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Preoperative MR Angiography in Free Fibula Flap Transfer for Head and Neck Cancer: Clinical Application and Influence on Surgical Decision Making

Aine M. Kelly1, Paul Cronin1, Hero K. Hussain1, Frank J. Londy1, Douglas B. Chepeha2 and Ruth C. Carlos1

1 Department of Radiology, University of Michigan, University of Michigan Hospitals, B1 132 H Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0030.
2 Department of Surgery, University of Michigan, Ann Arbor, MI.


Figure 1
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  		Fig. 1 —Normal calf artery anatomy (88%) and the more commonly seen significant anatomic variants with their incidence. a. = artery, AT = anterior tibial artery, Per = peroneal artery magna, PT = posterior tibia artery. Reprinted with permission from [20]. A, Absent anterior tibial artery (3.8%). B, Absent posterior tibial artery (1.6%). C, Peroneal artery magna (0.2%). D, Absent peroneal artery (< 0.1%). E, Abnormally long tibioperoneal trunk (0.1%).

 

Figure 2
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  		Fig. 2 —MR angiography of 39-year-old man shows normal lower limbs.

 

Figure 3
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  		Fig. 3 —MR angiography of 32-year-old woman with short tibioperoneal trunks (trifurcations) bilaterally (arrows). Posterior tibial arteries are also hypoplastic bilaterally (arrowheads), more so on left side. Consequently, right calf was judged more suitable for fibular flap harvest.

 

Figure 4
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  		Fig. 4 —MR angiography of 54-year-old man shows hypoplastic posterior tibial arteries bilaterally (arrows). This variant was not sufficient to cancel free fibula flap harvest.

 

Figure 5
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  		Fig. 5 —MR angiography of 54-year-old man shows hypoplastic right posterior tibial artery (arrowhead), with right peroneal artery (arrow) reconstituting posterior tibial artery/plantar arch.

 

Figure 6
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  		Fig. 6 —MR angiography of 48-year-old woman shows dominant peroneal artery on right side (arrow), which predominantly supplies plantar arch (arrowhead). Consequently, left fibula was used for free tissue transfer.

 

Figure 7
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  		Fig. 7 —MR angiography of 51-year-old man shows hypoplastic peroneal arteries bilaterally (arrows). This variant thought to be nonsignificant. Venous contamination is seen on right side. Fibular flap was performed using right side.

 

Figure 8
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  		Fig. 8 —MR angiography of 59-year-old man with high take-off of right posterior tibial artery (arrow). This variant is thought to be nonsignificant. Patient has normal arterial anatomy on left. Right fibular flap was performed.

 

Figure 9
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  		Fig. 9A —45-year-old man with stenosis of right external iliac artery (arrow, A) as measured on 3D MR angiography maximum-intensity-projection image. This stenosis is approximately 50%, indicating 75% reduction in cross-sectional area, which is significant.

 

Figure 10
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  		Fig. 9B —45-year-old man with stenosis of right external iliac artery (arrow, A) as measured on 3D MR angiography maximum-intensity-projection image. Opposite side was used for fibular flap harvest.

 

Figure 11
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  		Fig. 10A —MR angiogram of 75-year-old woman. Diffuse arteriosclerotic disease of superficial femoral arteries bilaterally with significant stenosis in right superficial femoral artery (arrow).

 

Figure 12
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  		Fig. 10B —MR angiogram of 75-year-old woman. Significant stenosis of both anterior tibial arteries (arrows).

 

Figure 13
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  		Fig. 10C —MR angiogram of 75-year-old woman. Significant stenosis of right anterior tibial artery (arrow).

 

Figure 14
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  		Fig. 10D —MR angiogram of 75-year-old woman. Significant stenosis of left anterior tibial artery (arrow) and left peroneal artery (arrowhead). Alternate flaps were used due to her bilateral calf arterial disease.

 

Figure 15
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  		Fig. 11A —MR angiography of 79-year-old woman. Diffuse disease of both superficial femoral artery (arrowheads) and total occlusion of left superficial femoral artery (arrow).

 

Figure 16
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  		Fig. 11B —MR angiography of 79-year-old woman. Bilateral occlusions of posterior tibial arteries (arrows). Patient had alternate site (scapula) used for free tissue transfer.

 

Figure 17
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  		Fig. 12A —MR angiography of 72-year-old man. Nonsignificant diffuse arteriosclerotic disease in superficial femoral artery bilaterally (arrows) and significant stenosis in right popliteal artery (arrowhead).

 

Figure 18
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  		Fig. 12B —MR angiography of 72-year-old man. Significant stenosis of left tibioperoneal trunk (arrow). Alternate flap transfer was performed because of his bilateral disease.

 

Figure 19
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  		Fig. 13 —MR angiography of 58-year-old man shows diffuse, nonsignificant disease of right posterior tibial artery (arrows) and hypoplastic left posterior tibial artery (arrowheads). Alternate flap was performed (rectus) because of large size of his mandibular defect.

 

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