Hydrogen Peroxide Priming of the Venous Architecture

Lie, Kwok Hao; Taylor, G. Ian; Ashton, Mark W.

doi:10.1097/prs.0000000000000228

Cited by 10 publications

(12 citation statements)

References 46 publications

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“…16 This main system is supported by the presence of a smaller network of venae comitantes which drain also to the deep DIEV system and whose territory generally matches the perforator artery angiosome which they accompany. 27 The territories of these venae comitantes can be referred to as 'cutaneous venosomes' and, similar to their angiosome counterparts, communicate with adjacent territories via small caliber avalvular 'oscillating' veins that allow bidirectional flow and therefore drainage via more than more venous route. 28 In the recent article by Lie et al, 27 Use of (when possible) medial row perforators for greater perfusion of zone IV.…”

Section: Resultsmentioning

confidence: 99%

Understanding the vascular anatomy of zone IV in DIEA perforator flaps

Connon

Gascoigne

et al. 2018

Australas J Plast Surg

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Introduction: Due to a longstanding controversy over the perfusion reliability of zone IV current this area is routinely discarded despite the mechanism behind zone IV necrosis not being fully understood. The authors review and investigate the vascular anatomy of zone IV with the aim of outlining the reasons for necrosis.Methods: A literature search and review of archival injection studies performed by the authors was undertaken to identify the arterial and venous maps of the abdomen. Unembalmed abdominal wall and full body specimens were used for cadaveric studies to demonstrate the arterial anastomotic patterns and venous drainage pathways of the deep inferior epigastric, superficial inferior epigastric, superficial circumflex iliac and intercostal systems.Results: Cadaveric injection studies demonstrated the presence of true and choke anastomoses between all lower abdominal arterial branch systems. Venous studies found that the dominant venous drainage is through large caliber superficial epigastric and circumflex iliac veins, a system which is interrupted in flap elevation and redirected to the perforator venae comitantes, with inter-territory communicating oscillating veins also becoming a limiting factor between territories. Conclusion: The mechanism behind the common failure of zone IV in the DIEP flap is explained with studies demonstrating both potential arterial and venous limiting factors. The authors conclude that the mechanism is indeed multifactorial, however suggest that when zone IV in DIEP tissue transfer is required, fat below Scarpa’s fascia is excised and the contralateral SIEV is preserved for use as an additional venous anastomosis.

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Section: Resultsmentioning

confidence: 99%

Understanding the vascular anatomy of zone IV in DIEA perforator flaps

Connon

Gascoigne

et al. 2018

Australas J Plast Surg

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“…This difficulty can be overcome in the extremities by anterograde perfusion using a tourniquet [13]; however, this is impossible in the abdomen. Lie et al weakened the valves using hydrogen peroxide priming and showed the venous anatomy of the abdomen clearly by venogram [2]; the midline crossover of the SIEV was shown in both the supraumbilical and infraumbilical areas. The infraumbilical venous crossover was connected to the main SIEV near the suprapubic crease.…”

Section: Plos Onementioning

confidence: 99%

“…A goal of this anatomical study was to obtain findings that will bring clinical improvement. We applied the suggestions of Lie et al during the elevation of the DIEP flap, including both the periumbilical perforator and the adjacent area to the suprapubic crease [2]. However, the flap was too large to adequately close the donor site.…”

Section: Plos Onementioning

confidence: 99%

“…This suggests that the venous drainage issues associated with the DIEP flap arise from poor midline crossing; studies on the venous anatomy of the abdominal wall support this [2,3,12,13]. Hydrogen peroxide priming has shown more detailed venous anatomy and elucidated the anatomical cause of venous drainage problems of the DIEP flap [2].…”

Section: Introductionmentioning

confidence: 99%

“…One of the most common complications of the deep inferior epigastric perforator (DIEP) flap, which is most commonly used for breast reconstruction, is poor venous drainage. Many venous drainage issues are related to venous congestion that occurs despite patent microvascular anastomosis sites [1,2]. Venous congestion has been reported in up to 10% of DIEP flaps in a large patient series, most commonly occurring above the midline-on the contralateral side from the pedicle [3][4][5][6].…”

Section: Introductionmentioning

confidence: 99%

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Differences of the midline-crossing venous drainage pattern in supraumbilical and infraumbilical regions: Angiographic study using fresh cadavers

2020

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Current clinical and anatomical studies show that the venous problem associated with the deep inferior epigastric perforator flap results from poor midline-crossing. We examined the venous anatomy of the infraumbilical midline area and the dynamic venous flow of the deep inferior epigastric perforator flap in nine fresh cadavers. All nine abdominal specimens were harvested between the subcostal margin and the groin crease. Two specimens were used to analyze the abdominal venous anatomy, one of which was divided into two hemi-abdominal specimens. The remaining seven specimens were harvested as deep inferior epigastric perforator flaps with one major paraumbilical perforator. Venous cannulation and serial angiographic agent injection were performed in several conditions. Each specimen was radiographed using a soft X-ray system. For additional information, computed tomography (CT) angiography-visualized superficial inferior epigastric veins (SIEVs) and the supraumbilical branch were analyzed. We noted that the venous drainage between the bilateral SIEVs was easier to configure in the supraumbilical area than in the infraumbilical area. Only one to two short polygonal venous networks connect the bilateral superficial inferior epigastric veins in the supraumbilical area; however, long and multiple polygonal venous networks connect the bilateral superficial inferior epigastric veins in the infraumbilical area, which could be a predisposing factor for venous congestion. The mean distance from the umbilicus upper border to evident supraumbilical midline crossover was 18.39±4.03 mm (range: 10.10–28.49) in CT angiograms. In cadaver specimens, the mean distance was 10.87±4.85 mm (range: 4.6–18.9). Supraumbilical midline crossover was more favorable than infraumbilical midline crossover in venous flow.

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Comments on “Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging”

Kim

Mun

2019

Microsurgery

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Comments on "Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging"Dear Editor:We read the article by Davis, Jones, Tillett, Richards, and Wilson (2019) with great interest. Venous congestion is a major concern when performing deep inferior epigastric perforator (DIEP) flap reconstruction and previous studies related to this subject primarily focused on the intraoperative or postoperative management or salvage of congested flaps (Bartlett, Zavlin, Menn, & Spiegel, 2018). Venous congestion in DIEP flaps is affected by a number of factors including surgical technique and anatomic impediments to adequate venous drainage, such as insufficient venous perforator caliber, inadequate communication between the superficial and deep systems, and absent communication of venous collaterals across the midline, and thus it may be difficult to identify specific causative factors that can help predict its occurrence (Dortch, Forte, Bolan, Kandel, & Perdikis, 2018). The notable work performed by Davis et al. (2019) was the prediction of venous congestion complications based on preoperative computed tomographic angiography (CTA) findings.Despite a few limitations, including the retrospective study design and small number of patients, the presence of atypical connections between the superficial and deep venous system on preoperative CT was found to increase the risk of venous congestion of DIEP flaps fivefold. Although further study on multivariate analysis is a better knowledge of surgical anatomy maximizes the benefits of the procedure while minimize the potential risks. We welcome the authors' suggestion to extend the CT scan field to the thorax, which we have also recommended to reinforce the role of preoperative CTA including volumetric planning (Kim et al., 2012). The role of CTA in DIEP flap surgery has expanded and evolved, and more data and information are available. We commend the authors' effort to quantify the risk of venous congestion using analysis of CTA data, which emphasized the importance of preoperative CTA-based DIEP flap planning.

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Hydrogen Peroxide Priming of the Venous Architecture

Abstract: Retrograde hydrogen peroxide priming of veins in cadavers renders valves incompetent and facilitates detailed venous studies that help refine flap design and explain venous complications.

Cited by 10 publications

References 46 publications

Understanding the vascular anatomy of zone IV in DIEA perforator flaps

Understanding the vascular anatomy of zone IV in DIEA perforator flaps

Differences of the midline-crossing venous drainage pattern in supraumbilical and infraumbilical regions: Angiographic study using fresh cadavers

Comments on “Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging”

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