Meta‐analysis of the effects of venous super‐drainage in deep inferior epigastric artery perforator flaps for breast reconstruction

Abstract

Introduction: Venous congestion is the most common vascular complication of the deep inferior epigastric artery perforator (DIEP) flaps. Adding a second venous drainage by anastomosing a flap vein and a recipient vein (super-drainage) is considered the solution of choice. Evidence to support this procedure, had not yet been confirmed by an analysis of the literature. We aimed to provide this evidence. Materials and methods: We searched the literature (MedLine, Scopus, EMBASE, Cochrane Library, and Google Scholar), for studies discussing venous congestion and venous super-drainage in DIEP flap for breast reconstruction. Thirteen of the 35 articles compared results between one or two venous anastomoses. Meta-analysis was performed following PRISMA guidelines. Pooled risk ratio (RRs) for congestion, fat necrosis, partial necrosis, and total necrosis with corresponding 95% confidence intervals (CI) were calculated using a fixed-effect model with the Mantel-Haenszel method. The need to return to surgery (95% CI) was estimated with a random effect model using the DerSimonian and Liard method. Results: We showed a statistically significant advantage of super-drainage to reduce the venous congestion of the flap (RR: 0.12, 95% CI: 0.04-0.34, p-value <.001), partial flap necrosis (RR: 0.50, 95% CI: 0.30-0.84, p-value .008), total flap necrosis (RR: 0.31, 95% CI: 0.11-0.85, p-value .023), and the need to take the patient back to surgery for perfusion-related complications (RR: 0.45, 95% CI: 0.21-0.99, p value .048). Conclusions: Performing a second venous anastomosis between the SIEV and a recipient vein (venous superdrainage) reduces venous congestion and related complications in DIEP flaps for breast reconstruction.

Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps

“…44 45 In addition to relieving congestion, venous superdrainage using the SIEV has also been shown to significantly decrease both total and partial flap necrosis as well as takebacks for perfusion-related complications. 46 Prior studies have demonstrated that SIEVs with diameters ranging from 0.5 to 4.06 mm can be identified on US, 39 41 comparable to those reported using CTA. 47 Thus, US may be useful in identifying large caliber SIEVs suggestive of a dominant superficial venous drainage system and in preserving the SIEV for use in the event of unexpected venous congestion.…”

Use of the superficial inferior epigastric vein in breast reconstruction with a deep inferior epigastric artery perforator flap

“…In terms of partial flap necrosis general trends toward lower risks were identified, without being statistically significant ( 86 ). Another metaanalysis published in 2021 showed a statistically significant advantage of super-drainage to reduce venous congestion of the flap, partial flap necrosis, total flap necrosis and the need to take the patient back to surgery for perfusion-related complications ( 87 ). A systematic review of the literature published in 2015 reported an incidence of intraoperative venous congestion of the free abdominal flap during breast reconstruction of 2.8%.…”

A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps

“…In brief, the complication reporting of the studies included in the present studies makes the result unreliable. It also casts doubt on the validity of the previous reviews where meta-analyses seem to have been performed on unacceptably heterogenic data [ 72 , 73 ]. To advance the field of abdominally based free flaps and refine our techniques in a scientific manner, as well as enabling comparison of the result from different studies, further studies on standardisation of diagnosing and reporting of specific complication must be performed.…”