Using 320-Slice Computed Tomography to Preoperatively Investigate

doi:10.21203/rs.3.rs-2630912/v1

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Research Article

Using 320-Slice Computed Tomography to Preoperatively Investigate

https://doi.org/10.21203/rs.3.rs-2630912/v1

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Purpose

To investigate the leg perforator arterial system, identify the perforator flap’s pedicle artery and its projected cutaneous point using a 320-slice computed tomography (CT 320) scanner.

Methods

A total of 24 patients with leg soft-tissue defects unilaterally underwent 320-slice CT angiography scanning (CTA 320) with 47 legs. The used method enabled investigation of the perforator arteries originating from the tibial, peroneal arteries, perforator flap’s pedicle artery and its projected cutaneous point. These data were used to preoperatively design an improved flap. Then, the CT-confirmed location and length of the flap’s pedicle artery were compared with intraoperative findings.

Results

Findings of the CTA 320 on 47 legs showed that 217 perforator arteries with diameters of ≥ 0.5 mm were detected; the average number of arteries per leg, their average length and diameter were 4.6 ± 2.1, 30.7 ± 10.4 mm and 1.16 ± 0.27 mm, respectively. The perforator arteries originating from the anterior tibial artery were mainly distributed in the proximal and middle thirds of the leg. Perforators from the posterior tibial and peroneal arteries were distributed abundantly in the middle and distal thirds of the leg. As identified in the CT, the location and length of the flap’s pedicle artery and its projected cutaneous point were consistent with those observed during the surgery.

Conclusions

The CTA 320 is a minimally invasive imaging method that provides high-quality images of the leg perforator arterial system and can identify the exact location and projected cutaneous point of the perforator flap’s pedicle artery.

Perforator arteries

320-slice computed tomography

leg soft-tissue defect

perforator flap

Lower-leg soft-tissue defects are commonly encountered and are often difficult to treat due to a lack of tissue coverage in the lower-leg area; further, the defect is usually accompanied by several other issues, such as fractures, pseudo-arthrosis, exposed tendons, exposed bones, or fixation hardware. Therefore, reconstructive surgery to cover the defect can be quite challenging for the surgeon. The free and pedicled flaps are two types of approaches frequently used for tissue coverage of leg defects. The free flap commonly involves tissues transferred from another location (such as the lateral arm, anterolateral thigh, and deltoid flaps). The surgery needed to transfer this flap requires the use of complex microsurgical techniques. Moreover, the color and histological structure of the flap are not usually homologous to the recipient site. Besides, only a few local pedicled flaps are available for use in the lower leg (i.e., cross-leg, local, gastrocnemius, and soleus muscle flaps), which have low versatility and aesthetics, resulting in significant lower-leg deformities [1–4].

Recently, the introduction and application of perforator flaps based on the anterior tibial (ATA), posterior tibial (PTA), and peroneal (PA) arteries have advanced the treatment for soft-tissue defects in the lower leg. A pedicled fascio-cutaneous flap, for example, has some advantages: 1) color and histological similarity to the recipient area (like-with-like) since the flap is taken in the vicinity of the soft-tissue defect and 2) versatility during surgery as the flap can easily be rotated, preserving the main arterial supply and limiting injury to the donor flap area [1, 5–7]. Conversely, this flap presents some disadvantages: 1) the size of the pedicle artery is very small and 2) the location and morphology of the artery are not constant, which may result in difficulty when selecting the best perforator artery with which to make the flap pedicle. Currently, imaging methods such as Doppler ultrasound, digital subtraction angiography (DSA), and magnetic resonance imaging (MRI) are commonly and widely used in the vascular examination. The investigations of small blood vessels, such as lower-leg perforator arteries, has been limited [8–11].

The 320-slice computed tomography (CT 320) is a relatively modern scanner with a high spatial resolution (< 0.5 mm), fast imaging speed (0.35 s for one rotation of the gantry), a large field of view (16 cm in the z-axis), and thin slice thickness (0.5 mm) allowing a minimally invasive investigation of the small vessels (such as leg perforator arteries and those within the hand, finger, foot, and toe) or moving vessels (i.e., coronary arteries) [12–14].

Therefore, this study aimed to investigate the arterial perforator system, originating from the ATA, PTA, and PA in the patients’ legs, and locate the perforator flap’s pedicle artery and its projected cutaneous point using the CT 320 angiography (CTA 320) scanning. The number, distribution, and size of these arteries were then compared with intraoperative findings.

Study design and patients

A total of 24 patients, consisting of 22 men and 2 women, were included in this study, all of whom aged > 18 years. They all underwent a CTA 320 scanning of the perforator arterial system in the lower leg, performed between June 2015 and December 2018 at the Department of Diagnostic Imaging, Hospital 108, Hanoi, Vietnam. Among them, 23 patients had both their legs examined, and one patient who is an amputated veteran had a single leg examined. These patients presented neither cardiovascular diseases nor chronic diseases, such as hypertension or diabetes mellitus.

After performing the CTA 320 assessment, 18 of 24 patients (16 men and 2 women) underwent reconstructive surgery – perforator flap coverage of soft-tissue defects in the lower leg – that was performed at the Department of Upper Extremity Surgery and Microsurgery, Hospital 108, Hanoi, Vietnam.

Ethical approval

was obtained from the institutional review board of Hospital 108, Hanoi, Vietnam (Number. 614/HDDD). Informed consent was obtained from the patients included in the study. All procedures in this study were performed following the ethical standards of the 1964 Helsinki Declaration and its later amends or comparable ethical standards.

This is a cross-sectional descriptive study focusing on the perforator arterial system and perforator flap’s pedicle artery of living humans. The arterial location, diameter, length, and projected cutaneous point were measured using the CTA 320. These measurements were then compared with those taken intraoperatively.

Tools and equipment

Aquilion One 320-slice CT scanner (Toshiba, Japan), Medrad Stellant Injector (Bayer, USA), infusion line with an 18-G needle, and nonionic contrast agent-Xenetic 350 mg/100 ml vial (Guerbet, France) were used.

Patient preparation

Patients were instructed to fast at least 4 h before the examination. The patient’s heart rate and blood pressure were checked before and after scanning.

Scanning technique

Patients were positioned supine. The technician adjusted the scanning that ranged from the knee to ankle and captured both sides of the legs. An 18-G needle was inserted into the antecubital vein to administer a nonionic contrast agent bolus (Xenetic 350 mg/100 ml vial) with a dose of 1.5 ml/kg, at a speed of 5 ml/s by a power injector, followed by a 50-ml saline flush at the same speed. The delayed time for scanning, usually 120–180 s after injecting the contrast agent, was to enable the maximum appearance of the contrast agent within the iliac artery (test bolus).

Arterial visualization and measurement

Post-scanning images were reconstructed on 2D and 3D rendering (multi-planar reformation [MPR], maximum intensity projection [MIP], and volume rendering technique [VRT]) using Vitrea.fx-Software Version 6.3 Toshiba VITAL installed in the workstation of the scanner. From the leg and its “arterial tree”, the perforator arterial system was visualized, identifying arterial origins, pathways, and measuring the inner diameter and length of perforator arteries (Fig. 1).

After acquiring data on the location of all perforator arteries in the lower leg, these arteries were distributed into three groups at three locations: proximal, middle, and distal thirds of the leg. In greater detail, the percentage of the distance was calculated from the medial ankle (for the perforator artery originating from ATA and PTA), lateral ankle (for the one originating from PA) to the origin of perforator artery/length of the tibia and fibula (from the ankles to the knee joint slot), respectively (Fig. 2, 3, 4) [15, 16].

The length of the perforator arteries was measured from their origins to the sites at which the arteries enter the subcutaneous fascia. Then, the arterial diameter was measured at its origin, on the arterial cross-section, perpendicular to the arterial walls (Fig. 1B).

A combination of the following criteria was used to select a suitable flap artery: proximity to the receiving site, the sufficiency of arterial diameter and length, and simple arterial morphology (i.e., relatively straight, less oblique with the flap, and avoiding zigzags).

For 18 patients undergoing surgery, a suitable artery was selected as the flap vascular pedicle; then, the location of the artery and its projected cutaneous point on CT were identified and marked on the patients’ skin. The procedure was performed as follows (Fig. 1A): 1) To determine the location of the pedicle artery: On the MIP or 3D image of the lower leg, the lateral ankle (A₁ point) or medial ankle (A₂ point) was marked; at the origin of the perforator artery intended for the flap pedicle, a horizontal line was drawn that intersected the lateral or medial skin of the lower leg at either point B₁ or B₂; the distance of A₁B₁ or A₂B₂ along a curved plane parallel to the skin was measured. 2) To determine the projected cutaneous point (P), the height and location of the projected cutaneous point were determined first, as was done in point 1), creating two lines – A₁C₁ or A₂C₂, and measuring their distance. To accurately locate the projected point on the cross-section (axial slice) through C₁ or C₂, a curve (d) was drawn along the skin surface, starting from the tibial crest to the projected point (P) of the perforator artery, and its length was shown numerically (Fig. 1C).

Based on the measured CT results, a tape ruler was used to measure the distances and determine the locations of points A₁, B₁, C₁ or A₂, B₂, C₂, and P on the patient’s lower leg, defining the flap demarcation (Fig. 1D).

Data analysis

Statistical analysis utilizing the Mann–Whitney U test (for a sample size of < 30) was used to determine the location, distribution, diameter, and length of the perforator arteries and compared the two mean values (location and length) acquired using CT and those acquired through surgery. The software, Microsoft Excel and SPSS 23.0 (IBM, USA), were used.

The mean age of 24 patients undergoing CT scans and 18 patients who underwent surgery were 55.2 ± 17.7 (22–85) and 56.3 ± 17.6 (24–85) years. The cause of the lower-leg soft-tissue defect was either the sequelae of the injury caused by a work accident or a war wound that caused long-lasting chronic ulcers. The ATA perforator flap was used in one patient, PTA perforator flaps were used in 11 patients, and PA flaps were used for 6 patients.

While scanning 47 legs, 217 perforator arteries were detected with a diameter at the origin of ≥ 0.5 mm (average 4.6 ± 2.1 arteries/1 leg, an average length of 30.7 ± 10.4 mm, and an average diameter of 1.16 ± 0.27 mm). Of these, 52 perforator arteries of the ATA (24.0%), 99 perforator arteries of the PTA (45.6%), and 66 perforator arteries of the PA (30.4%) were identified.

The perforator artery originating from the ATA has an average value of 1.10 ± 1.29 arteries per leg, an average length of 29.9 ± 8.4 mm, and an average diameter of 0.95 ± 0.28 mm, mainly distributed in the proximal third, ranging 70–85%, and in the middle third of the lower leg, ranging 35–60% (Tables 1–3, Fig. 2).

The perforator artery originating from the PTA has an average value of 2.11 ± 1.05 arteries per leg, an average length of 28.2 ± 10.6 mm, and an average diameter of 1.21 ± 0.24 mm, mainly distributed in the middle third of the lower leg, with the range of 35–65%, and in the distal third, with the range of 10–30% (Tables 1–3, Fig. 3).

The perforator artery originating at the PA has an average value of 1.40 ± 1.10 arteries per leg, an average length of 35.0 ± 10.5 mm, and an average diameter of 1.24 ± 0.23 mm, abundantly distributed in the middle third, with the range of 35–50% and in the distal third of the lower leg, with the range of 15–25% (Tables 1–3, Fig. 4).

Table 1

The distribution of perforator arteries following the segment of 1/3 of the leg and the distribution using Boriani’s method¹⁵ (2010)
Arteries	Locations	Number	Distribution using the Boriani (Min–Max)	x̄ ± SD	(Min–Max)
ATA	Proximal 1/3	16	0.71–0.91	0.79 ± 0.06	0.55 ± 0.19 (0.23–0.91)
	Middle 1/3	31	0.30–0.66	0.48 ± 0.10
	Distal 1/3	5	0.23–0.33	0.28 ± 0.04
PTA	Proximal 1/3	10	0.66–0.73	0.69 ± 0.02	0.42 ± 0.17 (0.08–0.73)
	Middle 1/3	52	0.31–0.68	0.49 ± 0.10
	Distal 1/3	37	0.08–0.33	0.24 ± 0.07
PA	Proximal 1/3	10	0.68–0.78	0.73 ± 0.03	0.38 ± 0.20 (0.09–0.78)
	Middle 1/3	25	0.28–0.62	0.45 ± 0.09
	Distal 1/3	31	0.09–0.35	0.22 ± 0.07

ATA, Anterior tibial artery; PTA, Posterior tibial artery; PA, Peroneal artery

On 18 surgical patients, the flap was designed for patients who were operated on after selecting the perforator artery for the flap pedicle and locating its projected cutaneous point (Fig. 1, 5, 6). The location and length of the flap’s pedicle artery measured intraoperatively were compared with the corresponding parameters measured using the CTA 320 to find differences (Table 2).

Table 2

Comparison of the location (distance to the ankles) and length of the perforator flap’s pedicle artery on the CTA 320 image with those of surgical findings
Patient	Arteries	Distance to the ankles (mm)		Length (mm)
Patient	Arteries	CTA 320	Surgery	CTA 320	Surgery
1	PTA	82	82	19.9	20
2	PTA	84	84	33	33
3	PTA	234.6	239	26.3	26
4	PTA	110.3	109	20	20
5	PTA	94	94	22	22
6	PTA	204	204	50	50
7	PTA	160.3	159	23	28
8	PTA	133	133	35	35
9	PTA	98.5	99	38.5	38
10	PTA	189.8	193	20	20
11	PTA	122.2	119	20	20
12	ATA	258	258	25	25
13	PA	62.5	65	27.5	28
14	PA	73.9	74	21	21
15	PA	85	85	28	28
16	PA	91	92	31	32
17	PA	89.5	90	29.5	30
18	PA	120	120	33	33
p		0.969		0.832

The Mann–Whitney U non-parametric test showed no statistically significant difference between the location and length of the perforator artery on 320 CTA images and those found during surgery (p > 0.05, Mann–Whitney U test). In fact, in this study, all 18 patients (100%) who had flaps fashioned with a perforator artery selected using its projected cutaneous point as determined via the CTA 320 kept their original flap design without any modification.

Age and gender

The mean age of 24 patients undergoing CT scans was 55.2 ± 17.7, with a quite wide range (22–85). Among them, 14 (58.4%) were of working age (22–-60). The male/female patient ratio was 11:1 (22 male/2 female), suggesting that men in our country are involved in many activities, such as production or combat labor that results in trauma or war wounds that leave long-lasting ulcers; not covered in time, such ulcers can threaten the preservation of the leg.

Anatomy of the perforator arterial system

Original arteries: During the examination of the 47 legs, 217 perforator arteries, an average of 4.6 ± 2.1 arteries/1 leg was documented. Of these, 52 perforator arteries originating at the ATA (24.0%), 99 perforator arteries at the PTA (45.6%), and 66 perforator arteries at the PA (30.4%). Thus, the number of perforator arteries originating at the ATA was the lowest as compared with that of the PTA and PA. In fact, perforator flaps supplied by the ATA have little clinical application as blood supply is generally poor [17,18]. In our study, an ATA flap was only applied to one patient.

Perforator arterial number: Using the 320 CTA, 1.10 ± 1.29 perforator arteries on average were found to originate from the ATA, 2.11 ± 1.05 from the PTA and 1.40 ± 1.10 from the PA. These values were lesser than those in studies carried out on cadavers (Table 3). Shaverien (2008) dissected cadavers and then injected color indicators (latex, barium sulfate/gelatin mixture) and a contrast agent into the main arteries under pressure, followed by a 16-slice CT scan to examine the vascular anatomy. Perforator arteries with a diameter of ≥0.5 mm, satisfying the pedicle artery criteria, were counted [19]. The results showed that the number of these arteries was much higher than that documented in our study. The difference could be attributable to the effects of direct-pressure pumping into the arteries of the cadaver. Such a pumping method could unintentionally increase the diameter of the perforator arteries, possibly resulting in some vessels becoming larger than 0.5 mm and falsely elevating the values. Some other anatomical cadaveric studies performed by Carriquiry (1985) and Whetzel (1997) demonstrated that anatomical dissection looking for perforator arteries, regardless of the size (both above and <0.5 mm) also gave similar results as compared [20,21].

Table 3 The number of perforator arteries in the leg according to some authors

Authors	Method	Patient	Diameter range (mm)	ATA	PTA	PA
Our study	CT 320	Living humans	≥ 0.5	1.10 ± 1.29	2.11 ± 1.05	1.40 ± 1.10
Carriquiry [19] (1985)	Dissection	Cadaver	No range	8 (6–10)	4–5	3–5
Whetzel [20] (1997)	Dissection	Cadaver	No range	9.8 (6–14)	5.4 (3–8)	4.8 (1–7)
Schaverien [18] (2008)	Dissection, CT 16	Cadaver	≥0.5	9.9 ± 4.4	4.9 ± 1.7	4.4 ± 2.3
Martin [14] (2013)	CT 16	Cadaver	No range	19 ± 2	8.4 ± 1.5	10.6 ± 0.5

Martin (2013) used the 16-slice CT with a contrast agent, a mixture of gelatin and lead oxide, to examine the perforator arterial system of the lower leg, such as arteries measuring <0.5 mm in diameter [15]. The results also showed that the number of arteries was much higher than that in our and other studies. Using different investigation methods will present different values. Martin’s study examined perforator arteries of all sizes, whereby these arteries were dissected to expose them, and then lead oxide contrast was injected. However, such a contrast agent is so toxic that it can only be used on a cadaver. Cadaveric examination allowed a thorough investigation, minimizing the possibility of missing a few perforator arteries.

Our study used the CT 320 first to investigate perforator arteries in the leg of living humans. Because anatomical characteristics of the perforator artery vary from individual to individual in terms of race, age, gender, and medical history [22], we believe that with the inherent spatiotemporal resolutions, tissue contrast of the CT 320, and the applied imaging protocol, the CT 320 may not visualize the entire network of perforator arteries in the lower leg, especially given the presence of smaller arteries of <0.5 mm in diameter and perforator arteries with a diameter of ≥0.5 mm but located at the distal extremity; accordingly, the contrast enhancement is poorer than that of the proximal arteries. Future studies with more refined imaging protocols should be performed (e.g., contrast display tracking the popliteal artery that is closer to the perforator arteries instead of the iliac artery; optimizing imaging speed to capture the motion of the contrast agent in the arterial lumen more favorably). Moreover, determining whether we should utilize a higher-configuration CT scanner (512-slice or Dual Source CT) or more powerful imaging and processing softwares, we may be able to get data closer to mirroring that of the cadaver study. Either way, data obtained on CT have been of great help in designing our flaps.

Arterial diameter: Accurately determining the diameter of blood vessels in general or of the perforator arteries in particular on a cadaver is always difficult because the cadaver has been embalmed with preservatives, which cause blood vessels to lose their elasticity and tone over time. Arterial morphology is also altered. Intravenous contrast-enhanced CT scan is a minimally invasive investigation method that helps visualize arteries in living humans under normal cardiac pumping pressure. For our 18 patients undergoing surgery, the arterial diameter on the CT and during surgery was not compared. This preclusion can be attributable to the use of a tourniquet in the lower third of the thigh, the presence of vasospasm intraoperatively, and the lack of exposure to the perforator artery as would be needed to accurately measure the diameter to ensure flap safety. However, the CTA 320 is still the least invasive investigation with the most accurate measurement of the leg perforator arterial diameter of living humans.

Arterial length: Comparing over 18 surgeries, a similarity was found between the length of the perforator artery on the 320 CTA image and intraoperative measurements (Table 2). The results of investigating the length of perforator arteries in our study were not that different from those of other studies [15,19,23]

Arterial distribution: The perforator arteries originating from the ATA were mainly distributed in the proximal third of the lower leg at the position of 70–85% and the middle third at the position of 35–60% (Table 1, Fig. 2). The perforator arteries from the PTA were abundantly distributed in the middle third of the leg positioned at 35–65% and in the distal third positioned at 10–30% (Table 1, Fig. 3). The perforator arteries from the PA were mainly distributed in the middle third of the leg positioned 35–50% and in the distal third positioned 15–25% (Table 1, Fig. 4). The percentage of perforator artery distribution is classified and based on the Boriani method (2010) [16], that is, the sites of perforator arteries were calculated as a percentage of the arterial height (from the lateral or medial ankles) with the tibial and fibular heights. This is a rather simple method of assessing the arterial distribution; however, it is very meaningful in clinical practice, helping the surgeon selects the region with the most vessels to make the flap [15,16].

The role of CT 320 in preoperatively investigating the perforator flap’s pedicle artery and its projected cutaneous point

In reconstructive surgery, the vascular pedicle supplying blood to the flap should be identified to determine the success of the surgery. The projected cutaneous point of this artery in the flap design will be the point at which the artery penetrates and nourishes the flap, serving as the pivot point around the flap that can be rotated to cover the entire soft-tissue defect. For these reasons, this projected point plays a crucial role in designing the perforator flap [3,12,17]. The smaller the height distance between the origin of the perforator artery and its projected point (distance B₁C₁ or B₂C₂ in Fig. 1A), the more likely the perforator artery is to travel perpendicularly to the skin surface, enabling more appropriate selection criteria of the flap’s pedicle artery.

Previously, several existing methods based on the cutaneous projection were used to locate the flap pedicle. One example would be using a large number of metal clips fixed on the skin surface and then locating the projected point by measuring the distance from metal clips to the projected point [13]. Another example is the use of a CT-guided stereotactic system with supporting tools, such as adhesive (fiducial) markers, frameless stereotactic wands (or “pointer”), and specialized computer software [24]. Generally, applying these methods is very complicated, requiring close coordination between the radiographer and the surgeon as well as more time and effort. For our previous surgeries, the use of Doppler ultrasound to detect the vascular pedicle was almost mandatory because the perforator artery morphology greatly varied. However, this method has a high false-positive rate, and locating the projected cutaneous point is sometimes inaccurate, requiring a surgeon to perform exploratory surgery. Intraoperatively, Doppler ultrasound would always be used with surgical dissection to detect the vascular pedicle. Once detected, the flap should be re-designed before being harvested. Unexpected variations in anatomy may catch the surgeon off-guard, prolonging the operative time and increasing surgical risks. With the use of CT and once the appropriate measurement method has been established, difficulty determining which perforator artery is suitable for flap pedicle and the location of its projected point is reduced.

Our method of determining the pedicle location and its projected cutaneous point is based on some advantages of using CT in general practice and that of the CT 320 in particular: 1) the CT has a very good ability to image bones (the tibia, fibula, medial ankle, lateral ankle, and joint space), much better than that of other imaging methods, such as X-ray, ultrasound, MRI; 2) measurement tools (line ruler, curve ruler, and automatic measurement display) within the computer software allowed us to determine the exact location of the flap pedicle, projected point, and size (diameter and length) of the flap artery; 3) the CTA 320 with intravenous contrast agent allows visualization of the pedicle artery and its selection as expected. For these reasons, the results to locate the flap’s pedicle artery and its projected point on the CT 320 (Fig. 1, 5) are not statistically different from those of surgery (Tables 2). With the guidance of the CT, determining the two components needed to design the flap in the lower leg becomes simpler. All of the designed flaps, which were based on information from using the CT 320, did not require modification intraoperatively (Fig. 6).

As to whether CTA 320 is the best imaging modality for visualizing the perforator arteries, DSA is the best imaging modality for blood vessels in general. However, for small and variable arteries with irregular morphology such as the leg perforator arteries, locating them by just using DSA can be extremely difficult. Visualizing blood vessels using an MRA is generally based on two principles: using a magnetic contrast agent (gadolinium) or based on the flow signal (TOF-time of flight sequence). Both of these principles require a relatively large blood vessel; if the blood vessel is too small (such as the perforator artery), then the vessels, especially those with a weak flow, will be poorly enhanced, and/or the image quality will likewise be poor, resulting in difficulties of noticing the blood vessels [9,10,25]. Doppler ultrasound is a noninvasive investigation method, which is valuable in determining the locations of perforator arteries; however, it has a high false-positive rate and does not reliably provide a clear image of the arteries in terms of morphology and size [11,26,27]

The CTA 320 is a minimally invasive imaging tool that provides high-quality images of the perforator arterial system from the ATA, PTA, and PA in living humans, playing an important role in accurately identifying the perforator flaps’ pedicle artery and its projected cutaneous point in the lower leg. This technique will preoperatively aid the surgeon in designing suitable flaps and improve surgical outcomes for flap reconstruction surgery of lower-limb soft-tissue defects.

Acknowledgments

We would like to thank the Department of Diagnostic Imaging and the Department of Upper Extremity Surgery and Microsurgery, Hospital 108, Hanoi, Vietnam for enabling us to carry out this research and facilitating our efforts.

Ethical Approval

This study was approved by the institutional review board of the Hospital 108 in Vietnam. Informed consents were obtained from the subjects included in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Conflict of Interest

The authors declare that they have no conflicts of interest.

Authors' contributions

Vu Huu Trung: Project development, data collection, and management, manuscript writing/editingLam Khanh: Protocol/project development, manuscript writing/editing, data analysis

Le Van Doan: Project development

Vu Huu Dung: Project development

Pham Anh Tuan: Data collection, data analysis

Nguyen Tung Lam: Data analysis, manuscript writing/editing

Funding

The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Author information

Vu Huu Trung MD. PhD.²^a, Lam Khanh MD. PhD.¹^a, Le Van Doan MD. PhD.¹, Vu Huu Dung MD. PhD.², Pham Anh Tuan MD. PhD.², Nguyen Tung Lam MD.^2*

^a These authors contributed equally to this article as co-first authors.

Prof. Lam Khanh MD. PhD. (Co-first author)

Department of Diagnostic Imaging

Hospital 108, No. 1 Tran Hung Dao street, Hai Ba Trung district, Hanoi, Vietnam

Phone: 84.986.520.516, Fax: 84.4.8213229

Email: [email protected]

First author: Vu Huu Trung MD. PhD.

Trauma and Orthopaedics Center

Military Medical University, No. 160 Phung Hung street, Ha Dong district, Hanoi, Vietnam

Phone: 84.988.977.789

Email: [email protected]

Assoc. Prof. Le Van Doan MD. PhD.

Department of Upper Extremity Surgery and Microsurgery

Hospital 108, No. 1 Tran Hung Dao street, Hai Ba Trung district, Hanoi, Vietnam

Phone: 84.913.571.717

Email: [email protected]

Vu Huu Dung MD. PhD.

Trauma and Orthopaedics Center

Military Medical University, No. 160 Phung Hung street, Ha Dong district, Hanoi, Vietnam

Phone: 84.915.936.888

Email: [email protected]

Pham Anh Tuan MD. PhD.

Department of Mathematics and Information

Vietnam Military Medical University, No. 160 Phung Hung street, Ha Dong district, Hanoi, Vietnam

Phone: 84.915.936.888

Email: [email protected]

* Corresponding author: Nguyen Tung Lam MD

Vietnam Military Medical University, No. 160 Phung Hung street, Ha Dong district, Hanoi, Vietnam

Phone: 39.3517414997

Email: [email protected]

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No competing interests reported.

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Using 320-Slice Computed Tomography to Preoperatively Investigate

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Abstract

Purpose

Methods

Results

Conclusions

Figures

Introduction

Materials And Methods

Study design and patients

Tools and equipment

Patient preparation

Scanning technique

Arterial visualization and measurement

Data analysis

Results

Discussion

Age and gender

Anatomy of the perforator arterial system

The role of CT 320 in preoperatively investigating the perforator flap’s pedicle artery and its projected cutaneous point

Conclusion

Declarations

References

Additional Declarations

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