Ein Konsensus der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie (DAM): Welche apparative Diagnostik ist für die Darstellung der Anschlussgefäße vor mikrochirurgischen Transplantationen an der unteren Extremität notwendig?

Zusammenfassung

Fragestellungen

Im Rahmen eines Konsensus-Workshops wurden folgende Fragen bezüglich der Darstellung der Anschlussgefäße vor mikrochirurgischen Transplantationen an der unteren Extremität diskutiert: • Braucht der klinisch gefäßgesunde Patient vor der Durchführung einer mikrochirurgischen Rekonstruktion an der unteren Extremität überhaupt eine apparative Diagnostik? • Welche apparative Diagnostik (wenn benötigt) stellt am besten die arteriellen Anschlussoptionen für eine mikrochirurgische Lappenplastik an der unteren Extremität dar? • Wann ist eine apparative Diagnostik der venösen Strombahn vor Durchführung einer mikrochirurgischen Lappenplastik an der unteren Extremität erforderlich: Routinemäßig oder nur in ausgewählten Fällen und welche ist hierfür am besten geeignet?

Methodik

Die Erfahrungen der teilnehmenden Expertinnen und Experten in Zusammenhang mit der aktuellen Literatur zu diesen Fragestellungen wurden im Rahmen eines interdisziplinären Expertenworkshops der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie (DAM) 2024 in Aachen diskutiert. Das Ziel des Workshops bestand darin, Empfehlungen zur Anwendung der bildgebenden Diagnostik unter Berücksichtigung individueller Patientencharakteristika zu erarbeiten und einen konsentierten Algorithmus zum diagnostischen Vorgehen zu entwickeln.

Ergebnisse

Hinsichtlich der oben genannten Fragestellungen wurde von den Teilnehmenden der folgende Konsensus formuliert: • Eine routinemäßige Basisdiagnostik der arteriellen Anschlussgefäße vor freier Lappenplastik an der unteren Extremität mittels klinischer Untersuchung und Duplexsonographie ist zu empfehlen. • Bei Notwendigkeit einer Schnittbildgebung sollte eine CTA oder MRA verwendet werden, für junge Patienten sollte die MRA favorisiert werden. Zusätzlich sollte eine dynamische Bildgebung mittels Duplexsonographie erfolgen. Eine DSA sollte überwiegend in Interventionsbereitschaft durchgeführt werden, die DSA ohne Intervention bleibt speziellen Fragestellungen vorbehalten. • Eine Duplexsonographie zur Darstellung der venösen Anschlussgefäße ist sinnvoll. Bei vorliegenden venösen Pathologien sollte eine weitere Diagnostik mittels vorzugsweise MR-Phlebographie erfolgen.

Abstract

Objectives

At a consensus workshop, the following questions were discussed regarding the preoperative imaging of recipient vessels prior to microsurgical transplantation in the lower extremity: • Is preoperative imaging necessary for patients with clinically intact peripheral vasculature undergoing microsurgical reconstruction of the lower extremity? • Which imaging modality (if required) best visualises the arterial recipient vessels for microsurgical flap reconstruction in the lower extremity? • In which cases is imaging of the venous outflow tract indicated prior to microsurgical flap reconstruction of the lower extremity: should it be performed routinely or only in selected cases, and which modality is best suited for this purpose?

Methods

At an interdisciplinary expert workshop held by the German-speaking Society for Reconstructive Microsurgery (GSRM) in Aachen in 2024, the experiences of the participating experts were discussed in the context of the current literature addressing these questions. The workshop aimed to develop recommendations for applying imaging diagnostics that take into account individual patient characteristics, and to establish a consensus-based diagnostic algorithm.

Results

Regarding the above-mentioned questions, the participants reached the following consensus: • Routine baseline assessment of the arterial recipient vessels by means of clinical examination and duplex ultrasonography is recommended prior to free flap transfer in the lower extremity. • If additional imaging is required, CT angiography (CTA) or MR angiography (MRA) should be used. In younger patients, MRA should be preferred. Additionally, dynamic imaging using duplex ultrasonography should be performed. Digital subtraction angiography (DSA) should primarily be reserved for cases where intervention is anticipated; diagnostic DSA without intervention should be limited to specific indications. • The evaluation of the venous recipient vessels using duplex ultrasonography is considered useful. If venous pathology is present, further imaging – preferably MR phlebography – should be performed.

Schlüsselwörter

Mikrochirurgie - freie Lappenplastiken - bildgebende Verfahren - Anschlussgefäße - Extremitätenrekonstruktion

Keywords

Microsurgery - free flaps - imaging procedures - recipient vessels - lower extremity reconstruction

Publikationsverlauf

Eingereicht: 29. Mai 2025

Angenommen: 03. September 2025

Artikel online veröffentlicht:
17. November 2025

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