Intraoperative Indocyanine Green Research Articles

SP3.1.7 Does using intra-operative indocyanine green impact the clinical suspicion of anastomotic leak?

Abstract Aims To see if the beneficial impact of indocyanine green (ICG) angiography on anastomotic leak (AL) rate was reflected in the “suspicion” of leak in patients undergoing rectal or sigmoid cancer resection. Methods Patients who have intra-operative ICG fluorescence have reduced clinical AL rates, with a shorter length of stay (LOS). Recent publications have suggested stricter criteria to categorize AL. A prospectively-maintained database was reviewed to see if there was a difference in the suspicion of AL between patients who did and did not receive intra-operative ICG. A total of 159 rectal and sigmoid cancers were diagnosed between 1 April 2020 and 31 March 2021 in our health board, with 75 patients proceeding to surgery. Only patients receiving primary anastomosis were included in this study (n=33). Post-operative CT scans performed, diagnosis of AL, Clavien-Dindo complication rates, use of antibiotics beyond 48 hours, and LOS, were studied. Results 39.4% (n=13/33) received intra-operative ICG whilst 60.6% (n=20/33) did not. The median LOS was 3 days in the ICG group and 6.5 days in the non-ICG group. There were less CT scans, antibiotic use, complications, and post-operative interventions in the ICG cohort. Conclusion This is a small-sized snapshot audit, however it demonstrates that the reduced AL rate in patients having intra-operative ICG is reflected in their post-op journey of care, with a clear difference in interventions, and no greater number of “sub-clinical” leaks in the ICG cohort. The study will be expanded to see if this data is consistent in a larger study.

Commentary: Far Lateral Approach With Intraoperative Indocyanine Green Angiography for Craniocervical Arteriovenous Fistula Obliteration: 2-Dimensional Operative Video.

Singh, Rohin BS*; Bocanegra-Becerra, Jhon E. MD‡,§,‖; Turcotte, Evelyn L. BS‡,§,‖; Melita, Nicolae Teodor MD‡,§,‖; Bendok, Bernard R. MD‡,§,‖,¶,# Author Information

Insufficient Closing Forces of Yasargil Titanium Clips in Two Small Aneurysms Detected with Intraoperative Indocyanine Green Videoangiography.

Aneurysm clips must have adequate closing forces because residual blood flow in clipped aneurysms may result in aneurysm recurrence. Such flow can be intraoperatively detected by visual inspection, microvascular Doppler sonography, indocyanine green videoangiography (ICG-V), angiography, and puncture. We present two patients with ruptured very small middle cerebral artery aneurysms (3 and 2.9 mm). The necks of both aneurysms were microsurgically clipped with Yasargil aneurysm clips without any complications. In both aneurysms, visual inspection suggested complete occlusion, but ICG-V showed persistent residual blood flow between the middle parts of the clip blades.The first patient was treated with a 5.4-mm FT744T clip (closing force of 1.47 N). After the ICG-V finding, a second 3.9-mm FT714T clip (closing force of 1.08 N) was placed on the tips of the already implanted clip to increase the closing forces. Subsequent ICG-V did not show any further residual blood flow. In the second patient, the aneurysm was clipped with an 8.0-mm FE764K clip (closing force of 1.77 N). Intraoperative ICG-V showed persistent residual blood flow within the aneurysmal dome despite complete closure of the clip. The clip was repositioned closer to the parent vessel. Consecutive ICG-V did not show any residual blood flow. Visually undetected incomplete aneurysm occlusion can be revealed with ICG-V. In very small aneurysms, standard closing forces of clips may not be sufficient and complete closure of the clip branches should be intraoperatively validated with ICG-V.

Far Lateral Approach With Intraoperative Indocyanine Green Angiography for Craniocervical Arteriovenous Fistula Obliteration: 2-Dimensional Operative Video.

Far Lateral Approach With Intraoperative Indocyanine Green Angiography for Craniocervical Arteriovenous Fistula Obliteration: 2-Dimensional Operative Video.

Correlation between Colon Perfusion and Postoperative Fecal Output through a Transanal Drainage Tube during Laparoscopic Low Anterior Resection.

Simple SummaryAnastomotic leakage (AL) is a major problem in patients who undergo operations for rectal cancers. Various solutions, such as ICG angiography and transanal drainage tubes (TDT), have been proposed to prevent AL. Although the microbiota has recently been recognized to play a role in the pathogenesis of AL, mainly from the results of experimental animal models, it remains unclear whether this mechanism can occur in humans. In this study, we investigated the relationship between intestinal perfusion and fecal volume through TDT in laparoscopic low anterior resection, and found that the need of a proximal shift of the transection site due to insufficient intestinal perfusion was significantly associated with high fecal volume, which might reflect the correlation between intestinal perfusion and postoperative diarrhea. In addition, we found that the intensity of ICG fluorescence at the transection site was significantly associated with fecal volume through TDT. To the best of our knowledge, this is the first clinical study to examine the relationship between intestinal perfusion and fecal volume through TDT. In order to prevent anastomotic leakage (AL) following rectal surgery, various solutions—such as intraoperative indocyanine green (ICG) angiography and transanal drainage tubes (TDT)—have been proposed. This study investigated the relationship between intestinal perfusion and fecal volume through TDT in laparoscopic low anterior resection (LAR). A total of 59 rectal cancer patients who underwent laparoscopic LAR with both intraoperative ICG angiography and postoperative TDT placement were retrospectively analyzed. The relationship between intestinal perfusion and fecal volume through TDT was examined. Based on the ICG fluorescence, the transection site was shifted more proximally in 20 cases (33.9%). Symptomatic AL occurred in seven patients (11.8%). The AL rate of the patients whose daily fecal volume exceeded 100 mL/day in 2 or more days was significantly higher than that of those whose daily fecal volume exceeded it in 0 or 1 day (44.4% vs. 6.0%; p < 0.01). Univariate and multivariate analyses showed that the need for a proximal shift of the transection site was significantly associated with a high fecal volume. The quantitative analysis of ICG fluorescence indicated that Fmax (the fluorescence difference between the baseline and maximum) was significantly associated with fecal volume through TDT.

Leak after sleeve gastrectomy with positive intraoperative indocyanine green test: Avoidable scenario?

BackgroundThe staple line gastric leak (GL) is estimated to be the most serious complication of the sleeve gastrectomy. The use of indocyanine green (ICG) has been introduced in minimally invasive surgery to show the vascularization of the stomach in real time and its application to the gastroesophageal junction (GE) during Laparoscopic Sleeve Gastrectomy (LSG) seems very promising.Case presentationWe present the case of a 40-year-old female underwent laparoscopic sleeve gastrectomy. Intraoperative indocyanine green test showed a small dark area in the proximal third of the staple line reinforced with fibrin glue. Two weeks later the patient presented to the emergency room (ED) with abdominal pain, fever, vomiting, intolerance to oral intake and the evidence of a leak on the abdomen Computer Tomography (CT). The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05337644 for the Organization UFoggia.ConclusionsThis case report shows that intraoperative ICG test can be helpful in determining which patients are at greater risk of the leak and, more importantly, the cause of the leak but further tests are needed to determine if the ICG predicts leak due to ischemia.

Indocyanine Green Angiography of Parathyroid Glands versus Intraoperative Parathyroid Hormone Assay as a Reliable Predictor for Post Thyroidectomy Transient Hypocalcemia

Background Prediction of postoperative hypocalcemia is a fundamental issue in thyroidectomy. Indocyanine green (ICG) angiography of parathyroid glands is a feasible method to detect the perfusion of parathyroid glands and predict postoperative hypocalcemia. Materials and Methods A prospective observational study was conducted at Ain Shams University Hospitals between April 2018 and April 2021. The included cases of total thyroidectomy underwent intraoperative ICG fluorescence angiography to identify the four parathyroid glands and score each gland according to the viability. Patients in which less than four glands were identified were excluded. Intraoperative intact parathyroid hormone (ioPTH) level assay was also measured to compare with ICG in predicting postoperative transient hypocalcemia. Results A total of 134 cases underwent total thyroidectomy during the study period. We could identify the four parathyroid glands in 90 patients, including them in the study. We had postoperative hypocalcemia in 28 cases (31.1%). The diagnostic accuracy of ICG angiography and ioPTH level assay was high and almost similar (82.22% versus 87.78%). Both were higher than the surgeons’ diagnostic accuracy of visual inspection (62.22%). Conclusions ICG angiography of the parathyroid gland is a safe, reliable predictor for postoperative transient hypocalcemia with a high and almost similar accuracy compared to intraoperative parathyroid hormone level.

Intraoperative Near-Infrared Fluorescence Imaging with Indocyanine Green for Identification of Gastrointestinal Stromal Tumors (GISTs), a Feasibility Study.

Simple SummarySurgical resection plays a pivotal role in the treatment of GIST patients. The current study aims to explore the use of near-infrared fluorescence imaging to optimize the intraoperative tumor identification of GISTs. For this purpose, the potential and limitations of the widely used, and non-specific, tracer indocyanine green were assessed in a multicenter study including 10 patients. Our results show that GISTs typically have similar fluorescence intensity to the surrounding tissue, within several minutes after the intravenous administration of indocyanine green. These findings justify future research into specific fluorescent tracers for GISTs, and set a reference for future intraoperative imaging trials.Background: Optimal intraoperative tumor identification of gastrointestinal stromal tumors (GISTs) is important for the quality of surgical resections. This study aims to assess the potential of near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) to improve intraoperative tumor identification. Methods: Ten GIST patients, planned to undergo resection, were included. During surgery, 10 mg of ICG was intravenously administered, and NIRF imaging was performed at 5, 10, and 15 min after the injection. The tumor fluorescence intensity was visually assessed, and tumor-to-background ratios (TBRs) were calculated for exophytic lesions. Results: Eleven GIST lesions were imaged. The fluorescence intensity of the tumor was visually synchronous and similar to the background in five lesions. In one lesion, the tumor fluorescence was more intense than in the surrounding tissue. Almost no fluorescence was observed in both the tumor and healthy peritoneal tissue in two patients with GIST lesions adjacent to the liver. In three GISTs without exophytic growth, no fluorescence of the tumor was observed. The median TBRs at 5, 10, and 15 min were 1.0 (0.4–1.2), 1.0 (0.5–1.9), and 0.9 (0.7–1.2), respectively. Conclusion: GISTs typically show similar fluorescence intensity to the surrounding tissue in NIRF imaging after intraoperative ICG administration. Therefore, intraoperatively administered ICG is currently not applicable for adequate tumor identification, and further research should focus on the development of tumor-specific fluorescent tracers for GISTs.

Noninfectious Endophthalmitis Following Intraoperative Indocyanine Green.

The purpose of this article is to describe a cluster of four cases of severe postoperative inflammation in eyes that received intraoperative indocyanine green (ICG) from the same lot. This was a retrospective chart review of patients from a single-center, retina-only group practice. The ICG lot associated with the inflammatory events was identified and analyzed with high-performance liquid chromatography with UV spectroscopy. Four patients presented on postoperative day 1 with severe inflammation. The first patient was treated with aqueous biopsy and injection of intravitreal antibiotics, followed by topical steroid and antibiotic drops. The subsequent three patients were treated with topical steroid and antibiotic drops. All patients had resolution of inflammation by postoperative day 14 (range 10 to 14 days). High-performance liquid chromatography with UV spectroscopy failed to identify a contaminant. The use of intravitreal ICG dye as a surgical adjuvant may uncommonly be associated with severe postoperative inflammation. This inflammation may resolve within weeks after topical corticosteroid and antibiotic treatment. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:148-151.].

A case of arteriovenous malformation in the inferior mesenteric artery region resected surgically under intraoperative indocyanine green fluorescence imaging.

Introduction and importanceAn arteriovenous malformation (AVM) is defined as a vascular malformation with a short, non-capillary communication between the arteries and veins. Most gastrointestinal AVMs are solitary, occurring predominantly in the stomach, small intestine and right colon, and rarely in the inferior mesenteric artery (IMA) region.Case presentationA 70-year-old man was first diagnosed with ischemic enteritis two years earlier, and was hospitalized several times with the same diagnosis. He visited our hospital because of left lower abdominal pain and melena. Colonoscopy showed findings suggestive of ischemic enteritis, and contrast-enhanced computed tomography (CT) and IMA angiography showed hyperplasia and dilation of blood vessels from the sigmoid-descending colon junction to the upper rectum. We performed conventional laparoscopic low anterior resection using intraoperative intravenous injection of indocyanine green (ICG). The final diagnosis was arteriovenous malformation in the IMA region. The patient had an uneventful postoperative course and was discharged on the 13th day after the operation.Clinical discussionCases of AVM in the IMA region are relatively rare. This is the first reported case of AVM in the IMA region that was resected under intraoperative ICG fluorescence imaging (FI), which provided useful information on the extent of intestinal resection and mesenteric dissection required, and confirmed the adequacy of intestinal blood flow during and after mesenteric dissection and anastomosis.ConclusionIt is advisable to use ICG FI intraoperatively during resection of AVMs in the IMA region, as with colorectal cancer surgery.

Evaluating gastric remnant ischemia by indocyanine green fluorescence-guided surgery after distal gastrectomy in a patient with prior Nissen fundoplication: A case report.

IntroductionRecent studies showed that intraoperative indocyanine green (ICG) fluorescence imaging-guided surgery helped evaluate organ perfusion. Whereas whether the gastric remnant can be preserved after distal gastrectomy for the cases of post-Nissen fundoplication remains unclarified. This case report demonstrated the applicability of intraoperative ICG fluorescence-guided surgery to assess the gastric remnant's blood supply after distal gastrectomy.Case presentationA 68-year-old man who previously underwent Nissen fundoplication for esophageal hiatal hernia was diagnosed with early gastric cancer in the lower body of the stomach. We performed laparoscopic distal gastrectomy to preserve the left gastroepiploic vessels considering the dissection of a part of the short gastric vessel from the previous Nissen fundoplication. After completing Billroth I reconstruction, the color of the serosal surface did not show any signs of ischemia. However, intraoperative esophagogastroduodenoscopy showed an ischemic change of the remnant stomach. In addition, ICG fluorography revealed insufficient blood supply to the gastric remnant compared with that to the pancreas and liver. Consequently, we converted to total gastrectomy to avoid necrosis in the gastric remnant.ConclusionWe performed intraoperative ICG fluorescence-guided surgery in patients with early gastric cancer after Nissen fundoplication. ICG fluorescence may be useful in preventing postoperative gastric remnant ischemia, especially in high-risk patients.

Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers.

The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications. Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment betweenJanuary 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6weeks after surgery via contrast enema and pouchoscopy. One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3years and average body mass index was 24.9kg/m2. Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of theileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemiaand theleak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7weeks. ICG perfusionassessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.

Intraoperative Indocyanine Green Dye Use in Ovarian Torsion: A Feasibility Study

To determine the feasibility of intravenous indocyanine green (ICG)dyeuse inpatients withadnexal torsion to intraoperatively evaluate ovarian perfusion after detorsion. A prospective multicenter single-arm feasibility study. A teaching hospital. A total of 12 nonpregnant patients, 18 to 45 years old with surgically confirmed adnexal torsion. Torsion was surgically confirmed, the involved adnexa were untwisted laparoscopically, and ICG dye was injected intravenously. The absence or presence of ICG perfusion was documented, and the clinical decision for ovarian conservation or removal was determined by the surgeon. The primary outcome was feasibility of using ICG dye including measures such as time to visualized perfusion and operative time. Secondary outcomes included presence or absence of ovarian preservation and postoperative follow-up measures. Intraoperative visualization of ICG perfusion to the detorsed adnexa was achieved in 10 patients (83%) in a median time of 1 minute (0, 2), resulting in entire (n=9) or partial (n=1) ovarian conservation. Perfusion was absent in 2 cases, and postoophorectomy histologic necrosis was confirmed in one case. Median operative time was 74 minutes (48, 94). There were no adverse events related to ICG dye use. Intraoperative ICG dye use in this study was logistically feasible and conservation of the entire or partial ovary was observed in 83% of patients, including one case where preoperative Doppler flow was absent.

The Influence of Flow Velocity in the Feeding Vessel on Flap Perfusion in Deep Inferior Epigastric Artery Perforator Flap

Contralateral perfusion of zones II and IV is critical to estimate the amount of fat necrosis and determine intraoperative flap sacrifice during autologous breast reconstruction. We aimed to determine whether perfusion of the contralateral side was affected by the peak flow velocity in the feeding vessels in the deep inferior epigastric artery (DIEA) perforator free flap reconstructions. This was a retrospective review of patients who received DIEA perforator flap for autologous breast reconstruction from February to July 2020. Intraoperative indocyanine green (ICG) angiography and measurement software (Image J) were used to validate the perfusion of the contralateral side of the flap. Peak flow in the vessels was measured with duplex color Doppler and linear correlation was used to analyze the association between perfusion and blood flow velocity. Forty-two patients received a DIEP flap. The average age of the patients was 48.5 years, and body mass index was 23.84 kg/m2. Peak flow velocity of the internal mammary artery (IMA) was significantly higher than that of the DIEA (p <0.05). Contralateral perfusion confirmed by ICG angiography was higher in the IMA than in the DIEA (p <0.05). A linear correlation was found between peak speed (p = 0.045) and ICG perfusion length (p = 0.00003). The status of flap perfusion depends on the feeding vessel. The velocity of blood flow between IMA and DIEA is different, and the flap perfusion varies accordingly. Therefore, ICG angiography should be performed after anastomosis at the recipient site for an accurate assessment.

A case report of duodenal arteriovenous malformation: usefulness of intraoperative indocyanine green angiography for precise identification of the lesion

BackgroundArteriovenous malformation (AVM) of the gastrointestinal (GI) tract can cause bleeding. The treatment choice for GI tract AVM is surgical resection of the involved bowel segment with complete resection of the nidus. The AVM formed in the duodenum or pancreatic head could also cause gastrointestinal bleeding, and there are several reports of pancreaticoduodenectomy as its treatment. However, if the area of AVM can be accurately identified during surgery, it may be possible to completely resect the AVM while preserving the organ. We report a case of duodenal AVM in a patient successfully treated with a subtotal stomach-preserving duodenal bulb resection using intraoperative indocyanine green (ICG) angiography technique.Case presentationAn 18-year-old man was diagnosed with duodenal AVM after several examinations for anemia and was referred to our hospital for further treatment. Preoperative imaging studies showed that the inflow vessels of this duodenal AVM were the inferior pyloric artery and the superior duodenal artery, and the AVM was localized to the duodenal bulb. Thereafter, stomach-preserving duodenal bulb resection preceded by ligation of the inflow vessels was performed. During the surgery, ICG angiography clearly demonstrated the area, where the nidus was distributed, and a duodenal bulb resection with complete resection of the AVM was successfully performed. There was no recurrence at the 6-month follow-up.ConclusionsIntraoperative ICG angiography was a useful procedure for precise identification of the AVM of the GI tract.

Mesenteric Vascular Evaluation with Pre-operative Multidetector Computed Tomographic Angiography and Intraoperative Indocyanine Green Angiography to Reduce Anastomotic Leaks after Minimally Invasive Surgery for Colorectal Cancer

Background:The aim of this prospective study was to determine the effect of mesenteric vascular evaluation using pre-operative multidetector computed tomography angiography (MDCTA) and intraoperative indocyanine green (ICG) angiography on reducing the anastomotic leak rate of colorectal cancer patients undergoing minimally invasive resection.Methods:Twenty-seven consecutive patients with colorectal cancer were studied, 18 males and 9 females, average age 69.1 ± 3.9 years. All patients underwent pre-operative mesenteric vascular evaluation using MDCTA with three-dimensional (3D) reconstruction and intraoperative evaluation of perfusion using ICG angiography. Twelve patients underwent laparoscopic resection (Olympus Visera Elite II OTV-S200) and 15 patients underwent robotic resection (DaVinci Si). Colorectal resection lines and anastomoses were guided by intraoperative ICG perfusion. Postoperative anastomotic leaks were assessed.Results:Pre-operative MDCTA 3D reconstructions defined the left colic and sigmoid artery anatomy and guided operative planning. The intraoperative ICG angiography resulted in a change of the planned lines of resection in seven patients (26%). The rate of postoperative anastomotic leaks in this study was 0% (0/27), compared to a leak rate of 6.8% at our institution in the preceding two years.Conclusion:Pre-operative evaluation of mesenteric vascular anatomy using MDCTA with 3D reconstruction and intraoperative evaluation of perfusion using ICG angiography were found to be technically feasible and safe. An appropriately designed study should be undertaken to prove whether it was truly effective at reducing the postoperative anastomotic leak rate in colorectal cancer patients undergoing minimally invasive resection at our institution.

Colorectal Liver Metastases Confirmation and Delineation Using Indocyanine Green Perfusion Quantification, Computer Vision and Machine Learning Methods

Fluorescence guided surgery utilizes near infrared imaging systems to detect the presence of intravenously administered Indocyanine Green (ICG), an albumin-binding fluorophore, to create a perfusion angiogram. Simple snapshot observation for ICG after predosing alone has identified colorectal metastases within the liver, the excretory organ for ICG, albeit with poor sensitivity. Dynamic perfusion pattern analysis using computer vision and machine learning methods may do better re predictive accuracy and margination. Patients with colorectal liver metastases (CLM) undergoing diagnostic and therapeutic procedures at a high-volume hepatobiliary unit were imaged continuously for up to ten minutes following intraoperative intravenous ICG administration (0.05mg/kg) using the Pinpoint/Stryker near infra-red imaging system(Fig1a). Motion (camera movement and tissue deformation) in the resulting multispectral videos was compensated by application of the estimated pixel movement between frames in the white light imagery in reverse. Fluorescence intensity/time curves were subsequently extracted for each pixel(Fig1b) in the corresponding near infrared sequences. Machine learning was then applied to classify tissue (liver vs CLM) using a single feature algorithm. 2d representations were created based on time/fluorescence centre of mass(Fig1c) with diverging colour maps of outflow slope(Fig1d) for boundary delineation. Metastases were successfully detected and classified in all cases (n=6). 2d boundary maps accurately recreated the visualised tissue morphology in perfusion time-series including clear boundary demarcations. Fluorescence angiograms, in combination with computer vision and machine learning methods, can be used to confirm and delineate colorectal liver metastases. The 2D boundary maps, created through interrogation of tissue perfusion, can provide real time intra-operative guidance.

Right Hepatectomy for Giant Liver Hemangioma Guided with Intraoperative Ultrasound and Indocyanine Green

Background: Hepatic hemangiomas are benign vascular tumors of the liver, most of them asymptomatic. Surgical management includes enucleation, embolization, and liver resection. We present a case with symptomatic hepatic hemangioma susceptible to surgical treatment. Case Presentation: A 73-year-old man with chronic obstructive pulmonary disease and a history of two small hemangiomas started with pain in the right upper quadrant. Computerized tomography showed multiple hypodense lesions highly suggestive of hepatic hemangioma. Tumor markers were found at normal levels. A right hepatectomy guided with indocyanine green and intraoperative ultrasound was performed minimal bleeding and pulmonary complications. Conclusion: Hepatectomy for giant hemangiomas combined with ultrasound and indocyanine green is a feasible option in patients with comorbidities, decreasing bleeding risk, and allowing complete and surgical resection.

A Case of Surgical Aortic Fenestration for Type B Acute Aortic Dissection with Visceral Malperfusion: Usefulness of Intra-operative Indocyanine Green Fluorescence Imaging

A Case of Surgical Aortic Fenestration for Type B Acute Aortic Dissection with Visceral Malperfusion: Usefulness of Intra-operative Indocyanine Green Fluorescence Imaging

Intraoperative Spinal Angiography during Microsurgical Occlusion of Spinal Dural Arteriovenous Fistula within the Hybrid Operation Room.

Spinal dural arteriovenous fistula (SDAVF) is a rare cause of progressive myelopathy in predominantly middle-aged men. Treatment modalities include surgical obliteration and endovascular embolization. In surgically treated cases, failure of obliteration is reported in up to 5%. The aim of this technical note is to present a safe procedure with complete SDAVF occlusion, verified by intraoperative digital subtraction angiography (DSA). We describe four patients with progressive leg weakness who underwent surgical obliteration of SDAVF with spinal intraoperative DSA in the prone position after cannulation of the popliteal artery. All surgeries took place in our hybrid operating room (OR) and were accompanied by electrophysiologic monitoring. Surgeries and cannulation of the popliteal artery were performed in the prone position. Ultrasound was used to guide the popliteal artery puncture. A 5-Fr sheath was inserted and the fistula was displayed using a 5-Fr spinal catheter. Spinal intraoperative DSA was performed prior to and after temporary clipping of the fistula point as well after the final SDAVF occlusion. The main feeder of the SDAVF fistula in the first patient arose from the right T11 segmental artery, which also supplied the artery of Adamkiewicz. The second patient initially underwent endovascular treatment and deteriorated 5 months later due to recanalization of the SDAVF via a small branch of the T12 segmental artery. The third and fourth cases were primarily scheduled for surgical occlusion. Access through the popliteal artery for spinal intraoperative DSA proved to be beneficial and safe in the hybrid OR setting, allowing the sheath to be left in place during the procedure. During exposure and after temporary and permanent occlusion of the fistulous point, intraoperative indocyanine green (ICG) video angiography was also performed. In one case, the addition of intraoperative DSA showed failure of fistula occlusion, which was not visible with ICG angiography, leading to repositioning of the clip. Complete fistula occlusion was documented in all cases. Spinal intraoperative DSA in the prone position is a feasible and safe intervention for rapid localization and confirmation of surgical SDAVF occlusion.