The need for preoperative leg angiography in fibula free flaps.

Among arterial anatomic conditions which will adversely affect the harvest of the fibula are 1) significant arteriosclerotic disease within the tibial-peroneal vessels; 2) peroneal arteria magna (PAM), a condition in which only the peroneal artery supplies the foot; and 3) absence of the peroneal artery, either congenitally or as an acquired defect. In each of these anatomic conditions, removal of the peroneal vessels and the fibula free flap will jeopardize either the donor leg, the fibula flap, or both. All patients considered for fibula flaps were evaluated with preoperative leg angiograms. In 28 consecutive patients evaluated with angiography for planned free-fibula flap reconstructions, 23 actually underwent free-fibula harvest. Angiographic abnormalities that altered the operative plan were found in seven (25 percent) patients. Four of the seven patients had vascular examinations prior to surgery with abnormal findings. Three of the seven (11 percent) patients with abnormal arterial anatomy had normal vascular examinations prior to surgery. Thus, if a preoperative angiogram had not routinely been done, the abnormal anatomy would not have been discovered until surgery. This could have resulted in an unusable flap in one patient, and an ischemic or gangrenous foot in two other patients. With this angiographic guidance, there were no vascular complications from harvest of the fibula. The routine use of preoperative bilateral leg angiography is recommended, or an alternative method of vessel imaging, in all patients evaluated for microvascular free-tissue transfer of the fibula.