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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 123 330 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 123 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 123 332 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 123 Surg Radiol Anat (2010) 32:329–334 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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