Super-Selective Intra-Arterial Indocyanine Green Administration for Near-Infrared Fluorescence-Based Positive Staining of Hepatic Segmentation: A Feasibility Study

Abstract

Background. Despite the increasing number of laparoscopic hepatic procedures for the resection of hepatocellular carcinoma (HCC), intraoperative tumor localization and demarcation remains challenging in comparison to open surgery. In this study, we evaluated the feasibility of positive liver segment staining through the super-selective intra-arterial indocyanine green (ICG) administration. Methods. Eight patients presenting with a single HCC underwent an interventional vascular procedure followed by laparoscopic surgery. A microcatheter was advanced into the hepatic artery branches perfusing the HCC followed by digital subtraction angiography and angiography computed tomography (angio-CT). Patients were then transferred to the operating room, and a laparoscopic hepatectomy was performed under ultrasound guidance. A 5 mL bolus of ICG with a concentration of .125 mg/mL was injected through the microcatheter, and a near-infrared laparoscope was used to detect the fluorescence signal to assess the correspondence between the fluorescence-based demarcation and the intraoperative ultrasound–based demarcation. Results. The duration for the angiography procedure was 32.7 +/− 5.3 min, and it took 242 +/− 118 min from the end of angiography procedure until the start of the surgical procedure. In all cases, the fluorescent liver segment was corresponding to the angio-CT findings. In 6/8 cases, fluorescence imaging was considered helpful in the identification of the resection line. In 3 patients, the resection line was changed according to the positively stained liver segment. Conclusion. We successfully demonstrated the feasibility of the super-selective intra-arterial ICG administration for fluorescence-based positive staining of hepatic segmentation during laparoscopic surgery for HCC (NCT04266548).

Trans-arterial positive ICG staining-guided laparoscopic liver watershed resection for hepatocellular carcinoma

“…With the guidance of DSA examination, Grade 4 (or higher) hepatic arteries could be reached; thus, the liver watershed (or sub-segment) staining could be achieved via injection of the ICG through the aimed hepatic artery. Li et al have proved that intra-arterial ICG injection provided a real-time image-guided intraoperative demarcation of targeted liver Couinaud segments (20). However, the liver watershed (or sub-segment) staining via the hepatic artery has not been explored in that study.…”

Recent Advances in Interventional Fluorescence Imaging: Toward the Precise Visualization of Transarterial Mini-Invasive Delivery Systems

“…Due to selective uptake by the liver and unique metabolic characteristics, ICG is particularly suitable for HCC resection. For instance, Wang et al reported the IVR-aided selective intra-arterial injection technique for ICG fluorescence-based positive staining of hepatic segmentation during laparoscopic surgery, verifying the feasibility of real-time imaging-guided demarcation and definition of the resection line for targeted liver segments . Likewise, the combined utilization of ICG fluorescence imaging and IVR for the determination of liver segments during laparoscopic HCC resection was investigated by Yamaue’s group .…”

Preliminary exploration of hepatic parenchymal near-infrared fluorescence imaging technique via retrograde biliary approach: a feasibility study (with video)

“…For navigation during anatomic hepatectomy (AR), the most widely used field of ICG, it mainly relies on “positive” or “negative” staining techniques to achieve fluorescence visualization of liver segments or lobes via portal vein 5 , 6 . Currently, various combined intervention techniques are also utilized to achieve fluorescence visualization, such as the “positive dyeing” technique via the hepatic artery 7 – 10 . Additionally, in the surgical treatment of intrahepatic bile duct calculi, some scholars have utilized the principle of ICG excretion through a biliary duct to accurately locate the scope of atrophic liver, intrahepatic calculi, and diseased bile duct, 11 , 12 .…”