Introduction: Popliteal artery has several branching variations, understanding its vasculature is substantial for fibular free flap (FFF) harvest. The atherosclerosis affects popliteal vasculature and leads to some acquired variants, which preclude FFF harvest. This study determined the variation of popliteal artery by computed tomography angiography (CTA) and association between atherosclerosis risks and stenosis of the popliteal vasculature to determine the benefit of preoperative CTA for surgical planning in FFF harvest.Materials and methods: The data and CTA images of legs from 443 patients, who underwent CTA of legs between January 2016 and December 2020, were retrieved and retrospectively reviewed. Popliteal artery branching patterns were classified according to the systems proposed by Kim, et al. and Abou-Foul and Borumandi. Then, we analyzed the correlation between atherosclerosis risks and degree of vessel stenosis. Results: The most common patterns were type I-A (90.5%), III-A (4.3%), and III-B (1.8%), and the prevalence of acquired variant was 4.3%. The mean diameter of anterior tibial artery, posterior tibial artery, and peroneal artery was 4.1±1.1 mm, 3.5±1.0 mm, and 3.7±1.0 mm, respectively. Popliteal artery branches were susceptible to different risk factors. Stenosis of the anterior tibial artery was influenced by peripheral arterial disease (PAD), hypertension (HT), and diabetes mellitus (DM); stenosis of the posterior tibial artery was influenced by PAD, chronic kidney disease (CKD), and DM; and, stenosis of peroneal artery was influenced by CKD and coronary artery disease. Conclusion: Although CTA is not a routine preoperative investigation in this setting, the results of this study suggest its benefit in patients with risk factors for atherosclerosis to determine the suitable limb for FFF harvest with consideration of cost-effectiveness and prevalence of variations in population.

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