Vascular Testing to Overcome Anatomical Contraindication: Fibula Free Flap in Bilateral Peronea Arteria Magna.

Abstract

Peronea arteria magna (PAM) is an established contraindication for fibula free flap due to concern for vascular compromise of the lower leg. This is a case of a 74-year-old male with a history of multiply recurrent oral cavity cancer who had undergone prior free flap reconstruction who presented with a new oral cavity primary requiring bony reconstruction. On preoperative CTA, the patient was identified as having bilateral PAM contraindicating fibula free flap. A preoperative balloon occlusion testing of the peroneal artery showed adequate arterial perfusion from collateral vasculature supported by arterial duplex ultrasound and venous mapping. A distal connection between the posterior tibial and peroneal artery was identified intraoperatively. The patient then underwent a fibula free flap without postoperative donor site complication. Fibula free flap reconstruction can be safely performed in patients with diagnosed PAM on CT angiography provided there are sufficient arterial collaterals.