CTA before a Diep Flap?

Hi connerdmc,
A CTA provides your surgeon with the information to draw a blood-vessel road map of your 6 pack (rectus) muscle and the perforator/blood vessel branching pattern out to the skin. The CTA allows your surgeon to create an operative plan, and ideally conceptualize a plan to include the most blood supply with the least muscle injury.
I have done DIEPS with and without CTA, and either is appropriate. But without a CTA, there is a lot more intra-operative decision making, and selecting perforators above the abdominal wall is not the same as knowing how they join to the main blood vessels within or below the muscle. This may mean that more muscle is taken up with the flap.
In summary, you can have DIEPs without a CTA.
Best,Chris Pannucci MDSpokane WA

Preoperative MR Angiogram or CT Angiogram helps the surgeon determine1. that the blood vessels are patent (surgery can be done)2. location of the blood vessels (most efficient way to get surgery done)

There are many DIEP surgeons who do not need to get a CTA beforehand as it is the dissection during the actual surgery that will determine whether you can have the DIEP or not.  This includes the vessels in the abdomen and the vessels in the chest. The CTA is only a roadmap and that map can look very different when you are looking at the actual vessels.  I have done this procedure without the CTA and it will depend on the comfort level of your surgeon to do so.  You have had abdominal surgeries and this may be a reason why the CTA was ordered to make sure that the DIEP vessels have not been damaged.  The DIEP is the gold standard in breast reconstruction for a patient who has had radiation as implants alone have a high complication rate. Other options are the TRAM or Latissimus flaps but both procedures sacrifice muscles.  When I discuss options with my patients I will tell them if I find during surgery that the DIEP cannot be performed then would they want to have a TRAM which means sacrificing muscle and can cause you problems in function.  This is something you need to discuss with your PS.  Best wishes.

Thanks for your question.

CT angiograms are helpful in planning the surgery, especially in your case with multiple previous abdominal operations.  If a CTA is not obtainable, I would recommend an MRA or Doppler imaging of the abdominal wall.

Your surgeon wants the study to map out the vessels in you flap so that he can determine what vessels would be appropriate.  Best of luck.

Thank you for asking this important question.

It is essential part of pre op planning for Breast reconstruction to obtain imaging study which maps your DIEP flap blood vessel for the surgeon (like a GPS guide for Driving :)

This used to be done by CTA( CT angiogram) until recently.  However,  more patients and surgeons are seeking MRA( M.R. Angiogram ) instead, especially  after the N.Y. Times article was published describing the potential  concerns of CT scans. Most of breast reconstruction dedicated Centers are able to offer "MRA-perforartor mapping study" . The advantage of MRA is that  it does not expose you to ionizing radiation. Both MRA and CTA requires IV contrast injection and ALL patients should be able to Have IV access for the scan.

Some of the useful tricks are:  

You can drink plenty of water ( or your favorite Drink) and hydrate yourself up to 4 hours before the procedure  (But you have to stop 4 hours before the procedure - nothing to eat or drink 4 hours before the scan).

On your way to the test (and while you are waiting for the study) exercise your arm/elbow/hand to increase circulation. 

Keep your  arm/hand warm. ( to "dilate" the Vein) 

Just before the medical professional puts the IV,  ask  if they can gently tap on the skin over the vein  ( a few times ) to "plump up" your vein while you make  a tight fist during the IV. 

You can also request for a most experienced "senior member" of the IV -TEAM /RN /MD- for the difficult  IV  access in advance (tell them to make a note of this when you confirm your appointment - that you are a challenging IV access patient due to your history ) 

Of course, Seek advice from your Reconstructive surgeon re all aspects of your care.

Wishing you a successful Scan and Reconstruction !