Computed Tomography Angiography-Based Mapping of Septocutaneous Fibular Artery Perforators: An Anatomical Analysis.

Abstract

Background: Reliable localization of septocutaneous fibular artery perforators is essential for fibula free flap planning. However, the influence of lower-leg vascular anatomy on perforator number and spatial distribution remains unclear. This study aimed to analyze perforator number and spatial distribution using computed tomography angiography (CTA) with both fibula- and artery-based reference systems.

Methods: In this retrospective study, patients undergoing lower-extremity CTA before mandibular continuity resection were screened. Parameters included run-off status, Kim classification, vascular anomalies, atherosclerotic plaque, and morphometric characteristics of the fibula and fibular artery. Perforator number per limb and relative perforator position were assessed using fibula- and artery-based reference systems. Associations were evaluated using nonparametric tests and multivariable regression models.

Results: A total of 491 limbs from 247 patients were included, yielding 812 septocutaneous perforators. Limbs with fibular artery stenosis showed fewer perforators compared with limbs without stenosis (median 0.5 [0-2] vs. 2 [1-2], p < 0.001). Perforator distribution was nonuniform in both reference systems, with clustering in mid-segments (p < 0.001). Notably, spatial distribution patterns differed depending on the reference system used. In multivariable analyses, non-1A Kim run-off classification was associated with a more proximal perforator position along the fibula (β = -10.0 percentage points, p < 0.001), whereas no limb-level factor was associated with artery-referenced perforator position, indicating greater stability of artery-based mapping.

Conclusion: Septocutaneous fibular artery perforators show reference-dependent spatial variability. Fibular artery stenosis is associated with fewer perforators, whereas only Kim run-off classification affects fibula-referenced location. These findings support artery-based mapping for fibula flap planning.