Location (medial perforators preferred)
  • Intramuscular course (shorter is better) 1, 2

3. DIEA Branching Pattern

• Classification of DIEA pattern:
  • Type 1: Single trunk
  • Type 2: Bifurcating trunk
  • Type 3: Trifurcating trunk 1
• Note that Type 2 patterns may facilitate easier DIEP flap harvesting due to shorter intramuscular courses 3

4. Venous Anatomy

• Document venous communication between right and left abdomen
• Note presence and caliber of superficial inferior epigastric veins (SIEVs) 1, 4

5. Alternative Vascular Options

• Presence and caliber of superficial inferior epigastric arteries (SIEAs)
• This information may guide surgeons to consider alternative flap types when appropriate 1, 5

6. Abdominal Wall Assessment

• Document any anatomical variants or abnormalities
• Note presence and impact of previous surgical scars on perforator patency 6
• Evaluate abdominal wall structure for potential donor site complications 4

Imaging Technique and Reporting Considerations

Optimal CTA Protocol

• Single contrast-enhanced phase with region of interest on femoral artery
• Reversed caudal-cranial scanning (pubic symphysis toward umbilicus) for improved DIEA enhancement 1
• 64-slice multi-detector row CT scanner for optimal image quality 4

Visualization Methods

• Provide maximum intensity projection (MIP) images showing perforator course
• Include 3D skin surface-rendered images with superimposed perforator locations 1, 2
• Consider using specialized software (OsiriX™, Horos™) for optimal analysis 4

Clinical Impact of Comprehensive CTA Reporting

Thorough CTA reporting directly impacts surgical outcomes by:

• Decreasing operative time
• Reducing flap loss rates and partial necrosis
• Minimizing donor site morbidity including hernia formation
• Decreasing intraoperative blood loss
• Shortening hospital stays 1, 2

Special Considerations

Scarred Abdomens

• Pay special attention to perforator patency in patients with previous abdominal surgeries
• Note that scarred abdomens may require single-perforator flaps more frequently 6
• CTA is particularly valuable in determining if DIEP flap is feasible in scarred abdomens 5

Flap Design Implications

• Note if dominant perforators are located outside standard DIEP flap design (especially those >2cm above umbilicus)
• This information allows surgeons to modify flap design to include optimal perforators 7

By providing this detailed information in a systematic, prioritized format, radiologists can significantly contribute to surgical planning and ultimately improve patient outcomes in DIEP flap breast reconstruction.