Intraoperative Assessment Of Blood Flow Research Articles

Clinical experience of using the technique of uterine artery embolization in the treatment of submucous uterine fibroids in the Vidar Medical Center, Vinnytsia (2008–2022)

Myoma of the uterus is a benign neoplasm. The technique of uterine artery embolization (UAE) is used to treat uterine fibroids and is highly effective. The principle of embolization is based on the fact that all blood vessels that supply the uterus end in the endometrium.During UAE small parts are injected – emboli, which are spread along these vessels with the blood flow. In the vessels of the myoma the emboli cannot pass through the capsule of the myoma, so they block the vessels that supply it with blood. This leads to the cessation of blood supply to myomatous nodes, and subsequently there is a decrease in the size of these nodes, on average by 50–60% during the year, with a gradual decrease during the following years of life.This minimally invasive procedure is performed under local anesthesia – after femoral artery puncture, with X-ray control of angiography and intraoperative assessment of blood flow in fibroid nodes using ultrasound (US).Over 15 years of work, 1,400 UAE operations of uterine fibroids have been performed, of which more than 70 cases are UAE of submucosal myomas. Later, when the clinical picture of expulsion of these submucosal nodes appeared, transvaginal myomectomy was performed. Such a combined technique demonstrated high efficiency.The article describes clinical cases of patients who received treatment of large submucosal myoma by the UAE method followed by transvaginal myomectomy of the nascent node. In total, 5 clinical cases are described, the results of ultrasound, macropreparations, and colposcopic images are presented. A clinical case of a uterine myoma, the size of which corresponded to 21 weeks of pregnancy and a volume of 1500 cm3, is presented: after the above complex treatment method the volume of the uterus decreased according to ultrasound examination to 122 cm3. Also, a clinical case of a patient with uterine myoma, massive bleeding, whose hemoglobin level was 67 g/l is described. The patient was performed by UAE followed by transvaginal myomectomy for expulsion of the submucosal node.So, the described complex method of treatment of submucous uterine fibroids demonstrated high efficiency of clinical results.

Evaluation of tissue blood supply during esophagectomy using fluorescent diagnostics and diffuse scattering spectroscopy in visible region

BackgroundThe success of the surgical treatment of a tumor or obstruction of the esophagus with subsequent anastomosis application depends on the level of blood supply to the stitched tissues. Intraoperative assessment of blood flow is widely used in medicine and can be used as a diagnostic method that affects the outcome of surgery and reduces the frequency of postoperative complications for the patient. MethodsIn this work, the assessment of blood supply during esophageal resection operations was carried out using two techniques sequentially: fluorescent diagnostics with indocyanine green and measurement of hemoglobin oxygen saturation by diffuse scattering spectroscopy in the visible wavelength range. The first method was used to assess the integrity of the vascular network structure in the area of anastomosis and blood flow through the sutured tissues, the second one – for local assessment of hemoglobin oxygen saturation in the investigated area. ResultsConducted clinical study involved the participation of nine patients with malignant neoplasms (six cases) or esophageal obstruction (three cases). The presence of postoperative complications was compared with the measurement results. Anastomosis failure was observed in only one patient. According to the results of the study, with the use of the investigated method of assessing blood supply, there is a tendency towards a decrease in the frequency of anastomosis leaks (11.1 % compared with 21.4 %). ConclusionsTherefore, fluorescent diagnostics with indocyanine green and measurement of hemoglobin oxygen saturation using diffuse scattering spectroscopy were affirmed as methods that allow increasing the safety of surgical procedures by assessing the risk of postoperative complications, including anastomosis failures.

Insonation angle impact on micro-Doppler evaluation in cerebrovascular surgery: technical note

Introduction: The insonation angle consideration is important in the Doppler-sonographic evaluation of blood flow velocities and volume, however, the concept is rarely applied to the intraoperatively used micro-Doppler.This technical note aims to emphasize the possibility and necessity of insonation angle correction and preservation for the blood flow assessment in cerebrovascular surgery.Methods: Bi-directional surgical Doppler with a 20MHz flexible bayonet 1.2mm diameter probe was used for the intraoperative blood flow assessment, with the variable insonation angle on the straight parts of the arteries, and the results were recorded to demonstrate the importance.Results: The measurements performed confirmed that the blood flow features, including the direction, velocity, and especially the volume, are highly susceptible to the insonation angle variations. Although there were significant alterations, positioning the probe at an angle of ~60 degrees resulted in the variable but less altering measurements.Conclusion: Positioning the probe at ~60 degrees is desirable; however, it appears that it is even more important to maintain the same insonation angle and probe position when assessing the vessels repeatedly for blood flow alterations that might occur in the course of cerebrovascular surgery.

Effectiveness of Bilateral Pulmonary Artery Banding in Patients with Hypoplastic Left Heart Syndrome and Congenital Heart Defects with A Functional Single Ventricle: A Single-Center Retrospective Study

Background: Bilateral banding of the branches of the pulmonary artery in patients with hypoplastic left heart syndrome (HLHS) and other duct dependent critical neonatal heart malformations can significantly reduce the incidence of severe complications in the postoperative period, especially in severely unstable patients. In our study we compared different surgical techniques of bilateral pulmonary artery banding (PAB) in respect to their success in balancing systemic and pulmonary blood flow. Methods: We included 44 neonates with a HLHS and congenital heart diseases (CHD) with a functional single ventricle underwent a hybrid operation: bilateral PAB and patent ductus arteriosus stenting. The hybrid surgery for method No. 1 is performed as a one-stage procedure, together with patent ductus arteriosus (PDA) stenting. After median sternotomy, two Gore-Tex 1–2 mm wide bands with a diameter of 3–3.5 mm are put. When we apply method No. 2 then the thread is used to create bands. Method No. 3 is distinguished by intraoperative assessment of blood flow at the site of narrowing of the branches of the pulmonary artery and optional stenting of the PDA. The cuff for banding is made of Gore-Tex tubing. Effectiveness when applying method Nos. 1 and 2 is assessed by the change in invasive blood pressure and oxygen saturation after narrowing of the branches of the pulmonary artery. Also, with these techniques PDA stenting by inserting the introducer via pulmonary artery trunk is performed. Results: HLHS with mitral or aortic valve atresia or both was present in 19 patients (43.1%), with severe left heart obstruction resulting in PDA dependent systemic circulation in 16 babies (36.4%). CHD with single ventricle physiology occurred in 9 patients (20.5%). 14 babies (31.8%) undergo the procedure following the method No. 1, 8 patients (18.2%) method No. 2 and 22 patients (50%) method No. 3. Qp/Qs = 1/1 was achieved in 30 patients (30/44, 68.1%): as a result of the method No. 1 was achieved in 5 patients (5/14, 35.7%), method No. 2 in 4 patients (4/8, 50%), method No. 3 in 21 patients (21/22, 95.5%). Multivariate regression analysis revealed that method No. 3 significantly increases the chances of hemodynamic efficacy operations (OR = 35.0; p = 0.005; CI (95%) 3–411.5). Conclusion: Application of the operation technique No. 3 in combination with the intraoperative assessment of blood flow parameters at the site of banding of the branches of the pulmonary artery are the most optimal criteria for achieving Qp/Qs = 1/1. If there are signs of restriction at the level of the foramen ovale, atrioseptostomy should be done in the second stage after bilateral pulmonary banding.

Results of flowmetric assessment of composite Y-grafts and autovenous coronary artery bypass grafts.

The purpose of the study was to perform intraoperative assessment of blood flow in coronary bypass grafts of the 'first' and 'third' order according to Calafiore A.M. with the help of the TTFM technique and to compare the obtained results. This retrospective, single-centre study enrolled a total of 222 patients subjected to coronary artery bypass grafting (CABG) from January to November 2017. Depending on the type of bypass grafting of the posterior interventricular artery (PIVA), the patients were divided into 2 groups. Group One consisted of 108 patients undergoing bypass grafting of the PIVA with the help of combined Y-grafts from the right internal thoracic artery (RTIA). Group Two was composed of 114 patients subjected to autovenous coronary artery bypass grafting of the PIVA. Blood flow was assessed with the help of the VeriQ MediStim® flowmeter after termination of extracorporeal circulation (ECC), at systolic pressure of 100-110 mm Hg. The parameters of blood flow were assessed using the 1.5- and 2-mm probes. In a specially designed protocol we registered the type of the shunt, the bypassed artery, and values of flowmetry parameters. We also evaluated the pattern of the flowmetric curve according to Takemi Handa et al. RESULTS: The obtained findings revealed a statistically significant difference in the values of Qmean (p=0.001), with the PI values in the groups not statistically differing (p=0.14). Thus, in patients with similar parameters influencing the volumetric velocity of blood flow (the degree of proximal stenosis, diameter of the bypassed artery, mean systolic AP and HR) the value of Qmean was higher in the group with coronary artery bypass grafting (CABG), i. e., in the group of the 'first-order' conduits. Therefore, an autovein directly anastomosed to the aorta experiences grater haemodynamic overload, which completely confirms the theory of Calafiore A.M. First-order conduits (CABG) appear to experience greater wall strain because of greater haemodynamic overload as compared with third-order conduits (Y-grafts). A composite Y-graft may be an alternative technique of bypass grafting of the basin of the right coronary artery (RCA). A composite Y-graft has greater resistance to wall shear stress than an autovein anastomosed to the aorta.

Identification of plaque location using intraoperative indocyanine green during carotid endarterectomy for patient with near occlusion.

Microscope-integrated near-infrared indocyanine green (ICG) videoangiography (VA) is an effective method of intraoperative blood-flow assessment and identification of plaque location during carotid endarterectomy (CEA). However, the validity of ICG-VA during CEA for patient with near occlusion has not been elucidated. Thirty-four CEA procedures were performed between June 2009 and December 2017 for patient with near occlusion, which are more than 95% stenosis. The lesions were classified into three groups according to the diameter of distal ICA compared with ipsilateral external carotid artery (ECA), as normal diameter (>100%), moderate diameter reduction (50-100%), severe diameter reduction (<50%). Five mg of ICG was injected intravenously before arteriotomy, and ICG-VA was taken to identify the distal end of the plaque. Depiction of the distal end and its accuracy were retrospectively reviewed. There were 18 cases with normal diameter group, 14 cases with moderate diameter reduction group, and 2 cases with severe diameter reduction group. All but one case in the severe diameter reduction group showed apparent distal end signal which were confirmed by arteriotomy afterward. The present study clearly denotes that ICG-VA can visualize the carotid plaque distal end during the CEA, even with the patient with near occlusion. However, it should be noted that there may be a difficulty in visualization of the distal plaque end for patient with severely collapsed distal ICA.

Influence of indocyanine green angiography on microsurgical treatment of spinal perimedullary arteriovenous fistulas

The microvascular anatomy of spinal perimedullary arteriovenous fistulas (AVFs) is more complicated than that of dural AVFs, and occlusion rates of AVF after open microsurgery or endovascular embolization are lower in patients with perimedullary AVFs (29%-70%) than they are in those with dural AVF (97%-98%). Reports of intraoperative blood flow assessment using indocyanine green (ICG) video angiography in spinal arteriovenous lesions have mostly been for spinal dural AVFs. No detailed reports on spinal perimedullary AVFs are available. Participants were 11 patients with spinal perimedullary AVFs (Type IVa in 5 patients, Type VIb in 4, and Type IVc in 2). Intraoperative ICG video angiography was assessed by measuring the number of cases in which this modality was judged essential by the surgeon to correctly occlude the fistula. In all patients, arterial feeders were identified and intravenous ICG video angiography was performed before and after blocking the feeders. In one patient, selective intraarterial ICG video angiography was also performed. The findings provided by ICG video angiography significantly changed the surgical procedure in 4 of 11 patients (36%). Postoperatively, complete occlusion of the AVF was achieved in 10 of the 11 patients (91%). Intraoperative ICG video angiography can have a significant impact on deciding surgical strategy in the microsurgical treatment of spinal perimedullary AVF.

Effect of indocyanine green dye administration on cerebral oxygen saturation.

Sir, Near-infrared spectroscopy (NIRS) is a non-invasive continuous method of measuring regional cerebral oxygen tissue saturation (SctO2).[1] It uses a technique similar to pulse oximetry where light absorption in wavelength 600–900 nm is used. Indocyanine green (ICG) is a water soluble and iodide containing dye that fluoresces when exposed to infrared light. This property of ICG is used for the intra-operative assessment of blood flow during aneurysm surgery. Safety of ICG usage in clinical settings has been demonstrated for determining cardiac output, hepatic function and liver blood flow and for ophthalmic angiography.[2] There have been hypotension, urticarial reaction or anaphylaxis and falsely low pulse oximetry recording during or following use of ICG.[3,4] Contrary to falsely low pulse oximetry recordings, ICG administration has been shown to increase SctO2.[4] Here, we are describing the effect of ICG administration on SctO2. A 65-year-old male patient was scheduled to undergo clipping of right supraclinoid internal carotid artery aneurysm under general anaesthesia. Apart from the routine monitoring, we placed bilateral NIRS sensors over the forehead of the patient. After administration of 10 mg of ICG, the SctO2 on both the sides suddenly increased to 100 from a baseline of about 65–75% and gradually decreased to the baseline value after about 15 min [Figure 1]. There were no associated haemodynamic changes. Figure 1 Snap shot of near infrared spectroscopy monitor showing the graphical trend of the cerebral oxygen saturation. Furthermore, clearly seen is the sudden acute increase in saturation after injection of indocyanine green at two different time points and gradual ... This sudden increase in SctO2 following administration of ICG can be explained by the principle applied in NIRS sensors. NIRS uses wavelengths between 700 and 850 nm to determine regional cerebral oxygen SctO2 by differentiating oxyhaemoglobin from reduced haemoglobin in the frontal lobe. Thus, any substances that absorb infrared light of the same wavelength produced by the light-emitting diodes may affect the absorption of light as they traverse the blood and tissues.[5] ICG has a characteristic absorption peak at around 805 nm and this is likely to reduce the amount of detected light in the 810 nm wavelength of the NIRS device, which would be interpreted as an increased oxyhaemoglobin concentration leading to falsely elevated SctO2 reading.[6] The effect of this falsely elevated SctO2 on the clinical outcome of the patients is not known. Despite these changes, the remaining of the surgical procedure was uneventful or did the patient develop any new neurological deficits and patient's trachea was successfully extubated at the end of the procedure. The anaesthesiologists and neurosurgeons must be aware of this interaction of ICG and cerebral oxygen SctO2 in the intra-operative period. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Intraoperative indocyanine green fluorescence angiography in surgery of brain aneurysms. The first experience with using the technique and literature review

Intraoperative blood flow assessment after aneurysm clipping has become a standard procedure in vascular neurosurgery worldwide. Intraoperative indacyanine green angiography (ICG) has recently been certified in Russia. Fifteen patients with aneurysms operated with ICG control in Burdenko NSI are described in present publication. ICG advantages and weaknesses are discussed along with alternative flow control techniques available now.

Use of indocyanine green videoangiography during intracranial aneurysm surgery reduces the incidence of postoperative ischaemic complications

Microscope-integrated near-infrared indocyanine green videoangiography (ICGVA) has been shown to be a useful adjunct for intracranial aneurysm surgery. That the routine application of this technique reduces the risk of postoperative ischaemic complication, however, has not been reported. We present a retrospective matched-pair comparison of ICGVA guided aneurysm surgery versus historic control surgical cohort treated by the same author. Index patients and controls were matched for aneurysm size, location, patient demographics, risk factors, comorbidities, and surgical treatments. Ninety-one eligible patients with 100 intracranial aneurysms were treated using ICGVA assistance. There were no statistically significant differences between the two groups in terms of patient age, sex, risk factors, comorbidities and aneurysm characteristics. Of the 100 aneurysms in the ICGVA group, 107 investigations of ICGVA were performed. In 79 aneurysms (79.0%), ICGVA was considered useful but did not affect surgical management. In six patients (6.0%), ICGVA led to a crucial change of intraoperative strategies. In nine patients (9.0%), it was considered critical in assuring patency of small perforators. ICGVA was of no benefit in four patients (4.0%) and was misleading in two (2.0%). Postoperative ischaemic complications occurred in three patients (3.3%) in the ICGVA group compared with seven patients (7.7%) in the control group (p<0.001). Our study supports the use of ICGVA in aneurysm surgery as a safe and effective modality of intraoperative blood flow assessment. With all limitations of a retrospective matched-pair comparison, the use of ICGVA during routine aneurysm surgery reduces the incidence of postoperative ischaemic complications.

Endoscopic indocyanine green video angiography in aneurysm surgery: an innovative method for intraoperative assessment of blood flow in vasculature hidden from microscopic view

Recently, intraoperative fluorescence video angiography using indocyanine green (ICG) has been widely used in aneurysm surgery. This is a simple and useful method to confirm complete occlusion of the aneurysm lumen and preservation of blood flow in the arteries around the aneurysm. However, the observation field of ICG video angiography is limited under a microscope, making it difficult to confirm the flow in the arteries behind the parent arteries or aneurysm. The authors developed a new technique of intraoperative endoscopic ICG video angiography to assess the blood flow in perforating arteries hidden by the parent arteries or aneurysm. The endoscope emits excitation light with a wavelength of approximately 800 nm, and video images were obtained through a cut filter. The authors used this ICG fluorescence endoscope in treating 3 patients with unruptured cerebral aneurysms. During clip placement, the endoscope was inserted to confirm aneurysm occlusion. Then, ICG was intravenously administered, and the fluorescence in the vessels was observed via the endoscope as well as under the microscope. The blood flow in the perforating arteries was clearly identified, and no procedural complication occurred. The authors conclude that the technique is very useful and facilitates intraoperative real-time assessment of the patency of perforating arteries behind parent arteries or aneurysms.

Use of panitumumab-IRDye800 to image microscopic head and neck cancer in an orthotopic surgical model.

Fluorescence imaging hardware (SPY) has recently been developed for intraoperative assessment of blood flow via detection of probes emitting in the near-infrared (NIR) spectrum. This study sought to determine if this imaging system was capable of detecting micrometastatic head and neck squamous cell carcinoma (HNSCC) in preclinical models. A NIR fluorescent probe (IRDye800CW) was covalently linked to a monoclonal antibody targeting epidermal growth factor receptor (EGFR; panitumumab) or nonspecific IgG. HNSCC flank (SCC-1) and orthotopic (FADU and OSC19) xenografts were imaged 48-96h after systemic injection of labeled panitumumab or IgG. The primary tumor and regional lymph nodes were dissected using fluorescence guidance with the SPY system and grossly assessed with a charge-coupled NIR system (Pearl). Histologic slides were also imaged with a NIR charged-coupled device (Odyssey) and fluorescence intensity was correlated with pathologic confirmation of disease. Orthotopic tongue tumors were clearly delineated from normal tissue with tumor-to-background ratios of 2.9 (Pearl) and 2.3 (SPY). Disease detection was significantly improved with panitumumab-IRDye compared to IgG-IRDye800 (P<0.05). Tissue biopsy samples (average size 3.7mm) positive for fluorescence were confirmed for pathologic disease by histology and immunohistochemistry (n=25 of 25). Biopsy samples of nonfluorescent tissue were proven to be negative for malignancy (n=28 of 28). The SPY was able to detect regional lymph node metastasis (<1.0mm) and microscopic areas of disease. Standard histological assessment in both frozen and paraffin-embedded histologic specimens was augmented using the Odyssey. Panitumumab-IRDye800 may have clinical utility in detection and removal of microscopic HNSCC using existing intraoperative optical imaging hardware and may augment analysis of frozen and permanent pathology.

Near Infrared Fluorescence Imaging With Robotic Assisted Laparoscopic Partial Nephrectomy: Initial Clinical Experience for Renal Cortical Tumors

We evaluated the utility of near infrared fluorescence of intravenously injected indocyanine green in performing robotic assisted laparoscopic partial nephrectomy. In addition, we evaluated the initial performance of a novel near infrared fluorescence imaging system integrated into the da Vinci® Si Surgical System during robotic assisted laparoscopic nephrectomy. Fluorescence imaging for the da Vinci Si Surgical System was used for all cases. Indocyanine green was injected before near infrared imaging. Immediate imaging assessed the renal vasculature while delayed imaging differentiated renal cortical tumors from normal parenchyma. The intraoperative performance of near infrared fluorescence of intravenous indocyanine green was evaluated for tumor appearance relative to surrounding renal parenchyma as well as identification of the renal vasculature. A total of 11 patients underwent robotic assisted laparoscopic nephrectomy with 2 converted to robotic assisted laparoscopic radical nephrectomy. Indocyanine green injections were repeated up to a total of 5 times depending on the goal of visualization. Of the 11 patients 10 demonstrated malignancy on final pathology. Of the malignant tumors 7 were hypofluorescent and 3 were isofluorescent compared to the surrounding renal parenchyma. Near infrared fluorescence imaging delineated the vascular anatomy in all cases. All surgical margins were negative on final pathology. Intraoperative imaging of indocyanine green with near infrared fluorescence is a safe and effective method to accurately identify the renal vasculature and to differentiate renal tumors from surrounding normal parenchyma. The capacity for multimodal imaging within the surgical console further facilitates this imaging. Further study is needed to determine if this technique will help improve outcomes of robotic assisted laparoscopic nephrectomy.

Microscope-integrated near-infrared indocyanine green videoangiography during surgery of intracranial aneurysms: the Helsinki experience

Background Microscope-integrated near-infrared indocyanine green videoangiography (ICG-VA) is a new method of intraoperative blood flow assessment. The objective of this study was to evaluate the reliability of this technique in the evaluation of neck residuals and patency of branches after microneurosurgical clipping of intracranial aneurysms (IAs). Methods During a period of 14 months, between November 2005 and December 2006, 289 patients with intracranial aneurysms were operated on in our institution. Intraoperative ICG-VA was performed during microneurosurgical clipping of 239 IAs in 190 patients. Postoperative computed tomography and computed tomography angiography (CTA) were performed for all patients. Intraoperative interpretation of ICG-VA in assessing the neck residual or the patency of vessels after clipping of each single aneurysm were recorded and correlated with postoperative CTA and/or digital subtraction angiography. Results Postoperative imaging studies revealed no incomplete occlusions of aneurysm domes. Unexpected neck residuals were observed in 14 aneurysms (6%). There were no parent artery occlusions. Unexpected branch occlusions including both major and minor branching arteries were observed in 15 aneurysms (6%). Conclusions Indocyanine green videoangiograph is a simple and fast method of blood flow assessment with acceptable reliability. Indocyanine green videoangiograph can provide real-time information to assess blood flow in vessels of different size as well as the occlusion of the aneurysm. Intraoperative assessment of blood flow in the perforating branches is one of the most important advantages. In selected cases such as giant, complex, and deep-sited aneurysms or when the quality of image in ICG-VA is not adequate, other methods of intraoperative blood flow assessment should be considered.

Real-time probe measurement of tissue oxygenation during gastrointestinal stapling: mucosal ischemia occurs and is not influenced by staple height

Tension, ischemia, and technical error are factors leading to anastomotic complications such as leak, stricture, and ulceration with bleeding. Currently, surgeons evaluate tissue ischemia without any simple routine measurement technique. A new tissue surface probe, T-Stat 303, provides continuous measurement of tissue hemoglobin oxygen saturation (StO(2)) and may have clinical utility for intraoperative assessment of blood flow in areas of surgical anastomosis. This pilot study aimed to determine local StO(2) during gut stapling using various staple sizes for the purpose of assessing the tool's ability to measure changes and the reproducibility of those changes with stapling. Measurements were made in nine anesthetized adult swine during laparotomy. Various staple heights were used to transect small bowel and colon. Serosal and mucosal surface measurements were obtained at baseline and on each side of the transection using the T-Stat device adjacent to the staple line and 2 cm away from it. Both small bowel and colon mucosal StO(2) adjacent to the staple line showed significant ischemia compared with baseline (p < 0.001) and 2 cm away from the staple line (p < 0.001) using all staple heights. The serosa of both small bowel and colon adjacent to the staple line was not significantly different from baseline serosa (p > 0.11) except when the grey stapler was used (baseline, 58 +/- 6.6 vs. staple line, 51 +/- 15.1; p = 0.022). The baseline mucosa of the small bowel and colon did not differ from mucosa 2 cm away from the staple line (p > 0.08). The small bowel serosa 2 cm away from the staple line did not differ from baseline mucosa, whereas the colon serosa 2 cm away significantly increased after stapling compared with baseline mucosa (p < 0.012). No statistically significant StO(2) difference was found between the various staple load sizes. Mucosal ischemia occurs after gastrointestinal stapling and is not affected by various staple heights. The T-Stat probe provides a real-time method for assessment of gut ischemia by surgeons during surgical procedures.

脳血管障害手術におけるＣａｒｌ Ｚｅｉｓｓ社製ＯＰＭＩ Ｐｅｎｔｅｒｏによる術中蛍光血管撮影の有用性

In the present study, we assess whether a new technique of surgical microscope-based videoangiography (VAG) using indocyanine green (ICG) is suitable for confirming a patent extracranial-intracranial bypass or a complete aneurysmal clipping. We also describe the usefulness of our approach combined with ICG-VAG and motor evoked potentials (MEP) for the intraoperative assessment of blood flow in cerebral arteries of clipping or bypass operations. We clinically and scientifically tested ICG VAG in 22 patients. In each patient, ICG (0.10-0.50 mg/kg body weight) was given systemically via an intravenous bolus injection. We used the Carl Zeiss Surgical Microscope OPMI Pentero INFRARED 800 system (Carl Zeiss Co., Tokyo, Japan). Images of ICG video angiography were excellent and permitted a real-time surgical assessment if the structures of interest were visible to the surgeon under the microscope. The visible structures included venous vessels or perforating arteries with a diameter of less than 0.3 mm. Of the 22 patients operated on, none suffered surgically related complications. ICG VAG is a simple, reliable method, and its real-time character allows the early confirmation of complete aneurysmal clipping in patient bypass surgery. This technique may improve neurosurgical procedures and reduce the application of intra- or postoperative digital subtraction angiography.

Assessment of Incomplete Clipping of Aneurysms Intraoperatively by a Near-Infrared Indocyanine Green-Video Angiography (Niicg-Va) Integrated Microscope

The objective of this article was to assess the clinical use and the completeness of clipping with total occlusion of the aneurysmal lumen, real-time assessment of vascular patency in the parent, branching and perforating vessels, intraoperative assessment of blood flow, image quality, spatial resolution and clinical value in difficult aneurysms using near infrared indocyanine green video angiography integrated on to an operative Pentero neurosurgical microscope (Carl Zeiss, Oberkochen Germany). Thirteen patients with aneurysms were operated upon. An infrared camera with near infrared technology was adapted on to the OPMI Pentero microscope with a special filter and infrared excitation light to illuminate the operating field which was designed to allow passage of the near infrared light required for excitation of indocyanine green (ICG) which was used as the intravascular marker. The intravascular fluorescence was imaged with a video camera attached to the microscope. ICG fluorescence (700-850 nm) from a modified microscope light source on to the surgical field and passage of ICG fluorescence (780-950 nm) from the surgical field, back into the optical path of the microscope was used to detect the completeness of aneurysmal clipping Incomplete clipping in three patients (1 female and 2 males) with unruptured complicated aneurysms was detected using indocyanine green video angiography. There were no adverse effects after injection of indocyanine green. The completeness of clipping was inadequately detected by Doppler ultrasound miniprobe and rigid endoscopy and was thus complemented by indocyanine green video angiography. The operative microscope-integrated ICG video angiography as a new intraoperative method for detecting vascular flow, was found to be quick, reliable, cost-effective and possibly a substitute or adjunct for Doppler ultrasonography or intraoperative DSA, which is presently the gold standard. The simplicity of the method, the speed with which the investigation can be performed, the quality of the images, and the outcome of surgical procedures have all reduced the need for angiography. This technique may be useful during routine aneurysm surgery as an independent form of angiography and/or as an adjunct to intraoperative or postoperative DSA.

ASSESSMENT OF FLOW IN PERFORATING ARTERIES DURING INTRACRANIAL ANEURYSM SURGERY USING INTRAOPERATIVE NEAR-INFRARED INDOCYANINE GREEN VIDEOANGIOGRAPHY

Perforating arteries are commonly involved during the surgical dissection and clipping of intracranial aneurysms. Occlusion of perforating arteries is responsible for ischemic infarction and poor outcome. The goal of this study is to describe the usefulness of near-infrared indocyanine green videoangiography (ICGA) for the intraoperative assessment of blood flow in perforating arteries that are visible in the surgical field during clipping of intracranial aneurysms. In addition, we analyzed the incidence of perforating vessels involved during the aneurysm surgery and the incidence of ischemic infarct caused by compromised small arteries. Sixty patients with 64 aneurysms were surgically treated and prospectively included in this study. Intraoperative ICGA was performed using a surgical microscope (Carl Zeiss Co., Oberkochen, Germany) with integrated ICGA technology. The presence and involvement of perforating arteries were analyzed in the microsurgical field during surgical dissection and clip application. Assessment of vascular patency after clipping was also investigated. Only those small arteries that were not visible on preoperative digital subtraction angiography were considered for analysis. The ICGA was able to visualize flow in all patients in whom perforating vessels were found in the microscope field. Among 36 patients whose perforating vessels were visible on ICGA, 11 (30%) presented a close relation between the aneurysm and perforating arteries. In one (9%) of these 11 patients, ICGA showed occlusion of a P1 perforating artery after clip application, which led to immediate correction of the clip confirmed by immediate reestablishment of flow visible with ICGA without clinical consequences. Four patients (6.7%) presented with postoperative perforating artery infarct, three of whom had perforating arteries that were not visible or distant from the aneurysm. The involvement of perforating arteries during clip application for aneurysm occlusion is a usual finding. Intraoperative ICGA may provide visual information with regard to the patency of these small vessels.

ASSESSMENT OF FLOW IN PERFORATING ARTERIES DURING INTRACRANIAL ANEURYSM SURGERY USING INTRAOPERATIVE NEAR-INFRARED INDOCYANINE GREEN VIDEOANGIOGRAPHY

Perforating arteries are commonly involved during the surgical dissection and clipping of intracranial aneurysms. Occlusion of perforating arteries is responsible for ischemic infarction and poor outcome. The goal of this study is to describe the usefulness of near-infrared indocyanine green videoangiography (ICGA) for the intraoperative assessment of blood flow in perforating arteries that are visible in the surgical field during clipping of intracranial aneurysms. In addition, we analyzed the incidence of perforating vessels involved during the aneurysm surgery and the incidence of ischemic infarct caused by compromised small arteries. Sixty patients with 64 aneurysms were surgically treated and prospectively included in this study. Intraoperative ICGA was performed using a surgical microscope (Carl Zeiss Co., Oberkochen, Germany) with integrated ICGA technology. The presence and involvement of perforating arteries were analyzed in the microsurgical field during surgical dissection and clip application. Assessment of vascular patency after clipping was also investigated. Only those small arteries that were not visible on preoperative digital subtraction angiography were considered for analysis. The ICGA was able to visualize flow in all patients in whom perforating vessels were found in the microscope field. Among 36 patients whose perforating vessels were visible on ICGA, 11 (30%) presented a close relation between the aneurysm and perforating arteries. In one (9%) of these 11 patients, ICGA showed occlusion of a P1 perforating artery after clip application, which led to immediate correction of the clip confirmed by immediate reestablishment of flow visible with ICGA without clinical consequences. Four patients (6.7%) presented with postoperative perforating artery infarct, three of whom had perforating arteries that were not visible or distant from the aneurysm. The involvement of perforating arteries during clip application for aneurysm occlusion is a usual finding. Intraoperative ICGA may provide visual information with regard to the patency of these small vessels.

Intraoperative assessment of blood flow to strangulated stomach by pulse oximetry

A pulse oximeter was used to detect safe margins for resection of a strangulated stomach. The sensor probe was placed intraoperatively on various portions of the stomach, which herniated through a left lateral diaphragmatic defect. Failure to detect blood flow by this device in equivocally compromised tissue helped in the assessment of safe viable margins for resection.