Table 4.
Publications of the Use of ICGA in Autologous Breast Reconstruction
| Clinical Studies | Sample Size (N) | Type of Reconstruction | Imaging System and Measurement | Summary |
|---|---|---|---|---|
| Autologous Reconstruction | ||||
| Onoda et al.36 | 50 patients | Free flaps | PDE Qualitative |
Flaps were assessed with MDCT first, then Doppler flowmetry, then ICGA to confirm intensity and position of perforators. Free flaps survived without complications. |
| Pestana et al.8 | 18 patients | DIEP | SPY Elite Quantitative (Spy-Q) |
Preoperative ICGA skin blush location, size, and intensity did not correlate to preoperative CTA imaging of perforating vessels. BMI was not associated with increased skin blush when using ICGA. CTA and SPY informed surgical decisions in 74% of patients. Decreased perfusion shown in ICGA images informed flap resection in 46% of patients. |
| Wu et al.37 | 16 patients | DIEP | SPY Elite Quantitative (Spy-Q) |
ICGA images correlated with CTA image in 85% of cases of perforator flap breast reconstruction. However, ICG underestimated and overestimated perfusion in 7% and 7%, respectively, of those cases. |
| Azuma et al.38 | 14 patients | DIEP | PDE Qualitative |
Qualitative assessment of ICGA was able to identify 2–6 perforators preoperatively. The perforators were confirmed during surgical dissection at the deep fascial level in all flaps. |
| Douglas et al.40 | 13 patients | DIEP | SPY Elite Qualitative |
Based on ICGA images, the study stated that perfusion of zone IV in DIEP flap was significantly higher when 1 perforator was used instead of 2. |
| Holm et al.41 | 25 patients | SIEA | Laser light source, digital video camera Qualitative |
In this study, SIEA flap was originally intended for all patients; however, intraoperative perfusion measurements with ICGA changed the surgical plan in 44% of patients. Partial flap necrosis was seen in 1 case (4%). |
| Yamaguchi et al.44 | 10 patients | TRAM | IC-View Qualitative |
The study found individual pattern “perfusion map” using ICGA and noted that Hartrampf zone II is sometimes less perfused than zone III. |
| Holm et al.45 | 15 patients | DIEP | IC-View Qualitative |
Hartrampf zone IV was not perfused in 5 patients, describe the abdomen perfusion pattern as 2 halves, separated by midline, with variable blood supply. |
| Girard et al.46 | 40 patients | DIEP | SPY Elite Qualitative and Quantitative (Spy-Q) |
Authors defined 3 perfusion zones of the unilateral DIEP flap based on qualitative color analysis. Then the study used ingress and ingress rate to confirm adequate perfusion of each region of the flap. Also, it found that young patients with diabetes mellitus and tamoxifen hormone therapy effected results of the SPY imaging. |
| Hembd et al.52 | 409 patients | DIEP | Not stated Qualitative |
Authors conducted a retrospective review of DIEP cases and compared odds ratios of different surgical variables. They found that a decrease in the odds of fat necrosis was seen if ICGA was used to assess flap perfusion (OR, 0.46; P = 0.04). |
| Malagon-Lopez et al.53 | 61 patients | DIEP | PDE Qualitative |
Incidence of fat necrosis was reduced to 29% from 59.5% when ICGA was used in this prospective study. Number of secondary surgeries due to fat necrosis also reduced from 45.9% to 20.8%. |
| Ludolph et al.43 | 32 patients | DIEP and ms-TRAM | SPY Elite Qualitative |
The study compared ICGA and combined laser Doppler spectrophotometry in assessment of flap perfusion. ICGA was found to be useful intraoperatively when clinical signs of perfusion were unclear because of its high sensitivity of poorly perfused flap areas. Combined laser Doppler spectrophotometry, however, was superior to ICGA in topographical mapping of well-perfused areas. |
| Schrogendorfer et al.55 | 41 patients | DIEP, TRAM, TMG | IC-View IC-Clac |
Microscopic ICG was able to detect vessel occlusion after anastomosis and led to immediate revision. No flap loss occurred. Authors note that this relationship is not necessarily a causation relationship. |
| Holm et al.56 | 50 patients | Random, pedicle, and free flaps | Modified microscope Qualitative |
The study used ITT to assess blood flow through the flap. A transit time greater than 90 s signified venous delay, and surgeons would then revise the anastomosis. Angiographic results were confirmed 100% during revisions and all flaps that were revised survived. Flaps that were not revised despite increased blood transit time resulted in necrosis. |
| Koonce et al.51 | 53 patients | ms-LDF | Not stated Qualitative |
The study used a laterally extended skin paddle on ms-LDF and defined 3 perfusions zones. All zones were adequately perfused. |
| Khansa et al.57 | 442 patients | Pedicle and free flaps | Not stated Qualitative |
ICGA was used intraoperatively to assess arterial insufficiency and venous congestion based on “turbulence” of flow through the anastomosis. This method of ICGA interpretation was 37.5% sensitive of predicting vascular compromise and 100% specific. They then propose a new systematic algorithm for assessing flaps when complications occur postoperatively. |
| Holm et al.17 | 86 patients | Random, pedicle, and free flaps | Modified microscope Quantitative (Spy-Q) |
Using ITT as previously described, a blood transit time of greater than 50 s had the strongest association with flap complications. |
| Hitier et al.58 | 20 patients | Pedicle and free flaps | Floubeam Quantitative (Fluobeam v1.47 Software) |
ITT and fluorescence intensity were used intraoperatively to assess blood flow of the flap. Slope of fluorescence intensity rise and amplitude of fluorescence were used postoperatively. The mean fluorescence intensity, slope of fluorescence rise, and amplitude of fluorescence all produced a significantly lower signal in flaps that resulted in vascular complications. Authors state that ICGA detected complications sooner than physical examination. |
| Alstrup et al.%%61 | 191 patients | LDF, ms-LDF, TRAM | SPY Elite Quantitative (Spy-Q) |
Authors found no significant difference in complication rates, minor or major, between patient groups that received intraoperative ICGA and those who did not. Within the ICGA group, immediately reconstructed breasts had significantly less complications. |
| Krishnan et al.59 | 9 patients | Random, pedicle, and free flaps | IC-View Quantitative (IC-Clac) |
The authors used relative perfusion, time to maximum fluorescence, and time of fluorescence fall to determine venous inflow and venous congestion, respectively, postoperatively. They found a delay in ICG uptake and clearance in 6 flaps (1 random pattern, 2 axial pattern, and 3 free flaps). However, clinical signs of congestion were only seen in 2 of the 6 flaps. |
BMI, body mass index; LDF, latissimus dorsi flap; MDCT, multiple-detector computed tomography; ms, muscle sparing, OR, odds ratio; PDE, photodynamic eye; TMG, transverse myocutaneous gracilis flap; TRAM, transverse rectus abdominis myocutaneous; SIEA, superficial inferior epigastric artery-based flap.