Impact of infrapopliteal artery variants and peripheral artery disease on fibula free flap planning

The fibula free flap (FFF) is a mainstay of head and neck reconstruction, however its safety depends on adequate lower-extremity perfusion. We present three patients evaluated for FFF reconstruction in whom preoperative computed tomography angiography identified infrapopliteal arterial variants or peripheral artery disease. In the first patient, congenital absence of the posterior tibial artery raised concern for inadequate collateral perfusion and a diagnostic angiogram was considered, but reconstruction was ultimately deferred given progression of her metastatic disease. The second patient had a peronea arteria magna variant which precluded fibula harvest from the right leg, and reconstruction was successfully performed using the contralateral fibula with normal three vessel runoff. In the third patient, severe bilateral posterior tibial artery occlusion increased the risk of postoperative ischemia. To confirm adequate perfusion, a diagnostic angiography and intraoperative peroneal artery clamping were completed which confirmed adequate collateral perfusion and allowed safe fibula harvest. Both patients in cases two and three successfully underwent FFF reconstruction without lower-extremity ischemic complications. These cases highlight the importance of preoperative vascular imaging in guiding safe surgical planning.