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PURPOSE: Anatomic studies have shown that the anterior abdominal wall is commonly dependent on the superficial venous network for adequate drainage. Despite this superficial system dominance, most DIEP/TRAM flaps drain adequately, through communicating veins with the deep system. In cases where such connections are inadequate, it is necessary for the surgeon to recognize this intraoperatively, not as an intra-operative venous thrombosis, but as an intrinsic flap issue. In addition, the surgeon must have a strategy for management.
METHODS: A retrospective analysis of 1201 consecutive TRAM and DIEP flaps over a 5-year period was performed. All cases of inadequate venous outflow not due to technical anastomotic problems or venous thrombosis were identified. In each case, clinical signs indicating intra-operative congestion despite patent deep inferior epigastric vein were assessed. In addition, the intra-operative strategy for venous outflow augmentation was recorded.
RESULTS:From this cohort of 1201 patients, 11 (.9%) exhibited intra-operative congestion due to superficial venous system dominance, despite patent and draining deep vein anastomosis. Taken separately, venous thrombosis rate over the same time period was .6%. All cases were successfully identified and managed intra-operatively. Cutaneous venous congestion was noted in 10 of 11 flaps following anastomosis (91%, p=.02), while all 11 flaps exhibited a tense superficial inferior epigastric vein that drained briskly when opened (100%, p=.01). In 10 flaps, strip test and doppler signal indicated patent deep venous anastomosis and outflow (91%, p=.02). In all cases, the preserved SIEV was anastomosed to a second recipient outflow vein, and excellent venous outflow was achieved. Most commonly (5 flaps), this was done by anastomosis of the SIEV to a proximally dissected vena commitante of the flap DIEV; thus, a superficial to deep venous loop was created within the flap [Figure]. In 4 flaps, the SIEV was anastomosed to a second internal mammary vein, in 1 to the lateral thoracic vein, and in 1 to the thoracodorsal vein.
CONCLUSION:Intra-operative congestion during autologous, abdominally based breast reconstruction is often attributed to venous thrombosis. In our experience, however, this is more commonly due to a superficially dominant flap in which the deep venous anastomosis is patent, yet adequate drainage cannot be achieved due to inadequate communicating veins between the two systems. Early recognition of the congestion, along with identification of patent venous outflow through the deep system, alerts the surgeon to superficial venous dominance. When this is correctly identified, establishing additional outflow through the SIEV has resulted in 100% salvage rate. Anastomosis of the SIEV to a proximally dissected vena commitante of the DIEV system on the flap was performed most commonly in our series. This technique allows anastomosis of 2 veins in close proximity, and avoidance of using a second recipient vein. Due to the potential for relief of venous congestion, it is imperative to preserve the SIEV with sufficient length during initial flap dissection.