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Abdominal Based Free Flap Planning in Breast Reconstruction with CT Angiography - Systematic Review and Meta-analysis
Rika Ohkuma, MD, Raja Mohan, MD, Justin Broyles, MD, Michiyo Yamazaki, Ph.D, Eric B. Schneider, Ph.D, Gedge D. Rosson, MD.
Johns Hopkins Hospital, Baltimore, MD, USA.

PURPOSE:
Computed tomography angiography (CTA) is often used preoperative mapping. The purpose of this systematic review is to evaluate outcomes of abdominal based free flap with preoperative CTA and compare with methods such as hand-held doppler devices or color duplex ultrasonography. This study includes meta-analysis of comparative operative times and complication.
METHODS:
We identified 301 English-language studies by searching PubMed and after a hand-search of relevant articles in October 2011. Three authors independently reviewed them and included studies that analyzed the relationship between pre-operative imaging and surgical findings, operative times, flap related complications, or donor site morbidity. Reports with fewer than 10 patients, outcomes described subjectively, or review papers were excluded.(Fig1)
Meta-analysis was performed with studies that compared operative time and flap related complications between preoperative CTA and Doppler. A Mantel-Haenszel pooled risk ratio was calculated to compare the risk of any complication between the CTA and Doppler groups. Comparison of operative time by diagnostic procedures was translated to a standardized effect size in each study (i.e. mean CT operative time minus mean Doppler operative time divided by the pooled SD), and then a pooled standardized mean difference (SMD) was calculated using the method of Cohen. If SMD was negative, it indicates CTA reduced the mean operative time compared to Doppler.
RESULTS:
27 studies were included in the systematic review; those studies evaluated the anatomic accuracy and outcomes associated with preoperative CTA. Of the 27 studies, 14 were studies comparing CTA to doppler ultrasonography. After removing studies that did not provide the standard error for the results or reported outcomes from prior, published data reported by same authors, meta-analysis was performed on the incidence of complications in 6 studies and on operative time in 5 studies. (Fig2)
Preoperative CTA was associated with a significant decrease in the risk of flap-related complications (Odds Ratio [95%CI]: 1.13 [1.07, 1.20]) and with a significant reduction in reconstructive operative time (SMD [95%CI]: -1.28 [-1.47, -1.10], mean difference 93.4 minutes). Outcomes from the remainder of the studies report the accuracy of pre-operative imaging and the reduction of donor site morbidity.
CONCLUSION:
CTA has been used in perforator flap planning for breast reconstruction. Several authors reported the accuracy to detect the location and estimated size of the perforators, and their relationship with other anatomical structures. Its disadvantages are radiation exposure and the use of iodinated contrast medium.
There appears to be a reduction of operative time, plus a significant decrease in post-operative flap related complications and donor site morbidity. Thus CTA has the potential to reduce the operative cost and to increase efficiency in the operating room. For these reasons, preoperative mapping by CTA should be strongly considered for abdominal based free flap breast reconstruction.


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