Developments in perforator imaging for the anterolateral thigh flap: CT angiography and CT‐guided stereotaxy

Rozen, Warren M.; Ashton, Mark W.; Stella, Damien; Ferris, Scott; White, David C.; Phillips, Timothy J; Taylor, G. Ian

doi:10.1002/micr.20485

Cited by 67 publications

(42 citation statements)

References 12 publications

(7 reference statements)

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“…3) and to demonstrate the volume, shape, and location of bone to be harvested preoperatively, as a guide to surgical approach. In addition to previous studies demonstrating that CTA is more accurate than ultrasound in flap planning, 8,15 the volumetric and structural analysis of iliac bone provides a further extension of the role of CTA over other imaging modalities.…”

Section: Discussionmentioning

confidence: 93%

“…8 A vascularized bone flap is thus preferred with vascularized proximal fibular described previously for distal radius reconstruction. 12 The major limitation of the use of fibular bone (as a flap or graft) is that it consists mostly of cortical bone with resultant poor osteogenicity and may be considered an inferior choice in the setting of infection.…”

Section: Discussionmentioning

confidence: 99%

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Free deep circumflex iliac artery vascularised bone flap for reconstruction of the distal radius: Planning with CT angiography

et al. 2009

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Distal radius fractures in the younger population are often comminuted and intra-articular, which can increase the complexity of their management. In addition, these patients tend to place high demands on their wrists, and the prevention of functional arthritis necessitates excellent anatomical reduction. Complicated cases such as these are often limited in their management options. We present a complex case of distal radius fracture and bone loss in which initial therapy with nonvascularized bone graft failed, and osteomyelitis was a further complicating factor. With the aid of preoperative planning with computed tomographic angiography (CTA), a deep circumflex iliac artery (DCIA) bone flap was able to be assessed as a reconstructive option. The use of preoperative CTA, the first description of such imaging in this role, was able to delineate the bone to be harvested, confirm its vascular supply, and plan flap harvest. The use of a vascularized bone flap in this setting was thus undertaken and was able to provide an autologous anatomical support for the wrist while reducing the risk of recurrent infection and still preserving internal fixation. This unique application of the free DCIA bone flap was potentiated by CTA, achieving complete healing and good functional outcomes.

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Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Free deep circumflex iliac artery vascularised bone flap for reconstruction of the distal radius: Planning with CT angiography

et al. 2009

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“…The use of preoperative CT has also been shown to significantly reduce operative times in select studies (17). Accuracy can be further improved with stereotactic localization, however, this technology is not widely available and is still based on a CT scan taken pre-operatively (6, 7). …”

Section: Discussionmentioning

confidence: 99%

“…Newer techniques such as CT and MRI have been described for pre-operative perforator identification and initial studies have shown potential for decreased operative times and complications (2-5). Stereotactic image-guided perforator imaging has also been described as a more accurate planning modality; however, it is still based on a pre-operative CT scan and its practical utility is limited (6,7). These techniques all evaluate perforators in the pre-operative planning phase as a majority of surgeons still rely on intraoperative clinical assessment of vessel size and location as the final determining factor.…”

Section: Introductionmentioning

confidence: 99%

Image-Guided Perforator Flap Design Using Invisible Near-Infrared Light and Validation With X-Ray Angiography

Matsui¹,

Lee²,

Winer³

et al. 2009

Annals of Plastic Surgery

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Although perforator flaps mark an important conceptual change in reconstructive surgery, individual perforator vessels show a high degree of variability with respect to anatomic landmarks. We have developed an intraoperative imaging system that simultaneously displays surgical anatomy and otherwise invisible near-infrared (NIR) images. In 22 adult pigs, perforating vessels were identified within seconds using this optical imaging system and systemic injection of indocyanine green. Perforator flaps were then designed based on these results, and vessel location confirmed by direct visualization and anatomic dissection. Since x-ray angiography remains the gold standard for identification of underlying vessels, conventional x-ray angiography was also performed in 8 pigs to verify the location of perforators. There was full correlation of all the perforators identified among NIR fluorescence angiography, x-ray angiography, and anatomic dissection. The technology we describe provides high-sensitivity real-time image guidance throughout perforator dissection, and permits patient-specific flap design.

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“…Some studies demonstrated the superiority of computed tomographic angiography (CTA) over the other options for the preoperative mapping in the perforator flaps because it could evaluate the perforators more precisely. 1 Nevertheless, CTA has a disadvantage that it cannot be used in real time and provide real-time feedback during harvesting flap. Color Doppler sonography is another effective tool for surgical planning.…”

mentioning

confidence: 99%

Intraoperative color Doppler sonography in the elevation of anterolateral thigh flap

et al. 2011

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There are currently multiple imaging techniques available for planning perforator flap harvest. Some studies demonstrated the superiority of computed tomographic angiography (CTA) over the other options for the preoperative mapping in the perforator flaps because it could evaluate the perforators more precisely.1 Nevertheless, CTA has a disadvantage that it cannot be used in real time and provide real-time feedback during harvesting flap. Color Doppler sonography is another effective tool for surgical planning. Color Doppler sonography has advantage that it can be used in real time.2 However, with regard to harvest of perforator flap, it is usually used for preoperative assessment, not for intraoperative detection of perforators in real time.Between April and November 2010, we have performed intraoperative color Doppler sonography in real-time use during anterolateral thigh (ALT) flap harvest in eight patients. Preoperatively, the locations of cutaneous perforators were evaluated, using color Doppler sonography with a 12-MHz linear probe. Perioperatively, according to the preoperative assessment, the longitudinal incision line was designed in the middle of the anterior thigh. An incision was made and extended down through the fascia of the rectus femoris. The cut end of the deep fascia of the vastus lateralis was grasped with several clamps and retracted laterally. We carefully dissected between the fascia and the underlying muscle, and cutaneous perforator could be found. We then looked for the intermuscular septum between vastus lateralis and rectus femoris. Having defined the septum, we explored the septum with finger dissection to expose the full extent of the descending branch of the lateral circumflex femoral artery and the origin of perforating vessels. We prepared color Doppler sonography when the perforators were identified with a myocutaneous type. The probe was placed directly on to the surface of the vastus lateralis, and intramuscular perforator could be visualized by color mode (Fig. 1). The course and depth of the intramuscular perforator could be identified, and we marked the dissecting line on the surface of vastus lateralis (Fig. 2). We then begun to dissect out the perforators according to the intraoperative color Doppler sonography assessment and elevated the flap. In all cases, intramuscular perforators were detected by intraoperative color Doppler sonography and the flaps could be harvested safely.There are two key steps involved in elevating ALT flap. The first step is to locate the cutaneous perforators at the subfascial level, and the second is to follow these perforators to their main pedicle.3 Therefore, knowledge about anatomic variation of the vessel and information regarding the distribution of the perforators might be required in elevating the ALT flap. Many studies have discussed anatomical variations of the descending branch of lateral circumflex pedicle and the relationships between the lateral circumflex femoral pedicle and perforators. 3,4 But the perforator anatomy of

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Developments in perforator imaging for the anterolateral thigh flap: CT angiography and CT‐guided stereotaxy

Abstract: CT Angiography and CT-guided stereotaxy are useful adjuncts to Doppler ultrasound for imaging perforators prior to ALT flaps. A larger study is suggested to quantify the accuracy of these techniques.

Cited by 67 publications

References 12 publications

Free deep circumflex iliac artery vascularised bone flap for reconstruction of the distal radius: Planning with CT angiography

Free deep circumflex iliac artery vascularised bone flap for reconstruction of the distal radius: Planning with CT angiography

Image-Guided Perforator Flap Design Using Invisible Near-Infrared Light and Validation With X-Ray Angiography

Intraoperative color Doppler sonography in the elevation of anterolateral thigh flap

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