Ann Surg Treat Res.  2016 May;90(5):279-286. 10.4174/astr.2016.90.5.279.

Intraoperative indocyanine green angiography for the objective measurement of blood flow

• Joh JH
• Park HC
• Han SA
• Ahn HJ

• KMID: 2163068
• DOI: http://doi.org/10.4174/astr.2016.90.5.279

Abstract

PURPOSE
Intraoperative assessment of tissue perfusion is important to predict wound healing or improvement of symptoms in patients with peripheral arterial disease (PAD) or vascular trauma. There is no widely accepted standard for intraoperative measurement of tissue perfusion. Here, we report the use of indocyanine green (ICG)-based angiography to determine the blood flow in patients with PAD and vascular trauma.
METHODS
The SPY fluorescent imaging system was utilized. A dose of 3-5 mL of ICG (2.5 mg/mL) was injected intravenously followed by a 10 mL normal saline flush. The SPY imaging system was used to quantitatively assess perfusion. During the study period, the SPY imaging system was applied in 4 patients with PAD and one patient with vascular trauma.
RESULTS
In 3 patients with PAD associated with an ischemic wound, complete wound healing was achieved with the indication of viable tissue by the SPY system. In one patient with severe claudication in both lower extremities, the ICG angiography was used to determine the increased blood flow after revascularization. In the case of vascular trauma, this imaging system enabled the delineation of viability of the injured tissue.
CONCLUSION
ICG angiography can determine the surface tissue viability in PAD patients. In cases of severe vascular trauma,the SPY system can be used to determine tissue perfusion. Further study is warranted to define the definite utility of this technology to assess perfusion, response to revascularization, and potentially, to predict the likelihood of wound healing.

Keyword

Indocyanine green; Angiography; Peripheral arterial disease; Perfusion

MeSH Terms

Angiography*
Humans
Indocyanine Green*
Lower Extremity
Perfusion
Peripheral Arterial Disease
Tissue Survival
Wound Healing
Wounds and Injuries
Indocyanine Green

Figure

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  Fig. 1 The SPY fluorescent imaging system (Novadaq Corp., Bonita Springs, FL, USA). The imaging head is attached to an articulating arm on a mobile cart containing the central processing unit, keyboard, monitor, and mouse.

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  Fig. 2 Indocyanine green angiography (ICG) before and after amputation. (A) Before the operation, it was impossible to delineate the viable margin. (B) Preoperative ICG angiogram shows clear demarcation between the viable and ischemic regions. (C) Three days after excision of the necrotic portion including the right 4th toe, clinical judgment revealed viable tissue around the excised area. (D) Postoperative ICG angiogram confirmed the presence of viable tissue in this region.

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  Fig. 3 Indocyanine green angiography (ICG) before and after revascularization. (A) Initial picture of the right foot shows ulceration over the plantar area (arrow). (B) Prerevascularization ICG angiogram shows decreased global perfusion in the right foot. (C) After balloon angioplasty, ICG angiogram shows slightly increased perfusion. (D) After stent placement in the region of the residual stenosis, ICG angiogram shows markedly increased perfusion.

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  Fig. 4 Indocyanine green angiography (ICGA) for toe gangrene. (A) Gangrene of the right second toe is shown (arrow). (B) An ICGA grayscale image after bypass surgery shows no perfusion in the right second toe and adequate perfusion in the surrounding tissue. (C) The objective numbers are shown in an ICGA grayscale image. (D) An ICGA heat-map image shows adequate perfusion in the right foot after bypass surgery.

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  Fig. 5 Indocyanine green (ICG) angiography after revascularization in a patient with claudication. (A, B) Baseline ICG angiograms show decreased perfusion in both feet at 87 seconds and 132 seconds, respectively. (C) After stent placement in the left external iliac artery, ICG angiogram shows increased blood flow in the left foot at 83 seconds. (D) After transluminal atherectomy of the right superficial femoral artery, ICG angiogram shows increased perfusion in the right foot at 123 seconds.

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  Fig. 6 Indocyanine green (ICG) angiography for vascular trauma. (A) Initial picture shows a deep lacerated wound on the right buttock. (B) The ICG angiogram after coil embolization shows adequate perfusion of the tissue surrounding the injury. (C) Complete wound healing was achieved with the indication of ICG angiogram.

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