Utility of indocyanine green angiography in delaying breast reconstruction postmastectomy

Abstract

Background Perfusion mapping with indocyanine green angiography (ICGA) in breast reconstruction can change intraoperative plans and reduce the risk of flap necrosis. We evaluated the utility of ICGA in the decision to delay reconstruction postmastectomy and its predictive power for necrosis. Methods Single-institution retrospective study of implant-based breast reconstructions following mastectomy using ICGA from 2015 to 2021. A decision was made to proceed with immediate reconstruction or delay reconstruction based on clinical assessment and perfusion analysis. Incidence of complications in the immediate and delayed cohorts were assessed. Intraoperative ICGA perfusion values were correlated with postoperative outcomes to calculate diagnostic accuracy. Results Three hundred twenty breast reconstructions were performed. Two hundred fifty-nine of these underwent immediate reconstruction, while 61 underwent delayed reconstruction due to poor perfusion. Median time between mastectomy and delayed reconstruction was 7.3 days (range, 4–21 days). All 8 cases (3.1%) of necrosis were in the immediate cohort. Cases of necrosis had significantly lower intraoperative ICGA perfusion values compared to cases without necrosis (absolute values 13.1 versus 27.1 units, p = 0.017). Increasing our ICGA cut-off score for necrosis from 14 to 22 units would have increased sensitivity from 63 to 100% but reduced specificity from 70 to 48%. Conclusions Delayed breast reconstruction due to poor perfusion on ICGA resulted in no cases of necrosis. A higher ICGA cut-off score for predicting necrosis is more sensitive but less specific. ICGA is useful as a supplement rather than a substitute for clinical assessment in flap perfusion evaluation. Level of Evidence Level III, Risk / Diagnostic Study.

A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy

“…In the previous clinical study from which this dataset was generated, 12 breast reconstruction was deferred in patients with poor perfusion by current clinical and ICGFA criteria, with a significant improvement in perfusion being evident at the second assessment a week later. In this current work, we confirm differences in initial brightness in deferred patients, with significant improvements in intensity and chronology at the second assessment.…”

“…Patients: In a previous single-centre study (Protocol X17-0359 HREC/17/RPAH/542, see Figure 1 for operative workflow) 12 , 213 patients undergoing NSM were subsequently assessed via ICGFA. The standardised mastectomy technique involved preoperative antibiotics, inframammary incision, electrocautery dissection superficial to the anterior mammary fascia, and no intraoperative local anaesthesia/epinephrine injection.…”

“…The mastectomy pocket was filled with a laparotomy sponge, and the incision was temporarily closed with staples.

Figure 1 Clinical pathway from the previous study protocol 12 . ICG denotes indocyanine green and NIR denotes near infrared.

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“… Clinical pathway from the previous study protocol 12 . ICG denotes indocyanine green and NIR denotes near infrared.…”

“… 10 , 11 A recent study also investigated its routine use in selecting patients who may benefit from a temporary delay in performing reconstruction (termed staged immediate breast reconstruction, SIBR) by measuring fluorescence intensity from still images 11 in decision-making albeit with modest sensitivity and specificity regarding complication prediction (62.5% and 69.5%, respectively). 12 , 13 , 14 …”