Table 1 Included studies

Al-Dhamin, Canda 2014 [27]

Evaluation of the retrograde limb of the internal mammary vein as a second recipient vein

Non-randomised study (retrospective) with controls

P1: 48 DIEPs (38 pats)

I1: 17

C: 31

NR

The DIEV was anastomosed to the proximal IMV and the SIEV was anastomosed to the distal IMV

O1. Flap complications

 − 

 + ?

 − 

Al Hindi, 2019, France [28]

Analyse the centre’s use of SIEVs

Non-randomised study (retrospective) with controls

P1: 198 DIEPs (183 pats)

I1: 15

I2: 2

C: 181

Blueish discoloration and increased capillary refill time (> 3 s)

SIEV 11/17

Second DIEV 6/17

Recipient vessels:

CV 8

IMV 4

LMV 2

CSV 2

TDV 1

O1. Flap complications

O3. LOS

O4. Operative time

-

-

-

Ali, 2010, Taiwan [29]

Investigation of compilations in intraoperatively congested DIEPs

Non-randomised study (retrospective) with controls

P1: 151 DIEPs

I1: 14

I2: 7

C: 130

‘A purplish or plethoric coolness of the flap associated with brisk capillary refill (< 1 s) and rapid and dark venous bleeding on puncture, despite a patent venous anastomosis’

SIEV

Second DIEV

Recipient vessels:

IMV

EJV

TDV

 ± VG

O1. Flap complications

O3. LOS

 − 

 − 

?

Akita, 2018, Japan [30]

Pilot-testing of a method to detect venous congestion intraoperatively

Non-randomised study (prospective) with controls

P1: 70 DIEPs (67 pats)

I1: 8

C: 62

NA

Ipsilateral SIEV to

LTV (n = 3)

DIEV (n = 2)

O6. Strategies

 − 

 + ?

?

Ayestaray, 2016, France [31]

Investigation of the effect of venous supercharging on complication

RCT

P1: 52 DIEPs

I3: 29

C: 23

Patients randomised to supercharging or not supercharging

NR

Ipsilateral SIEV to TAV

O1. Flap complications

O4. Operative time

O5. Operative takebacks

?

 + 

 − 

Bartlett, 2018, USA [32]

Description of centre’s algorithm for intraoperative salvage of congested flaps

Case series (retrospective)

P1: 67 DIEPs (38 pats)

C: 172 DIEPs (100 pats)

I1: 40

• Brisk capillary refill (< 1.5 s)

• Red/purple hue

• Dilated/ tense SIEV

• Brisk bleedning during flap trimming or de-epithelialisation

32 SIEV to DIEV

5 SIEV to IMV

O1. Flap complications

O4. Operative time

 − 

 − 

 − 

Bast, 2016 [33]

Investigation of the ratio of the sub- and supra-scarpal fat layers, the number of deep system perforators, and of the SIEV diameter and if indications for SIEV dissection can be predicted by these factors

Case series (retrospective)

P2: 50 women (100 hemiabdomens)

I4: 50 CTA

NA

NA

O6. Strategies

 − 

 + ?

?

Beier, 2013, German [34]

Investigation of assess the potential role for intra-operative CLDS for intra-operative decision-making

Case series (prospective)

P1: 25 DIEPs or muscle sparing TRAMs

I4: CTA (preop), Combined lased Doppler spectrophotometry (CLDS) (intraop)

NA

NA

O6. Strategies

 − 

 + ?

?

Blondeel, 2000, Belgium [9]

Comparison of venous congestion in DIEPs vs. TRAMs, suggestion of strategy for dealing with venous congestion and investigation of why venous congestion occur more frequently in zone IV of a DIEP flap

Non-randomised study (retrospective) with controls

and case series (prospective) of cadavaers

P1: 249 DIEPs (214 pats)

I1: 5

C: 245

‘Severe diffuse venous congestion that involved the whole flap. Particularly large SIEV (> 1.5 mm)’

NR

O6. Strategies

 − 

 + ?

?

Boutros, 2013, USA [35]

Investigate the outcome of the centre’s routine use of venous augmentation

Non-randomised study (retrospective) with controls

P1: 352 DIEPs (192 pats)

I3 (?): 311

C: 42

NR how the patients were allocated to the two groups. Authors describe their use of venous supercharging was routinely used

Ultrasound diagnosis

The largest superficial vein to the more medial IMV or to the perforator of IMV

O1. Flap complications

O5. Surgical takebacks

 − 

 − 

Davis, 2018, UK [18]

Correlation of preoperative CTA findings with postoperative venous congestion to predict patients at risk of congestion

Non-randomised study (prospective) with controls

P1: 240 DIEPs

I1 + 2: 13

C: 227

I4: CTA

‘Sufficient clinical evidence necessitating a salvage procedure’

SIEV to

DIEV (SOS-technique)

Retrograde IMV

Second v. comitantis of IMV

CV

TV

O6. Strategies

 − 

 + ?

?

Dortch, 2018, USA [36]

Investigate venous characteristics associated with SIEV augmentation

Non-randomised study (retrospective) with controls

P1. 99 DIEPs or muscle sparing TRAMs

I1: 29

I4: Ferumoxytol-enhanced magnetic resonance angiography

C: 73

NR

NR

O6. Strategies

 − 

 + ?

?

Enajat, 2010, Australia [37]

Comparison of one and two veins for drainage

Non-randomised study (retrospective) with controls

564 DIEPs (501 pats)

I1: 291

C: 273

‘Brisk capillary refill or bleeding or deep blue colour of the flap or draining blood’

SIEV (92%) or second DIEV (8%) to

CV 83%

IMV 10%

CSV 4%

TDV 4%

O1. Flap complications

O4. Operative time

 − 

Eom, 2011, South Korea [38]

Review of centre’s experiences and comparison of different recipient veins

Non-randomised study (retrospective) with controls

P1: 153 DIEPs and TRAMs

I2: 45

C: 108

‘Signs of congestion’

SIEV to

31 LTVs

10 branches of TAV

4 perforator of IMV

The contralateral SIEV was used as VG in 4 cases

O1. Flap complications

O5. Take backs

 − 

 − 

 − 

Galanis, 2014, USA [39]

Description of centre’s strategies to handle intraoperative venous congestion

Description of approach

NA

NA

NA

NA

O6. Strategies

 − 

 − 

 − 

Huang, 2022, USA [40]

Investigation of risk factors for venous congestion

Non-randomised study (retrospective) with controls

455 DIEPs (258 pats)

I1: 5

I2: 3

I4: CTA

C: 447

‘Flap engorgement and colour change’

NR

O6. Strategies

?

 + ?

?

Katz, 2010, USA [41]

Classification of clinically relevant

CTA scenarios

Case series (prospective)

P2: 172 hemiabdomens (86 pats)

P4: CTA

NA

NA

O6. Strategies

 − 

 + ?

?

La Padula, 2016, France [42]

Assesment of the retrograde IMV as a recipient vessel

Non-randomised study (retrospective) with controls

P1: 74 DIEPs

I2: 36

C: 38

Clinical signs of venous congestion

SIEV/second DIEV to retrograde limb of IMV

O1. Flap complications

O3. LOS

O5. Operative takebacks

 − 

 + ?

?

Lee, 2013, South Korea [43]

Evaluation of the association between ischaemic time and fat necrosis in DIEP

Non-randomised study (retrospective) with controls

P1: 86 DIEPs

P1: 18

C: 68

NR

O1. Flap complications

 − 

?

?

Lundberg, 2006, Sweden [44]

Evaluation of 50 consecutive DIEPs to develop a strategy to avoid complications

Non-randomised study (retrospective) with controls

P1: 50 DIEPs

P1:3

P2: 3

C:44

Capillary refill < 2 s

SIEV to CV

O6. Strategies

 − 

 − 

 − 

Nedomansky, 2018, Austria [45]

Evaluation whether SIEV dissection increases the risk for abdominal seroma

Non -randomised study (retrospective) with controls

P1: 100 DIEPs

39 pat with SIEV dissection (29 unilateral and 10 bilateral)

C: 61

‘Livid discoloration of the flap in combination with an erected SIEV stump’

NR

O2. Donor site complications

O3. LOS

 − 

? + 

?

Ochoa, 2013, USA [46]

Determination of the incidence of flap morbidity following venous augmentation among intraoperatively congested DIEP flaps

Non-randomised study (retrospective) with controls

Narrative review

P1: 87 DIEPs (81 patients)

I1: 87 DIEPs (81 pats)

C: 629 DIEPs (418 pats)

‘Brisk capillary refill. Cutaneous discoloration that improves promptly when release of venous blood through the SIEV’

59 SIEV

28 DIEV

To

50 IMV

24 IMV perforators

6 DIEV

5 LTV

2 TDV

15 VG

O1. Flap complications

O3. LOS

O4. Operative time

O6. Strategies

 − 

 − 

 − 

Rothenberger, 2013, Germany [47]

Investigate the venous drainage of the DIEP flap

Case series (prospective)

P1: 19 DIEPs

I4: Clamping of ipsilateral and contralateral and both SIEVs intraoperatively to determine the efficiency of venous outflow

NA

NA

O6. Strategies

 − 

 + ?

?

Rubino, 2009, Italy [48]

‘Investigation of the correlation between flow rate and size in perforator flaps and, estimation of the minimum diameter of the perforating vein needed to drain flaps of given weights.’

Case series (prospective)

P1: 19 DIEPs

I4: Echo-colour-Doppler

NA

NA

O6. Strategies

 − 

 + ?

?

Xin, 2012, China [49]

Investigation of the efficacy of venous augmentation

Presentation of a new technique

Non-randomised study (retrospective) with controls

P1: 79 DIEPs

I1: 32

C: 47

I4: Blood pressure measurements in anastomoses

Large flaps and/or

clinical signs

SIEV to TDV, LTV, IMV, or DIEV

O1. Flap complications

O4. Operative time

 − 

 − 

 − 

Sadik, 2013, USA [50]

Definition of predictors for a superficially dominant venous system

Non-randomised study (prospective) with controls

P1: 39 DIEPs

I1: 6

C: 33

I4: CTA—measurement of the SIEV diameter preoperatively. The diameter was also measured intraoperatively

NR

NR

O6. Strategies

 + ?

?

Santanelli, 2015, Italy [51]

Investigation of predictive and protective factors for perfusion related complication

Non-randomised study (retrospective) with controls

P1: 287 DIEPs

I1: 173

C:74

NR

NR

O1. Flap complications

 − 

 + ?

?

Schaverien, 2010, UK [52]

Investigation of the relationship between presurgical venous pattern analysed with MRA and venous compromises

Case series (retrospective)

P1: 54 DIEPs

I4: Preoperative contrast-enhanced magnetic resonance angiography

NR

NA

O6. Strategies

 − 

 + ?

?

Smit, 2010, Sweden (multicentre) [53]

Investigation of pressure in the SIEV before and after flap dissection and correlation to venous congestion

Case series (prospective)

P1: 26 DIEPs

I4: Measurement of venous pressure

NR

NR

O6. Strategies

 − 

 + ?

?

Svee, 2023, Sweden [54]

Investigation of arm lymphoedema after the usage of CV

Case series (retrospective)

P1: 54 DIEPs

I1: 27

C: 27

NR

SIEV to CV

O2. Donor site morbidity

 − 

 + ?

 + ?

Tokumoto, 2019, Japan [55]

Investigation of whether CV is equivalent to SA and LTV for superdrainage

Non-randomised study (retrospective) with controls

P1: 88 DIEPs (88 pats)

I1: 45

C: 43

Clinical signs of venous congestion and/or bleeding from the SIEV after anastomosis

SIEV to

22 SA

16 LT

7 CV

The extra anastomosis was performed in patients where the IMV diameter was smaller than that of the DIEV

O1. Flap complications

O2. Donor site complications

O4. Operative time

O5. Operative take backs

O6. Strategies

 − 

 − 

?

Unukovych, 2016, Sweden [56]

Evaluate perioperative predictors of complications and reoperations in DIEP

Case series (retrospective)

P1: 503 DIEPs (433 pats)

I1: 211

C: 292

‘Discretion of surgeon’

O1. Complications

 − 

?

?

Varnava, 2023, Germany [57]

Review of centres use of SIEV

Case series (retrospective)

P1: 150 DIEPs (107 pats)

I1: 4

C: 146

NR

NR

O1. Complications

O5. Operative take backs

 − 

 − 

 − 

Vijayasekaran, 2017, USA [58]

Analyse of the centres use of SIEV and retrograde IMV

Description of algorithm for routine use of SIEV

Non-randomised study (retrospective) with controls

Routine venous augmentation -two consecutive cohorts

P1: 60 DIEPs

I3: 30

C: 30

Two consecutive series

NA

SIEV to the retrograde IMV

O1. Flap complications

O5. Operative take backs

O6. Strategies

?

 + 

?

Wagels, 2015, Australia [59]

Investigation of signs on CTA that can predict venous congestion

Non- randomised study (retrospective) with controls

P1: 124 DIEPs/TRAMs (96 pats)

I4: CTA

NA

NR

O6. Strategies

 − 

 + ?

?

Zhu, 2023, Republic of Korea [60]

Investigation of the clinical efficacy of the use of SIEV using indocyanine green intraoperatively

Non- randomised study (retrospective)

P1: 62 ms-TRAMS, 6 DIEPs

I4: CTA and indocyanine green

NA

NR

O6. Strategies

 − 

 + ?

?