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Does Fluorescent Angiography Reduce Postoperative Complications After Breast Reconstruction? A Propensity-score Matched, Cohort Analysis
Victor Vakayil, MBBS, MS, MPH, Matthew Rich, MD, Christopher Stewart, MD, Ashish Mahajan, MD, Nicholas Kim, MD, Umar Choudry, MD.
University Of Minnesota, Minneapolis, MN, USA.

Purpose
There remains a paucity of randomized clinical trials or high-grade evidence substantiating the use of florescent angiography following reconstructive breast surgery. We utilize a national, multi-institutional, surgical outcomes database to design a pseudorandomization study that evaluates the comparative effectiveness of florescent angiography during breast surgery.
Methods
Using the American College of Surgeon National Quality Improvement Program database, we performed a retrospective, exposure-matched, cohort analysis over a 13-year period (2005-2017). International Classification of Disease-9/10 codes along with Current Procedure Terminology codes were used to identify all patients undergoing mastectomy with immediate implant-based, expander-based, or autologous breast reconstruction. We stratified patients into two cohorts: those receiving and not receiving fluorescent angiography (FA & nFA groups). We used propensity-score matching to mitigate selection bias and reduce baseline heterogeneity between >50 demographic, clinical, and perioperative variables. Using a caliper distance of 0.2 and nearest-neighbor matching technique, we identified two identical matches from nFA for each patient in FA (1:2 matching). Our outcomes of interest were 30-day rates of postoperative morbidity and mortality.
Results
113,504 patients met our initial inclusion criteria; 1.6% (1,809) of patients underwent concurrent FA. After matching we were left with 5,421 patients; 1,809 (33.3%) patients in FA and 3,612 (66.6%) patients in the nFA groups. 21.7% (1,174) patients underwent bilateral mastectomies. 66.3% (3,592) had a simple-total mastectomy, 14.1% (765) had modified-radical mastectomies and 5.9% (321) had skin sparing mastectomies. 47.1% (2,554) of reconstructions were expander-based, 14.4% (779) were implant-based, and 43.3% (2341) were autologous reconstructions (latissimus dorsi, transverse rectus abdominus flaps and free flaps). Before matching, the FA group on baseline had a higher proportion of co-morbidities and higher proportion of autologous reconstructions. Post-match diagnostics demonstrated successful matching on all baseline variables. Overall, 30-day postoperative wound complication rates were similar between both cohorts (FA: 4.8% [87], nFA: 4.8% [174], P =0.990). Rates of superficial surgical site infections (FA: 2.4% [88], nFA: 2.0% [37], P =0.366 ), deep surgical site infections (FA: 1.1% [19], nFA: 0.9% [33], P =0.626), organ space infections (FA: 1.0% [18], nFA: 0.8% [29], P =0.472 ) and wound/flap dehiscence ( FA: 1.4% [25], nFA: 1.0% [36]%, P =0.205 ) were also similar
between both groups. Other 30-day postoperative complication rates (all P >0.05) and reoperation rates (FA: 8.9% [161], nFA: 8.5%, P = 0.645) remained similar between both groups. There was no postoperative mortality in either group.
Conclusion
This national appraisal of surgical outcomes demonstrates that fluorescent angiography did not decrease postoperative morbidity following reconstructive breast surgery. Well-powered, prospective, randomized trials may help elucidate the effect of such technology within specific surgical cohorts or high-risk groups.


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