The role of CTA in the preoperative workup of Free Fibular

Flap surgery for madibular reconstruction

Poster No.: C-1895

Congress: ECR 2014
Type: Educational Exhibit
Authors: 1 2 3
P. L. Pegado , H. A. M. R. Tinto , J. Raposo , R. M. R. Mateus
3 1 2 3
Marques ; 199/PT, Lisbon/PT, Lisboa/PT
Keywords: Head and neck, Musculoskeletal bone, CT-Angiography, Contrast
agent-intravenous, Education and training
DOI: 10.1594/ecr2014/C-1895

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Learning objectives

To understand the microsurgical reconstruction of the oromandibular complex with a

fibula osteomyocutneous free flap and to put in evidence the role of CTA when planning
the procedure, in order to prevent complications.

To point out vascular variations of the lower leg vascular system and it's surgical
implications.

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Background

The human mandible is a horseshoe shaped bone, anatomically divided into a body,
angle and ramus. The mandible defines the profile and appearance of the lower third
of the face. Thus it contributes to facial contour, propper occlusion, mastication, airway
1
support, deglution and speech .

Lesion of the mandible is caused by trauma, infection or extripation of a tumor and

results in cosmetic deformity, psychological impairment and functional disability. The
most common indication for mandibular reconstruction remains ablative surgery for
2
advanced neoplastic processes .

Various donor sites in the body have been used as grafts, including the ribs, radius,
3
scapula, ilium and metatarsals. Since the description of their use in 1975 , fibular free
flaps have become one of the most commonly used donor sites of bone and tissue for
mandibular reconstructive surgery.

The fibula free flap is the first-choice flap for reconstruction of bony defects in the
mandibula at our institution. In the setting of fibular free-flap transfer procedures, the
peroneal artery is routinely resected along with the fibular flap so that once anastamosed
to an artery at the implantation site the arterial blood supply is preserved to the graft.
Thus evaluation of the vasculature at donor site is very important and may be performed
through clinical examination, radiological studies, or direct surgical exploration.

Currently, there is no consensus as to the optimal method to reliably evaluate the vascular
4
anatomy prior to microsurgical reconstruction .

Angiography is the traditional modality utilized for vascular imaging, but is associated with
a known risk of complications. Morbidity from angiography results from obtaining vascular
access as well as administering intravenous contrast. Lower extremity angiography
5
has a reported complication rate of 3 -9% . The complications include hematoma,
hemorrhage, pseudoaneurysm, thrombosis, arrhythmia, anaphylaxis, intimal damage,
renal insufficiency, urticaria, distal ischemia, and vascular spasm.

The ideal preoperative test would provide vascular imaging with minimal risk and at
low cost. Proposed imaging techniques include magnetic resonance imaging (MRI) and
6 7
duplex ultrasonography. Manaster et al. and Bretzman et al. demonstrated the precision
and accuracy of MRI, but noted its increased cost and decreased suitability for older
patients with arterial stenosisand atherosclerosis. In addition, implanted hardware is a

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strict contraindication to MRI. Duplex ultrasonography has a lower cost and decreased
morbidity, but provides only segmental images, making visualization of the entire vascular
pedicle problematic. In addition, it is highly dependent on the skill of the technician and
requires advanced technician education in lower extremity examination.

The utility of CT angiography in diagnosing vascular disease is well-documented. Here

we document the utility of CT angiography in these kind of microsurgical procedures and
report our two years experience. CT angiography provides high-resolution images of the
vasculature that are equivalent to those of standard angiography. The ability to selectively
add and subtract soft tissues and bones from images can provide useful landmarks for
the surgeon.

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Findings and procedure details

The most feared donor-site complication in fibula flap harvest is foot ischemia secondary
to sacrifice of the peroneal artery. In most people, the peroneal artery does not supply a
8
significant amount of the pedal circulation . In persons with peripheral arterial disease,
4,8
and in some congenital variants, peroneal artery becomes the main supply to the foot .

In spite of the lack of consesus among the various authors in which is the best exam to
perform they are agree of the need to perform preoperative radiological studies. Such
studies are mainly recommended in patients with arteriosclerotic disease, in patients with
abnormal pedal pulses, and in patients with history of significant lower leg trauma to
4
assess vessel anatomy and for vessel disease .

Anatomy and variations with implications on the procedure

The popliteal artery bifurcates to become the tibioperoneal trunk and the anterior tibial
artery. The tibioperoneal trunk then bifurcates and gives rise to the posterior tibial artery
and the fibular artery. Commonly the fibular artery finish just above the ankle (Figure 1,
2 and 3). The anterior tibial artery supplies mainly the dorsum of the foot via the dorsalis
pedis artery. The posterior tibial artery supplies the plantar aspect of the foot. Thus the
blood supply of the foot is mainly given by the tibial arteries. This pattern is observed in
9
88% of the population .

There are a lot of normal variants to this branching pattern, many of these are insignificant
and of no consequence, it is not in the scope of this work to do an exhaustive
description of these same variants. However there are some very important, that can even
contraindicate the procedure, such as Peronea arteria magna, a congenital condition in
which both the anterior and posterior tibial arteries are absent and the peroneal artery is
the main source of blood supply to the foot, is associated with a normal pulse examination
and is a contraindication to free fibula transfer. The incidence of peronea arteria magna
8
ranges from 0.2/8.3% in the literature .

The peroneal artery may be absent or hypoplastic and always may occur in the setting
4
of normal pulses, and is not compatible with free fibula transfer .

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In 3,8% of patients , the posterior tibial artery is absent or hypoplastic or ends at the lower
leg with the plantar arteries branching from the peroneal artery, the procedure is also
4
contraindicated at that leg, because of the high risk of feet ischemia (Figure 4).

In 1,6% of patients, the anterior tibial vessel is absent or hypoplastic or terminates in

the lower leg with the dorsalis pedis artery then originating from the anterior perforating
branch of the peroeal artery, as in the above variation the procedure is contraindicated
4
by the feet ischemia high risk (Figure 5).

Atherosclerotic disease, which can be diagnosed by CT angiography, is another aspect

that may influence the procedure, and may even contraindicated it. Atherosclerotic
disease is considered significant when the narrowing of the vessel is greater than 50%,
if significant stenosis is present in the iliac, femoral, or calf arteries, the opposite calf is
7
used .

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Images for this section:

Fig. 1: Illustration of the normal calf artery anatomy.

© Centro hospital de Lisboa central - Hospital de S. José - 199/PT

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Fig. 2: CT angiogram, MIP coronal view, demonstrating normal three vessel runoff in
lower extremity. Large arrow represents the tibial posterior artery; TA - Tibial Anterior
Artery; Arrow represents the tibioperoneal artery trunk; Arrowhead represents the
peroneal artery.

© Centro hospital de Lisboa central - Hospital de S. José - 199/PT

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Fig. 3: CT angiogram, MIP axial view, representing the normal vascular anatomy with
the three arteries, at superior calf level.

© Centro hospital de Lisboa central - Hospital de S. José - 199/PT

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Fig. 4: A,B - CT angiography, MIP sagittal view, shows hypoplastic right posterior tibial
artery, with right peroneal artery supplies plantar pedis artery. Consequently, left calf was
judged more suitable for fibular flap harvest.

© Centro hospital de Lisboa central - Hospital de S. José - 199/PT

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Fig. 5: CT angiography of the right lower limb, A- MIP coronal view; B- MIP axial view.
Demonstrating peroneal artery as dominant dorsal blood supply to the foot. Anterior tibial
artery is occluded in proximal leg, and peroneal artery supplies dorsal pedis artery. The
fibular flap harvest was made with the left side. PA- Peroneal Artery; PTA- Posterior Tibial
Artery; ATA- Anterior Tibial Artery

© Centro hospital de Lisboa central - Hospital de S. José - 199/PT

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Conclusion

Free fibular flap transfer for mandibular defects in head and neck cancer patients is widely
performed.

The utility of CT angiography in diagnosing vascular variations and disease is well-

documented.

CT angiography may be used preoperatively to evaluate the vascular supply of the lower
leg prior to free fibula flap harvest. The CT angiograms obtained provide images equal
to traditional angiography, with diminished risk to the patient.

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Personal information

1
Pedro Luís Pegado, is Resident of Radiology at "Serviço de Radiologia do Hospital de
São José - Centro Hospitalar de Lisboa Central (CHLC)"

2Hugo Alexandre Rio Tinto, is Resident of Radiology at "Serviço de Radiologia do

Hospital de São José - Centro Hospitalar de Lisboa Central (CHLC)"

3 3
Joana Raposo is Radiology Consultant and Rui Mateus Marques is a Senior Consultant
of Radiology (Chief of Department) at "Serviço de Radiologia do Hospital de São José
- CHLC"

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References

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4. Kelly AM et al. Preoperative MR angiography in free fibula flap transfer for
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