Annals of Surgical Oncology

, Volume 27, Issue 2, pp 399–406 | Cite as

Assessment of DIEP Flap Perfusion with Intraoperative Indocyanine Green Fluorescence Imaging in Vasopressor-Dominated Hemodynamic Support Versus Liberal Fluid Administration: A Randomized Controlled Trial With Breast Cancer Patients

  • Alexandra M. AnkerEmail author
  • Lukas Prantl
  • Catharina Strauss
  • Vanessa Brébant
  • Felix Schenkhoff
  • Michael Pawlik
  • Jody Vykoukal
  • Silvan M. Klein
Reconstructive Oncology



Dogmatic denial of vasopressor agents for blood pressure regulation during free-flap surgery is associated with concomitant large-volume intraoperative fluid administration. Yet, the doctrinal banning of vasopressors during microvascular breast reconstruction still is a subject of controversy. Several retrospective observations have recently drawn attention to serious iatrogenic consequences of intravenous crystalloid overload in microsurgery such as thrombus formation and increased flap failure rates.


This prospective randomized controlled trial investigated the potential effects of fluid-restrictive vasopressor-dominated hemodynamic support (FRV) compared with vasopressor-restrictive liberal fluid administration (LFA) on clinically relevant perfusion of the deep inferior epigastric perforator (DIEP) flap via intraoperative indocyanine green (ICG) fluorescence imaging. The primary end point of the study was quantitative assessment of the percentage of insufficiently perfused tissue (NP) on the overall flap. Major complications were assessed as secondary end points.


In 44 DIEP flap breast reconstructions after mastectomy, FRV circulatory support resulted in no statistically significant difference in total flap perfusion as detected via ICG fluorescence imaging in direct comparison with a traditional LFA strategy (NPFRV, 31.8% ± 12.2% vs NPLFA, 29.5% ± 13.3%; p = 0.559). One flap failure was registered with LFA, whereas no major complication occurred in the FRV cohort.


According to the results of this study, neither a norepinephrine concentration of 0.065 ± 0.020 μg/kg/min (FRV) nor fluid administration of 5.1 ± 2.2 ml/kg/h (LFA) has a clinically significant impact on microperfusion in a standard DIEP flap procedure for breast reconstruction. Consistent with the current literature reporting a rise in complications with intraoperative fluid over-resuscitation, one flap failure occurred in the LFA cohort.


Conflict of interest

There are no conflicts of interest.

Supplementary material

Supplementary material 1 (MP4 1009 kb)


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Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Alexandra M. Anker
    • 1
    Email author
  • Lukas Prantl
    • 1
  • Catharina Strauss
    • 1
  • Vanessa Brébant
    • 1
  • Felix Schenkhoff
    • 2
  • Michael Pawlik
    • 2
  • Jody Vykoukal
    • 3
  • Silvan M. Klein
    • 1
  1. 1.Center for Plastic, Reconstructive, Aesthetic, and Hand SurgeryUniversity Hospital Regensburg and Caritas Hospital St. Josef RegensburgRegensburgGermany
  2. 2.Department of AnesthesiologyCaritas Hospital St. Josef RegensburgRegensburgGermany
  3. 3.Department of Clinical Cancer Prevention and The McCombs Institute for the Early Detection and Treatment of CancerThe University of Texas MD Anderson Cancer CenterHoustonUSA

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