Color Doppler Ultrasonography for Precise Patency Evaluation of Injured Artery

We read the article “Evaluation of the American Society of Anesthesiologists Physical Status Classification System in Risk Assessment for Lower Extremity Reconstruction with Free Tissue Transfer” by Maldonado et al.[1] We strongly agree with the authors' conclusion that with an experienced multidisciplinary team, free flap reconstruction for lower extremity defects in high risk patients is safe and reliable. Moreover, in cases of severe lower extremity trauma, evaluation of injured artery perfusion is critical to consider optimal strategy for the challenging reconstruction.[2] [3] [4] [5] Especially, when free flap reconstruction is required, evaluation of arterial patency is critical to select an appropriate recipient artery. Distal capillary refilling, palpation of the artery pulsation, and sound Doppler are the mainstays of arterial patency evaluation. However, these evaluations can lead to false-positive result, as capillary refilling and bleeding can be seen and the artery can be pulsatile with positive sound Doppler examination even when completely obstructed. For definitive evaluation, color Doppler sonography is effective for evaluation of artery perfusion.

The dorsalis pedis artery (DPA) was considered an optimal recipient vessel in terms of the vessel location close to an extensive foot soft-tissue defect, needing free flap reconstruction. The distal skin was pink and showed capillary refilling, and the DPA was pulsatile with positive sound Doppler examination. However, on 15- to18-MHz portable color Doppler ultrasound device (ARIETTA Prologue; Hitachi-Aloka Medical, Tokyo, Japan), there was no signal in the DPA ([Fig. 1]), whereas the proximal anterior tibial artery was revealed with positive signal.[2] In cases where a recipient vessel is available close to a defect, a less-invasive flap, such as superficial circumflex iliac artery perforator flap, should be selected but a long-pedicled flap is needed when a recipient vessel is distant.[3] [4] In the following reconstructive surgery, the DPA showed no flow when transected as expected based on the preoperative color Doppler examination, and an anterolateral thigh flap was selected as a free flap reconstructive method with a long pedicle, using the anterior tibial artery as a recipient artery.

Fig. 1 The distal skin was pink and showed capillary refilling, and the dorsalis pedis artery (DPA) was pulsatile with positive sound Doppler examination; however, there was no signal in the DPA with color Doppler examination.

The preoperative evaluation of recipient artery perfusion in free flap surgery is sometimes very difficult by palpation or sound Doppler, especially in cases of the obstruction site is close, proximal strong pulsation is found or heard. In this letter, we suggest that the color Doppler is suitable for evaluation of conclusive artery perfusion. Although further studies are required with larger number of cases, preoperative color Doppler would be useful for evaluation of the conclusive recipient artery perfusion for free flap reconstructive surgery.

Publication History

Received: 28 March 2021

Accepted: 12 May 2021

Article published online:
07 September 2021

• References

• 1 Maldonado AA, Steinebach R, Morillo MC, Sauerbier M. Evaluation of the American Society of Anesthesiologists Physical Status Classification System in risk assessment for lower extremity reconstruction with free tissue transfer. J Reconstr Microsurg 2021; (e-pub ahead of print) DOI: 10.1055/s-0041-1724126.
• 2 Yamamoto T, Yamamoto N, Fuse Y, Kageyama T, Sakai H, Tsukuura R. Subdermal dissection for elevation of pure skin perforator flaps and super-thin flaps: the dermis as a landmark for the most superficial dissection plane. Plast Reconstr Surg 2021; 147 (03) 470-478
• 3 Yamamoto T, Yamamoto N. A triple-component deep inferior epigastric artery perforator chimeric free flap for three-dimensional reconstruction of a complex knee defect complicated with patella osteomyelitis. Microsurgery 2021; 41 (04) 370-375
• 4 Yamamoto T, Saito T, Ishiura R, Iida T. Quadruple-component superficial circumflex iliac artery perforator (SCIP) flap: A chimeric SCIP flap for complex ankle reconstruction of an exposed artificial joint after total ankle arthroplasty. J Plast Reconstr Aesthet Surg 2016; 69 (09) 1260-1265
• 5 Yamamoto T, Yamamoto N, Kageyama T. et al. Supermicrosurgery for oncologic reconstructions. Glob Health Med 2020; 2 (01) 18-23