Evaluation of Intranasal Flap Perfusion by Intraoperative Indocyanine Green Fluorescence Angiography

Geltzeiler, Mathew; Nakassa, Ana Carolina Igami; Turner, Meghan; Setty, Pradeep; Zenonos, Georgios; Hebert, Andrea; Wang, Eric; Fernández-Miranda, Juan C.; Snyderman, Carl H.; Gardner, Paul A.

doi:10.1093/ons/opy002

Cited by 24 publications

(26 citation statements)

References 21 publications

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“…34 Geltzeiler et al 19 concluded that lack of flap enhancement (with both intraoperative ICG angiography and imaging) is associated with postoperative necrosis of pedicled intranasal flaps. The observations of this study reinforce the findings of Geltzeiler et al 19 ICG has been demonstrated by certain groups to be a costeffective strategy that can assist in head and neck reconstruction excellent survival outcomes. 19,35 Cost per injection of ICG is U.S. $222 per 25-mg vial of ICG.…”

Section: Discussionmentioning

confidence: 99%

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Intraoperative Indocyanine Green Angiography for Assessing Flap Perfusion in Skull Base Reconstruction: A Systematic Review

Shaikh

O’Brien

Makary

et al. 2021

J Neurol Surg B Skull Base

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Objective This study was aimed to study the current use of intraoperative indocyanine green (ICG) angiography during skull base reconstruction and understand its efficacy in predicting postoperative magnetic resonance imaging (MRI) enhancement and flap. Study Design The Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google Scholar databases were searched from the date of inception until August 2020 for studies of ICG flap perfusion assessment during skull base reconstruction. The primary outcome of interest was the development of cerebrospinal fluid (CSF) leak after skull base reconstruction. Secondary outcomes of interest included postoperative meningitis, flap MRI enhancement, flap necrosis, flap perfusion measurements, and total complications. Results Search results yielded 189 studies, from which seven studies with a total of 104 patients were included in the final analysis. There were 44 nasoseptal flaps (NSF), two lateral nasal wall flaps (LNWF), 14 pericranial flaps (PCF), and 44 microvascular free flaps. The rates of CSF leak and postoperative MRI enhancement were 11 and 94%, respectively. There was one case of postoperative meningitis. Pooled analysis of the available data showed that intraoperative ICG flap perfusion was associated with flap enhancement on postoperative MRI (p = 0.008) and CSF leak (p = 0.315) by Fisher's exact test. Conclusion The available literature suggests intraoperative ICG enhancement is associated with postoperative MRI enhancement. Given the small sample sizes in the literature and the rarity of complications associated with skull base reconstruction, intraoperative ICG enhancement has not been predictive of flap necrosis or postoperative complications such as CSF leak or meningitis. Level of Evidence This study presents level 3 evidence as a systematic review of case studies, case reports, and retrospective and prospective trials with no blinding, controls, and inconsistently applied reference standards.

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Section: Discussionmentioning

confidence: 99%

“…14,19,22,24,25,29,30 Multiple attempts were made to retrieve full-text articles; however, no response was received from the authors. The literature search protocol for selection of eligible studies is presented as a PRISMA flow diagram in ►Fig.…”

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Intraoperative Indocyanine Green Angiography for Assessing Flap Perfusion in Skull Base Reconstruction: A Systematic Review

Shaikh

O’Brien

Makary

et al. 2021

J Neurol Surg B Skull Base

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“…28 Fixed doses in head and neck reconstruction have also been reported according to the region assessed, which include 5 mg in forehead flaps and supraclavicular flaps, 1,22,25 6.25 mg in deep plane facelift, 29 7.5 mg in radial forearm and fibula free flaps, 30 10 mg in salvage laryngectomy, 14 12.5 mg in anterolateral thigh flaps, 31 and up to 25 mg in nasoseptal flaps. 32,33 After the bolus is injected in a central or peripheral line, usually a 10-mL 0.9% normal saline flush is administered.…”

Section: Icg Dosing In Head and Neck Reconstructionmentioning

confidence: 99%

“…3 Endoscopic use has also been of value in skull base reconstruction, showing that fluorescence of the pedicle and the flap together was associated with 100% success of flap survival when evaluated postoperatively with MRI (magnetic resonance imaging) contrast enhancement, although absent pedicle fluorescence may require modifications or an alternate flap. 32,33…”

Section: Fistula Prediction After Salvage Surgerymentioning

confidence: 99%

The Use of Indocyanine Green Angiography for Cosmetic and Reconstructive Assessment in the Head and Neck

2020

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Reconstructive procedures in the head and neck can be a surgical challenge owing to the complex anatomical and physiological structure. Different locoregional and microvascular flaps are used for various defects to improve both function and cosmesis. Subjective clinical findings have been the mainstay for perfusion monitoring; however, areas of borderline perfusion are much more difficult to assess clinically. Multiple technologies that offer objective perfusion assessment have been developed to improve surgical outcomes. Indocyanine green (ICG) angiography has gained popularity owing to its minimal invasiveness and increased sensitivity and specificity in assessing flap perfusion particularly in the head and neck. It has been extensively used in free flaps, pedicled flaps (including nasal reconstruction), facelift procedures, random flaps, skull base reconstruction, and pharyngocutaneous fistula prediction. Its perioperative use has provided valuable qualitative and quantitative data that aid our understanding of flap hemodynamics. Clinically, this impacted decision-making in flap design, harvest, inset, and precocious salvage interventions. Though increased cost and intraoperative time could be limitations, cost-effectiveness studies have supported its use, particularly in high-risk individuals. Limitations include the lack of standardized dosing and consistent methodology agreement for data analysis. Future studies should involve larger cohorts and multi-institute studies to overcome such limitations.

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“…18 In addition, E-ICG has been suggested as a tool to enhance visualization of vasculature, assessment of blood supply to nasoseptal flaps, and tumor identification. 17,[19][20][21][22] Some investigators have concluded that there is a correlation between tumor fluorescence and radiological enhancement on T1-weighted gadolinium-enhanced (T1WGd) MR images. 2,9 To our knowledge, however, there have been no described criteria for the selection of cases in which E-ICG may be useful, and there has been no quantitative correlation of fluorescence to preoperative imaging.…”

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confidence: 99%

The role of indocyanine green fluorescence in endoscopic endonasal skull base surgery and its imaging correlations

Shahein¹,

Prevedello

Beaumont³

et al. 2021

Journal of Neurosurgery

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OBJECTIVEThe use of endoscope-integrated indocyanine green (E-ICG) has recently been introduced in skull base surgery. The quantitative correlation between E-ICG and T1-weighted gadolinium-enhanced (T1WGd) images for skull base tumors has not been previously assessed, to the authors’ knowledge. In this study, the authors investigated the indications for use and the limitations of E-ICG and sought to correlate the endoscopic fluorescence pattern with MRI contrast enhancement.METHODSFollowing IRB approval, 20 patients undergoing endoscopic endonasal skull base surgery between June 2017 and August 2018 were enrolled in the study. Tumor fluorescence was measured using a blue color value and blood fluorescence as a control. Signal intensities (SIs) of tumor T1WGd images were measured and the internal carotid artery (ICA) SI was used as a control. For pituitary adenoma, the pituitary gland fluorescence was also measured. The relationships between ICG fluorescence and MRI enhancement measurements were analyzed.RESULTSData showed that in pituitary adenoma there was a strong correlation between the ratios of gland/blood fluorescence to gland/ICA SI (n = 8; r = 0.92; p = 0.001) and tumor/blood fluorescence to tumor/ICA SI (n = 9; r = 0.82; p = 0.006). In other pathologies there was a strong correlation between the ratios of tumor/blood fluorescence and tumor/ICA SI (n = 9; r = 0.74; p = 0.022). The ICG fluorescence allowed perfusion assessment of the pituitary gland as well as of the nasoseptal flaps. Visualization of the surrounding vasculature was also feasible.CONCLUSIONSDefining the indications and understanding the limitations are critical for the effective use of E-ICG. Tumor fluorescence seems to correlate with preoperative MRI contrast enhancement.

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Evaluation of Intranasal Flap Perfusion by Intraoperative Indocyanine Green Fluorescence Angiography

Abstract: ICG fluorescence angiography of intraoperative flap perfusion is feasible and correlates well with outcomes of postoperative MRI flap enhancement and flap necrosis. Additional study is needed to further refine the imaging technique and optimally characterize the clinical utility.

Cited by 24 publications

References 21 publications

Intraoperative Indocyanine Green Angiography for Assessing Flap Perfusion in Skull Base Reconstruction: A Systematic Review

Intraoperative Indocyanine Green Angiography for Assessing Flap Perfusion in Skull Base Reconstruction: A Systematic Review

The Use of Indocyanine Green Angiography for Cosmetic and Reconstructive Assessment in the Head and Neck

The role of indocyanine green fluorescence in endoscopic endonasal skull base surgery and its imaging correlations

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