Use Of Fluorescence Angiography Research Articles

Predicting Nipple Necrosis with a "Lights-on" Indocyanine Green Imaging System: A Report of Two Patients.

Nipple-areolar complex (NAC) necrosis is a devastating complication in nipple-sparing mastectomies (NSMs) that significantly impacts patient's quality of life. The use of fluorescence angiography for intraoperative assessment of mastectomy skin flap perfusion in NSM has been successfully described and can be utilized to help guide surgical decision-making. Recently, a novel fluorescence-guided surgical imager was developed, OnLume Avata System (OnLume Surgical, Madison, WI), which provides intraoperative evaluation of vascular perfusion in ambient light. In this case report, we describe the use of OnLume fluorescence-guided surgery technology to help aid in clinical decision-making for two breast reconstruction cases with concern for intraoperative nipple hypoperfusion.

The Role of Fluorescent Angiography in Free Flap Reconstruction of the Head and Neck.

Highlight the use of fluorescent angiography in free flap reconstruction of the head and neck. Qualify how fluorescent angiography can be selectively added to management paradigms for head and neck free flap reconstruction. Retrospective chart review of 993 free flaps completed from the time the SPY Elite® system first became available at our institution between September 2013, until August 2020. Cases that used the SPY Elite® system were grouped into three broad categories: evaluation during initial flap harvest while still attached to the donor site, evaluation after anastomosis in the head and neck area, and evaluation post-operatively for questionable flap viability. The SPY Elite® system was used in 64 cases. Forty flaps were evaluated intraoperatively during initial harvest and before anastomosis to the head and neck area. Of these, 20 had signs of poor perfusion of the entire skin paddle, 12 had large myogenous or skin flaps with questionable perfusion of the distal aspect, and 8 were evaluated for other reasons. In this group the use of SPY Elite® changed the management of the patient in 20 cases (50%). Ten flaps were evaluated intraoperatively after anastomosis to the head and neck to ascertain adequate flow to the entire flap. In this group management was changed in two (20%). Fourteen flaps were evaluated 3-5 days post operatively due to suspected failure of a component. In five cases (36%), the use of SPY Elite® determined management with either trimming or discarding the flap. Assessment of flap perfusion via fluorescent angiography during initial flap harvest or when flap compromise is suspected post-operatively can guide decision making in free flap reconstruction of the head and neck and can be added to existing planning and management paradigms. 4 Laryngoscope, 133:1388-1393, 2023.

1037 The Use of Fluorescence Angiography with Indocyanine Green in Colorectal Surgery – A District General Hospital Experience

Abstract Introduction Indocyanine green (ICG) fluorescence imaging is used in a variety of procedures in in colorectal surgery. It optimises intraoperative vision of anatomical structures by improving blood and lymphatic flow. Traditionally, the vascularization of the colonic stump is subjectively evaluated by the surgeon based on the colour of the bowel wall, the bleeding of the colonic stump, and pulsation of the terminal artery. ICG aims to improve objectivity of this assessment. Aim To assess the feasibility and efficacy of ICG in colorectal operations and report on initial experience since introduction in November 2021. Method Retrospective review of prospectively collected database of all patients undergoing colorectal operations with intraoperative ICG use for any indication. Data collected included patient demographic details including age/gender/comorbidities; operative details including indication/type of surgery, 30day-complications, details/outcome of intraoperative ICG use. Results During the study period ten patients underwent colorectal surgical procedures with intra-operative use of ICG. Surgical options included resectional surgery (right hemicolectomy/transverse colectomy/anterior resection) and reconstructive surgery (reversal of hartmann's operation). Majority were done for colorectal cancer and one for inflammatory bowel disease. ICG was reported useful in all cases in demonstrating vascularity in anastomoses/resection margins. One notable case demonstrated decreased ability of discerning ICG uptake in the presence of tattoo pigmentation (preoperative tumour marking). No adverse events were reported. Conclusion The ICG assessment of colonic vascularization was simple, feasible, with no adverse events in our cohort. Our experience suggests caution is required when interpreting ICG readings in the presence of colonic tattoo.

Microvascular neural blood flow assessment for a chronic nerve compression neuropathy mouse model by fluorescein angiography

ABSTRACT Background and aims Intraoperative fluorescence angiography with indocyanine green or fluorescein is used in ophthalmology and neurosurgery. However, there are few reports on the use of fluorescence angiography for peripheral neuropathy. This study aimed to assess the validity of fluorescein angiography (FAG) for peripheral nerve entrapment neuropathy. Methods We used an established model of chronic nerve compression (CNC) neuropathy in C57BL/6 mice by entrapping their left sciatic nerve with a silastic tube. Mice were assigned to the uninjured group (control), two-week CNC neuropathy group, four-week CNC neuropathy group, or six-week CNC neuropathy group. We then performed FAG to assess neural blood flow and quantified the peak of the luminance at the compression site with luminance analysis software. Following FAG, histological examinations using an anti-fluorescein antibody and Masson’s trichrome staining were performed to evaluate the area of fluorescein distribution and epineural fibrosis. Results The luminance in the CNC neuropathy groups was significantly lower than that in the control group. Histological analysis revealed the fluorescein positive areas in the CNC neuropathy groups were significantly smaller than that in the control group, and the epineural fibrosis areas in the CNC neuropathy groups were significantly larger than that in the control group. Conclusion We observed a significant decline of luminance in the CNC neuropathy groups, and the histological assessment was consistent with this result. FAG was found to be a valid method for assessing CNC neuropathy in mice.

The use of fluorescence angiography to assess bowel viability in the acute setting: an international, multi-centre case series

IntroductionAssessing bowel viability can be challenging during acute surgical procedures, especially regarding mesenteric ischaemia. Intraoperative fluorescence angiography (FA) may be a valuable tool for the surgeon to determine whether bowel resection is necessary and to define the most appropriate resection margins. The aim of this study is to report on FA use in the acute setting and to judge its impact on intraoperative decision making.Materials and methodsThis is a multi-centre, retrospective case series of patients undergoing emergency abdominal surgery between February 2016 and 2021 in three general/colorectal units where intraoperative FA was performed to assess bowel viability. Primary endpoint was change of management after the FA assessment.ResultsA total of 93 patients (50 males, 66.6 ± 19.2 years, ASA score ≥ III in 85%) were identified and studied. Initial surgical approach was laparotomy in 66 (71%) patients and laparoscopy in 27 (29% and seven, 26% conversions). The most common aetiologies were mesenteric ischaemia (n = 42, 45%) and adhesional/herniae-related strangulation (n = 41, 44%). In 50 patients a bowel resection was performed. Overall rates of anastomosis after resection, reoperation and 30-day mortality were 48% (n = 24/50, one leak), 12% and 18%, respectively. FA changed management in 27 (29%) patients. In four patients (4% overall), resection was avoided and in 21 (23%) extra bowel length was preserved (median 50 cm of bowel saved, IQR 28–98) although three patients developed further ischaemia. FA prompted extended resection (median of 20 cm, IQR 10–50 extra bowel) in six (6%) patients.ConclusionIntraoperative use of FA impacts surgical decisions regarding bowel resection for intestinal ischaemia, potentially enabling bowel preservation in approximately one out of four patients. Prospective studies are needed to optimize the best use of this technology for this indication and to determine standards for the interpretation of FA images and the potential subsequent need for second-look surgeries.

Hyperbaric oxygen therapy and fluorescence angiography in arterial insufficiency secondary to injection of crushed hydromorphone

Introduction: Foreign body emboli can lead to acute arterial insufficiency. We present a case report of upper extremity arterial insufficiency in an intravenous (IV) drug user secondary to intra-arterial injection of crushed tablet particles successfully treated with hyperbaric oxygen (HBO2) therapy. Case: A 37-year-old right-hand-dominant male developed pain and swelling of the left hand after attempting to inject crushed hydromorphone tablets into his venous circulation. Angiography revealed incomplete distal filling of the proper digital arteries, princeps pollicis, and radialis indicis branches of the left hand. The patient was treated with HBO2 for acute arterial insufficiency, secondary to these findings. Fluorescence angiography was performed prior to, during and after completion of HBO2, which showed improved perfusion of the hand upon completion of serial imaging. The patient underwent subsequent partial amputation of the left second digit and removal of the thenar and third finger pads. Discussion: Much of the literature on treatment of arterial insufficiency with HBO2 are in relation to chronic problem wounds. However, there is limited data on adjunctive treatment with HBO2 for foreign body embolism. Fluorescence angiography and clinical exam were used to track tissue perfusion and progression throughout course of therapy with HBO2. Conclusion: Acute arterial insufficiency induced by foreign body embolism was successfully treated with HBO2 and provided increased tissue salvage of the patient’s hand. The use of fluorescence angiography as a secondary measure of perfusion can provide additional insight regarding qualitative tissue oxygenation and may be a viable tool to track patient progress during HBO2 treatment.

Fluorescent angiography used as a tool to guide angiosome-directed endovascular therapy for diabetic foot ulcers

Angiosome-directed endovascular therapy for the treatment of chronic limb-threatening ischemia (CLTI) remains controversial owing to the overlap of wound angiosomes. Angiographic grading of success has limitations and translesional pressure assessments are seldom performed in the infrapopliteal vessels. Objective criteria to determine revascularization success in tibiopedal vessels have not been well described. Quantifying perfusion to a wound bed after establishing direct or indirect (via collateral) flow after revascularization is an important component for treating CLTI patients yet is seldom performed. We report the use of fluorescent angiography to quantitatively examine perfusion of a diabetic foot ulcer before and after angiosome-directed endovascular therapy.

ICG fluorescence triple check during TaTME

The use of fluorescence angiography has been widespread for almost 50 years, and the use of Indocyanine Green angiography is one of the latest technical evolutions in colorectal surgery. Its application to evaluate the vascular supply of the colon is analyzed in many studies to assess its possible effectiveness to minimize the risk of anastomotic leak. This article describes the ICG fluorescence triple check technique, standardized in a high-volume colorectal center and applied during transanal total mesorectal excision (TaTME) to assess the vascularization of both the colonic stump and the rectal stump before the anastomosis. A last transanal check is performed after the construction of the anastomosis. This technique is now standardized in this center and it could represent a possible application of ICG fluorescence to minimize the risk of anastomotic leak following TaTME.

OCT and OCT‐A based management of vaso‐occlusive retinal disorders. Present indications for the use of fluorescent angiography

AbstractOCT angiography images, improved the detail observation regarding macular capillaries status and became a novel imaging technique for the diagnosis and treatment of the retinal ischemic microangiopathies. OCT angiography offer the ability to visualize the flow in various capillaries layers of the retina and the freedom and safety of not having to use an injected dye. The deeper capillaries layer selective involvement, in cases of ischemic microangiopathies, was precisely defined. Additional information concerning the health of vessels barrier assessing the vessels leakage and the wide field imaging view allowing the assessment of the peripheral retinal filling defects are obtained by the use of the fluorescein angiography.

Near-infrared fluorescence angiography for intra-operative assessment of pedicled omentoplasty for filling of a pelvic cavity: a pilot study

BackgroundDuring creation of a pedicled omentoplasty, blood flow to segments of the omentum might become compromised. If unrecognized, this can lead to omental necrosis. The purpose of this study was to investigate the potential added intra-operative value of the use of fluorescence angiography (FA) with indocyanine green (ICG) to assess omental perfusion.MethodsAll consecutive patients undergoing a pedicled omentoplasty in a 6-month period (April 1 2018–October 1 2018) in a University hospital were included. The primary outcome was change in management due to FA. Secondary outcomes included the amount of additionally resected omentum, added surgical time, and quantitative fluorescent values (time to fluorescent enhancement, contrast quantification).ResultsFifteen patients had pelvic surgery with omentoplasty and FA. Change in management occurred in 12 patients (80%) and consisted of resecting a median of 44 g (range 12–198 g) of poorly perfused omental areas that were not visible by conventional white light. The median added surgical time for the use of FA and subsequent management was 8 min (range 3–39 min). The first fluorescent signal in the omental tissue appeared after a median of 20 s (range 9–37 s) after injection of ICG. The median signal-to-baseline ratio was 23.7 (interquartile range 12.2–29.7) in well perfused and 2.5 (interquartile range 1.7–4.0) in poorly perfused tissue.ConclusionsFA of a pedicled omentoplasty allows a real-time assessment of omental perfusion and leads to change in management in 80% of the cases in this pilot study. These findings support the conduct of larger studies to determine the impact on patient outcome in this setting.

Fluorescence angiography for a safer anastomosis during transanal total mesorectal excision

We read with great interest the article recently published by Mizrahi et al. about the use of fluorescence angiography using indocyanine green during transanal total mesorectal excision (TaTME) to reduce the incidence of anastomotic leakage (1).

Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.

Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. Sixty-two patients (median age 38years; range 16-68years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266min (range 180-576min) and blood loss 100ml (range 10-500ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.

Does routine use of indocyanine green fluorescence angiography prevent anastomotic leaks? A retrospective cohort analysis

BackgroundInsufficient perfusion to anastomoses in colorectal surgery is known to lead to complications. This study aims to evaluate whether routine use of fluorescence angiography (FA) alters the incidence of anastomotic leaks after colorectal surgery. MethodsThis was a retrospective study of 554 colorectal resections with and without the use of intraoperative fluorescence angiography. Anastomotic leak rates and whether angiography altered surgical management were the main outcomes measured. ResultsThe anastomotic leak rate was found to be 1.3% both with and without use of FA (p > 0.05). Significantly more alterations were made to planned anastomotic site in FA group (n = 13, 5.6%) as compared to the group prior to use of FA in whom no alterations were made (p < 0.05). ConclusionsNo significant difference was found in anastomotic leak rates between the two groups studied. Routine use of fluorescence angiography significantly altered intra-operative decision-making without discernible change in clinical outcome.

How to reduce surgical complications in rectal cancer surgery using fluorescence techniques.

Anastomotic leakage (AL) is a serious complication in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. Adequate bowel perfusion has been stressed as one of the key elements for suture healing. Currently, there is no widespread method to assess and quantify the perfusion of gastrointestinal anastomoses intraoperatively, besides the subjective evaluation by the surgeon. The aim of this paper is to describe the basis of Indocyanine Green (ICG) fluorescence guided surgery applied to assessment of bowel perfusion and to highlight studies on the use of fluorescence angiography (FA) in laparoscopic rectal surgery. ICG fluorescence guided surgery has increasingly been used as a tool for intraoperative diagnostics to assess microperfusion and viability of tissues by means of a real-time FA; this technique has achieved the role of major contribution to intraoperative decision making during surgical procedures, especially in order to assess bowel perfusion before anastomosis creation in colorectal surgery. Several studies in literature already reported that ICG FA as a feasible technique to decrease AL rate in colorectal surgery; to date no randomized controlled trials have been completed but large series and prospective studies that focus on fluorescence perfusion assessment in rectal surgery have been published. Real time intraoperative ICG fluorescent angiography (FA) is a safe and feasible technique to guide the surgeon in intraoperative decision-making process. ICG FA seems to reduce AL rates following rectal surgery for cancer. However large well-designed RCTs are needed to provide evidence for its routine use.

The Use of Fluorescence Angiography During Laparoscopic Sleeve Gastrectomy.

Background and Objectives:A new technology involving indocyanine green (ICG) fluorescence angiography has been introduced to assess tissue perfusion and perform vascular mapping during laparoscopic surgery. The purpose of this study was to describe the use of this technology to identify the variable blood supply patterns to the stomach and gastroesophageal (GE) junction during laparoscopic sleeve gastrectomy (LSG), which may help in preserving the blood supply and preventing ischemia-related leaks.Methods:Eighty-six patients underwent LSG and were examined intraoperatively with fluorescence angiography at an academic bariatric center from January 2016 to September 2017. Before the construction of the SG, 1 mL ICG was injected intravenously, and near infrared fluorescence imaging technology was used to identify the blood supply of the stomach. Afterward, the LSG was created with attention to preserving the identified blood supply to the GE junction and gastric tube. Finally, 3 mL ICG was injected to ensure that all the pertinent blood vessels were preserved.Results:Eighty-six patients successfully underwent the laparoscopic procedure with no complications. The following patterns of blood supply to the GE junction were found: (1) a right-side–dominant pattern (20%), arising from the left gastric artery; (2) a right-side–accessory pattern (36%), running in the gastrohepatic ligament and comprising either an accessory hepatic artery or an accessory gastric artery; and (3) a left-side accessory pattern arising from tributaries from the left inferior phrenic artery significantly contributing to the right-side blood supply. In addition, in 10% of the cases both right and left accessory patterns were present simultaneously.Conclusion:ICG fluorescence angiography allows determination of the major blood supply to the proximal stomach before any dissection during sleeve gastrectomy, so that an effort can be made to avoid unnecessary injury to these vessels during the procedure.

Polypoidal choroidal vasculopathy

The article presents literature review devoted to the issue of polypoidal choroidal vasculopathy. The studies of Russian and foreign researchers were reviewed. Epidemiological and clinical characteristics of polypoidal choroidal vasculopathy, diagnostic features and modern treatment methods, the results of clinical studies are presented. Polypoidal choroidal vasculopathy is a subtype of neoascular AMD with specific characteristics including predisposition of certain races, clinical features, serosanguineous complications of different severity, tendency to relapsing course of neovascularization and development of secondary serosanguineous exfoliation. It was registered most frequently in patients aged 50 to 65 years. Prevalence among Caucasians is 4 to 9.8%, and among Asians - 23.9 to 54.7%. Diagnosis of polypoidal choroidal vasculopathy requires the use of fluorescent angiography, indocyanine green angiography and optical coherence tomography. Polyps regression accordng to angiography is considered one of the aims of initial therapy of active polypoidal choroidal vasculopathy. According to Expert group of polypoidal choroidal vasculopathy, while using laser photocoagulation and photodynamic therapy, affecting both polyps and vasculature is required. As a result of the analysis of population studies, the results of treatment with laser coagulation, photodynamic therapy (independently and in combination with angiogenesis inhibitors) and monotherapy with angiogenesis inhibitors were demonstrated. Regardless of the achieved results of polypoidal choroidal vasculopathy diagnosis, the treatment issues require further investigation. Additional studies are required to evaluate long-term correlation between initial polyp regression, relapses, response to repeated therapy and functional results.

Use of fluorescent angiography with indocyanine green for prediction of hypocalcemia development after thyroidectomy

Introduction. The future of thyroid gland fast-track surgery depends largely on early hypocalcemia prediction. We describe our experience of using intraoperative indocyanine green fluorescent angiography (IGFA) of parathyroid glands to access their function in the early postoperative period. The study objective is to evaluate the possibility of prediction of early postoperative hypocalcemia after thyroidectomy using intraoperative indocyanine green fluorescent angiography. Materials and methods. Thirty five (35) patients with benign and malignant thyroid tumors eligible for thyroidectomy were included in the study. Intraoperative IGFA was performed using the SPY SP2000 (Novadaq Technologies Inc., Canada) device and visual assessment of vascularization of the parathyroid glands. The glands without fluorescence were considered ischemic. Ionized calcium test was performed 4, 8, and 18–24 hours after the surgery. Significance of the difference in its levels in patients with normal and ischemic parathyroid glands was evaluated. Results. In 26 patients, vascularization was considered sufficient, in 9 patients the glands were ischemic per the fluorescent examination. Statistically significant difference of ionized calcium levels were observed between groups with ischemic and normal glands at 18 hours after the surgery (mean 1.060 ± 0.53 in ischemic vs. 1.110 ± 0.56 in normal group, p &lt;0.05). Conclusion. Intraoperative IGFA of the parathyroid glands can successfully predict early postoperative hypocalcemia. Further studies for accessing correlation with permanent hypocalcemia are required.

Fluorescence angiography in laparoscopic low rectal and anorectal anastomoses with pinpoint perfusion imaging--a critical appraisal with specific focus on leak risk reduction.

Anastomotic dehiscence is one of the most feared complications in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. One of the key factors is the perfusion of the bowel to be joined. Presently, surgeons rely on a variety subjective measures to determine anastomotic perfusion and mechanical integrity however these have shortcomings. The aim of this paper is to appraise the literature on the use of fluorescence angiography (FA) in laparoscopic rectal surgery. A Pubmed search was undertaken using terms 'fluorescence angiography' and 'rectal surgery'. The search was expanded using the related articles function. Studies were included if they used FA specifically for rectal surgery. Outcomes of interest including anastomotic leak rate, change of operative strategy and time taken for FA were recorded. Eleven papers detailing the use of FA in rectal surgery are outlined demonstrating that this technique may change operative strategy and lead to a reduction in anastomotic leak rate. In this paper, we discuss assessment of colorectal blood supply using FA and how this technique holds great potential to detect insufficiently perfused bowel. In so doing, the operator can adjust their operative strategy to mitigate these affects with the aim of reducing the complications of anastomotic leak and stenosis. However, it is highlighted that there is a clear need for randomised controlled trials in order to determine this definitively.

Equivocal effect of intraoperative fluorescence angiography on colorectal anastomotic leaks.

Intraoperative fluorescence angiography is beneficial in several surgical settings to assess tissue perfusion. It is also used to assess bowel perfusion, but its role in improving outcomes in colorectal surgery has not been studied. The purpose of this work was to determine whether intraoperative angiography decreases colorectal anastomotic leaks. This was a case-matched retrospective study in which patients were matched 1:1 with respect to sex, age, level of anastomosis, presence of a diverting loop ileostomy, and preoperative pelvic radiation therapy. The study was conducted at an academic medical center. Patients who underwent colectomy or proctectomy with primary anastomoses were included. The intraoperative use of fluorescence angiography to assess perfusion of the colon for anastomosis was studied. Anastomotic leak within 60 days and whether angiography changed surgical management were the main outcomes measured. Case matching produced 173 pairs. The groups were also comparable with respect to BMI, smoking status, diabetes mellitus, surgical indications, and type of resection. In patients who had intraoperative angiography, 7.5% developed anastomotic leak, whereas 6.4% of those without angiography did (p value not significant). Univariate analysis revealed that preoperative pelvic radiation, more distal anastomosis, surgeon, and diverting loop ileostomy were positively associated with anastomotic leak. Multivariate analysis demonstrated that level of anastomosis and surgeon were associated with leaks. Poor perfusion of the proximal colon seen on angiography led to additional colon resection before anastomosis in 5% of patients who underwent intraoperative angiography. The retrospective study design with the use of historical control subjects, selection bias, and small sample size were limitations to this study. Intraoperative fluorescence angiography to assess the perfusion of the colon conduit for anastomosis was not associated with colorectal anastomotic leak. Perfusion is but one of multiple factors contributing to anastomotic leaks. Additional studies are necessary to determine whether this technology is beneficial for colorectal surgery.

Use of fluorescent angiography to assess donor site perfusion prior to free tissue transfer.

To describe a novel use of fluorescent angiography in assessing donor limb perfusion prior to free tissue harvest in microvascular free tissue transfer. Retrospective case series. From January 2012 to June 2013, 59 patients underwent head-and-neck microvascular free tissue reconstruction. Evaluation of donor site perfusion via indocyanine green (ICG) fluorescent angiography was utilized in 12 patients and 13 free flaps. Eleven cases were radial forearm free flaps (RFFF) and two were fibula free flaps (FFF). Preoperatively, RFFF patients were evaluated with Allen's testing, Doppler ultrasound, or both. FFF patients underwent magnetic resonance angiography. ICG was used intraoperatively to evaluate donor limb perfusion prior to free flap harvest. Intraoperative and postoperative complications of the donor limb were evaluated with cost analysis. Average follow-up was 5.3 months. Preoperative Allen's testing was normal in six patients and ultrasound was performed in eight patients. One patient had a normal ultrasound, three showed minimal dampening, and four exhibited severe waveform flattening. There were no intraoperative complications using ICG. All 12 patients displayed adequate donor limb perfusion via fluorescent angiography. No digital or acute ischemic events were identified intraoperatively or postoperatively. There was no significant decrease in functionality or mobility of the donor limb. One patient noted mild arm pain with use. Fluorescent angiography is another method to evaluate donor site perfusion prior to free tissue harvest. Larger prospective analysis would be helpful to more thoroughly evaluate safety, although this is limited by the overall low risk of ischemic complications. 4.