Sir: We thank Drs. Kamdar, Rohde, and Spector for bringing to our attention their difficult case of an anterolateral thigh flap in a patient with a calcified descending branch of the lateral circumflex femoral artery. As we pointed out in our article, the descending branch of the lateral circumflex femoral artery is relatively atherosclerosis resistant, but not totally resistant. We noted no atherosclerotic changes in 87 percent of patients, mild changes in 4.5 percent, moderate changes in 1.5 percent, and severe disease in 7 percent. These findings are corroborated by others who have used this vessel in patients undergoing coronary artery bypass grafting with good success.1,2 Despite the encouraging results of our angiographic study, the challenge remains of what to do when presented with patients who are at high risk for atherosclerosis, such as the patient presented by Drs. Kamdar, Rohde, and Spector. We found no statistically significant correlation between comorbid condition and degree of stenosis in the descending branch of the lateral circumflex femoral artery, which might guide the clinical question of when is it mandatory to obtain preoperative angiography. We noted significant stenosis in only 7 percent of patients studied and therefore preoperative angiography for all patients at risk for atherosclerosis seems unwarranted. For patients with calcification of the tunica media, it is unclear what preoperative imaging might prove useful.3 Advanced computed tomography technology, namely, electron beam computed tomography and spiral computed tomography, has enabled quantitative measurement of calcium burden in the coronary arteries and may become the mainstay of noninvasive vascular imaging elsewhere in the body.4–6 We have on occasion obtained preoperative angiograms to rule out atherosclerosis in patients at very high risk, but we cannot provide definitive recommendations as to when such studies should be ordered based on our data, nor should a single case report form the basis for clinical decision making. Our study included six patients with end-stage renal disease and with angiographic profiles similar to the other patients. Nevertheless, we thank Drs. Kamdar, Rohde, and Spector for sharing their clinical experience with such a patient and for pointing out that the atherosclerotic process in a patient with end-stage renal disease may result in a normal angiographic appearance despite severe calcification of the tunica media. A prospective study correlating diagnostic imaging studies with surgical findings and clinical outcomes would be very useful in further clarifying these issues. Eric G. Halvorson, M.D. Division of Plastic and Reconstructive Surgery University of North Carolina Chapel Hill, N.C. Helena O. B. Taylor, M.D., Ph.D. Dennis P. Orgill, M.D., Ph.D. Division of Plastic Surgery Brigham and Women’s Hospital, Harvard Medical School Boston, Mass.