Radial Artery And Cephalic Vein Interposition Graft To Salvage A DIEP Flap And Prevent No-Flow Phenomenon: A Case Report And Literature Review.

摘要

Autologous tissue from the lower abdomen represents the optimal method for delayed breast reconstruction in the previously irradiated chest, as these flaps are capable of reproducing a reconstructed breast that approximates the shape, volume, softness and ptosis of the native breast.1 Unfortunately, delayed breast reconstruction in the setting of previous postmastectomy radiotherapy has been shown to have a higher complication rate2,3 due the soft-tissue sequelae caused by radiation including tissue fibrosis, edema and vasculitis which can interfere with healing of the reconstructed breast and can injure the internal mammary vessels increasing the risk of intraoperative and postoperative microvascular anastomotic complications.We present the relevant literature review and a case where a deep inferior epigastric perforator (DIEP) flap was not only salvaged with a radial artery vascular pedicle conduit graft, but fat cell damage was minimized by prompt revascularisation of flap to the arm. 1 Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP and SIEA flaps. Plast Reconstr Surg. 2010;125:1335-1341. 2 Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. 2001;108:78-82. 3 Kronowitz SJ, Robb GL. Breast reconstruction with postmastectomy radiation therapy: Current issues. Plast Reconstr Surg. 2004; 114:950-960. Introduction Autologous tissue from the lower abdomen represents the optimal method for delayed breast reconstruction in the previously irradiated chest, as these flaps are capable of reproducing a reconstructed breast that approximates the shape, volume, softness and ptosis of the native breast. 1 Unfortunately, delayed breast reconstruction in the setting of previous postmastectomy radiotherapy has been shown to have a higher complication rate 2 due the soft-tissue sequelae caused by radiation including tissue fibrosis, edema and vasculitis which can interfere with healing of the reconstructed breast and can injure the internal mammary vessels increasing the risk of intraoperative and postoperative microvascular anastomotic complications.We present the relevant literature review and a case where a deep inferior epigastric perforator (DIEP) flap was not only salvaged with a radial artery vascular pedicle conduit graft, but fat cell damage was minimized by prompt revascularisation of flap to the arm. Case Report A 48 year old non-smoking woman underwent left breast mastectomy and irradiation for breast cancer. (Figure 1) She underwent DIEP flap breast reconstruction 7 years after her mastectomy by the senior author (PH). The flap was based on 4 perforators on the left deep inferior epigastric vascular axis. Simultaneous harvest of the left internal mammary vessels was performed through the 3 rd intercostal space, revealing a macroscopically viable internal mammary artery and vein, which were deemed usable for microvascular anastomosis. The DIEP flap was divided and transferred to the chest wall for microvascular anastomosis. The irradiated artery was fragile but initial anastomosis of both artery and vein was uncomplicated with primary ischemic time of 55 minutes. After initially showing good blood flow with a well perfused flap the artery thrombosed. The decision was made to remove the 2 nd costal cartilage and attempt a more proximal anastomosis. This was performed yet again with minimal technical concerns, but unfortunately the arterial anastomosis suffered the same thrombotic fate. At this stage the total ischemic time was 3,5 hrs with concerns of flap damage and impending no-reflow phenomenon an alternate recipient vessel and interposition vascular conduit were required. The DIEP pedicle after the two anastomotic revisions was considerably shortened and thus wouldn’t reach the axillary vessels