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CTA vs. MRA perforator mapping for DIEP flap breast reconstruction: surgical outcomes from a propensity score-matched cohort
Sahil Sharma
*1, Aryna Armand*, Martha MacDonald
1, Sheuli Chowdhury
1, Abigail R. Tirrell
1, Sydney A. Mathis
1, Emma Lascar
1, Patricia Fuentes
1, Shahin Owji
2, Alexander Kagen
2, Alice Yao
1, Peter J. Taub
1, Peter W. Henderson
11Division of Plastic and Maxillofacial Surgery, Icahn School of Medicine, New York, NY; 2Division of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
Background: Preoperative perforator mapping (PM) with computed tomography angiography (CTA) or magnetic resonance angiography (MRA) for deep inferior epigastric perforator (DIEP) flap breast reconstruction (BR) is commonly performed. While CTA is more widely adopted than MRA, no study has directly compared postoperative outcomes between CTA- and MRA-mapped patients.
Methods: A retrospective chart review was conducted of female patients who underwent DIEP flap BR at a single academic medical center between March 2017 and June 2024. Patients were classified into the CTA group if they had CTA PM, and into the MRA group if they had MRA PM. 1:n propensity score matching (PSM) was performed to balance demographic, comorbidity, oncologic, and surgical characteristics between groups, with covariate balance assessed using standardized mean differences (SMD <0.1 indicating excellent balance). Outcomes included composite and individual donor- and recipient-site complications, as well as measures of healthcare utilization. Augmented inverse probability weighting (AIPW) with SuperLearner, an ensemble machine learning algorithm, was used as a sensitivity analysis for outcomes with sufficient events. Statistical significance was set at p<0.05.
Results: Of 535 patients, 65 (12.1%) were in the CTA group, and 470 (87.9%) were in the MRA group. After PSM, 57 CTA patients were matched to 231 MRA patients, with excellent covariate balance (all SMDs <0.1). Composite outcomes, operative duration, and healthcare utilization were comparable. CTA was associated with higher rates of donor-site surgical site infection (OR 6.94), recipient-site fat necrosis (OR 2.18), seroma (OR 5.50), and perioperative DIEP flap venous congestion (OR 5.95) (all p<0.05). On AIPW sensitivity analysis, recipient-site fat necrosis, the only outcome with sufficient events, remained significant (RD +12.6%; p=0.029).
Conclusion: MRA-based perforator mapping was associated with lower donor- and recipient-site morbidity compared with CTA. These findings provide early evidence supporting MRA over CTA for preoperative PM.
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