A Feasibility Study Of Ferumoxytol-Enhanced MR Angiography For Evaluation of DIEP Flap Vasculature

Background

Deep inferior epigastric vessel based (DIEP) free flaps have distinct advantages and disadvantages. It has been suggested that a large superficial inferior epigastric vein portends flap failure related to venous congestion.  One hypothesis is that inadequate communication between the superficial and deep venous systems may contribute to development of congestion in the dominant superficial system (1, 2).  Pre-operative imaging localization of abdominal wall perforators is also important. 

Ferumoxytol (Ferahemeª) is a bolus-injectable carbohydrate-coated iron oxide nanoparticle approved for treatment of anemia in patients with advanced renal disease (3).  As we have shown in other clinical scenarios, ferumoxytol in the appropriate concentration enhances the vasculature as intensely as gadolinium, yielding high quality venous and arterial images ideal for surgical planning, in combination with a unique and favorable side effect profile.

Aims

To investigate the feasibility of ferumoxytol-enhanced magnetic resonance angiography for  surgical planning of DIEP flaps.

Methods

Ferumoxytol-enhanced MRA was performed using a novel T1-weighted pulse sequence with reconstruction in 3 planes. Arterial perforators and their associated veins were evaluated with regard to size, overall distribution, and position.

Results

The deep and superficial inferior epigastric arteries and veins as well as multiple perforators were clearly depicted from groin to several centimeters above the umbilicus. 

Conclusions

Ferumoxytol-enhanced MRA produces excellent visualization  of the arterial and venous abdominal wall vasculature for DIEP flap planning, while avoiding the known drawbacks of iodinated and gadolinium-based contrast agents.

Figure 1.  MRA, equilibrium phase. A) Coronal MIP image depicts the deep inferior epigastric vessels, with individual demonstration of DIE arteries and venae comitantes (thick arrows). (arrowheads = perforators, long arrows = intramuscular course). Coronal thick MIP includes the SIE vascular bundle (arrowheads), the DIE group (long arrow) and the course of one of the perforators (small arrows).  B) Axial reformat of the abdominal wall just below the umbilicus demonstrates many perforators, both medial and lateral. (arrow = left rectus muscle, B = peristalsing bowel)