Indocyanine green fluorescence/thermography evaluation of intercostal muscle flap vascularization

Abstract

BackgroundDuring anatomical lung resection in high‐risk patients, the bronchial stump is covered with tissue flaps (e.g. pericardial fat tissue and intercostal muscle) to prevent bronchopleural fistula development. This is vital for reliable reinforcement of the bronchial stump. We evaluated the blood supply of the flap using indocyanine green fluorescence (ICG‐FL) and thermography intraoperatively in 27 patients at high risk for developing a bronchopleural fistula.MethodsBefore reinforcing the stump with a flap, the fluorescence agent was intravenously injected and the blood supply was evaluated. The surface temperature of the flap was measured with thermography. The two modalities were then compared.ResultsICG‐FL intensity and surface temperature on the distal compared to the proximal side of the flap decreased by 32.6 ± 29.4% (P < 0.0001) and 3.5 ± 2.0°C (P < 0.0001), respectively. In patients with a higher ICG‐FL intensity value at the tip than the median, the surface temperature at the tip decreased by 2.7 ± 1.7°C compared to the proximal side. In patients with a lower ICG‐FL value at the tip, the surface temperature decreased by 4.6 ± 1.7°C (P = 0.0574). The bronchial stump reinforced the part of the flap with adequate blood supply; none of the patients developed a bronchopleural fistula.ConclusionsICG‐FL confirmed variation in the blood supply of the intercostal muscle flap, even if prepared using the same surgical procedure. Thermography analysis tends to correlate with the fluorescence method, but may be influenced by the state of flap preservation during surgery.

The Role of ICG Angiography in Decision Making About Skin-Sparing in Pediatric Acute Trauma

“…Driessen et al ( 23 ) studied female patients undergoing mastectomies with or without immediate reconstruction and revealed a substantial decrease in skin necrosis with the use of ICG angiography. Kawamoto et al ( 24 ) report that, compared with thermography, ICG angiography could confirm variation in perfusion of the intercostal muscle flap and make it possible for reducing bronchopleural fistula development. Abdelwahab et al ( 25 ) notes that ICG angiography is an effective method to qualify and quantify neovascularization perfusion of forehead flaps, and time between stages and cartilage graft use were significantly associated with perfusion measures.…”

Thermal imaging for microvascular free tissue transfer monitoring: Feasibility study using a low cost, commercially available mobile phone imaging system

“…1,2,11,12 They have also been used to identify vascular perforators and flap integrity intraoperatively. [5][6][7][8][9] The application of thermal imaging technology or many other flap monitoring techniques involve the use of equipment with significant cost in the medical device marketplace.…”

“…Infrared thermography has been applied to medicine in many ways including assessing inflammatory conditions, monitoring flaps, and determining the extent of salvageable tissue after burns 1,2,11,12 . They have also been used to identify vascular perforators and flap integrity intraoperatively 5‐9 . The application of thermal imaging technology or many other flap monitoring techniques involve the use of equipment with significant cost in the medical device marketplace.…”

“…1,3,4 One study utilized indocyanine green fluorescence as measured by thermography to evaluate variations in vascularization during surgery. 5 Another animal study demonstrated the use of infrared thermography to identify a measurable change in flap surface temperature due to perforator thrombosis. 6 In one systematic review, two studies were found that utilized dynamic infrared thermography technology to evaluate intraoperative flap perfusion.…”

“…Several studies have demonstrated its efficacy in identifying vascular perforators prior to flap harvest, as well as in post‐operative flap monitoring 1,3,4 . One study utilized indocyanine green fluorescence as measured by thermography to evaluate variations in vascularization during surgery 5 . Another animal study demonstrated the use of infrared thermography to identify a measurable change in flap surface temperature due to perforator thrombosis 6 .…”