Download Clinical study of peroneal artery perforators with

Surg Radiol Anat (2010) 32:329–334
DOI 10.1007/s00276-009-0559-y
ORIGINAL ARTICLE
Clinical study of peroneal artery perforators with computed
tomographic angiography: implications for fibular flap harvest
Diego Ribuffo Æ Matteo Atzeni Æ Luca Saba Æ
Maristella Guerra Æ Giorgio Mallarini Æ Ernesto Biagio Proto Æ
Damien Grinsell Æ Mark W. Ashton Æ Warren M. Rozen
Received: 22 April 2009 / Accepted: 2 September 2009 / Published online: 12 September 2009
Ó Springer-Verlag 2009
Abstract
Purpose Previous studies of cutaneous perforators of the
peroneal artery have shown great variability, and attest
to the significant anatomical variability in this region.
Furthermore, the vascular anatomy of the region has been
considered unreliable in the prediction of ideal perforator
topography. Preoperative imaging has been suggested as a
means for improving preoperative awareness, with Doppler
ultrasound and eco-colour (duplex) ultrasound as useful
tools. Multi-detector row computed tomographic angiography (CTA or angio CT), has emerged as a significant
improvement, providing non-invasive operator-independent details of the vascular anatomy. We utilised this tool
to perform an in vivo, anatomical study of the peroneal
artery perforators, and demonstrating the usefulness of
CTA in planning the osteocutaneous free fibula flap.
D. Ribuffo M. Atzeni (&)
Section of Plastic Surgery, Department of Surgery,
Cagliari University Hospital, S.S. 554, Monserrato (CA), Italy
e-mail: [email protected]
Methods Forty-one consecutive patients (82 limbs)
underwent CTA of the lower limb vasculature, with the
anatomical details of the peroneal artery cutaneous perforators assessed.
Results CTA was able to demonstrate the size, course and
penetration pattern of all perforators over 0.3 mm in
diameter, with measurements for perforators over 0.8 mm
diameter recorded for analysis. Of 171 such perforators,
accurate identification of the size (mean diameter
1.91 mm), course (59.6% septocutaneous, 29.2% musculocutaneous and 11.1% septomusculocutaneous) and location was achieved.
Conclusion The vascular anatomy of peroneal artery
perforators is highly variable, and thus there is a role for
preoperative imaging. CTA can demonstrate cases where
there is aberrant or non-preferred anatomy, or select the
limb of choice for harvest.
Keywords Angiotomodensitometry Osteocutaneous Perforator flap Free flap
Introduction
L. Saba G. Mallarini
Department of Radiology, Cagliari University Hospital,
Monserrato (CA), Italy
M. Guerra
Division of Plastic Surgery, San Gallicano Institute, Rome, Italy
E. B. Proto
Division of Otolaryngology, S. Giovanni Hospital,
University of Cagliari, Cagliari, Italy
D. Grinsell M. W. Ashton W. M. Rozen
Jack Brockhoff Reconstructive Plastic Surgery Research Unit,
Room E533, Department of Anatomy and Cell Biology,
University of Melbourne, Grattan St, Parkville 3050, Australia
The osteocutaneous free fibula flap (OFFF), initially
described by Taylor in 1975 [43], has been used as a frontline reconstructive tool for trauma and cancer since 1983
[7, 50]. Its advantages include the fibula bone being long,
straight and strong, and since first described in the role by
Hidalgo [18], it has become the workhorse of free tissue
transfer for mandibular reconstruction in head and neck
cancer [10, 18, 22, 40]. Despite its routine use, variations in
lower leg circulation [2, 24, 27] and in the skin island
vascular supply can significantly influence its harvest:
septocutaneous perforators can be absent [3, 22, 39, 45] or
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perforators can arise from others source vessels [28, 42, 44,
49]. Anatomical studies have widely considered this anatomy unreliable and highly variable, potentially limiting the
use of this flap and increasing the surgical stress and
potential for complications to the procedure.
In such cases of unsuitable anatomy, a skin paddle can
still be reliably harvested by using musculocutaneous
perforators supplying the skin through the soleus muscle
[44, 47, 49], by raising two separate free flaps [48] or by
choosing the other leg for harvest. These options are not
ideal, and precise preoperative evaluation of individual
vascular anatomy of the leg, with details comprising the
size, location, origin and course of perforating vessels, is
highly desirable for improving surgical planning. The use
of preoperative imaging in the past has been for identification of the vascular pedicle itself, with the benefits of
such imaging not always apparent [11, 20, 26], and thus
conventional catheter angiography [23, 51] and ultrasound
[4, 13–16, 41] have remained equivocal in their widespread
usage. Despite gold-standard accuracy, catheter angiography is also invasive, with potential complications including
haematoma and false-aneurisms.
More recently, imaging technologies have become
available that can visualise cutaneous perforator vessels in
addition to the major pedicles, increasing the utility of
preoperative imaging [12, 34, 36]. At our institutions, we
have shown that CTA can provide accurate information
about perforator location, size and course in the planning of
perforator flaps in many body regions [36], and have shown
that with the use of imaging, operative time and complications can be reduced [31–33, 35]. While previous anatomical studies of peroneal perforators have been based on
either post-mortem cadaveric studies or small clinical
studies with limited operative exposure, the use of preoperative ‘in-vivo’ studies enables the analysis of living
vascular anatomy. The current study was thus undertaken
with a view to using this technology to demonstrate the in
vivo anatomy of the peroneal artery perforators, and to
demonstrate the utility of this technique in the planning of
the osteocutaneous fibula flap.
Surg Radiol Anat (2010) 32:329–334
comprised arterial phase imaging in all cases, with a bolus
tracking technique used to identify filling of the appropriate
vessels with contrast as a means to initiate scanning.
The CT scanners used were Siemens Somatom Sensation 64 multi-detector row CT scanner (Siemens Medical
Solutions, Erlangen, Germany) and Phillips MX8000
4-slice multi-detector row CT scanner (Philips MX8000,
Picker, Andover, MA). Intravenous contrast was used in all
cases, with no oral contrast used, and comprised non-ionic
iodinated contrast media: Iomeron 350 (Bracco, Milan,
Italy) or Omnipaque 350 (Amersham Health, Princeton,
USA). Total examination time, including that for patients
preparation, was between 10 and 20 min.
Three-dimensional image reconstructions were achieved
with reformatting software programs: Siemens Syngo InSpace (Siemens, InSpace2004A_PRE_19) and Phillips
Easy Vision (Phillips Easy Vision CT/MR R2). Multiplanar three-dimensional reconstructions included maximum intensity projection (MIP) reconstructions (see
Figs. 1, 2a) and volume rendered technique (VRT) reconstructions (see Fig. 2b, c, d). MIP reconstructions [29, 30],
and VRT reconstructions [21] used in combination permitted accurate identification of fine vessels and allowed
measurement of pedicle length and diameters.
A retrospective analysis of prospectively recorded data
was undertaken. The location, size (to the closest 0.1 mm),
course and number of perforators were recorded for each
limb. All perforator diameters were taken at the point of
deep fascial penetration, and comprised the internal
Methodology
Forty-one consecutive patients (82 limbs) underwent CTA
of the lower limb vasculature, with the anatomical details
of the peroneal artery cutaneous perforators assessed.
Patients age ranged from 35 to 75 and were of mixed sex
and body habitus. All patients had normal renal function
and no history of allergy to iodinated contrast material, and
all patients consented to involvement in the study. Patients
were recruited and imaged at two institutions, with a
similar scanning protocol utilised at both centres. This
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Fig. 1 Computed tomographic angiogram (CTA), axial slice, demonstrating a ‘thick slab maximum intensity projection (MIP)’
reconstruction of the right leg vasculature. A septocutaneous perforator (S.P.) of the peroneal artery is demonstrated (F. fibula; P.A.V.
peroneal artery and vein)
Surg Radiol Anat (2010) 32:329–334
331
Fig. 2 a Computed tomographic angiogram (CTA), axial slice,
demonstrating a ‘thick slab maximum intensity projection (MIP)’
reconstruction of the left leg vasculature. Arrow shows a musculocutaneous perforator (M.P.) of the peroneal artery. (F. fibula, P.A.V.
peroneal artery and vein) b Same patient. Computed tomographic
angiogram (CTA) three-dimensional volume rendered technique
(VRT) posterior aspect reconstruction of the lower limb vasculature
and muscles. c Same patient. Further computed tomographic angiogram (CTA) three-dimensional volume rendered technique (VRT)
posterior aspect reconstruction of the arterial anatomy of the leg,
demonstrating the trifurcation of the popliteal artery in supply to the
limb. d Same patient. Further computed tomographic angiogram
(CTA) three-dimensional volume rendered technique (VRT) reconstruction of the arterial anatomy of the leg, demonstrating a proximal,
musculocutaneous perforator (white arrow). The vessel was not
considered for supply to the fibula flap due to it proximal position and
long intramuscular course
diameters of perforating arteries. Only perforators over
0.8 mm in internal diameter were included in the analysis
based on their clinical applicability.
intermuscular septum to course superficially. The diameter
of the perforators, measured at the point of emergence from
the deep fascia, ranged from 0.8 mm to 3.2 mm (mean
1.91 mm, standard deviation 0.7). In cases in which multiple perforators were present, the septocutaneous perforators were found to be more distal in the limb (lower third
of fibula) than the musculocutaneous perforators (upper
third). The length of perforators (total pedicle length)
ranged from 8.32 to 13.71 cm (mean 9.95 cm, standard
deviation 1.85). It was notable that every extremity had at
least one septocutaneous perforator, although there was
variability in its diameter.
Results
The use of CTA was able to show that the perforators of the
peroneal artery with high resolution and accuracy demonstrate vessel size, location and course. There were no
allergic reactions or adverse effects after administration of
non-ionic iodinated contrast agents, and no complications
as a result of the use of CTA. In all cases, the popliteal
trifurcation and major arteries of the calf were well visualised. The peroneal artery in all cases was seen to course
medial to the fibula and giving rise to both septocutaneous
and musculocutaneous perforators, with the septocutaneous
perforators traced within the posterolateral intermuscular
septum throughout their course towards the skin.
In 82 limbs, 171 cutaneous perforators of the peroneal
artery greater than 0.8 mm were identified. Of these, 59.6%
(102/171) were septocutaneous perforators, remaining in
the posterolateral intermuscular septum throughout their
course; 29.2% (50/171) were musculocutaneous, traversing
either the soleus muscle, flexor hallucis longus, or both;
and 11.1% (19/171) were septomusculocutaneous, traversing muscle proximally but emerging from the
Discussion
There are two important and feared vascular complications
related to reconstructive surgery using flaps requiring
harvest of the peroneal artery (in particular, the fibula flap):
(1) foot ischaemia secondary to sacrifice of the peroneal
artery and (2) partial/total skin necrosis. The risk of these
complications is related to the variability in vascular supply
to the leg, with the peroneal artery and its branches not
always uniform in their size or distribution. Previous
studies of the osteocutaneous fibula flap have shown that a
skin flap can be harvested with the fibula bone based purely
on septocutaneous perforators [22, 40, 45], without the
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need to incorporate portions of the soleus or flexor hallucis
longus muscle. However, for this to occur, the viability of
the skin island depends upon the successful inclusion of a
sufficient number of perforators and the size and location
of these perforators are integral during flap design and
elevation. Most surgeons empirically restrict harvest of the
skin island to the skin of the distal calf because the
majority of anatomic studies have demonstrated that the
septocutaneous perforators are concentrated in this region
[3, 8, 22, 46, 50]. Where musculocutaneous perforators are
selected for inclusion in the vascular pedicle (based on
size, location and/or the absence of septocutaneous perforators), a muscle cuff of soleus and/or flexor hallucis longus is generally raised with the vessels in order to protect
them during harvest [1, 17, 44, 47, 49]. Furthermore, variability of the trifurcation of popliteal artery is not
uncommon [2, 24, 27], perforators in the distal lower limb
may be absent in 5 to 7 (10%) of cases [22, 39, 40, 48], and
perforators of the predicted location can origin from others
source vessels (such as the posterior tibial artery) [28, 42,
44, 49]. In such cases, the other leg or ultimately another
flap may be chosen, necessitating a re-exploration scar and
potentially prolonged or complicated surgery.
For these reasons, individual precise preoperative evaluation of vascular anatomy of the leg and specifics of
perforator anatomy, such as location, origin and course, is
highly desirable for improving surgical planning and execution. Conventional catheter angiography is considered
the gold standard for mapping the major vessels of the leg,
identifying variant trifurcation arterial anatomy of the leg
or atherosclerotic disease [23, 51], but limitations include
its invasive nature and potential morbidity. Although there
is contention in the literature, many authors have suggested
that routine preoperative angiography of the donor leg is
not justified [11, 20, 26]. In avoiding the morbidity associated with catheter angiography, newer modalities, such as
CTA [9] and magnetic resonance angiography (MRA) [5,
6, 19, 25] have also been used to map the major vascular
pedicles. In the past, these techniques were not able to
identify fine cutaneous perforators, however, more recently
this has changed. The use of preoperative duplex ultrasound to identify the location of perforator termination in
the skin has become routine in many centres [4, 16], but
ultrasound cannot accurately demonstrate the deeper
course of perforators, cannot accurately predict the origin
and perforator type and has a high inter-observer variability
[13–15, 41].
Fukaya [12] first described the use of advanced imaging
modalities to map peroneal artery perforators, and showed
that septocutaneous perforators could be mapped from its
origin to its termination with MRA. However, these images
were not optimal and other modalities were sought. We
thus described the use of CTA for this role, showing
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substantial benefit to the technique and high-resolution of
images. The current study utilises this technique to map the
vascular anatomy and record the details of the peroneal
artery perforators. Our CTA technique combines the
technology of conventional multi-detector row CT, with
that of traditional angiography to create detailed images of
the blood vessels in the body [37, 38]. While conventional
angiography requires intra-arterial injection (and the
potential risk of haematoma and false aneurism), CTA only
requires intravenous injection, and is thus substantially less
invasive. Furthermore, with advanced post-processing
protocols (such as MIP and VRT reconstructions), higher
level visualisation of fine vessels is achieved.
With the aid of CTA, thorough imaging of perforator
vessels amenable to the fibula flap was achieved. These
vessels were accurately mapped from their origin,
through the septum or intramuscular pathway and through
their subcutaneous course. In preoperative planning for
the free fibula flap, this technique permits the surgeon to
choose between the right and left leg, to design the
optimal skin paddle, or to abandon the flap if needed in
favour of other reconstructive options. While CTA is
associated with radiation exposure (up to 10 mS per
patient), this must be weighed against the benefits of such
imaging. The financial cost varies between institutions
but is certainly also a consideration. Given these factors,
CTA joins catheter angiography, MRA and ultrasound as
another tool in the preoperative evaluation of this
anatomy.
Conclusion
The vascular anatomy of peroneal artery perforators is
highly variable, and thus there is a role for preoperative
imaging. CTA can demonstrate the size, location and
course of individual perforators, and can identify cases
where there is aberrant or non-preferred anatomy, and
select the limb of choice for harvest. CTA is a useful tool
for mapping the cutaneous vasculature of the leg.
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