LASER-ASSISTED-INDOCYANINE-GREEN-ANGIOGRAPHY VERSUS CONVENTIONAL ASSESSMENT TO PREDICT OR LOCATE NECROTIC AREAS ON MASTECTOMY FLAPS: A PROSPECTIVE CLINICAL TRIAL

Abstract

Objective: The aim of this study was to determine whether laser-assisted-indocyanine-green-angiography (LA-ICGA) could accurately predict flap necrosis in comparison to conventional clinical assessment and visually identify its location during immediate reconstruction following a nipple-sparing mastectomy (NSM). Methods: Twenty-one patients with breast cancer were prospectively enrolled to undergo NSM with immediate implant reconstruction. In 19 cases LA-ICGA numbers were used to show the level of laser absorption of hypo-perfused areas on the mastectomy flaps. Those numbers were compared to conventional assessment to assess the predictive value of LA-ICGA. Results: Of the 19 mastectomy flaps, 3 (15.8%) examples of partial skin flap necrosis with an LA-ICGA value of ≤7 was observed. The sensitivity, specificity, false-positive rate, and accuracy of LA-ICGA were 43%, 100%, 57%, and 79%, respectively. Patients with an LA-ICGA value of ≤7 were found more likely to develop mastectomy flap necrosis, whereas patients aged >60 or, a history of smoking, a BMI >30, or intraoperative use of tumescence solution containing epinephrine were more likely to have an LA-ICGA score ≤7 which is not clinically reliable in predicting necrosis. Conclusion: Our results indicate that a low LA-ICGA score ≤7 is the only significant factor in predicting mastectomy flap necrosis. LA-ICGA could accurately show the location of necrosis. 

Keywords

• SPY,intraoperative angiography,breast Cancer

MASTEKTOMİ FLEBİ NEKROZUNU TAHMİN YA DA LOKALİZE EDEBİLEN LAZER YARDIMLI İNDOSİYANİN YEŞİLİ ANJİOGRAFİNİN KONVANSİYONEL YÖNTEMLE KIYASLANMASI: PROSPEKTİF KLİNİK ÇALIŞMA

Abstract

Amaç: Bu çalışmada meme-başı koruyucu mastektomi (MBKM) fleplerindeki nekrozu yada nekroz lokalizasyonunu, lazer yardımlı indosiyanin yeşilli angiografinin (LYIYA) tahmin edip edemeyeceğini konvansiyonel gözlem ile kıyaslayarak saptamaktı. Yöntem: Meme kanseri nedeniyle 21 hastaya MBKM ve eşzamalı silikon implant rekonstrüksiyon yapıldı. Ondokuz hastada flep üzerindeki hipoperfuze alanların lazer absorpsiyon derecesini anlamak için LYIYA sayıları kullanıldı. Elde edilen sayılar konvansiyonel gözlem ile kıyaslanarak LYIYA’nın nekroz prediktivitesi saptandı. Bulgular: Bu 19 mastektomi flebinin 3’ünde (15,8%) parsiyel cilt nekrozu saptanmış ve LYIYA sayısı ≤7 olarak saptanmıştır. LYIYA’nın duyarlılığı, özgüllüğü, yalancı pozitifliği ve doğruluğu sırasıyla 43%, 100%, 57%, ve 79% olarak bulunmuştur. LYIYA ≤7 olan hastalarda daha çok nekroz saptanmış, 60 yaş üstü, sigara öyküsü, BMI >30 veya intraoperatif tumescent solusyonu kullanılanlarda LYIYA ≤7 uyumsuz bulunmuş, nekroz tahmininde yanılgıya sebep olmuştur. Sonuç: LYIYA sayısı ≤7 bulgusu, mastektomi flep nekrozunu tahmin edebilmede kullanılabilecek tek anlamlı parametredir. LYIYA aynı anda nekrozun nerde lokalize olduğunu ve sınırlarını da gösterebilmektedir. 

Keywords

• SPY,lazer yardımlı indosiyanin yeşilli angiografi,meme kanseri

References

1. 1. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconst Surg 2010:125:1065-73.
2. 2. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconst Surg 2006:117:1711-9.
3. 3. Pestana IA, Coan B, Erdmann D, et al. Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstruct Surg 2009:123:1239-44.
4. 4. Newman MI, Samson MC, Tamburrino JF, et al. An investigation of the application of laser-assisted indocyanine green fluorescent dye angiography in pedicle transverse rectus abdominus myocutaneous breast reconstruction. Can J Plast Surg 2011:19:1-5.
5. 5. Jallali N, Ridha H, Butler PE. Postoperative monitoring of free flaps in UK plastic surgery units. Microsurgery 2005:25:469-72.
6. 6. Mothes H, Donicke T, Friedel R, et al. Indocyanine-green fluorescence video angiography used clinically to evaluate tissue perfusion in microsurgery. J Trauma 2004:57:1018-24.
7. 7. Olivier WA, Hazen A, Levine JP, et al. Reliable assessment of skin flap viability using orthogonal polarization imaging. Plast Reconstruct Surg 2003:112:547-55.
8. 8. Phillips BT, Lanier ST, Conkling N, et al. Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: Results of a prospective trial. Plast Reconstr Surg 2012;129:778-88.

9. 9. Newman MI, Samson MC. The application of laserassisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction. J Reconstr Microsurg 2009;25:21-6.
10. 10. Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg 2014;133:448-54.
11. 11. Sood M, Glat P. Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction. Ann Surg Innov Res 2013;7(1):9.
12. 12. Munabi NC, Olorunnipa OB, Goltsman D, et al. The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: A prospective trial. J Plast Reconstr Aesthet Surg 2014;67:449-55.
13. 13. Santanelli F, Benedetto L, Sorotos M, et al. Flap survival of skin-sparing mastectomy type IV: a retrospective cohort study of 75 consecutive cases. Ann Surg Oncol 2013;20:9819.
14. 14. McCarthy CM, Mehrara BJ, Riedel E, et al. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg 2008;121(6):1886-92.
15. 15. Reuthebuch O, Haussler A, Genoni M, et al. NovadaqSPY: intraoperative quality assessment in off-pump coronary artery bypass grafting. Chest 2004;125(2):418-24.
16. 16. Desai ND, Miwa S, Kodama D, et al. Improving the quality of coronary bypass surgery with intraoperative angiography: validation of a new technique. J Am Coll Cardiol 2005;46(8): 1521-5.
17. 17. Francisco BS, Kerr-Valentic MA, Agarwal JP. Laserassisted indocyanine green angiography and DIEP breast reconstruction. Plast Reconstr Surg 2010;2010:116-8.
18. 18. Azuma R, Morimoto Y, Masumoto K, et al. Detection of skin perforators by indocyanine green fluorescence nearly infrared angiography. Plast Reconstr Surg 2008;122:1062-7.
19. 19. Jones GE, Garcia CA, Murray J, et al. Fluorescent intraoperative tissue angiography for the evaluation of the viability of pedicled TRAM flaps. Plast Reconstr Surg 2009; 124: 53.
20. 20. Newman MI, Samson MC, Tamburrino JF, Swarz KA. Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction. J Reconstr Microsurg 2010;26(7):487-92.
21. 21. Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg 2012;129:1043-8.
22. 22. Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J 2014;34(1):61-5.