Präoperative CT Angiografie zur Planung freier Perforans-Lappenplastiken (DIEP-Flaps) zur Brustrekonstruktion

Zusammenfassung

Zur Planung von Perforans-Lappenplastiken ist die präoperative Dopplersonografie zur Lokalisation der Perforans-Gefäße seit langem etabliert. Hierdurch lässt sich der Durchtrittspunkt durch die Faszie präoperativ lokalisieren. Gleichzeitig ist aber weder der intramuskuläre Verlauf noch die Lagebeziehung zur A. epigastrica inferior dadurch ersichtlich. Das Verfahren der CT-Angiografie bietet neuerdings die Möglichkeit der Visualisierung der Perforans-Gefäße im Verlauf des Gewebes. Die vorliegende Arbeit fasst die Erfahrungen mit der präoperativen CT-Angiografie an unserem Brustzentrum zusammen. Seit Frühjahr 2009 führten wir bei 44 Patientinnen einen Brustwiederaufbau mit freien Lappenplastiken durch. 6 davon waren beidseitig. Bei insgesamt 50 Brustrekonstruktionen wurde bei 23 Patientinnen eine DIEP- und bei 27 eine muskelsparende TRAM-Lappenplastik benutzt. Bei 29 Patientinnen wurde neben der präoperativen Dopplersonografie der vorderen Bauchwand eine CT-Angiografie durchgeführt. In der CT-Angiografie konnten im Mittel sowohl auf der rechten als auch auf der linken Seite zumindest 2 Perforans-Gefäße dargestellt werden, die aufgrund der Signalstärke als Lappenstielgefäße infrage kamen. 3 nach späterem mikrochirurgischen Präparationsaufwand unterschiedliche Typen an Perforans-Gefäßen konnten unterschieden werden: 1. Das kurzstreckig intramuskuläre, direkte Perforans-Gefäß Typ A (39%), 2. Das langstreckig intramuskuläre Perforans-Gefäß Typ B (50%) und 3. Das medial um den M. rectus abdominis verlaufende („Turn around”) Perforans-Gefäß Typ C (11%). Das Verfahren der CT-Angiografie ermöglicht die zuverlässige Darstellung der Perforans-Gefäße im gesamten Verlauf und erleichtert dadurch sowohl die präoperative Auswahl des Perforans-Gefäßes als auch später die intraoperative Präparation erheblich. Die vorgeschlagene Einteilung in 3 unterschiedliche Typen erleichtert die präoperative Einschätzung des mikrochirurgischen Präparationsaufwandes. Im Vergleich zur bislang angewandten Doppler-Sonografie sind als Nachteile der zusätzliche Kostenfaktor sowie die Strahlenbelastung für die Patientin hinzunehmen.

Abstract

Preoperative Doppler ultrasonography for planning free perforator flaps is widely established to identify preoperatively perforators. The method allows one to localise the penetrating point of the perforator through the abdominal fascia. By this means it is not possible to see the intramuscular course or the position of the perforator in relation to the inferior epigastric artery. Lately the technique of computed tomographic angiography provides an opportunity for visualising the course of perforator vessels in these tissues. This paper summarises our experience with the preoperative CT angiography in our breast centre. Since spring 2009 we have reconstructed the breasts of 44 female patients by using free flaps from the lower abdominal wall. 6 of these were bilateral. In a total number of 50 breast reconstructions we used 23 deep inferior epigastric perforator (DIEP) flaps and 27 muscle-sparing transverse rectus abdominis muscle (TRAM) flaps. In addition to the preoperative ultrasonography, a CT angiography of the lower abdomen was conducted in 29 patients. On average they showed at least 2 perforators on the left as well as right abdominal sides, which could be used as flap vessels based on their signal intensity. Based on their estimated microsurgical dissection complexity, the perforator vessels could be classified into 3 groups: 1) direct perforators of category A with short intramuscular course (39%), 2) perforators with long intramuscular course of category B (50%) and 3) “turn around” perforators of category C, which pass medially around the rectus abdominis (11%). The technique of CT angiography permits a reliable preoperative visualisation of perforators in their entire course and facilitates the selection of the supplying perforator as well as the intraoperative procedure for the surgeon. The suggested classification of perforators into 3 groups simplifies the preoperative assessment of the microsurgical dissection effort. Compared to the commonly used Doppler ultrasonography there are disadvantages like the additional cost factor and the radiation exposure. However, in our experience the more detailed planning increases the safety of flap raising and reduces surgery time, so that we consider CT angiography a positive tool to facilitate free perforator flaps.

DIEP - Brustrekonstruktion - Perforans-Lappenplastik - Perforans-Gefäße - Doppler-Sonografie - CT-Angiografie

deep inferior epigastric perforator (DIEP) - breast reconstruction - perforator flap - perforator vessels - Doppler sonography - CT angiography

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