Safety of Salvaging Impending Flap Congestion in Breast Reconstruction by Venous Supercharging of the Cephalic Vein

Abstract

Autologous flap breast reconstruction is an established technique that carries a risk of vascular failure. We evaluated the safety of salvaging impending venous congestion by using the cephalic vein for supercharging autologous abdominal flaps. Our main outcome measures were flap survival, triggering or impairing lymphedema as measured by the physician or reported by the patient, and scar severity as measured by the Vancouver scar scale. We were able to save 100% of the flaps, but could not find any statistical association with or without increased lymphedema before and after the procedure. One patient reported that lymphedema worsened. The patients accepted the scars (mean Vancouver scar scale score, 5.7). In sum, using the cephalic vein to improve venous drainage of autologous breast reconstruction was safe and did not trigger or impair lymphedema, but scarring in the upper arm was unavoidable.

Anatomical features associated with venous congestion in DIEP flap using CT angiography with three-dimensional reconstruction

“…Other common strategies include the anastomosis of the SIEV to a second internal mammary vein, to an internal mammary perforator, or end-to-side to one of the DIEVs of the flap. [10,25,26] Less popular options include the anastomosis of the SIEV to the thoracoacromial vein, to the contralateral intermammary vein (which may need a vein graft), or to the toracodorsal vein (which may prevent the use of a latissimus dorsi as a rescue surgery in case the DIEP flap fails), among others. Notwithstanding, carrying out a second venous anastomosis is timeconsuming, which represents the main drawback of this procedure, taking between 30 to 90 min.…”

“…However, the overall risk appears to be reasonably low, being able to consider the harvest of the cephalic vein a safe option. [25] The systematic venous supercharging has been advocated to prevent the potential drainage insufficiency, after significant results experiencing less congestion. [26] However, a recent meta-analysis has failed to demonstrate the efficacy of the SIEV supercharging to reduce the flap-related complication rate.…”

“…[24,25] This salvage procedure decreases venous pressure, increases pressure gradient and overcomes the venous congestion. Adding large caliber venous anastomosis in parallel decrease the risk of venous congestion, because of the ability to provide a superior drainage.…”

A method using the cephalic vein for superdrainage in breast reconstruction

“…Several reports have described superdrainage to the CV for breast reconstruction (Audolfsson et al, ; Barnett et al, ; Enajat et al, ; Landin et al, ; Mehrara et al, ; Powell et al, ). Morteza et al previously reported that the ratio of anastomoses, which include superdrainage, was ~50%.…”

“…In general, the serratus anterior muscle branch of the thoracodorsal vein (SA) is anastomosed to the drainage vein (recipient vein), although blood vessel anastomosis can occasionally be difficult. Some reports have described a method using the cephalic vein (CV) for superdrainage (Audolfsson et al, ; Barnett, Carlisle, & Gianoutsos, ; Chang, Fearmonti, Chang, & Butler, ; Enajat, Rozen, Whitaker, Smit, & Acosta, ; Landin et al, ; Mehrara et al, ; Powell, Prousskaia, & Wilson, ). However, the suggestions of superdrainage, and which vein should be used, have been points of debate.…”