Lateral Circumflex Femoral Artery: Not Always Atherosclerosis-Resistant

Abstract

Sir: We read with great interest the article by Halvorson, Taylor, and Orgill (Plast. Reconst. Surg. 121: 121, 2008) about the radiographic patency of the descending branch of the lateral circumflex femoral artery. The group noted radiographic mean stenosis rates of 10 percent in the descending branch of the lateral circumflex femoral artery and 12.5 percent in the profunda femoris artery, suggesting that the vascular territory supplied by the profunda femoris is largely “atherosclerosis-resistant.” We are submitting a cautionary statement that in the end-stage renal disease patient these findings may not hold true. We recently reconstructed a 13 × 9-cm full-thickness defect of the anterior scalp created after excision of a malignant fibrous histiocytoma. The patient, a 75-year-old man with hypertension and coronary artery disease, underwent a renal transplant 12 years ago. Preoperatively, there was no overt evidence of significant lower extremity vascular disease, as he was noted to have palpable pulses distally. Two lateral thigh perforating vessels were identified on Doppler ultrasonography. We performed an anterolateral thigh flap reconstruction based on a single intramuscular perforator from the lateral circumflex femoral artery to the superficial temporal vessels. Although the flap perforator itself was relatively soft, the entirety of the lateral circumflex femoral artery was extensively and completely calcified. The extensive calcification resulted in a challenging anastomosis, possible only by using a slightly larger needle/suture (8-0) taking bites from the inside aspect of the flap vessels, as coming through the calcified vessel wall from the adventitial side proved impossible. The recipient vessels were soft and had good inflow without evidence of calcification. Postoperatively, the patient did well and the flap survived in its entirety. Pathologic calcification of the vascular system in dialysis patients and transplant recipients has been recognized since the 1960s. In 1973, Tatler and Baillod2 examined plain radiographs and described calcium deposition in a “ring” or “tubular” pattern in 27 percent of patients starting dialysis, with this proportion doubling over a 3- to 4-year period. Using more sophisticated imaging, such as electron beam technology, a 60 to 90 percent prevalence in dialysis patients is noted, with the most consistently associated factors being advanced age and number of years on dialysis.3 The cause of arterial calcification is unclear but may be related to dialysis calcium concentration and the pathologic process of renal osteodystrophy. In dialysis patients, angiographic studies note that arterial calcifications are not necessarily associated with stenotic coronary artery lesions. Although some intimal calcification is present in dialysis patients, the pipe and tubular patterns described by Tatler and Baillod and others are more consistent with calcium deposition in the tunica media. These observations have led to an alternative arterial abnormality occurring in chronic kidney disease, a process called chronic kidney disease–associated arteriopathy.4 Although not causing arterial occlusion, as would be visualized on angiography, medial calcification in these patients leads to extensive arterial thickening and stiffening, making microanastomosis of these vessels extremely difficult. Although Halvorson et al. provide radiographic support for the relative atherosclerosis-sparing of the profunda femoris system, the findings were not correlated with the clinical appearance of the vessels because their patients never went on to surgery. For the surgeon planning any microsurgical reconstruction in patients with a history of end-stage renal disease, we have learned that the lateral circumflex femoral artery system may not be spared from disease. Mehul R. Kamdar, M.D. Christine Rohde, M.D. Jason A. Spector, M.D. Division of Plastic Surgery New York Presbyterian Hospital Columbia University College of Physicians and Surgeons New York, N.Y.