Miguel Romariz

Abstract
Algorithms based on computer vision are commonly used in pre-operative procedures to help health professionals detecting blood vessels, which is also the case with the Deep Inferior Epigastric Perforators (DIEPs). These blood vessels are essential to produce a viable autologous DIEP flap, and the analysis of characteristics such as their location, diameter and course is essential to ensure the success of surgeries. This analysis is made by a team of radiology technicians and then validated by a surgeon, making it a complex process that can take up to 2 hours. The proposed algorithm called Assisted Vascular Analysis (AVA) was developed to ensure a faster alternative to the conventional methods, using automation to identify structures of interest such as the skin, umbilicus and fascia, while also requiring minimum input from the user to segment each DIEP (2 points for the subcutaneous portion and 2 for the intramuscular portion). The AVA feasibility tests where conducted using 6 Computed Tomography Angiographies (CTAs), with a total of 28 DIEP calibers obtained during surgery (ground truths) from patients that underwent breast reconstruction with a DIEP flap. The algorithm was evaluated for its capability to segment the DIEPs and measure their caliber, comparing the results with the ground truth calibers and the manual mapping done by the radiology technicians. The Root Mean Square Error (RMSE) metric shows that the calibers obtained by the AVA algorithm (0.57 millimeters) and the radiology technicians (0.46 millimeters) are very similar, with the radiology technicians gaining a smaller edge of 0.11 millimeters. These results are very promising, since the errors are inferior to the average image resolution (0.88 millimeters). It was also demonstrated that the AVA algorithm is a faster alternative to manual segmentation, taking around 10 minutes to fully analyze each CTA, while the radiology technicians takes around 1 hour to do the DIEP mapping and caliber measurements. In conclusion, AVA is a validated algorithm to segment DIEP vessels and a faster alternative compared with conventional methods. © 2025 IEEE.

Abstract

Abstract
Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction relies on the precise identification of perforator vessels supplying blood to transferred tissue. Traditional manual mapping from preoperative imaging is timeconsuming and subjective. To address this, AVA, a semi-automated perforator detection algorithm, was developed to analyze angiography images. AVA follows a three-step process: automated anatomical segmentation, manual annotation of perforators, and segmentation of perforator courses. This approach enhances accuracy, reduces subjectivity, and accelerates the mapping process while generating quantitative reports for surgical planning. To streamline integration into clinical workflows, AVA has been embedded into PACScenter, a medical imaging platform, leveraging DICOM encapsulation for seamless data exchange within a Vendor Neutral Archive (VNA). This integration allows surgeons to interactively annotate perforators, adjust parameters iteratively, and visualize detailed anatomical structures. AVA-PACScenter integration eliminates workflow disruptions by providing real-time perforator analysis within the surgical environment, ultimately improving preoperative planning and intraoperative guidance. Currently undergoing clinical feasibility testing, this integration aims to enhance DIEP flap reconstruction efficiency by reducing manual inputs, improving mapping precision, and facilitating long-term report storage within Dicoogle. By automating perforator analysis, AVA represents a significant advancement toward data-driven, patient-centered surgical planning.

Abstract

Abstract
TPS621 Background: Breast cancer treatments often pose challenges in balancing efficacy with quality of life. The CINDERELLA Project pioneers an artificial intelligence (AI)-driven approach (CINDERELLA APP) for shared decision-making process, aiming to harmonise locoregional therapeutic interventions with breast cancer patients' expectations about aesthetic outcomes. The CINDERELLA clinical trial aims to establish a new standard in patient-centred care by bridging the gap between clinical treatment options and patient expectations through innovative technology. The trial focuses on evaluating the effectiveness of the CINDERELLA APP in improving patient satisfaction regarding locoregional treatment aesthetic outcomes, aligning patient expectations with real-world results, and assessing its impact on overall quality of life and psychological well-being. Methods: Trial design and statistical methods: This international multicentric interventional randomised controlled open-label clinical trial will recruit and randomise patients into two groups: one receiving standard treatment information and the other using the AI-powered CINDERELLA APP. The primary objective is to assess the levels of agreement among patients' expectations regarding the aesthetic outcome before and 12 months after locoregional treatment. The trial will also evaluate the aesthetic outcome level of agreement between the AI evaluation tool and self-evaluation. The impact of the intervention on aligning expectations with outcomes will be evaluated using the Wilcoxon signed-rank test. The improvement in classification of aesthetic results post-intervention will be measured by calculating the Weighted Cohen's kappa. Outcomes across different groups will be compared using statistical tests and bootstrap methods. CANKADO functions as the base system, allowing doctors to supervise APP content for patients and handle data gathering, while upholding principles of privacy, data security, and ethical AI practices. Intervention planned: Using the CINDERELLA APP, the patient will have access to supervised medical information approved by breast cancer experts, and the AI system will match patient's information to pictures showing the potential aesthetic outcome (spectrum of good-poor) according to different locoregional approach. Major eligibility criteria: Non-metastatic breast cancer patients eligible for either breast-conserving surgery or mastectomy with immediate reconstruction. Current enrollment: Recruitment is currently open at six study sites. The recruitment started on 8 August 2023, aiming to enroll at least 515 patients/arm. As of January 26, 2024, clinical study sites have successfully randomised 177 patients. Clinical trial information: NCT05196269 .