Innovative DIEP flap perfusion evaluation tool: Qualitative and quantitative analysis of indocyanine green-based fluorescence angiography with the SPY-Q proprietary software

Abstract

Background Perfusion-related complications remain the most common concern in DIEP flap breast reconstruction. Indocyanine green-based fluorescence angiography can be used for the real-time intra operative assessment of flap perfusion. The SPY Elite system is the most widely used device in this setting. The main objective was to describe the use of SPY-Q proprietary software to perform qualitative and quantitative analysis of flap perfusion. Methods This retrospective cohort study was performed at the Curie Institute between 2013 and 2017. We included patients undergoing unilateral DIEP flap breast reconstruction for whom indocyanine green-based angiography videos were of sufficient quality for analysis. Videos were recorded with the SPY Elite System and analyzed with SPY-Q proprietary software. Results We included 40 patients. We used real-time dynamic color analysis to describe three different patterns of flap perfusion. SPY-Q proprietary software provides quantitative flap perfusion parameters. Our quantitative analysis confirmed that zone I is the best perfused part of the flap and zone IV the less perfused one. There was no significant association between flap perfusion pattern and perforator anatomy, patients’ clinical characteristics or postoperative outcomes. After exploratory univariate analysis, quantitative perfusion parameters were significantly impaired in young patients with diabetes mellitus or under hormone therapy by tamoxifen. Conclusions We here describe a new approach to assess DIEP flap perfusion using the SPY Elite System proprietary software. It provides interesting qualitative and quantitative analysis that can be used in further studies to precisely assess DIEP flap perfusion.

Perfusion Parameters in Near-Infrared Fluorescence Imaging with Indocyanine Green: A Systematic Review of the Literature

“…Fluorescent imaging was quantitatively reported in 15 articles, including 515 patients [ 6 , 7 , 10 , 13 , 17 , 19 , 22 , 23 , 36 , 37 , 46 , 51 , 52 , 53 , 57 ]. The fields of application included free-flap and DIEP flap perfusion, breast reconstruction surgery, and microvascular surgery.…”

Use of Indocyanine Green Angiography decreases the risk of complications in autologous- and implant-based breast reconstruction: A systematic review and meta-analysis

“…Based on the peroperative use of ICG-A, 11 studies evaluated mastectomy flaps [21][22][23][24][25][26][27][28][29][30][31] , 10 studies evaluated autologous flaps [32][33][34][35][36][37][38][39][40][41] , and 5 studies included both implant-based and autologous breast reconstructions [42][43][44][45][46] .…”

“…Of the 10 studies on autologous breast reconstruction [32][33][34][35][36][37][38][39][40][41] , 1 study found that ICG-A significantly lowered the incidence of major complications in immediate reconstructions 32 , while 5 studies described an association between ICG-A and a reduced risk of fat necrosis 33 , 34 , 38-40 . Though ICG-A was applied for flap design and arterial mapping of DIEP flap perfusion 36 , 37 , 41 , 1 study found no benefit in using ICG-A on the recipient site 35 and finally 1 study found no association between flap perfusion and perforator anatomy 37 .…”

Current and novel mapping substances in gynecologic cancer care

“…There are a variety of methods by which surgeons are able to evaluate tissue perfusion. Indocyanine green angiography provides real-time feedback on perfusion, providing the surgeon with valuable information when evaluating free and pedicled flaps 41. Recent studies have demonstrated that this imaging modality is helpful in the assessment of flap harvesting and design, and quantitative and objective perfusion parameters seem to be accurate for flap perfusion assessment 41.…”

“…Indocyanine green angiography provides real-time feedback on perfusion, providing the surgeon with valuable information when evaluating free and pedicled flaps 41. Recent studies have demonstrated that this imaging modality is helpful in the assessment of flap harvesting and design, and quantitative and objective perfusion parameters seem to be accurate for flap perfusion assessment 41. According to a recent investigation, indocyanine green angiography is a highly valuable tool in aiding flap shaping according to optimal perfusion zones42 (Figure 3).…”