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Zetzmann K, Papatheodorou N, Rühl E, Yagshyyev S, Haney B, Moosmann O, Li Y, Meyer A, Knieling F, Behrendt CA, Lang W, Rother U. Detection of wound healing disorders after major amputations by measurements of the microcirculation: A prospective single-center study. SAGE Open Med 2024; 12:20503121241263244. [PMID: 39055279 PMCID: PMC11271087 DOI: 10.1177/20503121241263244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024] Open
Abstract
Introduction Although major amputations can often be avoided due to evolving methods of endovascular and surgical revascularizations techniques, in patients with chronic limb-threatening ischemia, it is still necessary in some cases. Aim of this study was the detection of wound healing disorders through intraoperative microcirculation measurements in major limb amputations. Materials and methods In this single-center clinical study, patients with an indication for major amputation were enrolled prospectively. Cause of amputation, patients' comorbidities including cardiovascular risk profile were assessed. Macrocirculation, as well as microcirculation were assessed. Microcirculation measurements were performed by fluorescence angiography with the administration of indocyanine green. A preoperative measurement was obtained at the amputation level, followed by three additional measurements of the amputation stump postoperatively. Wound healing was monitored and correlated with the microcirculatory findings, based on the perfusion parameters ingress and ingress rate, calculated in the indocyanine green fluorescence video sequences of the amputation stumps. Results Forty-five patients were enrolled, including 19 (42%) below-the-knee amputations and 26 (58%) above-the-knee amputations. When considering the need for revision, a change in the microperfusion parameters was observed postoperatively. The mean value for ingress was significantly lower directly postoperatively in stumps requiring revisions (5 ± 0 A.U. versus 40.5 ± 42.5 A.U., p < 0.001). The mean value of ingress rate behaved similarly (0.15 ± 0.07 A.U./s versus 2.8 ± 5.0 A.U./s, p = 0.005). The evaluation of indocyanine green measurements when wound healing disorders occurred also showed nonsignificant differences in the mean values. Conclusion Fluorescence angiography after major lower limb amputations appears to be an option of depicting microperfusion. Especially, the early postoperative detection of reduced perfusion can indicate a subsequent need for revision. Therefore, this method could possibly serve as a tool for intraoperative quality control after major limb amputation.
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Affiliation(s)
- Katharina Zetzmann
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nikolaos Papatheodorou
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Eva Rühl
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Shatlyk Yagshyyev
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Briain Haney
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Oxana Moosmann
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Yi Li
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany
- Medical School Berlin, Berlin, Germany
| | - Ferdinand Knieling
- Department of Pediatrics, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Klinik Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Venermo M, Settembre N. Perfusion increase in foot angiosomes: Comparison between direct and indirect revascularization of crural arteries. Scand J Surg 2024; 113:174-181. [PMID: 38825887 DOI: 10.1177/14574969241242205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
BACKGROUND AND AIMS In retrospective studies, wound healing and leg salvage have been better if revascularization is targeted to the crural artery supplying arterial flow to the wound angiosome. No data exist on how revascularization changes the blood flow in foot angiosomes. The aim of this study was to evaluate the change in perfusion after infrapopliteal artery revascularization in all foot angiosomes and to compare directly revascularized (DR) angiosomes to the indirectly revascularized (IR) angiosomes. METHODS In this prospective study, foot perfusion was measured with indocyanine green fluorescence imaging (ICG-FI) before and after either surgical or endovascular below-knee revascularization. According to angiograms, we divided the foot angiosomes into DR and IR angiosomes. Furthermore, in a subanalysis, the IR angiosomes were graded as IR_Coll+ angiosomes if there were strong collaterals arising from the artery which was revascularized, and as IR_Coll- angiosomes if strong collaterals were not seen. RESULTS A total of 72 feet (28 bypass, 44 endovascular revascularizations) and 282 angiosomes were analyzed. Surgical and endovascular revascularization increased perfusion significantly in both DR and IR angiosomes. After bypass surgery, the increase in DR angiosomes was 55 U and 53 U in IR angiosomes; there were no significant difference in the perfusion increase between IR and DR angiosomes. After endovascular revascularization, perfusion increased significantly more, 40 U, in DR angiosomes compared to 26 U in IR angiosomes (p < 0.05). In the subanalysis of IR angiosomes, perfusion increased significantly after surgical bypass regardless of whether strong collaterals were present or not. After endovascular revascularization, however, a significant perfusion increase was noted in the IR_Coll+ but not in the IR_Coll- subgroup. CONCLUSION Open revascularization increased perfusion equally in DR and IR angiosomes, whereas endovascular revascularization increased perfusion significantly more in DR than in IR angiosomes. Strong collateral network may help increase perfusion in IR angiosomes.
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Affiliation(s)
- Maarit Venermo
- Abdominal Center Department of Vascular Surgery University of Helsinki and Helsinki University Hospital (HUS) P.O. Box 340 Helsinki FI00029 Finland
| | - Nicla Settembre
- Abdominal Center, Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital (HUS), Helsinki, Finland
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Huang C, Cheng Y, Zheng W, Bing RW, Zhang H, Komornicki I, Harris LM, Arany PR, Chakraborty S, Zhou Q, Xu W, Xia J. Dual-Scan Photoacoustic Tomography for the Imaging of Vascular Structure on Foot. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2023; 70:1703-1713. [PMID: 37276111 PMCID: PMC10809222 DOI: 10.1109/tuffc.2023.3283139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Chronic leg ulcers are affecting approximately 6.5 million Americans, and they are associated with significant mortality, reduced quality of life, and high treatment costs. Since many chronic ulcers have underlying vascular insufficiency, accurate assessment of tissue perfusion is critical to treatment planning and monitoring. This study introduces a dual-scan photoacoustic (PA) tomography (PAT) system that can simultaneously image the dorsal and plantar sides of the foot to reduce imaging time. To account for the unique shape of the foot, the system employs height-adjustable and articulating baseball stages that can scan along the foot's contour. In vivo results from healthy volunteers demonstrate the system's ability to acquire clear images of foot vasculature, and results from patients indicate that the system can image patients with various ulcer conditions. We also investigated various PA features and examined their correlation with the foot condition. Our preliminary results indicate that vessel sharpness, occupancy, intensity, and density could all be used to assess tissue perfusion. This research demonstrated the potential of PAT for routine clinical tissue perfusion assessment.
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Van Den Hoven P, Osterkamp J, Nerup N, Svendsen MBS, Vahrmeijer A, Van Der Vorst JR, Achiam MP. Quantitative perfusion assessment using indocyanine green during surgery - current applications and recommendations for future use. Langenbecks Arch Surg 2023; 408:67. [PMID: 36700999 PMCID: PMC9879827 DOI: 10.1007/s00423-023-02780-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/12/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE Incorrect assessment of tissue perfusion carries a significant risk of complications in surgery. The use of near-infrared (NIR) fluorescence imaging with Indocyanine Green (ICG) presents a possible solution. However, only through quantification of the fluorescence signal can an objective and reproducible evaluation of tissue perfusion be obtained. This narrative review aims to provide an overview of the available quantification methods for perfusion assessment using ICG NIR fluorescence imaging and to present an overview of current clinically utilized software implementations. METHODS PubMed was searched for clinical studies on the quantification of ICG NIR fluorescence imaging to assess tissue perfusion. Data on the utilized camera systems and performed methods of quantification were collected. RESULTS Eleven software programs for quantifying tissue perfusion using ICG NIR fluorescence imaging were identified. Five of the 11 programs have been described in three or more clinical studies, including Flow® 800, ROIs Software, IC Calc, SPY-Q™, and the Quest Research Framework®. In addition, applying normalization to fluorescence intensity analysis was described for two software programs. CONCLUSION Several systems or software solutions provide a quantification of ICG fluorescence; however, intraoperative applications are scarce and quantification methods vary abundantly. In the widespread search for reliable quantification of perfusion with ICG NIR fluorescence imaging, standardization of quantification methods and data acquisition is essential.
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Affiliation(s)
- P Van Den Hoven
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - J Osterkamp
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, The Capital Region of Denmark, Copenhagen, Denmark
| | - N Nerup
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, The Capital Region of Denmark, Copenhagen, Denmark
| | - M B S Svendsen
- CAMES Engineering, Copenhagen Academy for Medical Education and Simulation, Centre for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark
| | - Alexander Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J R Van Der Vorst
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - M P Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, The Capital Region of Denmark, Copenhagen, Denmark
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Van Den Hoven P, Tange F, Van Der Valk J, Nerup N, Putter H, Van Rijswijk C, Van Schaik J, Schepers A, Vahrmeijer A, Hamming J, Van Der Vorst J. Normalization of Time-Intensity Curves for Quantification of Foot Perfusion Using Near-Infrared Fluorescence Imaging With Indocyanine Green. J Endovasc Ther 2022; 30:364-371. [PMID: 35236169 DOI: 10.1177/15266028221081085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) is gaining popularity for the quantification of tissue perfusion, including foot perfusion in patients with lower extremity arterial disease (LEAD). However, the absolute fluorescence intensity is influenced by patient-and system-related factors limiting reliable and valid quantification. To enhance the quality of quantitative perfusion assessment using ICG NIR fluorescence imaging, normalization of the measured time-intensity curves seems useful. MATERIALS AND METHODS In this cohort study, the effect of normalization on 2 aspects of ICG NIR fluorescence imaging in assessment of foot perfusion was measured: the repeatability and the region selection. Following intravenous administration of ICG, the NIR fluorescence intensity in both feet was recorded for 10 mins using the Quest Spectrum platform®. The effect of normalization on repeatability was measured in the nontreated foot in patients undergoing unilateral revascularization preprocedural and postprocedural (repeatability group). The effect of normalization on region selection was performed in patients without LEAD (region selection group). Absolute and normalized time-intensity curves were compared. RESULTS Successful ICG NIR fluorescence imaging was performed in 54 patients (repeatability group, n = 38; region selection group, n = 16). For the repeatability group, normalization of the time-intensity curves displayed a comparable inflow pattern for repeated measurements. For the region selection group, the maximum fluorescence intensity (Imax) demonstrated significant differences between the 3 measured regions of the foot (P = .002). Following normalization, the time-intensity curves in both feet were comparable for all 3 regions. CONCLUSION This study shows the effect of normalization of time-intensity curves on both the repeatability and region selection in ICG NIR fluorescence imaging. The significant difference between absolute parameters in various regions of the foot demonstrates the limitation of absolute intensity in interpreting tissue perfusion. Therefore, normalization and standardization of camera settings are essential steps toward reliable and valid quantification of tissue perfusion using ICG NIR fluorescence imaging.
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Affiliation(s)
- Pim Van Den Hoven
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Floris Tange
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jurrian Van Der Valk
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Nikolaj Nerup
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Catharina Van Rijswijk
- Department of Interventional Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Van Schaik
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexander Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Joost Van Der Vorst
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Van Den Hoven P, Goncalves LN, Quax PHA, Van Rijswijk CSP, Van Schaik J, Schepers A, Vahrmeijer AL, Hamming JF, Van Der Vorst JR. Perfusion Patterns in Patients with Chronic Limb-Threatening Ischemia versus Control Patients Using Near-Infrared Fluorescence Imaging with Indocyanine Green. Biomedicines 2021; 9:biomedicines9101417. [PMID: 34680534 PMCID: PMC8533354 DOI: 10.3390/biomedicines9101417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 01/01/2023] Open
Abstract
In assessing the severity of lower extremity arterial disease (LEAD), physicians rely on clinical judgements supported by conventional measurements of macrovascular blood flow. However, current diagnostic techniques provide no information about regional tissue perfusion and are of limited value in patients with chronic limb-threatening ischemia (CLTI). Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has been used extensively in perfusion studies and is a possible modality for tissue perfusion measurement in patients with CLTI. In this prospective cohort study, ICG NIR fluorescence imaging was performed in patients with CLTI and control patients using the Quest Spectrum Platform® (Middenmeer, The Netherlands). The time–intensity curves were analyzed using the Quest Research Framework. Fourteen parameters were extracted. Successful ICG NIR fluorescence imaging was performed in 19 patients with CLTI and in 16 control patients. The time to maximum intensity (seconds) was lower for CLTI patients (90.5 vs. 143.3, p = 0.002). For the inflow parameters, the maximum slope, the normalized maximum slope and the ingress rate were all significantly higher in the CLTI group. The inflow parameters observed in patients with CLTI were superior to the control group. Possible explanations for the increased inflow include damage to the regulatory mechanisms of the microcirculation, arterial stiffness, and transcapillary leakage.
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Affiliation(s)
- Pim Van Den Hoven
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (P.V.D.H.); (L.N.G.); (P.H.A.Q.); (J.V.S.); (A.S.); (A.L.V.); (J.F.H.)
| | - Lauren N. Goncalves
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (P.V.D.H.); (L.N.G.); (P.H.A.Q.); (J.V.S.); (A.S.); (A.L.V.); (J.F.H.)
| | - Paulus H. A. Quax
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (P.V.D.H.); (L.N.G.); (P.H.A.Q.); (J.V.S.); (A.S.); (A.L.V.); (J.F.H.)
| | | | - Jan Van Schaik
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (P.V.D.H.); (L.N.G.); (P.H.A.Q.); (J.V.S.); (A.S.); (A.L.V.); (J.F.H.)
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (P.V.D.H.); (L.N.G.); (P.H.A.Q.); (J.V.S.); (A.S.); (A.L.V.); (J.F.H.)
| | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (P.V.D.H.); (L.N.G.); (P.H.A.Q.); (J.V.S.); (A.S.); (A.L.V.); (J.F.H.)
| | - Jaap F. Hamming
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (P.V.D.H.); (L.N.G.); (P.H.A.Q.); (J.V.S.); (A.S.); (A.L.V.); (J.F.H.)
| | - Joost R. Van Der Vorst
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (P.V.D.H.); (L.N.G.); (P.H.A.Q.); (J.V.S.); (A.S.); (A.L.V.); (J.F.H.)
- Correspondence: ; Tel.: +31-71-529-9143
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Gunnarsson T, Lindgren H, Gottsäter A, Pärsson H. Intraprocedural Transcutaneous Oxygen Pressure and Systolic Toe Pressure Measurements During and After Endovascular Intervention in Patients with Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2021; 62:583-589. [PMID: 34334314 DOI: 10.1016/j.ejvs.2021.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/27/2021] [Accepted: 06/06/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate changes in transcutaneous oxygen pressure (tcpO2) and systolic toe pressure (TP) during endovascular intervention. METHODS This was a single centre prospective, non-randomised, observational feasibility study. Patients with chronic limb threatening ischaemia (CLTI) due to infrainguinal disease scheduled for endovascular treatment were included between March 2018 and December 2019. TcpO2 was measured continuously bilaterally at foot level throughout the procedure and at follow up. Specific time points during the intervention were chosen for comparison to baseline (before arterial puncture): average tcpO2 level five minutes prior to percutaneous transluminal angioplasty (PTA); 10 minutes after PTA; and at completion. Bilateral TP was recorded using laser Doppler flowmetry before arterial puncture, at completion, and at clinical follow up. Angiograms were analysed for successful revascularisation and vascular lesions classified according to the Global Limb Anatomical Scoring System (GLASS). Rutherford and WIfI (Wound, Ischaemia, and foot Infection) classifications were registered, as well as clinical outcome. RESULTS Twenty-one patients completed the study. Completion angiograms showed inline flow to the foot in all but two patients. Median time to follow up was 10 weeks (range 8 - 13 weeks) and all patients except one improved clinically. TcpO2 decreased during the initial stage of the intervention, from before arterial puncture to five minute average before PTA (p < .001) and did not recover to above baseline values at the end of intervention. TcpO2 increased significantly at follow up (p < .001). TP increased statistically significantly during intervention (p < .001) and at follow up (p < .001) compared with baseline. CONCLUSION TcpO2 and TP measurements are safe and feasible non-invasive techniques for haemodynamic monitoring during endovascular revascularisation. TP increased significantly immediately after completion of the successful intervention, whereas tcpO2 did not. Both TP and tcpO2 demonstrated a significant increase at the 10 week follow up.
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Affiliation(s)
- Thordur Gunnarsson
- Faculty of Medicine, Lund University, Lund, Sweden; Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden.
| | - Hans Lindgren
- Faculty of Medicine, Lund University, Lund, Sweden; Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | - Anders Gottsäter
- Faculty of Medicine, Lund University, Lund, Sweden; Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden
| | - Håkan Pärsson
- Department of Biomedical and Clinical Sciences, Medical Faculty, Linköping University, Linköping, Sweden
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Goncalves LN, van den Hoven P, van Schaik J, Leeuwenburgh L, Hendricks CHF, Verduijn PS, van der Bogt KEA, van Rijswijk CSP, Schepers A, Vahrmeijer AL, Hamming JF, van der Vorst JR. Perfusion Parameters in Near-Infrared Fluorescence Imaging with Indocyanine Green: A Systematic Review of the Literature. Life (Basel) 2021; 11:life11050433. [PMID: 34064948 PMCID: PMC8151115 DOI: 10.3390/life11050433] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/01/2021] [Accepted: 05/05/2021] [Indexed: 01/16/2023] Open
Abstract
(1) Background: Near-infrared fluorescence imaging is a technique capable of assessing tissue perfusion and has been adopted in various fields including plastic surgery, vascular surgery, coronary arterial disease, and gastrointestinal surgery. While the usefulness of this technique has been broadly explored, there is a large variety in the calculation of perfusion parameters. In this systematic review, we aim to provide a detailed overview of current perfusion parameters, and determine the perfusion parameters with the most potential for application in near-infrared fluorescence imaging. (2) Methods: A comprehensive search of the literature was performed in Pubmed, Embase, Medline, and Cochrane Review. We included all clinical studies referencing near-infrared perfusion parameters. (3) Results: A total of 1511 articles were found, of which, 113 were suitable for review, with a final selection of 59 articles. Near-infrared fluorescence imaging parameters are heterogeneous in their correlation to perfusion. Time-related parameters appear superior to absolute intensity parameters in a clinical setting. (4) Conclusions: This literature review demonstrates the variety of parameters selected for the quantification of perfusion in near-infrared fluorescence imaging.
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Pärsson HN, Lundin N, Lindgren H. 2D perfusion-angiography during endovascular intervention for critical limb threatening ischemia - A feasibility study. JRSM Cardiovasc Dis 2020; 9:2048004020915392. [PMID: 32284859 PMCID: PMC7133075 DOI: 10.1177/2048004020915392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 02/05/2020] [Accepted: 02/27/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Two-dimensional perfusion angiography is a new method to quantify and evaluate tissue perfusion during endovascular intervention. The aim was to evaluate time-patterns and dynamics of contrast arrival and distribution before and after endovascular intervention in patients with critical limb threatening ischemia. Methods Data were collected from 37 patients with critical limb threatening ischemia due to infra-inguinal occlusive disease having a successful endovascular procedure. two-dimensional perfusion angiography was used as a post-processing software with analysis of numeric parameters related to arrival and distribution patterns of contrast. Results Thirty-three patients were successfully analysed whereas four patients were excluded due to motion artefacts. All patients were successfully treated with recanalization of the superficial femoral, popliteal, below the knee-vessels or a combination. Short-term improvement at 30-day follow-up was noted both clinically and by ankle-brachial index and toe pressure measurements. A significant reduction in contrast arrival time between pre-and post-angioplasty runs was noted as measured by arrival time median 3.2 and interquartile range (2.5–4.2) vs. 2.6 (1.6–3.4) and time-to-peak 4.1 (3.6–5.0) vs. 3.1 (2.3–3.9) p = 0.009. An increased wash-in rate was also observed 18.3 (12.6–21) vs. 30.1 (22–30.5) p = 0.001 between pre-and post-angioplasty runs. Conclusions The use of perfusion angiography for evaluation of foot-circulation during endovascular interventions provides new information regarding quantitative assessment of contrast inflow before and after endovascular intervention without the need for extra contrast or runs. No selective catheterisation is necessary. The technique is easily adopted in a clinical setting. Further studies are necessary to create robust clinical endpoints.
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Affiliation(s)
- Håkan N Pärsson
- Department of Experimental Medicine and Surgery, Medical faculty, Linköping University, Linkoping, Sweden
| | - Niklas Lundin
- Medicinska Fakulteten, Lunds Universitet, Malmö, Sweden
| | - Hans Lindgren
- Faculty of Medicine, Lunds University, Helsingborg, Sweden
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10
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Photodynamic therapy for atherosclerosis. The potential of indocyanine green. Photodiagnosis Photodyn Ther 2020; 29:101568. [DOI: 10.1016/j.pdpdt.2019.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 10/01/2019] [Accepted: 10/04/2019] [Indexed: 12/29/2022]
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Marcoccia A, Klein-Weigel PF, Gschwandtner ME, Wautrecht JC, Matuska J, Rother U, Houben AJHM. Microcirculatory assessment of vascular diseases. VASA 2020; 49:175-186. [PMID: 32040388 DOI: 10.1024/0301-1526/a000851] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The term "microcirculation" refers to the terminal vascular network of the body, which includes arterioles, capillaries, venules as well as initial lymphatic vessels. Additionally, it insinuates to their unique function in thermoregulation, fluid balance, maintenance of cellular exchange, and metabolism. Disturbances of microvascular function were identified to precede macrovascular involvement in the presence of cardiovascular risk factors and is the hallmark of terminal disease stages like critical limb or acral ischemia. Nevertheless, despite its obvious significance in vascular medicine assessment of microvascular function became increasingly neglected in the clinical institutions during the last decades and seems to play a subordinary role in medical education. We therefore provide an overview over relevant and clinically practicable methods to assess microcirculation in vascular medicine with critical estimations of their pros and cons and their perspectives in the future.
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Affiliation(s)
- Antonella Marcoccia
- Unità di Medicina Vascolare e Autoimmunità, CRIIS-Centro di riferimento interdisciplinare per la Sclerosi Sistemica, Rome, Italy
| | - Peter F Klein-Weigel
- Klinik für Angiologie, Zentrum für Innere Medizin II, Ernst von Bergmann Klinikum, Potsdam, Germany
| | - Michael E Gschwandtner
- Medizinische Universtiät Wien, Universitätsklinik für Innere Medizin II, Klinische Abteilung für Angiologie, Vienna, Austria
| | - Jean Claude Wautrecht
- Service de Pathologie Vasculaire, Hôpital ERASME, Université Libre de Bruxelle, Brussels, Belgium
| | - Jiri Matuska
- MATMED s.r.o., Private Angiology Facility, Hodonin, Czech Republic
| | - Ulrich Rother
- Gefäßchirurgische Abteilung, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Alfons J H M Houben
- Department of Internal Medicine, School for Cardiovascular Diseases CARIM; Maastricht University Medical Center+, Maastricht, The Netherlands
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Seinturier C, Blaise S, Tiffet T, Provencher CB, Cracowski JL, Pernod G, Carpentier P. Fluorescence angiography compared to toe blood pressure in the evaluation of severe limb ischemia. VASA 2020; 49:230-234. [PMID: 32026753 DOI: 10.1024/0301-1526/a000853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: Severity of limb ischemia in peripheral arterial disease (PAD) patients is usually evaluated by clinical assessment and toe blood pressure (TBP) or transcutaneous oxygen pressures (TcPO 2). Indocyanin green angiography (IGA) is a promising tool generating a foot cartography of skin microvascular perfusion. However, there is no consensus about the fluorescence parameters that should be used to evaluate ischemia. The purpose of this cross-sectional evaluation and 3-month clinical follow-up was to determine the best fluorescence parameter for the evaluation of severe PAD, using TBP as reference. Patients and methods: IGA was realized in patients with clinical suspicion of CLI in addition to TBP and TcPO 2. Parameters from the time intensity fluorescence curve measured on the foot were compared with TBP (primary reference), and with TcPO2. Clinical outcomes (amputation, revascularization, death) were recorded at 3 months follow-up. Results: Thirty-four patients were included and IGA could be analysed in 29 of them. When all limbs were studied, no significant correlation was found between any of the measured fluorescence parameters (saturation time, ingress slope, amplitude, delay) and TBP pressure neither TCPO2. In the limbs with CLI, a significant correlation between the TBP and amplitude on the forefoot was found. According to the outcome, none of the fluorescence parameters showed a significant prognostic value in contrast to the significant results for TBP and TcPO2. Conclusions: In this study, quantitative analysis of IGA parameters did not show any prognostic value, nor was there any significant statistical association with well-established prognostic parameters such as TBP and TcPO 2 in patients with suspected CLI. A correlation was found between amplitude and TBP in patients with CLI. Topographical information such as perfusion heterogeneity was not evaluated and remains a valuable target to be investigated.
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Affiliation(s)
- Christophe Seinturier
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, Grenoble, France
| | - Sophie Blaise
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, Grenoble, France
| | - Théophile Tiffet
- Clinical Pharmacology Department, Grenoble-Alpes University Hospital, Grenoble, France
| | | | - Jean Luc Cracowski
- Clinical Pharmacology Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Gilles Pernod
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, Grenoble, France
| | - Patrick Carpentier
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, Grenoble, France
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van den Hoven P, Ooms S, van Manen L, van der Bogt KEA, van Schaik J, Hamming JF, Vahrmeijer AL, van der Vorst JR, Mieog JSD. A systematic review of the use of near-infrared fluorescence imaging in patients with peripheral artery disease. J Vasc Surg 2020; 70:286-297.e1. [PMID: 31230648 DOI: 10.1016/j.jvs.2018.11.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/19/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE In the diagnosis of peripheral artery disease (PAD), the ankle-brachial index plays an important role. However, results of the ankle-brachial index are unreliable in patients with severe media sclerosis. Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) can provide information about tissue perfusion and has already been studied in oncologic, reconstructive, and cardiac surgery. For patients with PAD, this technique might give insight into skin perfusion and thereby guide treatment. We performed a systematic review of the literature on the use of NIR fluorescence imaging in patients with PAD. METHODS PubMed, MEDLINE, Embase, and Cochrane were searched for articles and abstracts on the application of NIR fluorescence imaging using ICG as fluorescent dye in patients with PAD. Our search strategy combined the terms "fluorescence," "ICG," or synonyms and "peripheral artery disease" or synonyms. The extracted data included fluorescence parameters and test characteristics for diagnosis of PAD. RESULTS Twenty-three articles were found eligible for this review using 18 different parameters for evaluation of the fluorescence signal intensity. NIR fluorescence imaging was used for four main indications: diagnosis, quality control in revascularization, guidance in amputation surgery, and visualization of vascular structures. For the diagnosis of PAD, NIR fluorescence imaging yields a sensitivity ranging from 67% to 100% and a specificity varying between 72% and 100%. Significant increases in multiple fluorescence parameters were found in comparing patients before and after revascularization. CONCLUSIONS NIR fluorescence imaging can be used for several indications in patients with PAD. NIR fluorescence imaging seems promising in diagnosis of PAD and guidance of surgeons in treatment, especially in patients in whom current diagnostic methods are not applicable. Further standardization is needed to reliably use this modality in patients with PAD.
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Affiliation(s)
- Pim van den Hoven
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Ooms
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Labrinus van Manen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jan van Schaik
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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Antonopoulos CN, Lazaris A, Venermo M, Geroulakos G. Predictors of Wound Healing Following Revascularization for Chronic Limb-Threatening Ischemia. Vasc Endovascular Surg 2019; 53:649-657. [PMID: 31405350 DOI: 10.1177/1538574419868863] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES After surgical or endovascular revascularization, some ischemic lesions will not heal, while some others will heal at a variable period of time from the intervention, indicating a multifactorial interaction between local and systematic "wound healing-promoting" factors. Our objective was to identify predictors of wound healing following revascularization for chronic limb-threatening ischemia (CLTI). METHODS A literature review was performed to identify published research concerning clinical, biochemical, and noninvasive methods as predictors of wound healing time and wound-free period after surgical and endovascular revascularization for CLTI. RESULTS Our review indicated that potential predictors included local wound factors, wound depth, patient's comorbidities, medications, smoking and alcohol abuse, poor vessel runoff, and direct versus indirect revascularization. Among the clinical biomarkers, platelet-derived growth factor, transforming growth factor β, basic fibroblast growth factor, tumor necrosis factor α, interleukin (IL) 1, and IL-6 have been proposed as potential predictors. Furthermore, the potential of noninvasive microcirculation assessment to predict proper wound healing has been the topic of extensive investigation. Among the novel methods, transcutaneous measurement of oxygen partial pressure, skin perfusion pressure, oxygen-to-see method, indocyanine green fluorescence imaging, and multispectral optoacoustic tomography have shown promising results. CONCLUSIONS The risk factor profile of an ischemic lesion in the lower extremities with a delayed/failed healing response, following a successful revascularization, is not fully clarified. Although many predictors have been assessed so far, further research needs to be done to identify the optimal clinical and biochemical indices and the noninvasive technique assessing the microcirculation that is associated with complete wound healing.
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Affiliation(s)
| | - Andreas Lazaris
- Department of Vascular Surgery, "Attikon" University Hospital, Athens, Greece
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, Athens, Greece
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15
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Wang Y, Zhan Y, Harris LM, Khan S, Xia J. A portable three-dimensional photoacoustic tomography system for imaging of chronic foot ulcers. Quant Imaging Med Surg 2019; 9:799-806. [PMID: 31281775 DOI: 10.21037/qims.2019.05.02] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Chronic leg ulcers affect approximately 6.5 million Americans and the disorder is associated with a range of serious complications. Since many chronic ulcers have underlying vascular insufficiency, accurate assessment of tissue perfusion is critical to treatment planning and post-surgical monitoring. However, existing clinical tests fail to meet this need in practice due to their low sensitivity or accuracy. Methods In this paper, we introduce a portable photoacoustic tomography (PAT) system for wound assessment. Since hemoglobin serves as the major endogenous contrast at near-infrared wavelengths, PAT provides label-free, three-dimensional (3D) imaging of hemoglobin distribution, which is closely related to blood perfusion. The proposed system consists of a 128-element linear transducer array, a data acquisition (DAQ) system, and a pulsed Nd:YAG laser source, all mounted on a portable cart for easy clinical testing. Results We validated our system through both phantom and human imaging studies. The phantom imaging results indicate that the system's spatial resolution ranges from 0.5 mm along the axial direction to 1.3 mm along the elevational direction. The healthy volunteer result shows clear foot vasculature, indicating good perfusion. The preliminary patient imaging results agree very well with the clinical test, demonstrating that PAT has a high potential for assessing the circulation around the wound. Conclusions We believe that our technique will be a valuable tool for assessing tissue perfusion and guiding wound treatment in vascular clinics.
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Affiliation(s)
- Yuehang Wang
- Department of Biomedical Engineering, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Ye Zhan
- Department of Biomedical Engineering, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Linda M Harris
- Department of Surgery, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Sikandar Khan
- Department of Surgery, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Jun Xia
- Department of Biomedical Engineering, University at Buffalo, The State University of New York, Buffalo, New York, USA
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16
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Duprée A, Rieß H, Detter C, Debus ES, Wipper SH. Utilization of indocynanine green fluorescent imaging (ICG-FI) for the assessment of microperfusion in vascular medicine. Innov Surg Sci 2018; 3:193-201. [PMID: 31579783 PMCID: PMC6604578 DOI: 10.1515/iss-2018-0014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/26/2018] [Indexed: 01/06/2023] Open
Abstract
Intraoperative valuation of organ and tissue microperfusion is always a current topic in different surgical situations. Although indocyanine green fluorescent imaging (ICG-FI) has turned to be a more and more common technique to evaluate organ perfusion, only few studies tried to quantitatively validate the technique for microperfusion assessment. The aim of the following manuscript is to present the results of our interdisciplinary research confirming additional quantitative assessment tools in different surgical conditions. Thus, we are implementing the background-subtracted peak fluorescent intensity (BSFI), the slope of fluorescence intensity (SFI), and the time to slope (TTS) using ICG-FI in several regions of interest (ROI).
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Affiliation(s)
- Anna Duprée
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
- Anna Dupréee and Henrik Rieß contributed equally to the manuscript
| | - Henrik Rieß
- Department of Vascular Medicine, University Heart Center, University Medical Center, Hamburg-Eppendorf, Germany
- Anna Dupréee and Henrik Rieß contributed equally to the manuscript
| | - Christian Detter
- Centre of Cardiology and Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Eike S. Debus
- Department of Vascular Medicine, University Heart Center, University Medical Center, Hamburg-Eppendorf, Germany
| | - Sabine H. Wipper
- Department of Vascular Medicine, University Heart Center, University Medical Center, Hamburg-Eppendorf, Germany
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Stimpson AL, Dilaver N, Bosanquet DC, Ambler GK, Twine CP. Angiosome Specific Revascularisation: Does the Evidence Support It? Eur J Vasc Endovasc Surg 2018; 57:311-317. [PMID: 30172663 DOI: 10.1016/j.ejvs.2018.07.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To explain the angiosome concept and explore the practical application of the angiosome literature to a clinical scenario, in this case a tibial angioplasty for critical ischaemia. METHODS Clinical vignette with explanation of the decisions made and subsequent clinical results based on the theory of the angiosome concept and the literature on angiosomal revascularisation; in this case the results of our group's recent update to a systematic review and meta-analysis. RESULTS Endovascular combined or direct angiosomal revascularisation if superior to indirect revascularisation. This was borne out in the clinical scenario, where an indirect peroneal reperfusion of the AT angiosome resulted in major amputation. Open surgery is less dependent on the angiosome concept. The presence of adequate collateralisation into a foot arch seems to be the most important factor predicting success of indirect revascularisation. The evidence for both suffers from selection bias and many of the findings in the literature are wholly due to selection bias. CONCLUSION The angiosome concept is useful during both open and endovascular tibial revascularisation. However, the runoff in the foot is critical to success and may not follow the 'classic' angiosome model in diabetes.
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Affiliation(s)
- A L Stimpson
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| | - N Dilaver
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| | - D C Bosanquet
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| | - G K Ambler
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK; Division of Population Medicine, Cardiff University, 3rd Floor Neuadd Meirionnydd, Cardiff, UK
| | - C P Twine
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK; Division of Population Medicine, Cardiff University, 3rd Floor Neuadd Meirionnydd, Cardiff, UK.
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Rother U, Lang W, Horch RE, Ludolph I, Meyer A, Gefeller O, Regus S. Pilot Assessment of the Angiosome Concept by Intra-operative Fluorescence Angiography After Tibial Bypass Surgery. Eur J Vasc Endovasc Surg 2018; 55:215-221. [PMID: 29305093 DOI: 10.1016/j.ejvs.2017.11.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 11/26/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The "angiosome" concept as a model for decision making in revascularisation of patients with critical limb ischaemia (CLI) has been subject to lively discussion in recent years. The aim of this prospective pilot study was to use intra-operative fluorescence angiography to provide further data on the angiosome concept on the level of microcirculation after tibial bypass surgery. DESIGN, MATERIALS, AND METHODS This was a prospective analysis of 40 patients presenting with CLI Rutherford stage IV to VI before and after tibial bypass surgery. The macrocirculation was measured by the ankle brachial index. Skin microcirculation was assessed by intra-operative fluorescence angiography. The alteration of microcirculation was compared in direct and indirect revascularised angiosomes. Clinical follow-up investigations were performed and the wound healing rate was compared between the different revascularisation methods. RESULTS Cumulated microcirculation parameters showed a significant improvement after surgery (ingress, ingress rate p<.001). Likewise, general microcirculatory improvement was observed in each foot angiosome after revascularisation, regardless of the tibial artery revascularised. Furthermore, a comparison of the direct (DR) and the indirect revascularised (IR) angiosomes did not show a significant difference concerning the improvement of microcirculation (difference DR-IR, ingress: 1.69, 95% CI 71.73-75.11; ingress rate: 0.08, 95% CI -12.91 to 13.07). The wound healing rate was similar in both groups, although the time to wound healing was faster by on average 2.5 months in the DR group (p=.083). CONCLUSION Microcirculatory improvement was seen over the whole foot after tibial bypass. Therefore, fluorescence angiography is a promising tool to evaluate the angiosome concept in future larger studies. Clinicaltrials.gov: NCT03012750.
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Affiliation(s)
- Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany.
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Olaf Gefeller
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Susanne Regus
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
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Wada T, Kawada K, Takahashi R, Yoshitomi M, Hida K, Hasegawa S, Sakai Y. ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoscopic colorectal surgery. Surg Endosc 2017; 31:4184-4193. [PMID: 28281123 DOI: 10.1007/s00464-017-5475-3] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/15/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fluorescence technology with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. However, a subjective evaluation of fluorescence intensity based on the surgeon's visual judgement is a major limitation. This study evaluated the quantitative assessment of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery. METHODS This is a retrospective analysis of a prospectively maintained database of 112 patients who underwent laparoscopic surgery for left-sided colorectal cancers. After distal transection of the bowel, the specimen was extracted extracorporeally and then the proximal colon was divided within the well-perfused area based on the ICG fluorescence imaging. We evaluated whether quantitative assessment of intestinal perfusion by measuring ICG intensity could predict postoperative outcomes: F max, T max, T 1/2, and Slope were calculated. RESULTS Anastomotic leakage (AL) occurred in 5 cases (4.5%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 18 cases (16.1%). Among the 18 patients, AL occurred in 4 patients (4/18: 22.2%), whereas it occurred in only 1 case (1/94: 1.0%) in the good perfusion patients who did not need proximal change of the transection line. The F max of the AL group was less than 52.0 in all 5 cases (5/5), whereas that of the non-AL group was in only 8 cases (8/107): with an F max cutoff value of 52.0, the sensitivity and specificity for the prediction of AL were 100 and 92.5%, respectively. Regarding postoperative bowel movement recovery, the T max of the early flatus group or early defecation group was significantly lower than that of the late flatus group or late defecation group, respectively. CONCLUSIONS ICG fluorescence imaging is useful for assessing anastomotic perfusion in colorectal surgery, which can result in more precise operative decisions tailored for an individual patient.
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Affiliation(s)
- Toshiaki Wada
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kenji Kawada
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Ryo Takahashi
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Mami Yoshitomi
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Settembre N, Kauhanen P, Albäck A, Spillerova K, Venermo M. Quality Control of the Foot Revascularization Using Indocyanine Green Fluorescence Imaging. World J Surg 2017; 41:1919-1926. [DOI: 10.1007/s00268-017-3950-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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