The transfer of composite tissue using microvascular techniques has become an invaluable method of reconstruction. Since the first free-tissue transfer,1 one problem for the reconstructive surgeon has been difficulty in determining the status of the vascular anatomy of the donor or the recipient site.

Preoperative arteriogram and Doppler studies have given the surgeon the best three- dimensional view of the vascular anatomy at the donor or recipient site. The preoperative arteriogram helps the surgeon to identify problems within the vessels. But, because of radiolucency of soft tissue and the inherent two-dimensional nature of arteriograms, one may have difficulty in seeing the vascular relationship to the overlying skin. The Doppler, on the other hand, helps establish this relationship but gives us little information on depth or flow characteristics. With both modalities, however, one can evaluate blood flow and anatomic relationships of the vessels in the donor and recipient areas.

Not all donor areas require preoperative arteriograms and Doppler. Nevertheless, in several free flaps, including the DCIA, dorsalis pedis, and free-toe transfer, the vascular anatomy is not predictable. Most recipient areas should be examined by arteriogram and Doppler, particularly defects resulting from trauma or congenital anomalies, in which the vascular anatomy is uncertain.

Indications

ARTERIOGRAM

The timing of the preoperative arteriogram is a controversial issue. Several authors 2-5 have described intimal damage from the contrast material and advocate delaying the operation at least 2 weeks from the time of the arteriogram. More recently, however, several scientific studies 6-10 to have documented little or no change in the vascular endothelium after contrast injection within 6 hours postarteriogram. No evidence of arteriographic intimal damage was seen intraoperatively in over 1000 free-tissue transfers at Davies Medical Center.

The radiology staff usually performs arteriograms of the donor or recipient area the day before surgery. Several techniques have been devised to avoid vasospasm. Arterial puncture is usually performed on the contralateral femoral artery, and the catheter is then advanced into the appropriate limb to be studied. A low ionic dye (ioxaglate meglumine, 39%, and ioxaglate sodium, 19% ) is used as the standard dye solution. Tolazoline, a potent alpha-blocking agent, is infused intraarterially when vascular spasm is recognized on the arteriogram.

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