Catheter-Based Computed Tomography Angiography in Anterolateral Thigh Perforator Mapping of Chinese Patients

Abstract

Background During reconstructive surgery, anterolateral thigh (ALT) flap harvest is challenging due to variation and uncertainty in perforator distribution. We performed a pilot study to identify the predictive value of catheter-based computed tomography angiography (C-CTA) and traditional CTA (T-CTA) in ALT perforator mapping for patients whose ALT perforators were difficult to identify. Methods Thirty-four consecutive T-CTA/C-CTA-mapped ALT flaps were evaluated for extremity reconstruction. The perforator location, origin, and course were compared between T-CTA/C-CTA imaging and intraoperative findings. The mapping efficiency of T-CTA and C-CTA was compared thoroughly. Results Among the 34 ALT thigh flaps, 117 (36) of the 130 perforators identified intraoperatively were visible on C-CTA (T-CTA) in a subgroup of Chinese limb trauma patients with limited activity. C-CTA showed a satisfactory efficiency in perforator mapping, which was much better than the efficiency of T-CTA. C-CTA also showed a much better sensitivity (90.00 vs. 27.69%), specificity (94.74 vs. 66.67%), and accuracy (91.07 vs. 36.69%), and a much lower false-positive (1.68 vs. 26.53%), and false-negative rate (10.00 vs. 72.31%). Moreover, C-CTA could accurately predict the origin and septocutaneous or intramuscular course in all identified perforators. All flaps were elevated successfully and survived. Conclusion C-CTA outperforms T-CTA in the preoperative perforator mapping of ALT flaps in a subgroup of Chinese limb trauma patients. C-CTA should be the method of choice for perforator mapping in patients whose ALT flaps are intended for extremity reconstruction.

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications

“…Despite its invasive nature, catheter-based CTA may have increased utility in this patient population where muscle disuse atrophy can distort perforators on traditional CTA. 35 Preoperative CTAs for perforator mapping and flap design have been shown to improve outcomes and decrease operative times in breast reconstruction; however, they have yet to be widely used in other forms of perforator flap planning. 35 In a direct comparison between the use of traditional handheld Doppler and CTA in 32 head and neck reconstructions using the ALT flap, Liu et al found significantly decreased major surgical complications, operative time, and length of hospital stay in the CTA group.…”

“…35 Preoperative CTAs for perforator mapping and flap design have been shown to improve outcomes and decrease operative times in breast reconstruction; however, they have yet to be widely used in other forms of perforator flap planning. 35 In a direct comparison between the use of traditional handheld Doppler and CTA in 32 head and neck reconstructions using the ALT flap, Liu et al found significantly decreased major surgical complications, operative time, and length of hospital stay in the CTA group. 16 Despite these documented benefits, further studies are required to determine the cost effectiveness of obtaining routine CTA for preoperative mapping in ALT reconstructions.…”

“…However, previous studies looking specifically at ALT perforator anatomy have found near perfect correlation between imaging and operative findings. 35 Our measurements of vessel length were also taken as straight-line approximations, which likely underreport the actual length of nonlinear vessels. Limited sensitivity of CTA for perforators <1 mm also limits any calculations of mean perforator size, as those <1 mm cannot reliably be incorporated into the dataset.…”

Versatile design of compound vastus lateralis muscle and anterolateral thigh musculocutaneous perforator free flaps for customized reconstruction of complex skin and soft tissue defects in the extremities

“…Perforator variability and availability can make it difficult to harvest a compound ALTP flap. Preoperative CTA can demonstrate the patient's vascular anatomy and aid perforator selection and operative success , but CTA still needs to be improved (Wang et al, 2019). In our practice, we combine CTA with a handheld Doppler to confirm the location of the perforators prior to surgery, which significantly reduces the The primary limitations of this report were the lack of a comparative group and lack of a standardized measure for long-term outcomes after complex extremity soft tissue reconstruction.…”

Catheter-Based Computed Tomography Angiography in Anterolateral Thigh Perforator Mapping of Chinese Patients: Statistical Estimates

“…With interest, we read the article, "Catheter-Based Computed Tomography Angiography in Anterolateral Thigh Perforator Mapping of Chinese Patients," by Wang et al, published in Journal of Reconstructive Microsurgery in October 2018. 1 Free anterolateral thigh (ALT) flap is a common reconstructive surgical modality. However, due to the unpredictability of the perforator vessels, ALT flap has been bothersome even for the experienced microsurgeons.…”