Case Report: Total atherosclerotic occlusion of perforators in anterolateral thigh flap

Atherosclerosis and calcification of vessels, commonly encountered in diabetic patients, is a well-known complicating factor in microsurgical reconstruction. However most studies on this problem have focused on axial vessels and their major branches. We present a case of total atherosclerotic occlusion of perforators rising from intact lateral circumflex femoral artery branches in bilateral anterolateral thigh (ALT) flap elevation. A 51-year-old male with a history of diabetes mellitus, ischemic heart disease and kidney transplantation presented with necrotizing fasciitis of the left foot. Serial debridement and antibiotics stabilized the patient, who was thereafter referred for foot reconstruction. Ipsilateral ALT free flap reconstruction was planned, however although preoperative computed tomography angiography (CTA) confirmed patency of the left lower extremity arterial system and Doppler mapping enabled uneventful suprafascial flap elevation based on a large pulsatile perforating vessel, the perforator was severely calcified on visual inspection, and no flap perfusion was found after perforator isolation. The same findings including total occlusion of the perforator pedicle on cross-section were discovered on contralateral ALT flap elevation. Foot reconstruction was ultimately achieved using a thoracodorsal artery perforator flap, which displayed no atherosclerotic lesions. Even with nonspecific lower extremity CTA and Doppler findings and clinically patent axial arteries, perforators perfusing major flaps can be totally occluded in atherosclerotic patients. More sensitive diagnostic tools such as color duplex sonography or high-quality CTA should be employed for preoperative perforator mapping in atherosclerosis-risk patients.