A Systematic Review and Meta-analysis on Computed Tomography Angiography Mapping for Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Roshan Rupra¹Francesca Ruccia^2*Kian Daneshi^3,4Fatema Aftab⁵Yousif Yousif²Gul Khan⁶Sina Dehnadi⁷Yaqoob Al-Saidi⁸Nicola Maggialetti⁹Giovanni Lorusso⁹Maria Yan¹⁰Ankur Khajuria¹¹

• ¹Department of Plastic Surgery, Royal Devon & Exeter NHS Foundation Trust, Exeter, England, United Kingdom
• ²Department of Plastic Surgery, Royal Marsden NHS Foundation Trust, London, Westminster, United Kingdom
• ³School of Population Health and Medicine, The University of Sheffield, Sheffield, United Kingdom
• ⁴Imperial College London, London, England, United Kingdom
• ⁵Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, United Kingdom
• ⁶Department of Emergency Medicine, West Hertfordshire Hospitals NHS Trust, Watford, United Kingdom
• ⁷Department of Surgery, James Paget Hospital, Great Yarmouth, United Kingdom
• ⁸Department of Neurosurgery, Suhar Hospital, Ministry of Health, Muscat, Oman
• ⁹Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari Aldo Moro, Bari, Italy
• ¹⁰Department of Surgery, University of Connecticut, Storrs, Connecticut, United States
• ¹¹Department of Surgery and Cancer, Imperial College London, London, England, United Kingdom

Breast cancer remains the most prevalent cancer among women globally, necessitating effective reconstructive options post-mastectomy. The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction, though anatomical variability of perforators presents surgical challenges. Computed tomography angiography (CTA) has been proposed to enhance preoperative planning and reduce operative time. The aim of this study is to identify how CTA affects surgical outcomes in autologous breast reconstruction.A systematic review and meta-analysis (PROSPERO: CRD42024596646) were conducted per PRISMA guidelines. A comprehensive search of six databases identified studies comparing CTA with non-CTA imaging for DIEP flap reconstruction. Primary outcomes included operative time and flap loss rates. Risk of bias was assessed using ROBINS-I and RoB2, with quality appraised via AMSTAR-2 and GRADE.Eighteen studies (3870 patients, 4283 flaps) were included. CTA guidance reduced unilateral flap operative time (mean 304.98 min vs. 390.18 min, CI -12.9 to 5.7; P = 0.2367), as well as partial and total flap loss rates (OR: 0.26, 95% CI: 0.14-0.47; OR: 0.30, 95% CI: 0.13-0.68). High heterogeneity (I² = 98.7%) limited generalizability. Prior reviews showed limitations in study design integrity, whereas this study achieved a high-confidence rating.Preoperative CTA improves surgical outcomes in DIEP flap reconstruction, though evidence quality is variable. Future research should compare CTA with MRA, assess cost-effectiveness, integrate AI-assisted imaging, and explore MRI-based protocols for optimized preoperative planning in microsurgical breast cancer reconstruction and enhanced oncologic care delivery.