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van Erk M, Lomme RMLM, Roozen EA, van Oirschot BAJA, van Goor H. A novel ex vivo perfusion-based mandibular pig model for dental product testing and training. BMC Oral Health 2023; 23:122. [PMID: 36823579 PMCID: PMC9948382 DOI: 10.1186/s12903-023-02794-6] [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: 08/28/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND A translational ex vivo perfusion-based mandibular pig model was developed as an alternative to animal experiments, for initial assessment of biomaterials in dental and maxillofacial surgery and training. This study aimed to assess the face and content validity of the novel perfusion-based model. METHODS Cadaveric porcine heads were connected to an organ assist perfusion device for blood circulation and tissue oxygenation. Dental professionals and dental trainees performed a surgical procedure on the mandibula resembling a submandibular extraoral incision to create bone defects. The bone defects were filled and covered with a commercial barrier membrane. All participants completed a questionnaire using a 5-point Likert scale to assess the face and content validity of the model. Validation data between the two groups of participants were compared with Mann-Whitney U test. RESULTS Ten dental professionals and seven trainees evaluated the model for face and content validity. Participants reported model realism, with a mean face validity score of 3.9 ± 1.0 and a content validity of 4.1 ± 0.8. No significant differences were found for overall face and content validity between experts and trainees. CONCLUSION We established face and content validity in a novel perfusion-based mandibular surgery model. This model can be used as an alternative for animal studies evaluating new biomaterials and related dental and maxillofacial surgical procedural training.
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Affiliation(s)
- Machteld van Erk
- Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Roger M. L. M. Lomme
- grid.10417.330000 0004 0444 9382Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Edwin A. Roozen
- grid.10417.330000 0004 0444 9382Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Bart A. J. A. van Oirschot
- grid.10417.330000 0004 0444 9382Department of Dentistry – Regenerative Biomaterials, Radboud University Medical Centre, Philips van Leydenlaan 25, 6525 EX Nijmegen, The Netherlands
| | - Harry van Goor
- grid.10417.330000 0004 0444 9382Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Mulica M, Horch RE, Arkudas A, Cai A, Müller-Seubert W, Hauck T, Ludolph I. Does indocyanine green fluorescence angiography impact the intraoperative choice of procedure in free vascularized medial femoral condyle grafting for scaphoid nonunions? Front Surg 2022; 9:962450. [PMID: 36117816 PMCID: PMC9478374 DOI: 10.3389/fsurg.2022.962450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Free vascularized medial femoral condyle (MFC) bone grafts can lead to increased vascularity of the proximal pole and restore scaphoid architecture in scaphoid nonunions. The intraoperative perfusion assessment of the bone graft is challenging because the conventional clinical examination is difficult. Indocyanine green (ICG) angiography has previously been shown to provide a real-time intraoperative evaluation of soft tissue perfusion in reconstructive surgery. The present study investigated the utility of ICG angiography in patients treated with a free medial femoral condyle graft for scaphoid nonunions. Methods We performed a retrospective analysis of patients with scaphoid nonunions, in which ICG angiography was used intraoperatively for perfusion assessment. The medical records, radiographs, intraoperative imaging, and operative reports of all patients were reviewed. Intraoperative ICG dye was administered intravenously, and laser angiography was performed to assess bone perfusion. The scaphoid union was examined using postoperative CT scans. Results Two patients had documented osteonecrosis of the proximal pole at the time of surgery. Four patients received a nonvascularized prior bone graft procedure, and a prior spongiosa graft procedure was performed in one patient. The mean time from injury to the MFC bone graft surgery was 52.7 months, and the mean time from prior failed surgery was 10.4 months. Perfusion of the vascular pedicle of the MFC and the periosteum could be detected in all patients. In two patients, even perfusion of the cancellous bone could be demonstrated by ICG angiography. Following transplantation of the bone graft, patency of the vascular anastomosis and perfusion of the periost were confirmed by ICG angiography in the assessed cases. No additional surgery regarding a salvage procedure for a scaphoid nonunion advanced collapse was necessary for the further course. Conclusion ICG-angiography has shown to be a promising tool in the treatment of scaphoid nonunion with medial femoral condyle bone grafts. It enables intraoperative decision making by assessment of the microvascular blood supply of the periosteum and the vascular pedicle of the MFC bone graft. Further studies need to evaluate the impact on union rates in a long-term follow-up.
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Wu Y, Yu Y, Wang Z, Gao S, Zhang D, Yu A. NIR-II imaging with ICG for identifying perforators, assessing flap status and predicting division timing of pedicled flaps in a porcine model. JOURNAL OF BIOPHOTONICS 2022; 15:e202200061. [PMID: 35474297 DOI: 10.1002/jbio.202200061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 06/14/2023]
Abstract
The use of skin flaps to fill large defects is a key surgical technique in reconstructive surgery, effective real-time in vivo imaging for flap design and use is urgent. Currently, fluorescent imaging in the second NIR window (NIR-II; 1000-1700 nm) is characterized by non-radiation, less expensive and higher resolution in comparisons with the first NIR window (NIR-I; 700-900 nm) and other traditional imaging modalities. In this article, we identified the location and numbers of perforators and choke zone via NIR-II imaging. Then, eight abdominal perforator flaps were established and the perfusion zones were evaluatedat special time points. Finally, after eight pedicled flaps establishment, NIR-II imaging was used to guide the optimal timing for division of flap pedicle. The results showed that NIR-II fluorescence imaging with indocyanine green (ICG) can reliably visualize vascular supply, which makes it to be an accurate and in vivo imaging approach to flap clinical design and use.
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Affiliation(s)
- Yifan Wu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yifeng Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zheng Wang
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Siqi Gao
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong Zhang
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Aixi Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
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Han X, Demidov V, Vaze VS, Jiang S, Gitajn IL, Elliott JT. Spatial and temporal patterns in dynamic-contrast enhanced intraoperative fluorescence imaging enable classification of bone perfusion in patients undergoing leg amputation. BIOMEDICAL OPTICS EXPRESS 2022; 13:3171-3186. [PMID: 35781962 PMCID: PMC9208615 DOI: 10.1364/boe.459497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 06/15/2023]
Abstract
Dynamic contrast-enhanced fluorescence imaging (DCE-FI) classification of tissue viability in twelve adult patients undergoing below knee leg amputation is presented. During amputation and with the distal bone exposed, indocyanine green contrast-enhanced images were acquired sequentially during baseline, following transverse osteotomy and following periosteal stripping, offering a uniquely well-controlled fluorescence dataset. An unsupervised classification machine leveraging 21 different spatiotemporal features was trained and evaluated by cross-validation in 3.5 million regions-of-interest obtained from 9 patients, demonstrating accurate stratification into normal, suspicious, and compromised regions. The machine learning (ML) approach also outperformed the standard method of using fluorescence intensity only to evaluate tissue perfusion by a two-fold increase in accuracy. The generalizability of the machine was evaluated in image series acquired in an additional three patients, confirming the stability of the model and ability to sort future patient image-sets into viability categories.
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Affiliation(s)
- Xinyue Han
- Thayer School of Engineering, Dartmouth College, 14 Engineering Dr., Hanover, NH 03755, USA
- Contributed equally
| | - Valentin Demidov
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Dartmouth Health, 1 Medical Center Dr., Lebanon, NH 03766, USA
- Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd, Hanover, NH 03755, USA
- Contributed equally
| | - Vikrant S. Vaze
- Thayer School of Engineering, Dartmouth College, 14 Engineering Dr., Hanover, NH 03755, USA
| | - Shudong Jiang
- Thayer School of Engineering, Dartmouth College, 14 Engineering Dr., Hanover, NH 03755, USA
| | - Ida Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Dartmouth Health, 1 Medical Center Dr., Lebanon, NH 03766, USA
- Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd, Hanover, NH 03755, USA
| | - Jonathan T. Elliott
- Thayer School of Engineering, Dartmouth College, 14 Engineering Dr., Hanover, NH 03755, USA
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Dartmouth Health, 1 Medical Center Dr., Lebanon, NH 03766, USA
- Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd, Hanover, NH 03755, USA
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Michi M, Madu M, Winters HAH, de Bruin DM, van der Vorst JR, Driessen C. Near-Infrared Fluorescence with Indocyanine Green to Assess Bone Perfusion: A Systematic Review. Life (Basel) 2022; 12:life12020154. [PMID: 35207442 PMCID: PMC8875533 DOI: 10.3390/life12020154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Adequate perfusion of a bone flap is essential for successful reconstruction of osseous defects. Unfortunately, complications related to inadequate bone perfusion are common. Near-infrared fluorescence (NIRF) imaging enables intraoperative visualization of perfusion. NIRF has been investigated in reconstructive surgery to aid the surgeon in clinical perioperative assessment of soft tissue perfusion. However, little is known on the beneficial use of NIRF to assess bone perfusion. Therefore, the aim of this review was to search for studies evaluating NIRF to assess bone perfusion. Methods: A systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, was performed. Studies up to October 2021 were included. We extracted data regarding the study population, size and design, reported objective fluorescence parameters and the methodology used for fluorescence imaging and processing. Results: Ten articles were included. Studies reported unevenly on the protocol used for NIRF imaging. Five studies reported objective parameters. Absolute and relative perfusion parameters and parameters derived from maximum fluorescence were reported. The clinical significance of these parameters has not been evaluated in humans. Conclusion: The evidence on bone perfusion as measured with NIRF is limited. More clinical studies are required.
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Affiliation(s)
- Marlies Michi
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Correspondence:
| | - Max Madu
- Department of Plastic Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.M.); (H.A.H.W.); (C.D.)
| | - Henri A. H. Winters
- Department of Plastic Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.M.); (H.A.H.W.); (C.D.)
| | - Daniel M. de Bruin
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
- Department of Urology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Joost R. van der Vorst
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Caroline Driessen
- Department of Plastic Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.M.); (H.A.H.W.); (C.D.)
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Reece EM, Davis MJ, Wagner RD, Abu-Ghname A, Cruz A, Kaung G, Verla T, Winocour S, Ropper AE. Vascularized Bone Grafts for Spinal Fusion-Part 1: The Iliac Crest. Oper Neurosurg (Hagerstown) 2021; 20:493-496. [PMID: 33616183 DOI: 10.1093/ons/opab037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 12/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Iliac crest autograft has been the gold standard for harvest of fusion materials in spine surgery. The benefits of a vascularized version of this bone graft-including delivery of stem cells, ability to deliver antibiotics to the fusion bed, and relative ease of harvest-make this technique superior to free bone transfer in the achievement of augmented spinal fusion. OBJECTIVE To present a brief summary of similar existing concepts before describing the novel technique of this vascularized posterior iliac crest bone graft. METHODS Vascularized posterior iliac crest bone graft can be harvested from the same midline lumbar incision used for thoracolumbar spinal fusion, through lateral dissection around the paraspinals to the iliac crest. Recipient sites in the posterolateral bony spinal gutters may be as rostral as T12 and caudal as the sacrum. The ability to cover multiple lumbar levels can be achieved with desired lengths of the donor iliac crest. RESULTS Over 14 vascularized iliac crest bone grafts have been performed to augment lumbar fusion for salvage after pseudoarthrosis. Operative time and bleeding are reduced compared to free flap procedures, and no patients have experienced any complications related to these grafts. Indocyanine green (ICG) angiography has been utilized in a novel way to ensure the vascularity of the bone graft prior to arthrodesis. CONCLUSION While long-term follow-up will be required to fully characterize fusion rates and patient morbidity, this innovative surgical option augments spinal fusion in patients with, or at increased risk for, pseudoarthrosis.
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Affiliation(s)
- Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Ryan D Wagner
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Alex Cruz
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Geoffrey Kaung
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sebastian Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Muangsiri P, Tanjapatkul R, Sriswadpong P, Jomkoh P, Jirawatnotai S. Indocyanine Green Fluorescence Angiography of the Transverse Cervical Arterial Supply to Clavicle Flaps: An Anatomical Study. Otolaryngol Head Neck Surg 2021; 166:68-73. [PMID: 33784191 DOI: 10.1177/01945998211000432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the anatomy of the transverse cervical artery and to prove its perfusion to the clavicle using indocyanine green fluorescence angiography as an alternative vascularized bone for head and neck reconstruction. STUDY DESIGN Cadaveric dissection. SETTING Anatomy lab. METHODS Twenty-two necks and shoulders from 11 fresh-frozen cadavers were dissected. The transverse cervical artery diameter, length, emerging point, and the length of clavicle segment harvested were described. Photographic and near-infrared video recordings of the bone's medial and longitudinal cut surfaces were taken prior to, during, and after indocyanine green injection. RESULTS The transverse cervical artery originated from the thyrocervical trunk and emerged at the level of the medial one-third of the clavicle in 22 of 22 (100%) specimens. The average length of the pedicle was 3.6 cm (range, 2.2-4.4 cm), and the mean diameter was 2.5 mm (range, 1.8-3.4 mm). The harvested bone had a mean length of 5.1 cm (range, 4.3-5.8 cm). After injecting the indocyanine green, 22 of 22 (100%) specimens showed enhancement in the periosteum, bony cortex, and medulla. CONCLUSION The middle third of the clavicle can be reliably harvested as a vascularized bone with its perfusion solely from the transverse cervical artery pedicle, as shown by the near-infrared fluorescence imaging. The pedicle was sizable and constant in origin.
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Affiliation(s)
- Pichtat Muangsiri
- Department of Plastic and Reconstructive Surgery, Lerdsin Hospital, Bangkok, Thailand
| | - Rungkit Tanjapatkul
- Department of Plastic and Reconstructive Surgery, Lerdsin Hospital, Bangkok, Thailand
| | - Papat Sriswadpong
- Department of Plastic and Reconstructive Surgery, Lerdsin Hospital, Bangkok, Thailand
| | - Pojanan Jomkoh
- Department of Plastic and Reconstructive Surgery, Lerdsin Hospital, Bangkok, Thailand
| | - Supasid Jirawatnotai
- Department of Plastic and Reconstructive Surgery, Lerdsin Hospital, Bangkok, Thailand
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Humbert J, Will O, Peñate-Medina T, Peñate-Medina O, Jansen O, Both M, Glüer CC. Comparison of photoacoustic and fluorescence tomography for the in vivo imaging of ICG-labelled liposomes in the medullary cavity in mice. PHOTOACOUSTICS 2020; 20:100210. [PMID: 33101928 PMCID: PMC7569329 DOI: 10.1016/j.pacs.2020.100210] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 08/26/2020] [Accepted: 09/13/2020] [Indexed: 05/20/2023]
Abstract
Few reports quantitatively compare the performance of photoacoustic tomography (PAT) versus fluorescence molecular tomography (FMT) in vivo. We compared both modalities for the detection of signals from injected ICG liposomes in the tibial medullary space of 10 BALB/c mice in vivo and ex vivo. Signals significantly correlated between modalities (R² = 0.69) and within each modality in vivo versus ex vivo (PAT: R² = 0.70, FMT: R² = 0.76). Phantom studies showed that signals at 4 mm depth are detected down to 3.3 ng ICG by PAT and 33 ng by FMT, with a nominal spatial resolution below 0.5 mm in PAT and limited to 1 mm in FMT. Our study demonstrates comparable in vivo sensitivity, but superior ex vivo sensitivity and in vivo resolution for our ICG liposomes of the VevoLAZR versus the FMT2500. PAT provides a useful new tool for the high-resolution imaging of bone marrow signals, for example for monitoring drug delivery.
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Key Words
- % ID, percent initial dose
- % PA signal, percent photoacoustic signal
- BMD, bone mineral density
- Bone
- DXA, dual-energy x-ray absorptiometry
- FLI, fluorescence imaging
- FMT, fluorescence molecular tomography
- Fluorescence imaging
- Hb, deoxygenated hemoglobin
- HbO2, oxygenated hemoglobin
- ICG, indocyanine green
- In vivo imaging
- LDF, laser-doppler flowmetry
- Liposomes
- M, mean
- Medullary space
- NIR, near-infrared
- PAI, photoacoustic imaging
- PAT, photoacoustic tomography
- Photoacoustic imaging
- QUS, quantitative ultrasound
- RFU, relative fluorescence units
- SD, standard deviation
- SEM, standard error of the mean
- Tibia
- US, ultrasound
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Affiliation(s)
- Jana Humbert
- Section Biomedical Imaging, Molecular Imaging North Competence Center (MOIN CC), Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Am Botanischen Garten 14, 24118 Kiel, Germany
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Arnold-Heller-Straße 3, 24105 Kiel, Germany
- Corresponding author at: Molecular Imaging North Competence Center (MOIN CC), Am Botanischen Garten 14, 24118 Kiel, Germany.
| | - Olga Will
- Section Biomedical Imaging, Molecular Imaging North Competence Center (MOIN CC), Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Am Botanischen Garten 14, 24118 Kiel, Germany
| | - Tuula Peñate-Medina
- Section Biomedical Imaging, Molecular Imaging North Competence Center (MOIN CC), Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Am Botanischen Garten 14, 24118 Kiel, Germany
| | - Oula Peñate-Medina
- Section Biomedical Imaging, Molecular Imaging North Competence Center (MOIN CC), Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Am Botanischen Garten 14, 24118 Kiel, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Arnold-Heller-Straße 3, 24105 Kiel, Germany
| | - Marcus Both
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Arnold-Heller-Straße 3, 24105 Kiel, Germany
| | - Claus-Christian Glüer
- Section Biomedical Imaging, Molecular Imaging North Competence Center (MOIN CC), Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Am Botanischen Garten 14, 24118 Kiel, Germany
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Gitajn IL, Slobogean GP, Henderson ER, von Keudell AG, Harris MB, Scolaro JA, O’Hara NN, Elliott JT, Pogue BW, Jiang S. Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery. JOURNAL OF BIOMEDICAL OPTICS 2020; 25:JBO-200070-PER. [PMID: 32869567 PMCID: PMC7457961 DOI: 10.1117/1.jbo.25.8.080601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Abstract
SIGNIFICANCE Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues. AIM The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery. APPROACH The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative. RESULTS Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management. CONCLUSION While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.
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Affiliation(s)
- Ida L. Gitajn
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire, United States
| | - Gerard P. Slobogean
- University of Maryland, Orthopaedic Associates, Baltimore, Maryland, United States
| | - Eric R. Henderson
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire, United States
| | - Arvind G. von Keudell
- Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, United States
| | - Mitchel B. Harris
- Massachusetts General Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, United States
| | - John A. Scolaro
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, California, United States
| | - Nathan N. O’Hara
- University of Maryland, Orthopaedic Associates, Baltimore, Maryland, United States
| | - Jonathan T. Elliott
- Dartmouth-Hitchcock Medical Center, Department of Surgery, Lebanon, New Hampshire, United States
| | - Brian W. Pogue
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Shudong Jiang
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
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10
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Gioux S, Mazhar A, Cuccia DJ. Spatial frequency domain imaging in 2019: principles, applications, and perspectives. JOURNAL OF BIOMEDICAL OPTICS 2019; 24:1-18. [PMID: 31222987 PMCID: PMC6995958 DOI: 10.1117/1.jbo.24.7.071613] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/09/2019] [Indexed: 05/20/2023]
Abstract
Spatial frequency domain imaging (SFDI) has witnessed very rapid growth over the last decade, owing to its unique capabilities for imaging optical properties and chromophores over a large field-of-view and in a rapid manner. We provide a comprehensive review of the principles of this imaging method as of 2019, review the modeling of light propagation in this domain, describe acquisition methods, provide an understanding of the various implementations and their practical limitations, and finally review applications that have been published in the literature. Importantly, we also introduce a group effort by several key actors in the field for the dissemination of SFDI, including publications, advice in hardware and implementations, and processing code, all freely available online.
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Affiliation(s)
- Sylvain Gioux
- University of Strasbourg, ICube Laboratory, Strasbourg, France
- Address all correspondence to Sylvain Gioux, E-mail:
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11
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Gioux S, Mazhar A, Cuccia DJ. Spatial frequency domain imaging in 2019: principles, applications, and perspectives. JOURNAL OF BIOMEDICAL OPTICS 2019. [PMID: 31222987 DOI: 10.1117/1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Spatial frequency domain imaging (SFDI) has witnessed very rapid growth over the last decade, owing to its unique capabilities for imaging optical properties and chromophores over a large field-of-view and in a rapid manner. We provide a comprehensive review of the principles of this imaging method as of 2019, review the modeling of light propagation in this domain, describe acquisition methods, provide an understanding of the various implementations and their practical limitations, and finally review applications that have been published in the literature. Importantly, we also introduce a group effort by several key actors in the field for the dissemination of SFDI, including publications, advice in hardware and implementations, and processing code, all freely available online.
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Affiliation(s)
- Sylvain Gioux
- University of Strasbourg, ICube Laboratory, Strasbourg, France
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Aguénounon E, Dadouche F, Uhring W, Gioux S. Single snapshot of optical properties image quality improvement using anisotropic two-dimensional windows filtering. JOURNAL OF BIOMEDICAL OPTICS 2019; 24:1-21. [PMID: 30927346 PMCID: PMC6996016 DOI: 10.1117/1.jbo.24.7.071611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/12/2019] [Indexed: 05/04/2023]
Abstract
Imaging methods permitting real-time, wide-field, and quantitative optical mapping of biological tissue properties offer an unprecedented range of applications for clinical use. Following the development of spatial frequency domain imaging, we introduce a real-time demodulation method called single snapshot of optical properties (SSOPs). However, since this method uses only a single image to generate absorption and reduced scattering maps, it was limited by a degraded image quality resulting in artifacts that diminished its potential for clinical use. We present filtering strategies for improving the image quality of optical properties maps obtained using SSOPs. We investigate the effect of anisotropic two-dimensional filtering strategies for spatial frequencies ranging from 0.1 to 0.4 mm - 1 directly onto N = 10 hands. Both accuracy and image quality of the optical properties are quantified in comparison with standard, multiple image acquisitions in the spatial frequency domain. Overall, using optimized filters, mean errors in predicting optical properties using SSOP remain under 8.8% in absorption and 7.5% in reduced scattering, while significantly improving image quality. Overall this work contributes to advance real-time, wide-field, and quantitative diffuse optical imaging toward clinical evaluation.
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Affiliation(s)
| | - Foudil Dadouche
- University of Strasbourg, ICube Laboratory, Illkirch, France
| | - Wilfried Uhring
- University of Strasbourg, ICube Laboratory, Illkirch, France
| | - Sylvain Gioux
- University of Strasbourg, ICube Laboratory, Illkirch, France
- Address all correspondence to Sylvain Gioux, E-mail:
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Tyrell R, Kilmartin C, Acevedo E, Keshavamurthy S, Gassman A. Is non-invasive indocyanine-green angiography a useful adjunct for the debridement of infected sternal wounds? JPRAS Open 2018; 16:117-120. [PMID: 32158822 PMCID: PMC7061572 DOI: 10.1016/j.jpra.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/30/2017] [Indexed: 10/28/2022] Open
Abstract
Laser-assisted indocyanine-green imaging (ICG) has a wide range of surgical applications, and has been used in reconstructive surgery to aid in assessing the viability of free tissue transfers and to help predict poor tissue perfusion. However, its indications for use is limited to assessing free flap tissue perfusion, coronary artery perfusion during coronary artery bypass (CABG), and tissue perfusion in diabetic foot ulcers, to name a few. This system has been proven to be a safe, reliable adjunctive modality to assess microvascular compromise or poor perfusion peri-operatively, which could minimize skin necrosis and other post-operative complications (Further et al., 2013).1 The ability to objectively assess tissue perfusion has led to improved post-operative outcomes in breast, abdominal wall, colorectal, and cardiac surgery. To date, no studies have reviewed the use of ICG in delineating devitalized bone during sternal wound debridement after cardiac surgery. At our institution, we have encountered a cohort of patients with post-cardiac surgery sternal wound infections who have required debridement of infected and devitalized bone. We propose that SPY technology aids in delineating this devitalized bone, and may aid in the timing muscle flap coverage. In this paper, we will demonstrate two cases of patients who had post-operative sternal wound infections after undergoing cardiac surgery for which ICG was used to demarcate debridement zones and subsequent flap coverage. In these cases, ICG allowed for efficient and reliable intraoperative evaluation of bony perfusion and has aided in early adequate debridement and flap coverage.
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Affiliation(s)
- Richard Tyrell
- Department of Plastic Surgery, Temple University Hospital, 3401 N Broad St, Philadelphia, PA 19140
| | - Catherine Kilmartin
- Department of Surgery, Temple University Hospital, 3401 N Broad St, Philadelphia, PA 19140
| | - Edwin Acevedo
- Department of Surgery, Temple University Hospital, 3401 N Broad St, Philadelphia, PA 19140
| | - Suresh Keshavamurthy
- Department of Cardiothoracic Surgery, Temple University Hospital, 3401 N Broad St, Philadelphia, PA 19140
| | - Andrew Gassman
- Department of Plastic Surgery, Temple University Hospital, 3401 N Broad St, Philadelphia, PA 19140
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14
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Cornelissen AJM, van Mulken TJM, Graupner C, Qiu SS, Keuter XHA, van der Hulst RRWJ, Schols RM. Near-infrared fluorescence image-guidance in plastic surgery: A systematic review. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018; 41:269-278. [PMID: 29780209 PMCID: PMC5953995 DOI: 10.1007/s00238-018-1404-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/12/2018] [Indexed: 01/15/2023]
Abstract
Background Near-infrared fluorescence (NIRF) imaging technique, after administration of contrast agents with fluorescent characteristics in the near-infrared (700–900 nm) range, is considered to possess great potential for the future of plastic surgery, given its capacity for perioperative, real-time anatomical guidance and identification. This study aimed to provide a comprehensive literature review concerning current and potential future applications of NIRF imaging in plastic surgery, thereby guiding future research. Methods A systematic literature search was performed in databases of Cochrane Library CENTRAL, MEDLINE, and EMBASE (last search Oct 2017) regarding NIRF imaging in plastic surgery. Identified articles were screened and checked for eligibility by two authors independently. Results Forty-eight selected studies included 1166 animal/human subjects in total. NIRF imaging was described for a variety of (pre)clinical applications in plastic surgery. Thirty-two articles used NIRF angiography, i.e., vascular imaging after intravenous dye administration. Ten articles reported on NIRF lymphography after subcutaneous dye administration. Although currently most applied, general protocols for dosage and timing of dye administration for NIRF angiography and lymphography are still lacking. Three articles applied NIRF to detect nerve injury, and another three studies described other novel applications in plastic surgery. Conclusions Future standard implementation of novel intraoperative optical techniques, such as NIRF imaging, could significantly contribute to perioperative anatomy guidance and facilitate critical decision-making in plastic surgical procedures. Further investigation (i.e., large multicenter randomized controlled trials) is mandatory to establish the true value of this innovative surgical imaging technique in standard clinical practice and to aid in forming consensus on protocols for general use. Level of Evidence: Not ratable
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Affiliation(s)
- Anouk J M Cornelissen
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Tom J M van Mulken
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Caitlin Graupner
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Shan S Qiu
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Xavier H A Keuter
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - René R W J van der Hulst
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.,2NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Rutger M Schols
- 1Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
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Feasibility of Bone Perfusion Evaluation in Cadavers Using Indocyanine Green Fluorescence Angiography. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1570. [PMID: 29263970 PMCID: PMC5732676 DOI: 10.1097/gox.0000000000001570] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/26/2017] [Indexed: 11/29/2022]
Abstract
Supplemental Digital Content is available in the text. Bone perfusion evaluation methods in cadaver studies have yet to be established. The aim of this report was to introduce and validate the feasibility of indocyanine green (ICG) fluorescence angiography for evaluation of bone perfusion in the femoral medial condyle in cadavers. In 4 fresh nonembalmed cadavers (2 female), the descending genicular artery was dissected and carefully cannulated bilaterally. A 10 mL solution containing 5 mL ICG solution and 5 mL methylene blue solution was injected into the descending genicular artery. After the injection, the medial femoral condyle was cut with an oscillating saw. A photograph was taken of the cut ends of the bone. The cut ends of the bones were observed using a near-infrared camera. Images corresponding to the previously taken photographs of the cut ends were captured for comparative analysis. After injection of methylene blue and ICG, the blue dye could be seen in the periosteum in all specimens, but not inside the cortex or the cancellous region of the bone. When observed with ICG fluorescence angiography, however, the cancellous region was highlighted through small perforators penetrating the periosteum. Perfusion inside the medial femoral condyle in cadavers was confirmed using ICG fluorescence angiography. Our method can be especially beneficial in confirming the bone perfusion of a new bone flap based on a particular artery, both in cadavers as well as in patients, because ICG can be injected into specific arteries.
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Chien JS, Mohammed M, Eldik H, Ibrahim MM, Martinez J, Nichols SP, Wisniewski N, Klitzman B. Injectable Phosphorescence-based Oxygen Biosensors Identify Post Ischemic Reactive Hyperoxia. Sci Rep 2017; 7:8255. [PMID: 28811566 PMCID: PMC5558004 DOI: 10.1038/s41598-017-08490-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/11/2017] [Indexed: 11/09/2022] Open
Abstract
Novel injectable biosensors were used to measure interstitial oxygenation before, during, and after transient ischemia. It is well known that reactive hyperemia occurs following a period of ischemia. However, increased blood flow does not necessarily mean increased oxygen tension in the tissue. Therefore, the purpose of this study was to test the hypothesis that tissue reactive hyperoxia occurs following release of hind-limb tourniquet occlusions. Rats were injected with bilateral hind-limb biosensors and were simultaneously subjected to a unilateral femoral vessel ligation. After approximately one and three months, the rats underwent a series of oxygenation challenges, including transient hind-limb tourniquet occlusion. Along with the biosensors, near infrared spectroscopy was used to measure percent oxyhemoglobin in capillaries and laser Doppler flowmetry was used to measure blood flow. Post-occlusion reactive hyperemia was observed. It was accompanied by tissue reactive hyperoxia, affirming that the post-occlusion oxygen supply must have exceeded the expected increased oxygen consumption. The measurement of the physiologic phenomenon of reactive hyperoxia could prove clinically beneficial for both diagnosis and optimizing therapy.
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Affiliation(s)
- Jennifer S Chien
- Kenan Plastic Surgery Research Labs and Biomedical Engineering, Duke University Medical Center, Durham, NC, 27710, USA
| | - Mahmoud Mohammed
- Kenan Plastic Surgery Research Labs and Biomedical Engineering, Duke University Medical Center, Durham, NC, 27710, USA
| | - Hysem Eldik
- Kenan Plastic Surgery Research Labs and Biomedical Engineering, Duke University Medical Center, Durham, NC, 27710, USA
| | - Mohamed M Ibrahim
- Kenan Plastic Surgery Research Labs and Biomedical Engineering, Duke University Medical Center, Durham, NC, 27710, USA
| | - Jeremy Martinez
- Kenan Plastic Surgery Research Labs and Biomedical Engineering, Duke University Medical Center, Durham, NC, 27710, USA
| | - Scott P Nichols
- Profusa, Inc., 345 Allerton Ave, South San Francisco, CA, 94080, USA
| | | | - Bruce Klitzman
- Kenan Plastic Surgery Research Labs and Biomedical Engineering, Duke University Medical Center, Durham, NC, 27710, USA.
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17
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Indocyanine Green Angiography: A Helpful Tool for Intraoperative Assessment of Upper Extremity Perfusion. Tech Hand Up Extrem Surg 2017; 21:101-106. [PMID: 28614275 DOI: 10.1097/bth.0000000000000162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Assessment of tissue perfusion can be a challenge for the hand surgeon. Indocyanine green (ICG) angiography has been shown to be a valuable adjunct to physical examination and clinical judgment when there is a concern for tissue perfusion. The use of this technology has risen sharply in recent years in reconstructive surgery. Applications of ICG angiography have been developed throughout the field of surgery, including breast surgery, free tissue transfer, bowel surgery, neurosurgery, and lymphatic reconstruction. In this study, we discuss the novel applications of ICG angiography within the field of upper extremity surgery, and provide specific case examples of its successful use.
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18
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Echalier C, Pluvy I, Pauchot J. Angiographie au vert d’indocyanine en chirurgie reconstructrice : revue de la littérature. ANN CHIR PLAST ESTH 2016; 61:858-867. [DOI: 10.1016/j.anplas.2016.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/27/2016] [Indexed: 02/05/2023]
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20
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Azagury DE, Dua MM, Barrese JC, Henderson JM, Buchs NC, Ris F, Cloyd JM, Martinie JB, Razzaque S, Nicolau S, Soler L, Marescaux J, Visser BC. Image-guided surgery. Curr Probl Surg 2015; 52:476-520. [PMID: 26683419 DOI: 10.1067/j.cpsurg.2015.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/01/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Dan E Azagury
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Monica M Dua
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - James C Barrese
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Jaimie M Henderson
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Nicolas C Buchs
- Department of Surgery, University Hospital of Geneva, Clinic for Visceral and Transplantation Surgery, Geneva, Switzerland
| | - Frederic Ris
- Department of Surgery, University Hospital of Geneva, Clinic for Visceral and Transplantation Surgery, Geneva, Switzerland
| | - Jordan M Cloyd
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - John B Martinie
- Department of Surgery, Carolinas Healthcare System, Charlotte, NC
| | - Sharif Razzaque
- Department of Surgery, Carolinas Healthcare System, Charlotte, NC
| | - Stéphane Nicolau
- IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
| | - Luc Soler
- IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
| | - Jacques Marescaux
- IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
| | - Brendan C Visser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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Noninvasive Multimodal Imaging to Predict Recovery of Locomotion after Extended Limb Ischemia. PLoS One 2015; 10:e0137430. [PMID: 26368024 PMCID: PMC4569513 DOI: 10.1371/journal.pone.0137430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/17/2015] [Indexed: 01/19/2023] Open
Abstract
Acute limb ischemia is a common cause of morbidity and mortality following trauma both in civilian centers and in combat related injuries. Rapid determination of tissue viability and surgical restoration of blood flow are desirable, but not always possible. We sought to characterize the response to increasing periods of hind limb ischemia in a porcine model such that we could define a period of critical ischemia (the point after which irreversible neuromuscular injury occurs), evaluate non-invasive methods for characterizing that ischemia, and establish a model by which we could predict whether or not the animal’s locomotion would return to baselines levels post-operatively. Ischemia was induced by either application of a pneumatic tourniquet or vessel occlusion (performed by clamping the proximal iliac artery and vein at the level of the inguinal ligament). The limb was monitored for the duration of the procedure with both 3-charge coupled device (3CCD) and infrared (IR) imaging for tissue oxygenation and perfusion, respectively. The experimental arms of this model are effective at inducing histologically evident muscle injury with some evidence of expected secondary organ damage, particularly in animals with longer ischemia times. Noninvasive imaging data shows excellent correlation with post-operative functional outcomes, validating its use as a non-invasive means of viability assessment, and directly monitors post-occlusive reactive hyperemia. A classification model, based on partial-least squares discriminant analysis (PLSDA) of imaging variables only, successfully classified animals as “returned to normal locomotion” or “did not return to normal locomotion” with 87.5% sensitivity and 66.7% specificity after cross-validation. PLSDA models generated from non-imaging data were not as accurate (AUC of 0.53) compared the PLSDA model generated from only imaging data (AUC of 0.76). With some modification, this limb ischemia model could also serve as a means on which to test therapies designed to prolong the time before critical ischemia.
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22
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Vargas CR, Nguyen JT, Ashitate Y, Silvestre J, Venugopal V, Neacsu F, Kettenring F, Frangioni JV, Gioux S, Lee BT. Near-infrared imaging for the assessment of anastomotic patency, thrombosis, and reperfusion in microsurgery: a pilot study in a porcine model. Microsurgery 2015; 35:309-14. [PMID: 25571855 DOI: 10.1002/micr.22376] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/13/2014] [Accepted: 12/19/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Advances in microsurgical techniques have increased the use of free tissue transfer. Methods of intraoperative flap perfusion assessment, however, still rely primarily on subjective evaluation of traditional clinical parameters. Anastomotic thrombosis, if not expeditiously identified and revised, can result in flap loss with significant associated morbidity. This study aims to evaluate the use of near-infrared (NIR) fluorescence imaging in the assessment of microsurgical anastomotic patency, thrombosis, and vascular revision. MATERIALS AND METHODS A model of pedicle thrombosis was created using bilateral abdominal flaps isolated on deep superior epigastric vascular pedicles in four Yorkshire pigs. Following flap elevation, microvascular arterial and venous anastomoses were performed unilaterally, preserving an intact contralateral control flap. Thrombosis was induced at the arterial anastomosis site using ferric chloride, and both flaps imaged using NIR fluorescence angiography. The thrombosed vascular segments were subsequently excised and new anastomoses performed to restore flow. Follow-up imaging of both flaps was then obtained to confirm patency using fluorescence imaging technology. RESULTS Pedicled abdominal flaps were created and successful anastomotic thrombosis was induced unilaterally in each pig. Fluorescence imaging technology identified large decreases in tissue perfusion of the thrombosed flap within 2 minutes. After successful revision anastomosis, NIR imaging demonstrated dramatic increase in flow to the reconstructed flap, but intensity did not return to pre-thrombosis levels. CONCLUSIONS Early identification of anastomotic thrombosis is important in successful free tissue transfer. Real-time, intraoperative evaluation of flap perfusion, anastomotic thrombosis, and successful revision can be performed using NIR fluorescence imaging.
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Affiliation(s)
- Christina R Vargas
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John T Nguyen
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Yoshitomo Ashitate
- Division of Cancer Diagnostics and Therapeutics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Jason Silvestre
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vivek Venugopal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Florin Neacsu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Frank Kettenring
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John V Frangioni
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Curadel, LLC, Worcester, MA
| | - Sylvain Gioux
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Bernard T Lee
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Green JM, Thomas S, Sabino J, Howard R, Basile P, Dryden S, Crecelius C, Valerio I. Use of Intraoperative Fluorescent Angiography to Assess and Optimize Free Tissue Transfer in Head and Neck Reconstruction. J Oral Maxillofac Surg 2013; 71:1439-49. [DOI: 10.1016/j.joms.2013.01.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/14/2012] [Accepted: 01/21/2013] [Indexed: 11/27/2022]
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Near-infrared imaging of face transplants: are both pedicles necessary? J Surg Res 2013; 184:714-21. [PMID: 23706565 DOI: 10.1016/j.jss.2013.04.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/25/2013] [Accepted: 04/18/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Facial transplantation is a complex procedure that corrects severe facial defects due to traumas, burns, and congenital disorders. Although face transplantation has been successfully performed clinically, potential risks include tissue ischemia and necrosis. The vascular supply is typically based on the bilateral neck vessels. As it remains unclear whether perfusion can be based off a single pedicle, this study was designed to assess perfusion patterns of facial transplant allografts using near-infrared (NIR) fluorescence imaging. METHODS Upper facial composite tissue allotransplants were created using both carotid artery and external jugular vein pedicles in Yorkshire pigs. A flap validation model was created in n = 2 pigs and a clamp occlusion model was performed in n = 3 pigs. In the clamp occlusion models, sequential clamping of the vessels was performed to assess perfusion. Animals were injected with indocyanine green and imaged with NIR fluorescence. Quantitative metrics were assessed based on fluorescence intensity. RESULTS With NIR imaging, arterial perforators emitted fluorescence indicating perfusion along the surface of the skin. Isolated clamping of one vascular pedicle showed successful perfusion across the midline based on NIR fluorescence imaging. This perfusion extended into the facial allograft within 60 s and perfused the entire contralateral side within 5 min. CONCLUSIONS Determination of vascular perfusion is important in microsurgical constructs as complications can lead to flap loss. It is still unclear if facial transplants require both pedicles. This initial pilot study using intraoperative NIR fluorescence imaging suggests that facial flap models can be adequately perfused from a single pedicle.
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