Predictive Factors of a Dominant Superficial Venous Drainage System in DIEP Flap Surgery With Preoperative Computed Tomography Angiography

Background: Venous congestion due to superficial venous system dominance (SVD) in deep inferior epigastric perforator (DIEP) flap surgery occurs in approximately 2% of cases, with attendant sequelae and increased cost to healthcare systems. This study aimed to describe the predictive factors for SVD in DIEP flap breast reconstruction based on preoperative computed tomography angiography (CTA) findings. Methods: All women who required takebacks for additional venous anastomosis to the cephalic vein because of SVD after DIEP flap breast reconstruction between 2015 and 2022 were included. Complication-free DIEP breast reconstruction patients were then randomly selected based on a 1:2 enrollment ratio to form a control group. A retrospective analysis of pre-operative CTAs was performed for both groups to compare the size and location of the perforators, diameter of the superficial inferior epigastric vein (SIEV), diameter of the deep inferior epigastric vein (DIEV), and flap thickness. Results: Twenty-four women were identified in the SVD group; however, only 18 were included in the final analysis. CTA analysis suggested that the ratio between SIEV and DIEV (SIEV/DIEV) diameters was significantly higher in the SVD group than in the controls (0.98 vs. 0.83; p = 0.043). The mean flap thickness was also significantly lower in the SVD group than in the controls (29.4 vs. 36.3 mm; p < 0.001). Perforator characteristics and the SIEV diameter did not differ between the two groups. Conclusions: The SIEV/DIEV diameter ratio on preoperative CTA can be used to predict whether the DIEP flap has SVD. This may then be used to anticipate whether additional venous anastomosis is required to reduce postoperative complications.