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Zhang et al. Plast Aesthet Res 2019;6:30 I http://dx.doi.org/10.20517/2347-9264.2019.040 Page 7 of 11

Figure 2. A: adult male following degloving injury to left lower extremity; B: preoperative marking for posterior tibial artery perforator
propeller flap; C: immediate postoperative result, medial view; D: immediate postoperative result, lateral view

performance and cost to the hospital system [53,54] . Since its introduction in clinical practice in the early
1990s, computed tomographic angiography (CTA) has become the de-facto diagnostic modality of choice
[55]
to assess vascular injury in the setting of lower-extremity trauma . Due to a more favorable side-effect
profile, as well as imaging resolution comparable to that of angiography, CTA has begun to replace
arteriography as the preferred diagnostic modality to evaluate vascular injury [56,57] . Despite the obvious
advantage of predisposing patient’s to less ionizing radiation and the avoidance of complications such as
pseudoaneurysm, vessel thrombosis, and vessel injury, the routine use of CTA has long been continuously
[58]
debated but has gained routine acceptance in clinical practice . While CT imaging may demonstrate
vascular injury, and patency of residual vessels, this modality does little to evaluate flow in potential
donor vessels to sustain microvascular reconstruction in the setting of collateral flow. Furthermore, the
[59]
sensitivity of CTA is limited in the identification of vasospasm and local injury . For these reasons, many
institutions continue to rely on arteriography for preoperative imaging and planning. In individuals whose
renal function preclude administration of iodinated dyes, carbon dioxide angiography remains a viable
and underutilized imaging modality [60,61] . Compared with iodinated contrast, CO angiography decreases
2
the incidence of acute kidney injury from 11.1% to 4.7%. As such, CO angiography may provide valuable
2
diagnostic data in populations unable to receive large contrast loads secondary to compromised renal
function or adverse reactions to iodinated contrast.

When microvascular reconstruction is required, recipient vessel selection outside the zone of injury is
of paramount importance, made more so by the limitations conferred by the associated injury. Some
institutions argue for the continued utility of obtaining formal arteriography, but primarily in the setting
of chronic lower extremity wounds, as these studies may demonstrate previously unrecognized vascular
[62]
pathology and allow for prompt endovascular intervention facilitating ultimate reconstruction . Others
argue that any diagnostic imaging in the setting of trauma is superfluous, as thorough clinical examination
[63]
and intraoperative adaptation are sufficient to conduct soft-tissue reconstruction .