Three- and Four-Dimensional Computed Tomographic Angiography and Venography for the Investigation of the Vascular Anatomy and Perfusion of Perforator Flaps

TLDR

Two‑dimensional contrast radiography is the current standard for evaluating perforator flap vascular anatomy, but static 3‑D CT angiography and dynamic 4‑D CT angiography provide multi‑plane and time‑resolved visualization of macro‑ and microvascular structures. The authors performed an anatomical study on 11 fresh adult cadavers, harvesting various perforator flaps—including anterolateral thigh, deep inferior epigastric, superior gluteal, inferior gluteal, thoracodorsal, anteromedial thigh, and dorsal intercostal—to assess vascular anatomy. They demonstrated novel static and dynamic 3‑D CT angiography techniques that enable sequential investigation of adjacent vascular territories, improving understanding of perforator flap perfusion and informing future flap design.

Abstract

Background: Two-dimensional contrast radiography is the current standard for investigating the vascular anatomy of surgical flaps. The microvascular anatomy of the perforator flap, however, is limited conceptually by representation in two dimensions. Static three-dimensional computed tomographic angiography enables vascular anatomy to be evaluated in the coronal, axial, and sagittal planes, and dynamic four-dimensional computed tomographic angiography allows the vascular filling of a perforator flap to be visualized over short time intervals in three dimensions. Methods: An anatomical study was performed using 11 fresh adult cadavers acquired through the Willed Body Program at the University of Texas Southwestern Medical Center, in Dallas, Texas. Four male and seven female cadavers were included in the study. Perforator flaps harvested included the following: anterolateral thigh, deep inferior epigastric perforator, superior gluteal artery perforator, inferior gluteal artery perforator, thoracodorsal artery perforator, anteromedial thigh, and dorsal intercostal artery perforator. Conclusions: Novel techniques for acquiring both static and dynamic three-dimensional images of macrovascular and microvascular perforator flap anatomy using computed tomographic angiography have been described. This methodology has also allowed the sequential investigation of adjacent vascular territories. This can provide a better understanding of how perforator flaps and the skin are perfused and may aid in the future design of new flaps.