Multidetector Computed Tomography (CT) Analysis of 168 Cases in Diabetic Patients with Total Superficial Femoral Artery Occlusion: Is It Safe to Use an Anterolateral Thigh Flap without CT Angiography in Diabetic Patients?
24 April 2017
31 July 2017
13 September 2017 (eFirst)
Background The superficial femoral artery (SFA) is the most common site of lower extremity atherosclerosis, and collateral vessels from the deep femoral artery (DFA) play an important compensatory role between the iliofemoral segment and the popliteal artery. We examined SFA occlusion and collateral vessel developments in patients with diabetes mellitus using computed tomography (CT) angiography. We also compared the collateral systems from the DFA and the descending branch of the lateral circumflex femoral artery (dbLCFA) in the case of SFA occlusion.
Methods We retrospectively reviewed 1,316 sets of CT angiographic data collected from 673 patients with diabetes between 2008 and 2010. The degree of stenosis in each segment of the proximal and distal SFA and the number and size of collateral vessels originating from the DFA and dbLCFA were measured using established scoring systems. In cases where the SFA was occluded, the numbers of collateral vessels originating from the DFA and the dbLCFA vessel were compared.
Results The mean occlusion rate of the SFA was 15.6%. We noted that collateral vessels from DFA and dbLCFA were the main circulatory route in cases of occlusions of the SFA. More collateral vessels developed from the DFA than from the dbLCFA. Overall, 0.6% of the patients had only collateral systems from the dbLCFA.
Conclusion When planning to use anterolateral thigh free flaps in diabetic patients with suspected SFA total occlusion, thorough investigations of the peripheral vessels are essential.
- 1 Nosrati N, Chao AH, Chang DW, Yu P. Lower extremity reconstruction with the anterolateral thigh flap. J Reconstr Microsurg 2012; 28 (04) 227-234
- 2 Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21 (05) 855-859
- 3 Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care 2003; 26 (02) 491-494
- 4 Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care 2001; 24 (01) 84-88
- 5 Prompers L, Huijberts M, Apelqvist J. , et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 2007; 50 (01) 18-25
- 6 McDermott MM, Carroll TJ, Kibbe M. , et al. Proximal superficial femoral artery occlusion, collateral vessels, and walking performance in peripheral artery disease. JACC Cardiovasc Imaging 2013; 6 (06) 687-694
- 7 Wecksell MB, Winchester PA, Bush Jr HL, Kent KC, Prince MR, Wang Y. Cross-sectional pattern of collateral vessels in patients with superficial femoral artery occlusion. Invest Radiol 2001; 36 (07) 422-429
- 8 Hage JJ, Woerdeman LA. Lower limb necrosis after use of the anterolateral thigh free flap: is preoperative angiography indicated?. Ann Plast Surg 2004; 52 (03) 315-318
- 9 Kruse RR, Vinke EJ, Poelmann FB. , et al. Computation of blood flow through collateral circulation of the superficial femoral artery. Vascular 2016; 24 (02) 126-133
- 10 Baumgartner I, Thoeny HC, Kummer O. , et al. Leg ischemia: assessment with MR angiography and spectroscopy. Radiology 2005; 234 (03) 833-841
- 11 Rutherford RB, Baker JD, Ernst C. , et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26 (03) 517-538
- 12 Keeling AN, Carroll TJ, McDermott MM. , et al. Clinical correlates of size and number of collateral vessels in peripheral artery disease. Vasc Med 2012; 17 (04) 223-230
- 13 Wu SC, Driver VR, Wrobel JS, Armstrong DG. Foot ulcers in the diabetic patient, prevention and treatment. Vasc Health Risk Manag 2007; 3 (01) 65-76
- 14 Skrepnek GH, Mills Sr JL, Armstrong DG. A diabetic emergency one million feet long: disparities and burdens of illness among diabetic foot ulcer cases within emergency departments in the United States, 2006-2010. PLoS One 2015; 10 (08) e0134914
- 15 Most RS, Sinnock P. The epidemiology of lower extremity amputations in diabetic individuals. Diabetes Care 1983; 6 (01) 87-91
- 16 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
- 17 Lee YC, Chen WC, Chou TM, Shieh SJ. Anatomical variability of the anterolateral thigh flap perforators: vascular anatomy and its clinical implications. Plast Reconstr Surg 2015; 135 (04) 1097-1107
- 18 Ziegler MA, Distasi MR, Bills RG. , et al. Marvels, mysteries, and misconceptions of vascular compensation to peripheral artery occlusion. Microcirculation 2010; 17 (01) 3-20
- 19 Kitamura S, Inoue K, Kawachi K. , et al. Lower extremity ischemia secondary to internal thoracic-coronary artery bypass grafting. Ann Thorac Surg 1993; 56 (01) 157-159
- 20 Dua A, Desai SS, Johnston S. , et al. The impact of geniculate artery collateral circulation on lower limb salvage rates in injured patients. Ann Vasc Surg 2016; 30: 258-262
- 21 Sabalbal M, Johnson M, McAlister V. Absence of the genicular arterial anastomosis as generally depicted in textbooks. Ann R Coll Surg Engl 2013; 95 (06) 405-409
- 22 Sakakibara Y, Abe M, Hiramatsu Y. , et al. The descending branch of the lateral femoral circumflex artery for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1999; 118 (04) 753-754
- 23 Tsui SS, Parry AJ, Large SR. Leg ischaemia following bilateral internal thoracic artery and inferior epigastric artery harvesting. Eur J Cardiothorac Surg 1995; 9 (04) 218-220
- 24 Halvorson EG, Taylor HO, Orgill DP. Patency of the descending branch of the lateral circumflex femoral artery in patients with vascular disease. Plast Reconstr Surg 2008; 121 (01) 121-129
- 25 Ahn JH, Mirza T, Thomas D, Ameerally P. Effect of peripheral vascular disease on the blood supply of the anterolateral thigh free flap: a radiographic study. J Reconstr Microsurg 2014; 30 (08) 509-514
- 26 Dai G, Kaazempur-Mofrad MR, Natarajan S. , et al. Distinct endothelial phenotypes evoked by arterial waveforms derived from atherosclerosis-susceptible and -resistant regions of human vasculature. Proc Natl Acad Sci U S A 2004; 101 (41) 14871-14876
- 27 Jude EB, Eleftheriadou I, Tentolouris N. Peripheral arterial disease in diabetes--a review. Diabet Med 2010; 27 (01) 4-14
- 28 Rafael Sadaba J, Conroy JL, Burniston M, Maughan J, Munsch C. Effect of radial artery harvesting on tissue perfusion and function of the hand. Cardiovasc Surg 2001; 9 (04) 378-382
- 29 Iida Y, Numata T, Shiba K, Nagata H, Terada N, Konno A. Hemodynamic changes of the hand after radial forearm flap harvesting. Ann Plast Surg 2002; 49 (02) 156-160
- 30 Gaudino M, Serricchio M, Tondi P. , et al. Chronic compensatory increase in ulnar flow and accelerated atherosclerosis after radial artery removal for coronary artery bypass. J Thorac Cardiovasc Surg 2005; 130 (01) 9-12
- 31 Tanaka Y, Hamamoto Y, Oda A, Kogure T, Sano N. Ischaemic complications 20 years after harvesting of a radial forearm flap in a patient with scleroderma. J Plast Surg Hand Surg 2012; 46 (05) 374-376