CTA before a Diep Flap?

Question

I have had a c-section and a few months later my tubes tied in 1994 and a total hysterectomy in 1995 and am now having a mastectomy and possibly a Diep Flap reconstruction in a few weeks. My plastic surgeon wants a CTA before and I went to have it done but I have very deep and small veins and they could not find one big enough for the contrast. Since I have already had radiation treatments I have been recommended that implants aren't a good idea. What other options do I have if I can't have a CTA?

Christopher Pannucci, MD, MS · Answer

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

Neil Tanna, MD, FACS · Answer

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)

Anh Lee, MD, FACS · Answer

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.

Ali Sadeghi, MD, FACS · Answer

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.

Steven Wallach, MD · Answer

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.

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