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The Utility of Preoperative Arteriography for Free Flap Planning in Patients with Chronic Lower Extremity Wounds

Background: In patients with lower extremity wounds, free tissue transfer is often the last option before amputation, making it crucial to optimize preoperative planning to prevent flap breakdown. No consensus exists regarding preoperative vascular workup before lower extremity free tissue transfer. In this study, the authors analyzed the utility of using arteriography for lower extremity free flap planning. Methods: A retrospective review was performed of 57 patients who underwent lower extremity arteriography and 59 free flap operations for lower extremity wounds between November of 2014 and August of 2017. Findings were used to guide flap recipient vessel selection. Arterial abnormality was addressed by means of endovascular intervention, where appropriate. Encountered abnormality was described and patient demographics, comorbidities, and outcomes were analyzed for correlation with abnormal angiographic studies. Results: Angiographic abnormalities were observed in 40 patients (67.8 percent), including 23 (57.5 percent) with stenosis/occlusion, 20 (50.0 percent) with atretic/nonvisualized vessels, and 11 (27.5 percent) requiring endovascular intervention. Stenosis/occlusion was detected in nine patients (15.3 percent) with no previously known arterial disease, leading to a new diagnosis of peripheral vascular disease. The flap survival rate was 98.3 percent, six patients (10.2 percent) ultimately progressed to amputation, and 53 patients (89.8 percent) were able to continue community ambulation at a mean follow-up time of 15.1 ± 9.51 months (range, 1.67 to 35.2 months). After arteriography, two patients (3.39 percent) suffered contrast-induced acute kidney injury. No other complications were noted. Conclusion: Preoperative lower extremity arteriography aids in the diagnosis of peripheral vascular disease, allows for timely endovascular intervention, and allows for optimal flap recipient vessel selection with a low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENC: Diagnostic, IV.