Alberto Alonso-Burgos

Preoperative planning of DIEP and SGAP flaps: preliminary experience with magnetic resonance angiography using 3-tesla equipment and blood-pool contrast medium.

BACKGROUND Autologous breast reconstruction techniques can be used to create a breast, in particular the superior gluteal artery perforator (SGAP) and deep inferior epigastric artery perforator (DIEP) flaps. Preoperative imaging is an essential planning tool in mapping the location and size of perforator vessels. The aim of this report is to show the usefulness of angio-MR technique for preoperative planning of DIEP and SGAP flaps. Initial experience, surgical findings correlation and imaging findings will be described. METHODS From February 2007 to September 2007, ten consecutive women considered for breast reconstruction with DIEP (eight patients) and SGAP flaps (two patients) after previous mastectomy for breast cancer were studied. After written informed consent was obtained, a preoperative angio-MR using 3-Tesla equipment and blood-pool contrast medium was performed to localize and evaluate the main perforator vessels in each patient and procedure. RESULTS Angio-MR showed all the main perforator vessels later observed during the surgical procedure with a very good location concordance, but missed one main perforator vessels in each of two patients. In all patients undergoing SGAP flaps, an accurate identification of the main perforator vessels was achieved. Angio-MR clearly showed the intramuscular course of the perforator vessels for DIEP and SGAP flaps. Exact correlation between angio-MR and surgical findings was observed. CONCLUSIONS The use of angio-MR for preoperative perforator flaps evaluation yielded promising results and would allow not only to locate perforator vessels but also to globally assess presurgical planning of perforator flaps in a noninvasive, radiation and toxicity-free way.

Preoperative Imaging for Perforator Flaps in Reconstructive Surgery A Systematic Review of the Evidence for Current Techniques

BackgroundAlthough preoperative imaging of perforator vasculature in planning microvascular reconstruction is commonplace, there has not been any clear demonstration of the evidence for this practice, or data comparing the many available modalities in an evidence-based approach. This article aims to

The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: A cadaveric and clinical study with clinical implications

The anterior abdominal wall integument is frequently used in a range of reconstructive flaps. These tissues are supplied by the deep and superficial inferior epigastric arteries (DIEA and SIEAs) and the deep and superficial superior epigastric arteries (DSEA and SSEAs). Previous abdominal wall surgery alters this vascular anatomy and may influence flap design. One hundred and sixty‐eight patients underwent abdominal wall computed tomographic angiography (CTA) for preoperative imaging. Fifty‐eight of these patients had undergone previous abdominal surgery, and were assessed for scar pattern and relationship to the course and distribution of all major axial vessels and perforators. Two cadaveric abdominal wall specimens with midline abdominal scars underwent contrast injection of the DIEAs and DSEAs, with subsequent CTA. The course and distribution of all cutaneous vessels were assessed. In all clinical and cadaveric cases, the vasculature of the abdominal wall had been altered by previous surgery. In the clinical cases, vascular architecture was universally altered in the region of the scar, often modifying the filling patterns of the abdominal wall and occasionally precluding the use of an abdominal wall flap. In both cadaveric specimens, regions of non‐filling were evident upon contrast injection, highlighting the angiosomes not supplied by the DIEA or DSEA. Previous abdominal wall surgery necessarily alters the vascular architecture of the abdominal wall, and may alter the source vessels supplying cutaneous tissues. CTA was useful in identifying and delineating these changes, and may be used as a preoperative tool in this role. Clin. Anat. 22:815–822, 2009.

The anatomy and variations of the internal thoracic (internal mammary) artery and implications in autologous breast reconstruction: clinical anatomical study and literature review

BackgroundThe internal thoracic (IT) vessels (otherwise known as the thoracica interna or internal mammary vessels) are widely used as recipient vessels in autologous breast reconstruction. Despite this, normal and pathological variations in IT artery architecture have been described, and these have the potential to complicate dissection and the selection of suitable vessels.MethodsA clinical anatomical study of 240 IT arteries (120 patients) and review of the literature was undertaken. Participants comprised 120 female patients undergoing preoperative imaging of the IT artery prior to autologous breast reconstruction, 42 with computed tomographic angiography (CTA) and 78 with ultrasound.ResultsThere was complete concordance between surgical and radiological findings. An IT artery was present in 100% of cases, with a duplicate IT artery in two cases (1% overall). The position of the IT artery was between two IT veins most frequently (71.5% of cases), and was lateral to the vein(s) least frequently (6%). There were large IT perforators from the first and second intercostal spaces in 87 and 91% of cases, respectively, with the incidence of such perforators reducing in the lower spaces. The literature highlighted a range of cadaveric and clinical cases in which there was absence of a patent IT artery, variant course or size, and variant relationship to the IT vein.ConclusionA range of congenital, pathological and iatrogenic variants in IT artery anatomy have the potential to limit the use of the IT artery in autologous breast reconstruction. Preoperative imaging with ultrasound or CTA may provide a clear and accurate method of identifying these anatomical variations pre-operatively.

Foot or hand malformations related to deep venous system anomalies of the lower limb in Klippel-Trenaunay syndrome

BACKGROUND Klippel-Trénaunay syndrome (KTS) is a capillary-lymphatic-venous malformation associated with soft tissue and skeletal hypertrophy of one or more limbs. Deep venous system (DVS) anomalies are reported to be present in 8% to 18% of patients with KTS; approximately 25% of patients with KTS have hand or foot malformations. OBJECTIVE We sought to assess whether the presence of hand or foot malformations in KTS is a predictor of DVS anomalies. METHODS Retrospective data were collected from 51 consecutive patients with KTS seen in a university hospital between January 2000 and February 2008. Patients with possible Proteus syndrome were not included. The presence and patency of the DVS was studied using conventional venography, multidetector computed tomography, or fast 3-dimensional magnetic resonance imaging venography. RESULTS Seventeen hand or foot malformations were present in 9 patients, consisting of: toe macrodactyly in 5 patients (two bilateral and one with plantar expansion); toe microdactyly in one patient; finger macrodactyly in one patient; finger macrodactyly and ectrodactyly in one patient; syndactyly in 4 patients; and clinodactyly with camptodactyly of the hand of one patient with lower limb KTS. Eleven patients had DVS anomalies (one with aplasia of entire DVS; one with duplication of the superficial femoral vein; 7 with hypoplasia of femoral vein; and 7 with aplasia of the popliteal vein). All patients with hand or foot malformations also had DVS anomalies (P < .001). LIMITATIONS Small sample size was a limitation. CONCLUSION The presence of hand or foot malformations in KTS may predict the presence of DVS anomalies.

Is There a Need for Preoperative Imaging of the Internal Mammary Recipient Site for Autologous Breast Reconstruction

AbstractPreoperative imaging of recipient-site vasculatur in autologous breast reconstruction may potentiate improved outcomes through the identification of individual variations in vascular architecture. There are a range of both normal and pathologic states which can substantially affect the internal mammary vessels in particular, and the identification of these preoperatively may significantly affect operative approach. There are a range of imaging modalities available, with ultrasound particularly useful, and computed tomography angiography (CTA) evolving as a useful option, albeit with radiation exposure. The benefits of CTA must be balanced against its risks, which include contrast nephrotoxicity and allergic reactions, and radiation exposure. The radiation risk with thoracic imaging is substantially higher than that for donor sites, such as the abdominal wall, with reasons including exposure of the contralateral breast to radiation (with a risk of contralateral breast cancer in this population 2 to 6 times higher than that of primary breast cancer, reaching a 20-year incidence of 15%), as well as proximity to the thyroid gland. Current evidence suggests that although many cases may not warrant such imaging because of risk, the benefits of preoperative CTA in selected patients may outweigh the risks of exposure, prompting an individualized approach.

Computed Tomographic Appearance of Chest Ports and Catheters: A Pictorial Review for Noninterventional Radiologists

Medical practice has expanded the need for long-term central venous catheterization. Chest ports play an important role in the management of oncology patients who need frequent blood products, chemotherapy, and other intravenous drugs. Imaging-guided placement of chest ports and catheters (CR) is a safe and efficacious procedure. Moreover, many cases of catheter-induced central thrombosis go unrecognized, but the incidence of pulmonary embolism in this group may be as high as 12%. Multi-detector computed tomography represents the main imaging method in the follow-up of oncologic patients. We review the radiologic features, mainly on multi-detector computed tomography, of CR commonly used for chemotherapy administration and describe the radiological findings of the complications associated with these devices. Examples of complications include the following: pneumothorax, inversion of the reservoir and malpositioned catheter, great vessel perforation, fibrin sheath formation and catheter-related venous thrombosis, infection, Pinch-off syndrome, and extravasation. When interpreting computed tomography (CT) in oncologic patients, radiologists should be familiar with CR and comment on catheters position, and the presence or absence of complications. General radiologists should keep in mind the medical history of the patient with regards to the CR and the specific CT findings when they read radiological studies in oncologic patients. Appropriate window values and multi-plane CT reconstructions are useful in the diagnosis of CR-related complications.

Non-invasive vascular imaging in perforator flap surgery.

Preoperative imaging using a range of imaging modalities has become increasingly popular for preoperative planning in plastic surgery, in particular in perforator flap surgery. Modalities in this role include ultrasound (US), magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). The evidence for the use of these techniques has been reported in only a handful of studies. In this paper we conducted a non-systematic review of the literature to establish the role for each of these modalities. The role of state-of-the-art vascular imaging as an application in perforator flap surgery is thus offered.

Direct hepatic artery puncture for transarterial therapy in liver cancer.

In the treatment of liver malignancies, therapies such as bland embolization, chemoembolization and radioembolization require access to the hepatic artery by means of conventional transfemoral or brachial catheterization. Challenging vascular anatomy can impede selective access to tumoral vessels, preventing the safe and effective delivery of embolic material. Direct percutaneous hepatic arterial puncture under ultrasonographic guidance may be an alternative method to obtain intrahepatic arterial access for the purposes of hepatic arteriography and delivery of therapeutic agents. In this case series, the authors describe the use of direct hepatic artery puncture to successfully perform two radioembolization procedures and one bland embolization procedure.

Función, volúmenes y masa ventricular izquierda por resonancia magnética en estudios realizados en un modelo animal con secuencias SSFP y FLASH: comparación de los resultados

OBJECTIVE To compare the accuracy of two cine-gradient-echo sequences to quantify left ventricular function, volumes, and mass in an animal model. MATERIAL AND METHODS We studied ten Gottingen miniature pigs (seven male, three female; mean weight 49.8+/-10.65kg; range: 35-65kg) with a 1.5 Tesla MRI scanner using free-breathing SSFP and FLASH sequences. We used 8-mm short-axis images to estimate left ventricular ejection fraction (EF), volumes (end-diastolic (EDV), end-systolic (ESV), and stroke volume (SV)), mass, and signal-to-noise ratio (SNR) on SSFP and FLASH sequences. We analyzed the correlation and concordance of the two sequences for each variable. RESULTS Using the SSFP sequence, the mean estimated EF was 77.35+/-3.13%; mean EDV 61.55+/-8.64ml; mean ESV 13.83+/-1.92ml; mean SV 47.72+/-7.78ml; and mean myocardial mass 75.87+/-11.44g. Using the FLASH sequence, the mean EF was 81.87+/-2.22%; mean EDV 55.4+/-8.08ml; mean ESV 10.03+/-1.87ml; mean SV 45.38+/-6.83ml; and mean myocardial mass 87.74+/-15.21g. The correlation between SSFP and FLASH to quantify EDV, SV, and myocardial mass was excellent (r>0.8) and moderate (r>0.4) for quantifying ESV and EF. The SNR in the SSFP sequence was significantly higher than in the FLASH sequence (mean difference 120.94+/-42.94). CONCLUSIONS In the SSFP sequence, ventricular volumes are slightly higher and ventricular mass is slightly lower than in the FLASH sequence, probably because of the higher SNR on SSFP sequences.