The congenital popliteal vasculature patterns in fibular free flap reconstruction by means of surgical anatomy in cadavers.

Fibular free flap (FFF) is frequently used for reconstruction requiring vascularized bone. Thus, understanding its vasculature variation is crucial. This study investigates the popliteal artery branching variations in Thai cadavers and compares them with previous studies. One hundred and sixty-two legs from 81 formalin-embalmed cadavers were dissected. The popliteal artery branching patterns were classified. The previous data retrieved from cadaveric and angiographic studies were also collected and compared with the current study. The most common pattern is type I-A (90.7%). For the variants, type III-A was the majority among variants (6.2%). Type IV-A, hypoplastic peroneal artery, was found in one limb. A symmetrical branching pattern was found in 74 cadavers. Compared with cadaveric studies, type III-B and III-C are significantly common in angiographic studies (p = 0.015 and p = 0.009, respectively). Type I-A is most common according to previous studies. Apart from this, the prevalence of type III-A variant was higher than in previous studies. Furthermore, type III-B and III-C are more frequent in angiographic studies which might be from atherosclerosis. Thus, if the pre-operative CTA policy is not mandatory, the patients at risk for atherosclerosis and population with high variants prevalence should undergo pre-operative CTA with cost-effectiveness consideration.

Standardize routine angiography assessment of leg vasculatures before fibular flap harvest: lessons of congenital and acquired vascular anomalies undetected by color Doppler and physical examinations.

BACKGROUND: Fibular flaps have been widely used for mandibular and maxillary reconstructions. On occasion, anatomical variants of fibular arteries (FA) will be encountered. PURPOSE: Although anatomical variants of FA during fibular harvest have been reported, controversy exists regarding whether simple color Doppler ultrasonography (CDU) and physical examinations (PE) are sufficient for early preoperative detection. MATERIAL AND METHODS: A 10-year retrospective analysis in our department was performed to find the patients with various FA anomalies confirmed by computed tomography angiography (CTA) or intraoperative findings. RESULTS: A total number of 19 FA anomalies were found either pre- or intraoperatively in 16 patients, in whom three cases were with bilateral FA variants. Type IIIC variants, also called arteria peronea magna (great peroneal artery), were confirmed in two legs, while the majority (13 legs) had type IIIA hypoplastic/aplastic posterior tibialis arteries (PTA). Four legs had new type IIID (low FA and PTA bifurcations). Preoperative CDU and PE only suspected anomalies in two legs. Six cases proceeded with using the affected fibulas, within whom vascular grafts were used in half of them for lengthening the FA pedicle. Local ischemia, partial soleus muscle necrosis, and claudication were reported in one. CONCLUSIONS: Routine CTA before every fibular harvest, rather than simple PE and CDU, should be added for screening contraindications and ensuring safety for fibular flap harvest.

Contrast-enhanced ultrasound (CEUS) in the diagnostic evaluation of popliteal artery aneurysms, a single-center study.

BACKGROUND: Popliteal artery aneurysms (PAA) are the most common peripheral artery aneurysms. Most common cause is arteriosclerosis. Acute thromboembolic limb ischemia and rupture of the PAA depict severe complications. Diagnostic tools for identifying PAAs are (Doppler) ultrasound, CT/MR angiography and DSA. PURPOSE: The aim of the present retrospective single-center study is to assess the application and safety of CEUS for assessing untreated and treated PAAs. MATERIALS AND METHODS: 13 patients were included in this study on whom CEUS was performed between 2007-2016. CEUS examinations were performed and interpreted by an experienced single radiologist (EFSUMB Level 3). RESULTS: CEUS allowed for the detection of PAAs in all cases. CEUS allowed for detection of partial thrombosis of PAA in 7/8 of untreated patients, proper exclusion of PAA upon femoro-popliteal bypass in 3 patients, incomplete exclusion of PAA upon femoro-popliteal bypass in 1 patient and ruling out of in-stent stenosis in 1 patient. CONCLUSION: CEUS is a useful and safe tool for in real-time evaluation of PAAs in the pre-/post-treatment status. In addition to conventional (Doppler) ultrasound and as an alternative tool to more elaborate imaging modalities, CEUS might be integrated in the future diagnostic work-up and follow-up of PAA patients.

A rare disease with a rare presentation: hemi-atrophy caused by fibromuscular dysplasia in a 27 month old girl.

We discuss the case of a 27-month-old girl afflicted with fibromuscular dysplasia. She presented with hemiatrophy of left upper and lower limbs, nail dystrophy, ulcers on the tips of her toes, cold and painful limbs, foot drop, and hypertension. The initial appearance started at 2 months of age and other diagnoses such as complex regional pain syndrome, reflex sympathetic syndrome, vasculitis and coagulation disorders had been considered. Angiography revealed that all the arterial branches of the left lower and upper limbs, from brachial to ulnar and radial, and from iliac and femoral to tibialis arteries were affected. Sural nerve biopsy confirmed the diagnosis. In the follow-up visits until 2 years after the patient's discharge she did not develop any new problem and her blood pressure was controlled by enalapril and amlodipine.

The evidence-based surgical anatomy of the popliteal artery and the variations in its branching patterns.

OBJECTIVE: The goal of our study was to analyze the prevalence of branching pattern variations in the popliteal artery (PA) along with morphometrics of the PA to better address its importance in disease and vascular surgical procedures. METHODS: An extensive search for the PA and its anatomic variations was done in the major online medical databases. The anatomic data found were extracted and pooled for a meta-analysis. RESULTS: A total of 33 studies (N = 12,757 lower limbs) were included in the analysis. The most common variant was a division of the PA below the knee into the anterior tibial artery and a common trunk for the posterior tibial and peroneal arteries, with a prevalence of 92.6% (95% confidence interval [CI], 90.2-93.8). The second most common variation was a trifurcation pattern of all three branches dividing within 0.5 cm of each other, with a prevalence of 2.4% (95% CI, 1.4-3.5). Of the three studies that reported the diameter of the PA at the level of the subcondylar plane, a mean diameter of 8 mm (95% CI, 7.29-8.70) was found. CONCLUSIONS: The PA most commonly divides below the knee into the anterior tibial artery and the common trunk of the posterior tibial artery and the peroneal artery. Knowledge of the prevalence of possible variations in this anatomy as well as morphometric data is crucial in the planning and execution of any surgical intervention in the area of the knee.

Aplastic Posterior Tibial Artery in the Presence of Trimalleolar Ankle Fracture Dislocation Resulting in Below-the-Knee Amputation.

We present an interesting, but unfortunate, case of an 86-year-old female who sustained a trimalleolar ankle fracture dislocation that resulted in below-the-knee amputation after open reduction and internal fixation of the fracture. To the best of our knowledge, this is the first case report describing popliteal variants that ultimately resulted in critical limb ischemia and below-the-knee amputation after foot and ankle trauma. The anatomic variation altered the expected outcome from a relatively straightforward surgical case. We introduce the previously described lower extremity Allen test and describe how it can be a useful adjunct in the initial physical examination of lower extremity trauma. The ability to identify abnormal distal perfusion to the foot could provide enough insight to warrant evaluating the patient with angiography or computed tomography angiography.

Aneurismas poplíteos pequeños. ¿Son todos benignos? / Small popliteal artery aneurysms. Are all of them benign?

INTRODUCCIÓN: Los aneurismas poplíteos (AP) son infrecuentes, sin embargo, sus complicaciones tromboembólicas son usuales y pueden conducir a la pérdida de la extremidad. El comportamiento de los AP pequeños (APP) es incierto. El objetivo de nuestro estudio es: 1) describir y analizar el comportamiento de los APP dentro de una extensa serie quirúrgica de AP; 2) realizar un estudio comparativo con aquellos AP>2cm. MATERIAL Y MÉTODOS: Entre el 31 de agosto de 1986 y el 31 de diciembre de 2013, 157 AP en 132 pacientes fueron intervenidos en nuestro Servicio de Cirugía Vascular. La información ha sido recogida en una base de datos retrospectiva. Se consideran APP aquellos con diámetro transversal ≤ 2 cm. Se establecen 2 grupos: 31 AP ≤ 2 cm (grupo 1) y 126 AP>2cm (grupo 2). RESULTADOS: En el grupo de APP (grupo 1) el 67,7% de los casos fueron sintomáticos y en el grupo 2, el 58,7%, sin diferencias estadísticamente significativas. Los APP se manifiestan con isquemia aguda en el 32,3% de los casos, claudicación en 9,7%, dolor de reposo en el 19,4% y lesiones tróficas en el 6,5%. En el grupo, 2 los casos de dolor de reposo y lesiones tróficas son 5,6 y 0,8%, respectivamente, p = 0,026. La trombosis aneurismática está presente como complicación principal en el 58,1% en el grupo 1 y en el 33,3% en el grupo 2, en tanto que la rotura es del 0% en el grupo 1 y del 6,3% en el grupo 2, p = 0,040. CONCLUSIONES: Los APP no son tan benignos como pudiera pensarse ya que pueden trombosarse y producir isquemia crítica de la extremidad. Puesto que el objetivo de la reparación quirúrgica de un AP es prevenir las complicaciones tromboembólicas, se ha de considerar la reparación de los APP≤2 cm (AU)

BACKGROUND: Popliteal artery aneurysms (PAAs) are uncommon; however thromboembolic complications are usual and may result in limb loss. The natural history of small PAA is unknown. The aim of our study is: 1) to describe and analyse the behaviour of small PAA through our wide experience, and 2) to compare small PAAs to those PAA > 2 c m. MATERIAL AND METHODS: A total of 157 PAAs were operated on in 132 patients were operated on in our vascular surgery department from 31 August 1986 to 31 December 2013. Data from all the patients were retrospectively collected int a database. A small PAA was defined as a popliteal artery with a diameter ≤ 2 cm. Two groups were formeded: 31 PAA ≤ 2 cm (group 1) and 126 PAA > 2 cm (group 2). RESULTS: In group 1, 67.7% PAAs were symptomatic and 58.7% in group 2. In group 1 acute limb ischaemia was observed in 32.3%, claudication in 9.7%, ischaemic rest pain in 19.4%, and tissue loss in 6.5%. There was rest pain in 5.6% and tissue loss in 0.8% of group 2: P=.026. Aneurysm thrombosis was present as a primary complication, in 58.1% of group 1, and in 33.3% of group 2, with aneurysm rotura in 0% of group 1 and in 6.3% of group 2; P=.040. CONCLUSION: A small PAA is not as benign as it might seem, since it may thrombose and can result in limb ischaemia and limb loss. As the objective of popliteal artery aneurysm repair is to prevent thromboembolism, a surgical approach must be considered in small PAAs before complications appear

Clinical features of a rare anatomical variation of the posterior tibial and fibular arteries / Aspectos clínicos de uma variação anatômica rara das artérias tibial posterior e fibular

Abstract The posterior tibial artery normally arises from tibial-fibular trunk at the popliteal fossa, together with the fibular artery. The classic course of the posterior tibial artery is to run between the triceps surae muscle and muscles of the posterior compartment of the leg before continuing its course posteriorly to the medial malleolus, while the fibular artery runs through the lateral margin of the leg. Studies of both arteries are relevant to the fields of angiology, vascular surgery and plastic surgery. To the best of our knowledge, we report the first case of an anastomosis between the posterior tibial artery and the fibular artery in their distal course. The two arteries joined in an unusual “X” format, before division of the posterior tibial artery into plantar branches. We also provide a literature review of unusual variations and assess the clinical and embryological aspects of both arteries in order to contribute to further investigations regarding these vessels.

Resumo A artéria tibial posterior e a artéria fibular se originam do tronco tibiofibular, na fossa poplítea. A trajetória clássica da artéria tibial posterior é correr entre o tríceps sural e os músculos do compartimento posterior da perna, e, então, seguir posteriormente ao maléolo medial. Já a artéria fibular corre na margem lateral da perna, seguindo profundamente aos músculos. O estudo dessas artérias é relevante para o campo da angiologia, cirurgia vascular e cirurgia plástica. O presente trabalho é o primeiro relato de caso de uma anastomose entre ambas artérias, na porção distal de suas trajetórias. Tais artérias se anastomosaram em formato de “X”, antes da divisão da artéria tibial posterior em ramos plantares. Foi feita uma revisão de literatura das variações de tais artérias, dando ênfase ao aspecto clínico e embriológico, de modo a contribuir para novas investigações sobre esses vasos.

Degeneración aneurismática de la arteria poplítea por síndrome de atrapamiento poplíteo / Aneurysmal degeneration of the popliteal artery due to popliteal entrapment syndrome

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A segmental hypoplastic anterior tibial artery coexisting with a hypertrophied perforating fibular artery a case report and clinical implications / Coexistencia de una arteria tibial anterior hipoplásica segmentaria con una arteria fibular perforante hipertrofiada. Reporte de caso e implicancias clínicas

Vascular injuries of the lower limb, especially from penetrating gunshot wounds, and peripheral arterial diseases are on the increase and management of these and many other lower limb injuries involve increasing usage of vascular interventions like by-pass surgery, per-cutaneous transluminal angioplasty, arterial cannulation, arterial bypass graft or minimally invasive measures like percutaneous trans-arterial catheterization, among others. A thorough knowledge of infrapopliteal branching most especially their pathways and luminal diameters are important to surgeons in selecting appropriate surgical interventions or procedures. We report the case in which one of the 3 terminal branches of the popliteal artery (PPA), the anterior tibial artery (ATA) of good caliber size at origin became hypoplastic in the anterior leg region after giving off numerous muscular branches. Continuing as an almost attenuated dorsalis pedis artery (aDPA) in the dorsum of the foot, the latter was reinforced by an enlarged hypertrophied fibular artery. This case illustrates yet the importance of the fibular artery as the dominant of the 3 infrapopliteal branching arteries, reinforcing or replacing the posterior tibial artery (PTA) when it is weak or absent by a strong communicating branch or, reinforcing a weak ATA and dorsalis pedis artery (DPA) by a strong perforating fibular artery as being reported. The PTA however travelled a normal course yielding the medial and lateral plantar arteries posterior to the abductor hallucis muscle. This case demonstrates the importance of collateral communications and reinforcements from other infrapopliteal arteries, whenever one of its members or subsequent branches are absent or hypoplastic. A very sound knowledge of the various branching patterns of the PPA can be gained via pre-operatively vascular angiography, designed to guide the surgeon in the selection of appropriate surgical interventions, adding value to patients care in helping to reduce iatrogenic surgical vascular complications and reduction in total number of limb loss.

Las lesiones vasculares de los miembros inferiores, especialmente las heridas penetrantes por arma de fuego y enfermedades arteriales periféricas, están en aumento. Su manejo, así como el de otras lesiones en los miembros inferiores, implican un mayor uso de intervenciones vasculares como la cirugía de by-pass, angioplastía transluminal percutánea, canulación arterial, injerto de derivación arterial o medidas mínimamente invasivas como el cateterismo transarterial percutáneo, entre otros. El conocimiento profundo de las ramificaciones infrapoplíteas, muy especialmente sus vías y diámetros luminales son importantes para los cirujanos en la selección de las intervenciones o procedimientos quirúrgicos apropiados. Presentamos un caso en el cual, una de las 3 ramas terminales de la arteria poplítea (APP), la arteria tibial anterior (ATA), de buen calibre en su origen se hizo hipoplásica en la región anterior de la pierna después de un desprendimiento de numerosas ramas musculares. Continuó como una arteria dorsal del pie (ADP) casi atenuada en el dorso del pie; esta última se vio reforzada por una amplia arteria fibular hipertrofiada. Este caso ilustra la importancia de la arteria fibular como dominante de las 3 ramificaciones de las arterias infrapoplíteas, un refuerzo o sustitución de la arteria tibial posterior (ATP) cuando es débil o está ausente, por una fuerte rama comunicante, o bien refuerzo de una débil ATA y ADP por una fuerte arteria fibular perforante como en el caso reportado. La ATP sin embargo tenía un trayecto con un curso normal generando las arterias plantares medial y lateral, posterior al músculo abductor del hállux. Este caso demuestra la importancia de las comunicaciones colaterales y refuerzos de otras arterias infrapoplíteas, cada vez que uno de sus componentes o ramas posteriores están ausentes o hipoplásicas. Un conocimiento detallado de los diferentes patrones de ramificación de la APP puede ser adquirido a través de una angiografía vascular previo a la cirugía, diseñada para guiar al cirujano en la selección de las intervenciones quirúrgicas adecuadas, agrega valor a la atención de los pacientes, ayuda a disminuir las complicaciones vasculares quirúrgicas iatrogénicas y reduce el número total de pérdidas de miembros inferiores.

Exclusión endovascular de aneurisma poplíteo roto / Endovascular exclusion of a ruptured politeal aneurysm

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[Open wedge osteotomy of the tibial head. Management of vascular complications]. / Aufklappende Osteotomie des Tibiakopfes. Management von vaskulären Komplikationen.

BACKGROUND: Lesions of the popliteal artery during high tibial osteotomy are rare complications, consequently the majority of publications are case related. The interval between surgery and diagnosis is reported to be as long 3 years; therefore, the current literature probably does not reflect the true incidence of vascular injuries. OBJECTIVE: The case reports published in the literature were further evaluated. The focus was on the normal vascular anatomy of the popliteal region and anatomical deviations that predispose to vascular injury. As the flexion angle of the knee joint is considered to be decisive for vascular injury, this aspect was also an additional focus. For the unlikely event of a vascular injury, recommendations are presented which indicate diagnostic and therapeutic decisions. METHODS: We analyzed the available literature and present own magnetic resonance imaging (MRI) investigations of the popliteal artery with different angles of flexion in six healthy volunteers. RESULTS AND DISCUSSION: A variation of the origin of the anterior tibial artery with a course between the posterior tibial cortex and the popliteal muscle was found in 6% of all patients and predisposes to an accidental injury during osteotomy. The results in the literature and our own MRI findings suggest that a flexion angle of 90° facilitates anatomical dissection and osteotomy but cannot be regarded as a reliable protection against vascular injury.

Atypical presentation of popliteal artery entrapment syndrome: involvement of the anterior tibial artery.

Popliteal artery entrapment syndrome (PAES) is a rare condition that should be suspected in a young patient with exertional lower extremity pain. We report the case of an 18-year-old female volleyball player with bilateral exertional lower extremity pain who had been previously diagnosed with tendinitis and periostitis. Diagnostic studies showed entrapment of the left popliteal artery and the left anterior tibial artery. To our knowledge, there has only been 1 previous report of anterior tibial artery involvement in PAES.

Retrospective analysis of incidence of peroneal artery hypoplasia in 101 free fibula transfers and new classification of popliteal branch anomalies.

It is generally recognised by surgeons that there are anatomical variations of the popliteal artery and its branches, and knowledge of these has important clinical implications for fibula flap harvest. The aim of this study was to report our experience on 101 fibula free flaps, highlighting a new type of anatomical variation of the peroneal artery in a patient undergoing osteocutaneous fibula free flap for tibial reconstruction. During flap harvest, the peroneal vascular pedicle was shown to be hypoplastic and aberrant to its origin, branching between the proximal and medium third of the leg from the posterior tibialis artery with a diameter of 1mm. A modification of Kim's classification with the addition of a further "type IIID" group is suggested, to include peroneal artery hypoplasia or aplasia. This is an uncommon case of a rare infrapopliteal branching pattern that was undetected clinically and sonographically, exposing both the surgeon and patient to high risk of flap failure and/or leg ischaemic complication. Surgeons conducting free fibula transfer surgery should be aware of such a possibility as well as other variations, and could consider performing routine angiographic study on the donor limb, or they may be skilful enough to apply instant tricks to enable them to conduct the procedure safely.