Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 580e599
CORRESPONDENCE AND COMMUNICATIONS CTA and contrastenhanced MRA are equally accurate for localizing deep inferior epigastric perforator flap arteries: A systematic review Dear Sir, The deep inferior epigastric perforator (DIEP) flap has become popular for breast reconstruction. Preoperative imaging has been shown to reduce operating time and donor site complications.1 For preoperative perforator localization current modalities include handheld Doppler, color Doppler (duplex) ultrasound, computed tomographic angiography (CTA), and contrast-enhanced magnetic resonance angiography (MRA).2 CTA and contrastenhanced MRA are the most promising modalities for preoperative planning, given their high spatial resolution. To compare the diagnostic performance of CTA and contrast-enhanced MRA in the preoperative localization of DIEP flap perforators, we conducted a systematic review of prospective trials comparing CTA and contrastenhanced MRA data with intraoperative findings. We report the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Details of compliance with PRISMA Guidelines are included in the Appendix. MEDLINE and EMBASE databases were searched through September 2014 with the following key words: deep inferior epigastric perforator, magnetic resonance angiography, and computed tomographic angiography. Only studies that performed CTA and MRA in the same patient group were included. Titles and abstracts of potential articles for inclusion were independently examined by two reviewers (E.W.S. and H.T.C.). Full articles were retrieved and examined by both reviewers when their title and abstract did not provide enough information for a definite decision. When the two reviewers disagreed, the third investigator (Y.C.H) was included, and consensus was reached after discussion. Using the raw data provided in the articles, we independently calculated the diagnostic metrics using MetaDiSc version 1.4. Perforators found in preoperative imaging
studies and intraoperatively were defined as true positive. Perforators found in preoperative imaging studies, but not identified intraoperatively, were defined as false positive. Additional perforators found intraoperatively were regarded as false negative. Pooled summary statistics for sensitivity with 95% confidence intervals (CIs) were computed. The Fisher’s exact test was used for statistical comparison between the diagnostic sensitivities of CTA and contrast-enhanced MRA using the MedCalc version 11.4.2.0 statistical software (MedCalc Software, Mariakerke, Belgium). Values of p < 0.05 were considered significant. Three studies totaling 38 patients met inclusion criteria (Figure 1, Table 1). The pooled sensitivities for all three studies showed no statistically significant difference
Figure 1
Summary of literature search and study selection.
Correspondence and communications Table 1
581
Results of CTA and contrast-enhanced MRA studies for the preoperative localization of DIEP flap perforators.
Author, year
No. of patients
Imaging modality
TP
FP
FN
Rozen WM, 20093
5a
Siemens SOMATOM Sensation 64 multi-detector row CT scanner 1.5 Tesla General Electric Echospeed HDx scanner, 3 Tesla Siemens Magnetom Trio scannerb Siemens SOMATOM Definition Flash 64-channel CT scanner 3 Tesla General Electric Signa Excite scanner General Electric LightSpeed VCT 64-slice multi-detector CT scanner 1.5 Tesla General Electric Signa Excite 2 scanner
18
0
0
8
0
10
44.4% (21.5%69.2%)
59
0
11
84.3% (73.6%e91.9%)
67 66
0 0
3 3
95.7% (88.0%e99.1%) 95.7% (87.8%e99.1%)
61
0
8
88.4% (78.4%e94.9%)
Pauchot J, 20124
10
Cina A, 20135
23
Sensitivity (95% CI) 97.3% (77.4%e100.0%)
Abbreviation: TP: true positive, FP: false positive, FN: false negative, CI: confidence interval. a One patient that did not receive computed tomographic angiography evaluation was not included in the analysis (originally 6 total patients in study). b The first three patients were imaged using a 1.5 Tesla MRI and the last two patients were imaged using a 3 T MRI.
Table 2 studies.
Summary of pooled data from three included 2.
Imaging True False Sensitivity (95% CI) modality positive negative CTA MRA
143 136
14 21
p value
90.8% (85.2%e94.8%) 0.282 86.6% (80.3%e91.5%)
3.
Abbreviation: CI: confidence interval. 4.
between CTA and contrast-enhanced MRA for the preoperative localization of the DIEP flap perforators (p Z 0.282) (Table 2). We believe that diagnostic modalities should be chosen according to familiarity with the imaging technique (surgeon and radiologist), risk of radiation and contrast exposure for the patient, and clinical cost effectiveness.
5.
tomographic angiography: systematic review and meta-analysis. Plast Reconstr Surg 2014;133:483e94. Mathes DW, Neligan PC. Current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction. J Reconstr Microsurg 2010;26: 3e10. Rozen WM, Stella DL, Bowden J, et al. Advances in the preoperative planning of deep inferior epigastric artery perforator flaps: magnetic resonance angiography. Microsurgery 2009;29:119e23. Pauchot J, Aubry S, Kastler A, et al. Preoperative imaging for deep inferior epigastric perforator flaps: a comparative study of computed tomographic angiography and magnetic resonance angiography. Eur J Plast Surg 2012; 35:795e801. Cina A, Barone-Adesi L, Rinaldi P, et al. Planning deep inferior epigastric perforator flaps for breast reconstruction: a comparison between multidetector computed tomography and magnetic resonance angiography. Eur Radiol 2013;23: 2333e43.
Conflict of interest statement There is no potential conflict of interest that exists. No funding was received. All authors have no financial and personal relationships with other people or organizations that could inappropriately influence this work. Ethical approval not required.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2014.11.009.
References
Edward W. Swanson Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA Yung-Chang Hsu Hsu-Tang Cheng Department of Plastic and Reconstructive Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.11.009
1. Ohkuma R, Mohan R, Baltodano PA, et al. Abdominally based free flap planning in breast reconstruction with computed
CORRESPONDENCE AND COMMUNICATIONS CTA and contrastenhanced MRA are equally accurate for localizing deep inferior epigastric perforator flap arteries: A systematic review Dear Sir, The deep inferior epigastric perforator (DIEP) flap has become popular for breast reconstruction. Preoperative imaging has been shown to reduce operating time and donor site complications.1 For preoperative perforator localization current modalities include handheld Doppler, color Doppler (duplex) ultrasound, computed tomographic angiography (CTA), and contrast-enhanced magnetic resonance angiography (MRA).2 CTA and contrastenhanced MRA are the most promising modalities for preoperative planning, given their high spatial resolution. To compare the diagnostic performance of CTA and contrast-enhanced MRA in the preoperative localization of DIEP flap perforators, we conducted a systematic review of prospective trials comparing CTA and contrastenhanced MRA data with intraoperative findings. We report the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Details of compliance with PRISMA Guidelines are included in the Appendix. MEDLINE and EMBASE databases were searched through September 2014 with the following key words: deep inferior epigastric perforator, magnetic resonance angiography, and computed tomographic angiography. Only studies that performed CTA and MRA in the same patient group were included. Titles and abstracts of potential articles for inclusion were independently examined by two reviewers (E.W.S. and H.T.C.). Full articles were retrieved and examined by both reviewers when their title and abstract did not provide enough information for a definite decision. When the two reviewers disagreed, the third investigator (Y.C.H) was included, and consensus was reached after discussion. Using the raw data provided in the articles, we independently calculated the diagnostic metrics using MetaDiSc version 1.4. Perforators found in preoperative imaging
studies and intraoperatively were defined as true positive. Perforators found in preoperative imaging studies, but not identified intraoperatively, were defined as false positive. Additional perforators found intraoperatively were regarded as false negative. Pooled summary statistics for sensitivity with 95% confidence intervals (CIs) were computed. The Fisher’s exact test was used for statistical comparison between the diagnostic sensitivities of CTA and contrast-enhanced MRA using the MedCalc version 11.4.2.0 statistical software (MedCalc Software, Mariakerke, Belgium). Values of p < 0.05 were considered significant. Three studies totaling 38 patients met inclusion criteria (Figure 1, Table 1). The pooled sensitivities for all three studies showed no statistically significant difference
Figure 1
Summary of literature search and study selection.
Correspondence and communications Table 1
581
Results of CTA and contrast-enhanced MRA studies for the preoperative localization of DIEP flap perforators.
Author, year
No. of patients
Imaging modality
TP
FP
FN
Rozen WM, 20093
5a
Siemens SOMATOM Sensation 64 multi-detector row CT scanner 1.5 Tesla General Electric Echospeed HDx scanner, 3 Tesla Siemens Magnetom Trio scannerb Siemens SOMATOM Definition Flash 64-channel CT scanner 3 Tesla General Electric Signa Excite scanner General Electric LightSpeed VCT 64-slice multi-detector CT scanner 1.5 Tesla General Electric Signa Excite 2 scanner
18
0
0
8
0
10
44.4% (21.5%69.2%)
59
0
11
84.3% (73.6%e91.9%)
67 66
0 0
3 3
95.7% (88.0%e99.1%) 95.7% (87.8%e99.1%)
61
0
8
88.4% (78.4%e94.9%)
Pauchot J, 20124
10
Cina A, 20135
23
Sensitivity (95% CI) 97.3% (77.4%e100.0%)
Abbreviation: TP: true positive, FP: false positive, FN: false negative, CI: confidence interval. a One patient that did not receive computed tomographic angiography evaluation was not included in the analysis (originally 6 total patients in study). b The first three patients were imaged using a 1.5 Tesla MRI and the last two patients were imaged using a 3 T MRI.
Table 2 studies.
Summary of pooled data from three included 2.
Imaging True False Sensitivity (95% CI) modality positive negative CTA MRA
143 136
14 21
p value
90.8% (85.2%e94.8%) 0.282 86.6% (80.3%e91.5%)
3.
Abbreviation: CI: confidence interval. 4.
between CTA and contrast-enhanced MRA for the preoperative localization of the DIEP flap perforators (p Z 0.282) (Table 2). We believe that diagnostic modalities should be chosen according to familiarity with the imaging technique (surgeon and radiologist), risk of radiation and contrast exposure for the patient, and clinical cost effectiveness.
5.
tomographic angiography: systematic review and meta-analysis. Plast Reconstr Surg 2014;133:483e94. Mathes DW, Neligan PC. Current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction. J Reconstr Microsurg 2010;26: 3e10. Rozen WM, Stella DL, Bowden J, et al. Advances in the preoperative planning of deep inferior epigastric artery perforator flaps: magnetic resonance angiography. Microsurgery 2009;29:119e23. Pauchot J, Aubry S, Kastler A, et al. Preoperative imaging for deep inferior epigastric perforator flaps: a comparative study of computed tomographic angiography and magnetic resonance angiography. Eur J Plast Surg 2012; 35:795e801. Cina A, Barone-Adesi L, Rinaldi P, et al. Planning deep inferior epigastric perforator flaps for breast reconstruction: a comparison between multidetector computed tomography and magnetic resonance angiography. Eur Radiol 2013;23: 2333e43.
Conflict of interest statement There is no potential conflict of interest that exists. No funding was received. All authors have no financial and personal relationships with other people or organizations that could inappropriately influence this work. Ethical approval not required.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2014.11.009.
References
Edward W. Swanson Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA Yung-Chang Hsu Hsu-Tang Cheng Department of Plastic and Reconstructive Surgery, China Medical University Hospital, China Medical University, Taichung City, Taiwan E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.11.009
1. Ohkuma R, Mohan R, Baltodano PA, et al. Abdominally based free flap planning in breast reconstruction with computed
