PERFORATÖR HARİTALAMADA GÜNCEL YÖNTEMLER

Year 2011, Volume: 19 Issue: 2, 53 - 59, 01.08.2011

Serhan Tuncer Başar Kaya Kırdar Güney Çiğdem Ünal Ali Yusuf Öner M.sühan Ayhan

Abstract

Deri perforatörlerinin yerleşiminde, doku planları arasındaki seyrinde ve dallanmalarında görülen farklılıklar nedeniyle perforatör flep cerrahisi öncesi vasküler haritalandırmaya ihtiyaç vardır. Bu makalede amaç, perforatör flep cerrahisinin planlanmasında perforatör damar haritalamasının önemini vurgulamak ve kullanılan yöntemleri tartışmaktır. Taşınabilir akustik dopler sonografi, renki dopler ultrasonografi, multi-detektör bilgisayarlı tomografik-anjiografi (MDBT-ANJ) ve manyetik rezonans anjiografi (MR-ANJ) karşılaştırılmıştır. Taşınabilir akustik dopler sonografi ucuz ve kolay uygulanabilir bir yöntemdir. Ancak yanlış pozitiflik yüksektir ve çoğu zaman tek başına yeterli olmamaktadır. Renkli dopler ultrasonografi akım hızını, damar çapını ve dallanmaları değerlendirir. Ancak deneyimli bir radyolog gerekliliği ve incelemenin uzun sürmesi zayıf yönleridir. MDBT-ANJ ile damar haritalaması, perforatör flep cerrahi planlanmasında en iyi yöntemlerden birisidir. Hassasiyeti yüksektir, hızlı uygulanır ve üç boyutlu detaylı anatomik bilgi verir. Ancak cihazın kendisinin ve uygulamasının maliyeti yüksektir, iyonizan radyasyonun ve kontrast maddelerin zararlı etkileri bu görüntüleme yönteminin dezavantajlarıdır. MR-ANJ ise radyasyon ve kontrast madde kullanılmayan bir görüntüleme yöntemi olması nedeniyle MDBT-ANJ’den üstündür. Ancak görüntü kalitesi halen MDBT-ANJ kadar iyi değildir. Sonuç olarak, perforatör flep cerrahi planlamasında seçilecek yöntemi, çalışılan merkezin olanakları ile kişisel deneyim ve tercih belirlemektedir. MDBT-ANJ veya MR-ANJ bu amaç için kullanılabilecek en ileri tekniklerdir. MDBT-ANJ yüksek kalitede, detaylı görüntü sunarken, MR-ANJ radyasyon vermeksizin buna yakın kalitede görüntü sağlamaktadır. Ameliyat planlamasında tercih edilen görüntüleme yöntemine, akustik dopler sonografi ve ameliyat sırasında görsel değerlendirmenin eklenmesi ile doğru perforatör damar seçiminde hata payı sıfırlanabilir.

Keywords

Perforatör flep, perforatör haritalama, dopler, multidetektör BT anjiyografi, MR anjiyografi

CURRENT TRENDS IN PERFORATOR MAPPING

Abstract

Due to variations in location, course between tissue planes and branching of the skin perforators, a preoperative vascular mapping is mandatory during perforator flap surgery. The aim of this article is to emphasize the importance of perforator mapping in preoperative planning of the perforator flaps and discuss each method used. Hand held acoustic doppler sonography, color doppler ultrasonography, multi-detector computed tomographic angiogram (MDCT-ANG) and magnetic resonance angiography (MR-ANG) were compared. Hand held acoustic doppler sonography is a cheap and simple method, but it has a high rate of false positivity and most of the time it is inadequate when used alone. Color doppler ultrasonography evaluates the flow rates, vessel diameters and branching. But an experienced radiologist is needed and the examination takes long time. Vascular mapping with MDCT-ANG is one of the most valuable methods in preoperative planning of perforator flaps. It has high sensitivity, can be applied fast and gives detailed three-dimensional anatomical information. But the expensive cost of the machine itself and its application, and unwanted effects of ionizing radiation and radio-opaque are the disadvantages. MR-ANG is a radiation and contrast free imaging technique, however the quality of the images is not as good as MDCT-ANG. In conclusion, the facilities of the center, experiences and personal preferences determine the method chosen for surgical planning of the perforator flaps. MDCT-ANG and MR-ANG are the most advanced and powerful tools for this purpose. MDCT-ANG provides high quality detailed images; MR-ANG gives moderate quality images without the need of radiation. If verification with acoustic doppler sonography and intraoperative visual evaluation is added to the chosen imaging technique during preoperative planning, possibility of errors in correct perforator selection can be minimized.

Keywords

Perforator flap, perforator mapping, doppler, multidetector CT angiography, MR angiography

References

• Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113-41.
• Masia J, Kosutic D, Clavero JA, Larranaga J, Vives L, Pons G. Pre- operative computed tomographic angiogram for deep inferior epigastric artery perforator flap breast reconstruction. J Recon- str Microsurg. 2010;26(1):21-28.
• Giunta RE, Geisweid A, Feller AM. The value of preoperative dop- pler sonography for planning free perforator flaps. Plast Recon- str Surg. 2000;105(7): 2381-6.
• Alonso-Burgos A, García-Tutor E, Bastarrika G, Cano D, Martínez- Cuesta A, Pina L J. Preoperative planning of deep inferior epigas- tric artery perforator flap reconstruction with multisection-CT angiography: imaging findings and initial experience. J Plast Reconstr Aesthet Surg 2006;59(6):585–93.
• Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989;42(6):645-8.
• Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg. 2004;114(4):910-6.
• Blondeel PN, Beyens G, Verhaeghe R, Van Landuyt K, Tonnard P, Monstrey SJ, Matton G. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg. 1998;51:202-9.
• Muneuchi G, Matsumoto Y, Tamai M, Kogure T, Igawa HH, Nagao S. Rhomboid perforator flap for a large skin defect due to lum- bosacral meningocele: a simple and reliable modification. Ann Plast Surg. 2005;54(6):670-2.
• Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a compara- tive study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg. 2008;121(1):9-16.
• Alonso-Burgos A, Garcia-Tutor E, Bastarrika G, Cano D, Martinez- Cuesta A, Pina LJ. Preoperative planning of deep inferior epi- gastric artery perforator flap reconstruction with multislice-CT angiography: imaging findings and initial experience. J Plast Reconstr Aesthet Surg. 2006;59:585-93.
• Hijjawi JB, Blondeel PN. Advancing deep inferior epigastric ar- tery perforator flap breast reconstruction through multidetec- tor row computed tomography: an evolution in preoperative imaging. J Reconstr Microsurg. 2010;26(1):11-20.
• Masia J, Clavero JA, Larranaga JR, Alomar X, Pons G, Serret P. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59:594–9.
• Hallock GG. Doppler sonography and colour duplex imaging for planning a perforator flap. Clin Plast Surg. 2003;30:347–57.
• Chow LC, Napoli A, Klein MB, Chang J, Rubin GD. Vascular map- ping of the leg with multi–detector row CT angiography prior to free-flap transplantation. Radiology 2005;237(1):353-60.
• Clemenza JW, Rogers S, Magennis P. Pre-operative evaluation of the lower extremity prior to microvascular free fibula flap har- vest. Ann R Coll Surg Engl. 2000;82:122–7.
• Hu H, He D, Foley D, Fox SH. Four multidetector-row heli- cal CT: image quality and volume coverage speed. Radiology 2000;215(1):55-62.
• Choi SI, George RT, Schuleri KH, Chun EJ, Lima JA, Lardo AC. Re- cent developments in wide-detector cardiac computed tomog- raphy. Int J Cardiovasc Imaging 2009;25(Suppl1):23-29.
• Chernyak V, Rozenblit AM, Greenspun DT, Levine JL, Milikow DL, Chia FA, et al. Deep inferior epigastric artery perforator flap: 3.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall perforators. Radiology. 2009;250(2):417-24.
• Hölzle F, Ristow O, Rau A, Mücke T, Loeffelbein DJ, Mitchell DA, et al. Evaluation of the vessels of the lower leg before microsur- gical fibular transfer. Part II: magnetic resonance angiography for standard preoperative assessment Br J Oral Maxillofac Surg. 2011;49(4):275-280.
• Leiner T, de Vries M, Hoogeveen R, Vasbinder GB, Lemaire E, van Engelshoven JM. Contrast-enhanced peripheral MR angiogra- phy at 3.0 Tesla: initial experience with a whole-body scanner in healthy volunteers. J Magn Reson Imaging 2003;17(5):609-14.
• Randoux B, Marro B, Koskas F, Chiras J, Dormont D, Marsault C. Proximal great vessels of aortic arch: comparison of three- dimensional gadolinium-enhanced MR angiography and digital subtraction angiography. Radiology 2003;229(3):697-702.
• Hamdi M, Van Landuyt K, Van Hedent E, Duyck P. Advances in autogenous breast reconstruction: the role of preoperative per- forator mapping. Ann Plast Surg. 2007;58:18–26.