Intra-Operative Acute Leg Ischaemia after Free Fibula Flap Harvest for Mandible Reconstruction

Abstract

Osteosarcomas of the cranial bones need a large surgical radical resection. The best option to reconstruct mandible defect after resection is the free fibula flap. In our patient an acute ischaemic leg occurred just after the free fibula flap harvest for mandible reconstruction. The abnormal distribution of the calf arteries leads to catastrophic consequences. The peroneal artery could be the main dominant artery of the leg in a small number of patients. We reported an extremely rare case of "peronea magna", described in less than 0.2% of the global population. A careful pre-operative workup of the calf vessels is required in all the patients who need free fibula flap harvest.

Anatomical variants of lower limb vasculature and implications for free fibula flap: Systematic review and critical analysis

“…However, the degree of contribution of dPR to pedal circulation is widely variable. In peronea arteria magna (subtype III‐C variant), the PR is the only vessel supplying the foot; suggesting absolute dominance, and hence its removal for FFF harvest may lead to significant limb ischemia . In the other two subtypes, the PR shares the blood supply to the foot along with the remaining tibial vessel, and usually has larger diameter suggesting a relative dominance of the vessel .…”

“…Because of its dominant role for perfusion, PR is named as dominant peroneal artery (dPR) in the context of this systematic review. Although anatomical variants such as dPR do not imply less blood supply to the foot in healthy individuals, they may preclude the FFF harvest, or greatly impact the donor‐side morbidity by ischemia and potentially loss of the limb …”

“…The routine practice of pre‐operative vascular mapping (POVM) of lower limbs has been controversially discussed in the literature . This may be due to variable, and contradicting reports about the prevalence of dPR variants, and their true impact on surgical practice.…”

“…Although anatomical variants such as dPR do not imply less blood supply to the foot in healthy individuals, 17 they may preclude the FFF harvest, or greatly impact the donor-side morbidity by ischemia and potentially loss of the limb. 13,[18][19][20][21] The routine practice of pre-operative vascular mapping (POVM) of lower limbs has been controversially discussed in the literature. 5,19,[22][23][24] This may be due to variable, and contradicting reports about the prevalence of dPR variants, and their true impact on surgical practice.…”

Preoperative Evaluation of Lower Extremity Arteries for Free Fibula Transfer Using MDCT Angiography

“…4,29,30 Arteria magna is an absolute contraindication of peroneal artery sacrifice, and acute foot ischemia after free fibular flap harvest in patients with this variant has recently been reported. 32 The imaging criteria that contraindicate the safe use of a fibula free flap are not well established. Clearly, a 3-vessel runoff to the foot is ideal and a single-vessel runoff is unusable (Fig.…”