study, Dr. Alireza Ghassemi

1. Factors influencing the necessity for preoperative vascular
imaging before harvesting a vascularized fibular flap
Alireza Ghassemi, MD, DMD, PhD,a
Maike Jost, DMD,b
Christina Fitzner, MA,c
Houman Jalaie, MD,d
Frank Hölzle, MD, DMD, PhD,a
Jonas Apitzsch, MD,e
Ali Modabber, MD, DMD,a
and Lloyd Nanhekhan, MDf
University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany; Private Dental Practice, Oberhausen, Germany;
University Hospitals Leuven, Leuven, Belgium
Objective. This study was carried out to identify groups of patients who would benefit from this angiography. The
angiographic images of a random group of patients were studied; the correlations between the vascular state of the lower
extremities and vessel pathology were investigated; and the possible links of these findings with certain medical conditions
were explored.
Study Design. Three experienced observers independently evaluated the angiograms of 185 patients. The status of all 3 vessels
of the lower extremities (anterior tibial artery, posterior tibial artery, and peroneal artery) was evaluated. The patients’ gender,
age, drinking and smoking habits, and medical conditions were documented.
Results. We found a significant correlation between pathology of the arteries of the lower extremity and blood cholesterol
level, blood pressure, coronary heart disease, diabetes mellitus, and age.
Conclusions. We suggest that preoperative vascular imaging be carried out in patients with comorbidities to reduce the
potential for flap failure and to minimize donor site complications. (Oral Surg Oral Med Oral Pathol Oral Radiol 2014;117:
289-292)
Reconstructive procedures of the head and neck region
can be technically challenging; however, with refine-
ments in microvascular techniques, surgical outcomes
have improved both functionally and esthetically.1,2
The
success of a reconstruction, however, is not exclusively
dependent on the esthetic and functional result of
the reconstructed deficit. The success of the reconstruc-
tion is additionally dependent on minimal donor site
morbidity.1,2
Free vascularized bone flaps offer the best
option for reconstructing large bony defects, especially
load-bearing and continuity defects.3
The decision to
use a vascularized versus a nonvascularized bone graft
is extremely important when considering donor site
morbidity.1,2
Typically, the vascularized fibula flap offers suffi-
cient bone length with a long pedicle and can also be
harvested as a composite flap.3
In most cases, because
the vascular state of the lower extremity is independent
of the presence of the peroneal artery, routine perfor-
mance of preoperative vascular imaging of the vessels
of the lower leg is controversial.4,5
However, there are
arterial conditions that can adversely affect the lower
extremity when harvesting the fibula. These include
significant arteriosclerotic disease of the tibioperoneal
vessels, arterial anatomic variations (such as the pero-
neal arteria magna and the absence of the peroneal ar-
tery), or congenital or traumatic arterial defects.6-9
Harvesting of the free fibula flap in the presence of
many of these anatomic conditions may jeopardize the
donor leg, the fibula flap, or both.
Based on the assumption that certain medical con-
ditions lead to arterial disease, we evaluated additional
factors that would require the preoperative vascular
imaging of the lower extremity if a fibula flap is to be
considered as the donor site.
MATERIALS AND METHODS
Owing to the retrospective course of the study,
no ethical approval was required. Written informed
consent was obtained from each patient for the
Coauthors Ghassemi and Jost contributed equally to this article as first
authors.
a
Department of Oral, Maxillofacial and Plastic Facial Surgery, Uni-
versity Hospital of Rheinisch-Westfälische Technische Hochschule
Aachen.
b
Private Dental Practice, Oberhausen, Germany.
c
Institute of Medical Statistics, University of Rheinisch-Westfälische
Technische Hochschule Aachen.
d
Department of Vascular Surgery, University Hospital of Rheinisch-
Westfälische Technische Hochschule Aachen.
e
Department of Diagnostic and Interventional Radiology, University
Hospital of Rheinisch-Westfälische Technische Hochschule Aachen.
f
Department of Plastic, Reconstructive and Aesthetic Surgery, Uni-
versity Hospitals Leuven.
Received for publication May 21, 2013; returned for revision Oct 13,
2013; accepted for publication Nov 4, 2013.
Ó 2014 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2013.11.492
Statement of Clinical Relevance
Preoperative vascular imaging of the lower extrem-
ity provides information on vascular pathology (if
present) and therefore reduces the risk of fibular flap
failure and helps to avoid potential donor site
complications.
289
Vol. 117 No. 3 March 2014

2. diagnostics of lower extremities before examination.
Three independent experienced observers (1 radiologist,
1 vascular surgeon, and 1 maxillofacial surgeon) eval-
uated 185 angiographies of the lower extremities. These
were selected blindly out of the pool of vascular images
in the Department of Diagnostic and Interventional
Radiology, University Hospital, Rheinisch-West-
fälische Technische Hochschule Aachen. The patients
included 121 men (65.41%) and 64 women (34.59%),
with a mean age of 66.7 years (range, 17-94 years). The
women’s ages ranged from 33 to 94 years, with a mean
of 68.7 years, and the men’s ages ranged from 17 to
84 years, with a mean of 65.7 years (Figure 1). Indications
for the intervention were diverse: stent implantation,
balloon dilatation, hemodynamic examination, or pure
postoperative monitoring.
The 3 observers looked separately for any pathologic
change in the anterior tibial artery, posterior tibial ar-
tery, and peroneal artery. Both quality of imaging and
vascular pathology were assessed. The assessment of
vascular pathology was rated descriptively as unaf-
fected (0), minimal change (1), significant change (2),
or complete occlusion (3). The data that were docu-
mented included the gender, age, and medical condi-
tions such as high blood pressure, drinking and
smoking habits, overweight status, high blood choles-
terol, diabetes mellitus, and coronary heart disease.
Statistical analysis
All statistical analyses were conducted with SAS
(version 9.2; SAS Institute Inc, Cary, NC, USA). Cat-
egorical data are presented by frequencies and per-
centage. Analyses for the outcomes for all 3 arteries
after the procedure were conducted separately. Uni-
variate logistic regression was carried out to select
relevant independent prognostic factors (P .2). All
selected prognostic factors were considered in a
multivariate logistic regression analysis. No alpha
adjustment was performed. Statistical tests were per-
formed and 2-tailed, and values of P .05 were
considered as statistically significant.
RESULTS
Out of 185 single-sided angiographies, 176 could be
evaluated and 9 were excluded owing to proximal
arterial occlusion or unclear radiologic findings. Out of
176 assessable angiographies, 171 patients had at least
1 affected vessel and warranted further examination if a
vascularized fibula flap was the planned option. In 5
patients, no pathologic changes at all were seen, and 30
patients had significant stenosis or complete occlusion
of all vessels. In addition, we found that 33 patients had
mild stenosis in all 3 vessels; 49 patients had 2 vessels
with mild stenosis and 1 vessel with significant steno-
sis; and 59 patients had 1 vessel with mild stenosis and
2 vessels with significant stenosis.
We found a significant correlation between anterior
tibial artery pathology and high blood cholesterol (P ¼
.0145), coronary heart disease (P ¼ .0059), and age
(P ¼ .0023). A significant correlation was found be-
tween posterior tibial artery disease and high blood
cholesterol (P ¼ .0617), coronary heart disease (P ¼
.0162), and age (P ¼ .0001). A significant correlation
was found between peroneal artery disease and high
blood pressure (P ¼ .0064), high blood cholesterol
(P ¼ .0467), coronary heart disease (P ¼ .0104), dia-
betes mellitus (P ¼ .0235), and age (P .0001).
Multivariate analysis for all 3 arteries (anterior tibial
artery, posterior tibial artery, and peroneal artery) found
that age was the only significant factor. There was an
increased probability to develop vessel pathology in
relation to higher age (Figures 2 to 4). Because there
were no healthy candidates who were overweight or
Fig. 1. Age distribution.
Fig. 2. Predicted probability of vessel pathology of anterior
tibial artery with increasing age.
ORAL AND MAXILLOFACIAL SURGERY OOOO
290 Ghassemi et al. March 2014

3. had excessive alcohol intake, we excluded these factors
from statistical analyses.
DISCUSSION
The development and particularly the refinements of
microvascular techniques have revolutionized free tissue
transfers and reconstructive procedures of the head and
neck region.1,2
Defects of this region may be difficult to
correct and are often associated with considerable psy-
chological stress for the patient; they should not be
intensified by flap failure. The challenge is to restore
function and esthetics with high success rates.
One of the most important prerequisites for suc-
cessful flap transfers is careful preoperative planning.
Many factors must be considered when justifying the
choice of possible reconstructive options. Vascularity is
fundamental, and the need for information concerning
vascular anatomy and pathology of the donor site is
essential.5
The choice of reconstructive option on the
basis of preoperative examinations can increase the
margin of safety and avoid the stress of flap failure for
both the patient and the surgeon.
The fibula is increasingly being used as the preferred
donor site for vascularized bony reconstructions of the
head and neck region.1,4
The viability of the flap is
dependent on the integrity of its vascular supply.
Vascular pathology at the donor site may compromise
blood supply and lead to flap failure, jeopardize the
vascularization of the foot, or cause intraoperative tech-
nical difficulties. The vessels of the lower extremities can
be affected by congenital deformities, traumatic de-
formities, or acquired pathologic damage leading to
stenosis.6-9
Atherosclerosis is the most common cause of
stenosis in industrialized countries.7,8
Many factors,
including high blood cholesterol, high blood pressure,
diabetes, smoking, and alcohol consumption, can pro-
mote peripheral vascular disease. The coexistence of
multiple factors can potentially increase the chance of
vascular disease and affect many different vessel types.
There is a high comorbidity of various vascular dis-
eases such as coronary heart disease and peripheral
vascular disease, with direct implications for the vessels
of the lower extremities.8
Patients with oral cavity
cancer treated by resection often have a history of
cigarette and alcohol abuse, often are elderly and obese,
and often have diabetes and high blood pressure.
Although the reliability of the vascular supply of the
lower extremities is always a concern in these patients,
especially when a fibula flap is harvested, the necessity of
preoperative vascular imaging is still highly disputed.4
Routine preoperative vascular imaging is arguable, and
some recommend this examination only in selected cases,
dictated by symptoms or an unusual clinical situation.10,11
Others insist on a routine angiography of the lower
extremity and believe that clinical examination cannot
always assure a patent peroneal vessel for safe flap
transfer, despite what some may claim.12,13
To confine the indication of preoperative vascular
imaging to known risks, we examined the correlation to
vascular diseases of the lower extremities. The objec-
tive of our study was to identify important factors that
can affect an intact vascularity of the lower extremity
and justify performing preoperative vascular imaging.
The age distribution of the selected angiographies cor-
relates to that of the patients treated for cancer (see
Figure 1). The factors we identified that would justify
preoperative vascular imaging were known vascular
disease, high blood pressure, history of excessive
tobacco abuse, family history of vascular pathology,
high blood cholesterol, and diabetes.
We perform preoperative vascular imaging regularly
and recommend angiography of the lower extremity or
an alternative method of vessel imaging, especially if
any of the aforementioned factors apply.14-16
Benefit
and risk should be weighed against each other when
Fig. 3. Predicted probability of vessel pathology of posterior
tibial artery with increasing age.
Fig. 4. Predicted probability of vessel pathology of peroneal
artery with increasing age.
OOOO ORIGINAL ARTICLE
Volume 117, Number 3 Ghassemi et al. 291

4. considering the patients’ and surgeons’ expectations
and the goal of the reconstruction. These images pro-
vide information on vascular pathology and therefore
reduce the risk of flap failure and help to avoid potential
donor site complications. Furthermore, these images
can also enable preoperative navigated planning of
exact bony reconstruction.17,18
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Reprint requests:
Alireza Ghassemi
Department of Oral, Maxillofacial and Plastic Facial Surgery
University Hospital of RWTH-Aachen
Pauwelsstrasse 30
52074 Aachen
Germany
aghassemi@ukaachen.de
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