Cannulation Indocyanine Green Method for Strategic Management of Postoperative Arterial Thrombosis after Free Jejunal Flap Transfer

Summary:

Indocyanine green (ICG) angiography is widely used in reconstructive surgery to confirm the perfusion of the flap. Here, we report a case in which the use of the “cannulation ICG method” was useful for strategic management of postoperative arterial thrombosis after free jejunal flap transfer. A 64-year-old woman underwent cervical esophagectomy followed by a free jejunal transfer. On postoperative day 3, ischemia of the free jejunum was suspected, and takeback was performed. In the reoperation, re-anastomosis of the artery was planned after the removal of arterial thrombus. However, before re-anastomosis, it was unclear whether there was venous thrombus and whether this jejunum flap was salvageable. To resolve these two questions, we performed the cannulation ICG method. In this method, we injected a mixture of 1.0 mL of ICG and 20 mL of blood into the jejunal artery via 24-gauge cannula. We then evaluated the perfusion of the jejunal flap and monitoring jejunum, and the patency of the venous anastomosis site using a near-infrared fluorescence imaging device (LIGHTVISION; Shimadzu Corporation, Kyoto, Japan). In this case, the whole jejunal flap (including the monitoring jejunum) and venous anastomosis site were highlighted. We determined that there were no venous thrombi and that the entire jejunum was salvageable. After the arterial re-anastomosis, ICG angiography showed good perfusion of the whole jejunum. The postoperative course was uneventful, and the free jejunal flap survived completely. The cannulation ICG method may be effective for determining the surgical method for reoperation due to arterial thrombosis after reconstruction of the free jejunum.

Indocyanine green (ICG) angiography is widely used in reconstructive surgery to confirm the perfusion of the free flap.^1,2 Previous research has demonstrated that ICG angiography is effective in detecting ischemia, congestion, and areas of poor blood flow, and has been reported to be useful in preventing postoperative complications.^3–5 Additionally, ICG angiography can be useful in decision-making when free-flap perfusion cannot be clearly assessed through clinical symptoms.⁶ Despite this, there are limited accounts of its application in devising intraoperative strategies in the event of postoperative takeback.

Free jejunal transplantation is an established and highly reliable reconstructive surgery.⁷ However, according to previous studies, the rate of postoperative vascular thrombosis is 3.0%, which is still a problem.^8,9 To address the issue of postoperative necrosis in the free jejunum, a study has been conducted to evaluate the palliative jejunal blood flow through quantitative analysis of the time-fluorescence intensity curve using ICG during surgery.^8,10

The aim of this article was to present a case in which the use of the “cannulation ICG method” was useful for strategic management of postoperative arterial thrombosis after free jejunal flap transfer.

CASE REPORT

A 64-year-old woman with cervical esophageal cancer presented to us for treatment. Cervical esophagectomy followed by a free jejunal transfer was planned. A 20-cm jejunal flap was elevated and transferred to the 10-cm defect. The second jejunal artery and vein were anastomosed to the left transverse cervical artery and left internal jugular vein, respectively. We confirmed the perfusion of transferred jejunal flap after the anastomosis using indocyanine green (ICG) angiography. Then, the monitoring jejunum was created, and the surgical wound was closed. No chemoradiotherapy was administered.

On postoperative day 3, the monitoring jejunum turned pale and pulsation disappeared. (Fig. 1) Ischemia of the free jejunal flap was suspected, and takeback was performed. In the reoperation, a thrombus was confirmed at the anastomosis site. After the thrombus was removed, re-anastomosis of the artery was planned. However, before re-anastomosis, it was unclear whether there was venous thrombus and whether this jejunal flap was salvageable. To answer these questions, we performed the cannulation ICG method. In this method, we injected 5.0 mL of a mixture of 1.0 mL of ICG and 20 mL of blood into the jejunal artery via a 24-gauge cannula (Fig. 2). The blood was obtained by the anesthesiologist via peripheral venous puncture. We ligated around the artery over the cannula. We then evaluated the perfusion of the jejunal flap using a near-infrared fluorescence imaging device (LIGHTVISION; Shimadzu Corporation, Kyoto, Japan). (Fig. 3). The whole jejunal flap, including the monitoring jejunum, and the venous anastomosis site were highlighted. It took approximately 5 seconds for the mixture to circulate before the near-infrared fluorescence imaging device yielded discernible images. [See Video (online), which displays the intraoperative ICG image. We injected a mixture of 1.0 mL of ICG and 20 mL of blood into the jejunal artery via 24-gauge cannula. The whole area of the jejunal flap and the monitoring jejunum was highlighted.] We determined that there were no venous thrombi and that the entire jejunum was salvageable. After the arterial re-anastomosis, ICG angiography showed good perfusion of the whole jejunal flap. The postoperative course was uneventful, and the free jejunal flap survived completely. [See figure, Supplemental Digital Content 1, which displays (A) intraoperative view after the arterial re-anastomosis. Yellow arrow: the jejunal artery; white arrow: the transverse cervical artery. (B) Postoperative view. Red arrow: the monitoring jejunum. http://links.lww.com/PRSGO/C920.] On the postoperative day 8, the monitoring jejunum was cut off, and on the postoperative day 15, the intake of liquid diet was started.

Fig. 1.

On postoperative day 3, the monitoring jejunum (red arrow) turned pale and pulsation disappeared.

Fig. 2.

Intraoperative view. We injected a mixture of 1.0 mL of ICG and 20 mL of blood (green arrow) into the jejunal artery (yellow arrow) via a 24-gauge cannula.

Fig. 3.

Near-infrared fluorescence images of the intraoperative view. A, Whole area of the jejunal flap (orange arrow) and the monitoring jejunum (red arrow) were highlighted. B, The venous anastomosis site was highlighted. White arrow: the jejunal artery; yellow arrow: the jejunal vein; blue arrow: the internal jugular vein.

Video 1. displays the intraoperative ICG image. We injected a mixture of 1.0 ml of ICG and 20 ml of blood into the jejunal artery via 24-gauge cannula. The whole area of the jejunal flap and the monitoring jejunum were highlighted.

Download video file ^{(61.2MB, mp4)}

DISCUSSION

We developed the cannulation ICG method, in which ICG is mixed with blood and injected through the artery, followed by visualization using near-infrared light. The blood is mixed with ICG so that the dye binds with plasma proteins, which is required for its fluorescent imaging. Using this technique, we could salvage a jejunal flap without the need for venous re-anastomosis.

In the previous ICG method, ICG was often injected transvenously, and it was possible to objectively evaluate the patency of the vascular anastomosis and the blood perfusion of the free flap.⁴ However, in this case, transarterial injection of ICG was used via the cannulation ICG method, allowing imaging and salvage of the whole jejunal flap. It was determined that reanastomosis of the vein was unnecessary because no thrombus was suspected to be present in the vein. The rationale for transarterial ICG injection in this case was to rapidly assess the condition of the free jejunal flap during the surgery by administrating ICG after removal of arterial thrombus, before arterial reanastomosis, thereby determining whether the flap was salvageable or venous reanastomosis was imperative.

If there exists an uncontrasted area of ICG presumed to be an intravenous thrombus, despite contrasting all regions of the free jejunal flap, salvaging the free jejunal flap is possible but requires venous reanastomosis. In instances where the free jejunal flap exhibits an absence of contrast with ICG, indicating the onset of necrosis due to prolonged ischemia or the formation of thrombi throughout the segment, harvest and transplantation of another free jejunal flap will be necessary.

This method offers an advantage in reconstructive surgery using the free jejunal flap by providing objective determinants for its salvageability and need for venous reanastomosis before arterial reanastomosis in the setting of reoperation for arterial thrombosis. As a result, ischemia time of the free flap is reduced, increasing the probability of salvage and shortening the operative time. In this surgery, we were able to complete the operation in a relatively short time (2 hours and 14 minutes) with a smooth postoperative course, and the free jejunal flap survived completely. Furthermore, the entire procedure takes under 3 minutes, and we believe that it does not notably extend ischemic time. Instead, it rapidly indicates the viability of the ischemic free jejunum. This method also offers the benefit of displaying not only the arterial and venous patency, but also revealing any necrosis or thrombus in the flap resulting from prolonged ischemia. Thus, it yields more insights than either the strip test or the handheld Doppler.

A limitation of this report is that it only constitutes an account of this particular case; thus, no major conclusions can be drawn. Therefore, further investigation into additional cases is necessary.

CONCLUSION

The cannulation ICG method was useful for determining the surgical method for reoperation due to arterial thrombosis after free jejunal flap transplant.

DISCLOSURE

The authors have no financial interests to declare in relation to the content of this article.