(IP227) The Role of Revascularization to Enable Fibular Free Flap Harvest in Patients with Peronea Arteria Magna

Objectives: The peroneal artery (PA) based fibular free flap (FFF) is widely used to reconstruct bony defects after oncological resections. Congenital tibial arterial variants are a relative contra-indication to FFF. One such variant is Peronea-Arteria-Magna (PAM) in which either the anterior tibial (ATA) or posterior tibial (PTA) artery is aplastic or hypoplastic, rendering the PA as the dominant or co-dominant pedal blood supply. PAM has been described in 0.2-0.9% of population. The literature does not provide clear guidance on the feasibility of FFF in patients with PAM; concern exists regarding the risk of limb-threatening ischemia if the PA is harvested in this scenario. We present an institutional experience in managing patients with PAM requiring FFF for reconstructions, and propose an algorithm for imaging and prophylactic revascularization.

Methods: A retrospective analysis of departmental free-flap database was performed to identify all patients with PAM who underwent FFF. Patient demographics, surgical procedures and post-operative complications were recorded. All patients underwent pre-operative computed tomography angiography (CTA) leading to identification of PAM.

Results: Three patients with PAM who underwent FFF were identified. The mean age was 57 (43-75) years. All were female and had palpable pedal pulses. Two patients required FFF for midface reconstruction, and the third patient underwent FFF for contralateral proximal tibial reconstruction. No other acceptable free flap donor sites were identified. All underwent pre-operative CTA demonstrating PAM. Digital subtraction angiography (DSA) confirmed the presence of bilateral PAM (Figure 1 and 2), and absence of angiographically robust pedal arches in each patient. We discourage the use of balloon occlusion testing in PAM as this may cause unintended vessel trauma. Bypass graft with autologous vein was therefore recommended at the time of FFF harvest. All patients underwent successful tibioperoneal trunk to distal PA bypass with reversed greater saphenous vein and were discharged on daily aspirin. They recovered well with patent bypass grafts and absence of limb ischemia or claudication symptoms at mean follow up of 19 (12-25) months.

Conclusions: Our case series is the first to demonstrate that an algorithmic approach to preprocedural DSA and intraprocedural revascularization allows the safe utilization of FFF in patients with PAM. All FFF candidates are screened with vein mapping and CTA. Those with PAM and no other appropriate free flap donor options undergo DSA to define pedal arch and collateral anatomy, followed by autologous vein bypass at the time of FFF harvest.