Multidetector-row computed tomography analysis of the anatomical characteristics of thoracoacromial artery perforator

Journal OF MILITARY PHARMACO - MEDICINE N⁰4 - 2021

MULTIDETECTOR-ROW COMPUTED TOMOGRAPHY

ANALYSIS OF THE ANATOMICAL CHARACTERISTICS OF

THORACOACROMIAL ARTERY PERFORATOR

Tong Thanh Hai¹, Vu Quang Vinh¹, Tran Van Anh¹

SUMMARY

Objectives: To analyze the anatomical characteristics of thoracoacromial artery perforators

by using multidetector-row computed tomography (MDCT). Subjects and methods: The study

was performed in 11 cases. For all cases, the origin of perforator vessel, the direction and the

course also were determined. The concern of origin of perforator with local anatomical

landmarks (acromion, clavicle) was described. Length of perforator, diameter of perforators at

their origin, diameter of perforators at the point where the perforator pierces the fascia into

overlying skin were also measured. Results: The perforator vessels were divided into deltoid

branch of thoracoacromial axis (66.7%), acromial branch (23.8%) or pectoral branch (9.5%). As

a result, the perforators ran to the humeral region in subdermal tissue in direction. The length

from the origin of perforator artery to acromion was 66.53 11.57 mm to acromion (69.30 9.31

mm on the right side and 63.49 13.48 mm on the left) and was 54.72 17.57 mm to clavicle

(64.37 11.11 mm on the right side and 44.11 17.59 mm on the left). The mean diameter of

perforator vessel at its origin was 1.63 0.26 mm and that of the perforator piercing the fascia

into overlying skin was 1.22 0.23 mm. Our study also identified the mean length of artery

pedicled perforator was 49.06 17.86 mm (50.60 22.22 mm on the right, 47.37 12.42 mm

on the left). Conclusion: Multidetector-row computed tomography is the powerful procedure to

determine the anatomical features of perforator ves sels. This is the first time in literature,

we have also applied successfully this technique to analyze the characteristics of thoracoacromial

artery perforators.

* Keywords: Thoracoacromial artery; Perforator; Multidetector computed tomography.

INTRODUCTION

pectoral branches, and two further

branches with highly variable anatomy, of

which the clavicular branch sometimes

arises from the main thoracoacromial

trunk itself and the acromial branch

originates in almost all cases from the

deltoid branch. These branches are

probably the most commonly used

perforator flaps for reconstruction [1].

The thoracoacromial artery arises

below the junction of the middle and

lateral thirds of the clavicle as a large-

caliber vessel from the forepart of the

axillary artery, with its origin being

generally overlapped by the upper edge

of the pectoralis minor. It gives rise to two

large constant branches, the deltoid and

¹Le Huu Trac National Burn Hospital

Corresponding author: Tong Thanh Hai (Drtonghai@gmail.com)

Date received: 19/02/2021

Date accepted: 25/4/2021

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thoracoacromial artery and its branches

A number of perforator-based flaps

and those who suffered from trauma

and/or chest wall ulcers were excluded in

this study.

have been described in the previous

articles. Although there have been in-

depth studies on this issue, there are no

reports on the anatomical study for the

effective and safe flap design [2]. To the

best of my knowledge, research on the

use of MDCT in identifying the anatomical

characteristics of thoracoacromial artery

perforators. Consequently, we conducted

this study: To analyze the anatomical

2. Methods

The CT examination was performed by

using a 320-slice MDCT scanner (Aquilion

320, Toshiba, Japan) and Ultravist 300 as

the contrast material. The patients were

instructed to hold their breath during the

CT-scan, which was performed with a

rotation speed of 0.5 s/rot, a detector

coverage of 100 mm. This acquisition

protocol allowed for a table speed of 5 mm/s

and a scan time of about 10s for CT

angiography, axial images of 0.625mm

thickness. The CT angiographic images

were reconstructed by using the maximum

intensity projection (MIP) technique of

Vitrea software.

characteristics

of

perforators

of

thoracoacromial artery by using MDCT.

SUBJECTS AND METHODS

1. Subjects

A total of 21 thoracoacromial artery

perforators from 11 patients that were

stored in the Department of Radiology,

Hoa Hao Medical Centre, Ho Chi Minh

city, Viet Nam between April, 2019 and

July, 2020 underwent the anatomy by

using the MDCT. These 11 cases were

randomly selected for the purpose of

examining the chest wall. Patients with

acquired anatomical anomalies of the

The anatomical characteristics of

perforator arteries consisted of the origin of

perforator, its origin with local anatomical

landmarks, the direction of perforator

artery, the length and diameter of

perforator vessel.

RESULTS

1. General characteristics of the patients

There was a total of 11 patients including 21 perforator arteries with 11 arteries on the

right and 10 on the left.The average age of the patients was 57.1 years (ranging 25 - 77 years).

2. The anatomical characteristics of perforators of thoracoacromial artery

* The origin of perforator artery:

Table 1: The origin of perforator artery.

Branches of

thoracoacromial artery

Acromial

branch

Deltoid

branch

Pectoral

branch

Clavicular

branch

Right

Left

0

5

10

4

1

0

Total (n, %)

5 (23.8)

14 (66.7)

2 (9.5)

The perforator originating from the deltoid branchwas seen in most patients (66.7%).

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* The direction of perforator vessel:

On MDCT images, the perforator ran to the humeral region in subdermal tissue in

most cases.

3. The association between the origin of perforatorwith local anatomical landmarks

In our study, we identified the distance from the origin of perforators to acromion

and clavicle - the important landmarks which is usually used in clinical practice.

Table 2: The distance from origin to acromion (mm)

Distance (mm)

Right (n = 11)

Maximum

81.0

Minimum

51.9

Average

p

69.30 9.31

63.49 13.48

66.53 11.57

0.2949

Left (n = 10)

79.5

39.6

Total (n = 21)

81.0

39.6

This distance was measured from the origin of thoracoacromial artery perforator to

the tip of acromion, which was 66.53 11.57 mm (69.30 9.31 mm on the right side

and 63.49 13.48 mm on the left). This length did not depend on the the source of

perforator artery.

Table 3: The distance from the origin to clavicle.

Distance (mm)

Right (n = 11)

Left (n = 10)

Maximum

82.2

Minimum

47.8

Average

p

64.37 11.11

44.11 17.59

54.72 17.57

0.0048

73.9

20.2

Total (n = 21)

82.2

20.2

The distance from the origin to clavicle was 54.72 17.57 mm (64.37 11.11 mm

on the side and 44.11 17.59 mm on the left).

* The length of perforators:

Table 4: The length of perforator

p

Length (mm)

Right (n = 11)

Left (n = 10)

Total (n = 21)

Maximum

104.0

66.7

Minimum

25.2

Average

50.60 22.22

47.37 12.42

49.06 17.86

0.6899

25.6

104

25.2

The length was identified by measuring the distance between the origin of perforator

and the point where the perforator pierces the fascia into the skin. Mean length was

49.06 17.86 mm (50.60 22.22 mm on the right and 47.37 12.42 mm on the left).

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* The diameter of perforators:

Table 5: Diameter of perforators at their origin

Diameter (mm)

Right (n = 11)

Left (n = 10)

Maximum

Minimum

1.2

Average

1.58 0.22

1.69 0.29

1.63 0.26

p

2

0.3369

2.1

1.1

Total (n = 21)

1.1

Table 6: Diameter of perforators at the point where the perforator pierces the fascia

into overlying skin.

Diameter (mm)

Right (n = 11)

Left (n = 10)

Maximum

1.8

Minimum

1.0

Average

1.24 0.22

1.21 0.25

1.22 0.23

p

0.7730

1.8

1.0

Total (n = 21)

1.8

1.0

DISCUSSION

these muscles and to the mammary

gland. It anastomoses with the intercostal

branches of the internal thoracic artery

and with the external thoracic artery.

It irrigates in particular the sterno-costal

portion of the pectoralis major muscle. It

quickly divides into 3 branches: a lateral

branch which runs in the direction of the

lateral thoracic artery, and two medial and

caudal branches which go towards the 4^th

intercostal space and anastomose with

the anterior intercostal arteries and the

perforators of the internal mammary

artery [3].

1. Anatomy of branches of

thoracoacromial artery

The thoracoacromial artery arises

below the junction of the middle and

lateral thirds of the clavicle as a large-

caliber vessel from the forepart of the

axillary artery, with its origin being

generally overlapped by the upper edge

of the pectoralis minor. It gives rise to two

large constant branches, the deltoid and

pectoral branches, and two further

branches with highly variable anatomy,

of which the clavicular branch sometimes

arises from the main thoracoacromial

trunk itself and the acromial branch

originates in almost all cases from the

deltoid branch [1].

* The deltoid branch:

The deltoid branch crosses the upper

part of the deltopectoral groove and is

generally divided into two branches, one

deep and the other superficial. The deep

* The pectoral branch:

The pectoral branch runs between the branch travels in the groove itself, inside

2 pectoral muscles and is distributed to

a small channel formed by the doubling of

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Journal OF MILITARY PHARMACO - MEDICINE N⁰4 - 2021

the fascia. Arriving at the lower end of the

intermuscular space, this deep branch

perforates the superficial layer of the

facial canal in which it is located. It thus

arrives in the subcutaneous plane and

quickly branches into the skin which

covers the tendon of the pectoralis major

and the distal insertion of the deltoid

muscle. It irrigates the pectoralis major

and deltoid muscles with numerous small

branches. The superficial branch (which

* The clavicular branch:

The clavicular branch moves cranially

and medially towards the sternoclavicular

joint which it irrigates, as well as the

subclavian muscle. It is usually of small

caliber. Nyemb PMM et al [5] researched

in 24 thoracoacromial arteries showed that

the clavicular branch was absent in more

than half of the dissections. The length of

its extrafascial pedicle varied between 0.5

and 2.5 cm. The length of the pedicle after

represents the acromial branch proper) transmuscular dissection varied between 3

and 6 cm. The general direction of this

clavicular branch was ascending and

medial. Geddes et al [4] measured the

average pedicle length of the clavicular

perforators being 6.0 2.1 cm.

goes obliquely down and laterally; its size

is sometimes important, and its length

can reach 12 cm [3]. Geddes et al

identified the dominant perforator from the

deltoid branch with an average length of

7.9 2.0 cm [4].

2. Clinical application

* The acromial branch:

In clinical application, the pectoralis

major and the deltopectoral have been two

workhorse flaps in reconstruction based

on the pectoral artery [1]. Although, both

flaps have demonstrated several advantages,

they have shown several shortcomings.

Geddes CR et al in 2003 [4] had found

the perforators through the pectoralis

muscle to the overlying skin separated

from perforators of the thoracoacromial

axis; perforators of the medial intercostal

vessels; and perforators of the lateral

thoracic artery. However, author believed

that the pectoral branch of the

thoracoacromial artery was not a good

donor site for pedicled perforator flaps.

However, musculocutaneous perforator

flaps are possible from the clavicular and

deltoid branches of the thoracoacromial

artery.

The acromial branch is directed above

the coracoid process and under the

deltoid muscle, to which it gives several

branches. It pierces the deltoid muscle

towards the acromion to participate in an

arterial network to which the suprascapular

artery, the deltoid branch and the posterior

humeral circumflex artery contribute. It ends

at the lateral part of the deltoid region.

Along its route, it gives a series of small

branches on both sides of its trunk that

quickly join the skin. This acromial branch

presents many variations: it can be short

from 2 to 3 cm, or very long and reach the

posterior face of the deltoid region; it remains

deep in 25% of cases and then pierces

the deltoid at a greater or lesser distance

from its anterior border.

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In a study by Portenard AC et al [6], enables the best perforator to be selected

before the dissection has begun.

Therefore, the diagnostic value of the

ultrasound and radiological methods for

the preoperative flap evaluations has

been widely discussed in the plastic

surgery community lately [7].

the mean distances from the origin of the

perforator artery on the abTAA were

14.25 cm to the sternum, 3.45 cm to the

acromion, 5.65 cm to the clavicle. The

mean diameter of the abTAA was 1.20

0.2 mm and the length of the perforator

pedicle could be extended to 7.46 cm

In the last 15 years, the development

1.15 mm. Authors also suggest that the of MDCT has radically changed the way

the computed tomography angiography is

used for the study of the vascular

pathology. Interestingly, over the years,

MDCT proved to be not only a very useful

tool for the study of aorta and peripheral

acromial branch of the TAA perforator is

constant and provides a reliable blood

supply to a cutaneous flap.

3. Role of multidetector-row computed

tomographic angiography in the study

of the perforator flap

arteries but also

a

very promising

noninvasive method for the localization,

visualization, and characterization of the

coronary artery stenosis. Moreover,

MDCT allows for the investigation of the

coronary vessels, the lumen diameter,

and the occlusion site. Consequently, the

idea of studying the perforator vessels by

The introduction of perforator flaps into

the surgical practice over the last decades

has expanded the reach of plastic surgery.

The use of these flaps greatly simplifies

the reconstruction procedures and decreases

the number of surgical stages and

minimizes the amount of trauma at the

site of the flap harvesting. In addition, the

utilization of the perforator flaps shortens

the duration of operations and allows for

the maintenance of the intactness of the

great vessels at both the donor and the

recipient sites. However, surgery challenges

remain, as the perforator vessels are highly

variable in number, localization type,

hemodynamic specifications, and their

anatomical interactions with other structures.

For these reasons, the identification of the

best perforator before the procedure is

very important for the choice of the main

feed vessel and the design of the

perforator flap [7].

MDCT has emerged as

a

natural

extension of its current applications and

as a reliable method for the precise

localization of the vessels most suitable

for the flap formation.

Indeed, since 2003, MDCT has been

proving itself as

a

highly reliable

technique for the preoperative planning of

Deep Inferior Epigastric Perforator (DIEP)

flap for breast reconstruction. Notably,

this application of MDCT has been shown

to yield great results, including the

significant decrease in the duration of the

surgery and the amount of the postsurgical

complications. Consequently, over the

past few years, a number of reports have

mentioned the possibility of employing

MDCT for the planning of various flap

types, and/or the identification of perforators

In recent years, the flap design

techniques have begun to incorporate the

preoperative evaluation, localization, and

calibration of the perforator. Such approach

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in various body parts, even including

The original point of perforator was

those that are smaller in diameter than 66.53 11.57 mm to acromion (69.30

the perforators in the front abdominal

wall. Herein, we share our experience of

using MDCT with 3-dimensional (3D)

visualization in the planning of the local

perforator flaps in various body parts and

9.31 mm on the right side and 63.49

13.48 mm on the left), and 54.72 17.57

mm to clavicle (64.37 11.11 mm on the

right side and 44.11 17.59 mm on the

left). The mean diameter of perforator

vessel at its origin was 1.63 0.26 mm,

and 1.22 0.23 mm at the point where

the perforator pierces the fascia into

overlying skin. Our study also identified

the mean length of perforator vessel being

49.06 17.86 mm (50.60 22.22 mm on

demonstrate

the

effectiveness

and

precision of this method.

4. Anatomical characteristics of

thoracoacromial artery perforators

on MDCT

Identifying the anatomical features of

the perforator vessels of flap is important

before taking surgical procedures. For

the right and 47.37

the left).

12.42 mm on

perforator

skin

flap

based

on

CONCLUSION

thoracoacromial artery, the numerous

reseaches have showed the characteristics

of perforator vessels reported in literature.

Although these studies just restrictedly

provided information in basic features,

other features have not showed.

Nowadays, MDCT technique is a new

powerful procedure to provide the hidden

information applied in clinical practice.

As far as we know, there have been no

reports on the use of MDCT in identifying

Multidetector-row computed tomography

is a powerful procedure to determine the

anatomical features of perforator vessels.

This is the first time in literature, we have

also applied successfully this technique to

analyze

thoracoacromial artery perforators. This

technique provided the significant

the

characteristics

of

information in clinical application.

REFERENCES

the

anatomical

characteristics

of

thoracoacromial

artery perforators.

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Thoracoacromial artery perforator flap:

Anatomical basis and clinical applications.

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Because there were no previous studies

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The origin of perforator vessel: Our

data showed that the perforator vessels

were divided into deltoid branch of

thoracoacromial axis (66.7%), acromial

branch (23.8%) or pectoral branch (9.5%).

As a result, the perforators ran to the humeral

region in subdermal tissue in direction.

2. Ono S, Ogawa R, Hayashi H, et al.

Multidetector-row computed tomography

analysis of the supra-fascial perforator

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Reconstructive and Aesthetic Surgery 2010;

63(10):1602-1607.

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3. Nyemb PMM, Fontaine C, Duquennoy-

6. Portenard AC, Auquit-Auckbur I, Gardeil L,

et al. Anatomical study of the perforator flap

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acromial artery (abTAA flap): A cadaveric

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Martinot V, et al. Anatomical study of the

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CASE REPORT

The perforator vessel of thoracoacromial artery.

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The source, direction and course of perforator vessel.

The distance from its origin to clavicle

The distance between its origin and acromion

The length of perforator.

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Diameter of perforator.

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Brand tree of perforator.

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