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Revisiting the internal mammaries as recipient vessels in breast reconstruction: considerations in current practice

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Abstract

Background

The internal mammary artery (IMA) has supplanted the thoracodorsal artery as the primary recipient vessel in autologous breast reconstruction. Additionally, the IMA continues to be the preferred bypass graft choice in patients undergoing coronary artery bypass grafting (CABG). However, practice patterns in breast reconstruction have evolved considerably since the adoption of the IMA for this application. The authors sought to evaluate the safety of IMA harvest for breast reconstruction in our current practice, given the possibility that patients may require CABG in the future.

Methods

The authors reviewed the prospective database of free flaps for breast reconstruction performed at their center from 2009 to 2017. Patients were divided into three groups (2009–2011, 2011–2013, 2014–2017) and compared on the basis of demographics, medical comorbidities, and laterality of reconstruction. Patients were further risk stratified for 10-year risk of cardiovascular events using the American College of Cardiology’s atheroscletoric and cardiovascular disease (ASCVD) risk calculator.

Results

There was a marked increase in the number of patients who underwent microsurgical breast reconstruction at our institution over the past three years (2009–2011, n = 55; 2012–2014, n = 50; 2015–2017, n = 145). The distribution of unilateral versus bilateral flaps changed meaningfully; however, they did not change statistically significantly over the study period (2009–2011 = 32.7%, 2012–2014 = 28.0%, 2015–2017 = 49.0%, p = 0.12). The rise in bilateral reconstructions over the study period is commensurate with the observed significant rise in contralateral prophylactic mastectomies (2009–2011 = 25.5%, 2012–2014 = 20.0%, 2015–2017 = 42.1%, p = 0.022). The mean 10-year risk of major cardiovascular events in the entire sample was 6.3 ± 7.1% (median 4.0%). The maximum individual risk score exceeded 25% in all three groups.

Conclusion

Given overall trends in breast reconstruction and the sometimes-elevated cardiac risk profiles of our patients, the authors recommend risk stratification of all patients using the proposed Breast Reconstruction Internal Mammary Assessment (BRIMA) scoring system and consideration of left internal mammary artery preservation in select cases.

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Funding

This study was not funded.

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Authors and Affiliations

  1. Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

    Steven M. Sultan, Amanda M. Rizzo, Heather A. Erhard, Teresa Benacquista & Katie E. Weichman

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  1. Steven M. Sultan
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  2. Amanda M. Rizzo
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  3. Heather A. Erhard
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  4. Teresa Benacquista
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  5. Katie E. Weichman
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Correspondence to Steven M. Sultan.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Sultan, S.M., Rizzo, A.M., Erhard, H.A. et al. Revisiting the internal mammaries as recipient vessels in breast reconstruction: considerations in current practice. Breast Cancer Res Treat 184, 255–264 (2020). https://doi.org/10.1007/s10549-020-05878-x

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