Lower Extremity Free Tissue Transfer in Peronea Arteria Magna: An Observational Retrospective Cohort Study of Anatomic and Microsurgical Considerations

Background: Patients with only peroneal artery blood supply to the foot, known as peronea arteria magna (PAM), represent a rare cohort and a unique challenge in the setting of complex lower free (LE) tissue transfer (FTT). The present study aims to leverage a high volume lower extremity reconstruction center to determine the incidence and microsurgical considerations in PAM. Methods: A retrospective cohort study was conducted at a single tertiary limb salvage center, reviewing all patients who underwent lower LE FTT from July 2011 to January 2024. Patients were included if they had preoperative arteriography and underwent LE FTT for atraumatic wounds. Patient demographics, vascular anatomy, microsurgical technique, and postoperative outcomes were analyzed. Results: Arteriograms for a total of 334 patients who underwent lower extremity FTT were reviewed, of which 34 patients (10.2%) had Kim–Lippert Class III variant patterns, and six patients (1.8%) had Class IIIc (PAM). Of these, all six anastomoses were performed in an end-to-side fashion. There were no instances of postoperative lower extremity devascularization or ischemia. There were no flap losses. One of the six patients required immediate return to the operating room for venous thrombosis with successful flap salvage after clot evacuation and a second venous anastomosis. Conclusion: PAM is a rare yet important anatomic variant that is occasionally observed in the lower extremity FTT population. The following features are important in managing patients with PAM undergoing FTT: the routine use of preoperative arteriography, an understanding of venous anatomic variability, the use of a smaller target window for microsurgery given the majority of vessels residing in the deep posterior compartment, the preservation of all peroneal side branches, and the use of ETS anastomosis when possible.