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MR Angiography of Lower Extremities at 3 T: Presurgical Planning of Fibular Free Flap Transfer for Facial Reconstruction

Derek G. Lohan1, Anderanik Tomasian1, Mayil Krishnam1, Praveen Jonnala1, Keith E. Blackwell2 and J. Paul Finn1

1 Division of Cardiovascular Imaging, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, University of California Los Angeles, Peter V. Ueberroth Bldg., Ste. 3371, 10945 Le Conte Ave., Los Angeles, CA 90095-7206.
2 Division of Head and Neck Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA 90095-7206.


Figure 1
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  		Fig. 1A —Classification of popliteal artery branching. PT = posterior tibial artery, PR = peroneal artery, AT = anterior tibial artery. (Reprinted with permission from Kim D, Orron DE, Skillman JJ. Surgical significance of popliteal artery variants: a unified angiographic classification. Ann Surg 1989; 210:776–781 [12]) Type I-A: Usual pattern of popliteal arterial branching and arterial supply to foot. Type I-B: Trifurcations: anterior, peroneal, and posterior tibial arteries arise at same point without intervening tibioperoneal trunk. Type I-C: Posterior tibial artery is first branch. Anterior tibial and peroneal arteries arise from common trunk.

 

Figure 2
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  		Fig. 1B —Classification of popliteal artery branching. PT = posterior tibial artery, PR = peroneal artery, AT = anterior tibial artery. (Reprinted with permission from Kim D, Orron DE, Skillman JJ. Surgical significance of popliteal artery variants: a unified angiographic classification. Ann Surg 1989; 210:776–781 [12]) Type II-A1: Anterior tibial artery arises above knee joint and has straight course in its proximal segment. Type II-A2: Anterior tibial artery arises above knee joint but takes medial swing, presumably resulting from its passage anterior to popliteus muscle. Type II-B: Posterior tibial artery arises at level of knee joint. Type II-C: Peroneal artery arises above knee joint.

 

Figure 3
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  		Fig. 1C —Classification of popliteal artery branching. PT = posterior tibial artery, PR = peroneal artery, AT = anterior tibial artery. (Reprinted with permission from Kim D, Orron DE, Skillman JJ. Surgical significance of popliteal artery variants: a unified angiographic classification. Ann Surg 1989; 210:776–781 [12]) Type III-A: Posterior tibial artery is hypoplastic and peroneal artery is large. At ankle, distal posterior tibial artery is replaced to peroneal artery. Type III-B: Anterior tibial artery is hypoplastic and peroneal artery is large. At ankle, dorsalis pedis artery is replaced to peroneal artery. Type III-C: Both anterior tibial artery and posterior tibial artery are hypoplastic. At ankle, dorsalis pedis and posterior tibial arteries are replaced to peroneal artery.

 

Figure 4
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  		Fig. 2 —72-year-old man with oropharyngeal squamous cell carcinoma. Composite volume-rendered abdominopelvic, thigh, and calf station image from 3-T MR angiography shows diffuse arteriomegaly with small infrarenal abdominal aortic aneurysm and left common iliac ectasia. Note presence of atherosclerotic occlusion of left anterior tibial artery, with focal high-grade stenosis of distal right anterior tibial artery. Conventional type I-A popliteal branching is present bilaterally. Arrow indicates incidental splenic artery aneurysm.

 

Figure 5
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  		Fig. 3 —58-year-old woman with squamous cell carcinoma of the right neck. Composite thigh and calf MRA stations show type II-B right lower extremity trifurcation branch pattern.

 

Figure 6
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  		Fig. 4 —72-year-old woman with salivary mucoepidermoid carcinoma. Full thickness calf contrast-enhanced MRA maximum intensity projection shows type III-A right lower extremity trifurcation branch pattern. As a result, left peroneal artery was used for fibular flap harvesting.

 

Figure 7
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  		Fig. 5 —60-year-old woman with buccal squamous cell carcinoma. Calf contrast-enhanced MRA shows bilateral type III-B lower extremity branch patterns. Physical examination in this patient revealed presence of bilaterally strong dorsalis pedis and posterior tibial pulses. Patient subsequently underwent latissimus dorsi–serratus anterior vascular rib flap mandibular reconstruction.

 

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