PROSPECTIVE EVALUATION OF SURGICAL MICROSCOPE–INTEGRATED INTRAOPERATIVE NEAR-INFRARED INDOCYANINE GREEN ANGIOGRAPHY DURING CEREBRAL ARTERIOVENOUS MALFORMATION SURGERY

Abstract OBJECTIVE Microscope-integrated indocyanine green (ICG) fluorescence angiography is a novel technique in vascular neurosurgery with potential utility in treating arteriovenous malformations (AVMs). METHODS We analyzed the application of intraoperative ICG in 10 consecutive AVM surgeries for which surgical video was available. The ability to distinguish AVM vessels (draining veins, feeding and nidal arteries) from each other and from normal vessel was evaluated, and ICG angiographic findings were correlated with intra- and postoperative findings on digital subtraction angiography (DSA). RESULTS ICG angiography was found to be useful by the surgeon in 9 of 10 patients. In 8 patients, it helped to distinguish AVM vessels. In 3 of 4 patients undergoing a postresection injection, it demonstrated that there was no residual arteriovenous shunting. In 1 patient, it helped to identify a small AVM nidus that was otherwise inapparent within a hematoma. Intraoperative DSA showed residual AVM in 2 of 10 patients requiring further resection of AVM not visualized during surgery. CONCLUSION Microscope-integrated ICG angiography is a useful tool in AVM surgery. It can be used to distinguish AVM vessels from normal vessels and arteries from veins based on the timing of fluorescence with the dye. Our experience suggests that it is less useful with deep-seated lesions or when AVM vessels are not on the surface. ICG angiography complements rather than replaces DSA.

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Evaluation of Serial Intraoperative Surgical Microscope-Integrated Intraoperative Near-Infrared Indocyanine Green Videoangiography in Patients With Cerebral Arteriovenous Malformations

Operative Neurosurgery ◽

10.1227/neu.0b013e31822d9749 ◽

2011 ◽

Vol 70 (suppl_1) ◽

pp. ons34-ons43 ◽

Cited By ~ 16

Author(s):

Yasushi Takagi ◽

Keiko Sawamura ◽

Nobuo Hashimoto ◽

Susumu Miyamoto

Keyword(s):

Indocyanine Green ◽

Digital Subtraction Angiography ◽

Arteriovenous Malformations ◽

Near Infrared ◽

Fluorescence Angiography ◽

Digital Subtraction ◽

Cerebral Arteriovenous Malformations ◽

Viable Option ◽

Indocyanine Green Videoangiography ◽

Surgical Microscope

Abstract BACKGROUND: With the use of indocyanine green (ICG) as a novel fluorescent dye, fluorescence angiography has recently reemerged as a viable option. OBJECTIVE: To show the result of ICG videoangiography in cases of cerebral arteriovenous malformations. METHODS: Twenty-seven ICG videoangiography procedures were performed in 11 patients with cerebral arteriovenous malformations. Intraoperative digital subtraction angiography (DSA) was performed 27 times in these patients. The timing of intraoperative DSA was before dissection, after clipping of feeders, and after dissection of the nidus. RESULTS: The procedures were performed in 4.7 ± 1.4 minutes (mean ± SD; n = 27 minutes), whereas intraoperative digital subtraction angiography was performed for a mean of 16.6 ± 3.8 minutes (n = 27 minutes). In predissection studies, feeders were visualized by ICG in 3 of 9 cases. The nidus was visualized in all 9 cases, and drainers were visualized in 8. Intraoperative DSA visualized the feeders, nidus, and drainers in all 9 cases. After clipping of feeders, ICG videoangiography showed flow reduction of the nidus in 7 of 7 cases. Intraoperative DSA also showed that finding in 9 of 9 cases. After total dissection of the nidus, all cases disclosed that the drainers were without ICG filling. Intraoperative DSA also showed that result in all of the cases. Unexpected residual nidus was not visualized in our series with either method. CONCLUSION: We found that ICG videoangiography is helpful for resecting cerebral arteriovenous malformation. It is especially effective in visualizing the nidus and superficial drainers, as well as changes in flow after clipping or coagulating of feeders.

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Evaluation of Angiographically Occult Spinal Dural Arteriovenous Fistulae With Surgical Microscope-Integrated Intraoperative Near-Infrared Indocyanine Green Angiography: Report of 3 Cases

Neurosurgery ◽

10.1227/neu.0b013e318207ac3b ◽

2011 ◽

Vol 68 (3) ◽

pp. 781-787 ◽

Cited By ~ 44

Author(s):

Brendan D Killory ◽

Peter Nakaji ◽

Peter H Maughan ◽

Scott D Wait ◽

Robert F Spetzler

Keyword(s):

Indocyanine Green ◽

Digital Subtraction Angiography ◽

Near Infrared ◽

Imaging Features ◽

Digital Subtraction ◽

Resonance Imaging ◽

Arteriovenous Fistulae ◽

Surgical Microscope ◽

Fluorescent Microscope ◽

Icg Angiography

Abstract BACKGROUND: Spinal dural arteriovenous fistulae (dAVFs), are lesions involving an aberrant connection between a radicular feeding artery and the venous system of the spinal cord at the dural sleeve of the nerve root. When rare dAVFs are occult on digitally subtracted catheter-based angiography, they present a diagnostic and therapeutic challenge. OBJECTIVE: We report 3 cases of angiographically occult spinal dAVFs that were evaluated during surgery with indocyanine green (ICG) fluorescent microscope-integrated angiography. METHODS: Three patients with clinical and magnetic resonance imaging features suggestive of a spinal dAVF but no abnormality on digital subtraction angiography underwent surgical exploration with the aid of microscope-integrated ICG videoangiography. RESULTS: In all 3 cases, ICG identified the intradural vein draining the fistula, clearly distinguishing it from an artery or uninvolved medullary vein. CONCLUSION: ICG angiography can rapidly identify a draining vein as it enters the spinal canal even in dAVFs not identifiable on catheter-based digital subtraction angiography.

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Intraoperative indocyanine green angiography for obliteration of a spinal dural arteriovenous fistula

Journal of Neurosurgery Spine ◽

10.3171/2009.6.spine09315 ◽

2009 ◽

Vol 11 (6) ◽

pp. 705-709 ◽

Cited By ~ 33

Author(s):

Geoffrey P. Colby ◽

Alexander L. Coon ◽

Daniel M. Sciubba ◽

Ali Bydon ◽

Philippe Gailloud ◽

...

Keyword(s):

Indocyanine Green ◽

Vascular Anatomy ◽

Endovascular Embolization ◽

Spinal Dural Arteriovenous Fistula ◽

Lower Extremity Weakness ◽

Spinal Arteriovenous Malformation ◽

Arteriovenous Fistulas ◽

Icg Angiography ◽

Clip Occlusion ◽

Vascular Neurosurgery

Spinal dural arteriovenous fistulas (DAVFs) are the most common type of spinal arteriovenous malformation and are an important, underdiagnosed cause of progressive myelopathy and morbidity in patients with spine disorders. Successful microsurgical management of these lesions is dependent on the surgeon's ability to identify vessels of the fistula and to confirm its successful obliteration postintervention. Indocyanine green (ICG) fluorescent angiography is an emerging tool for delineating intraoperative vascular anatomy, and it has significant potential utility in the treatment of vascular disease in the spine. The authors present the case of a 76-year-old man with progressive and debilitating bilateral lower-extremity weakness and numbness on exertion, in whom a left T-8 spinal DAVF was diagnosed based on results of conventional spinal angiography. Unfavorable anatomy based on angiographic findings precluded endovascular embolization of the fistula, and the patient subsequently underwent T7–9 bilateral laminectomies for microsurgical clip occlusion. Intraoperative ICG fluorescent angiography was used before clip placement to identify the arterialized veins of the fistula, and after clip placement to confirm obliteration of the fistulous connection and restoration of normal blood flow. Intraoperative ICG angiography serves an important role in the microsurgical treatment of DAVF. It can be used to map the anatomy of the fistula in real time during surgery and to verify fistula obliteration rapidly after clip placement. This report adds to the growing body of literature demonstrating the importance of ICG angiography in vascular neurosurgery of the spine.

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Evaluation of Intranasal Flap Perfusion by Intraoperative Indocyanine Green Fluorescence Angiography

Operative Neurosurgery ◽

10.1093/ons/opy002 ◽

2018 ◽

Vol 15 (6) ◽

pp. 672-676 ◽

Cited By ~ 7

Author(s):

Mathew Geltzeiler ◽

Ana Carolina Igami Nakassa ◽

Meghan Turner ◽

Pradeep Setty ◽

George Zenonos ◽

...

Keyword(s):

Indocyanine Green ◽

Skull Base ◽

Near Infrared ◽

The Body ◽

Fluorescence Angiography ◽

Flap Necrosis ◽

Endonasal Surgery ◽

Mri Contrast ◽

Postoperative Mri ◽

Flap Perfusion

Abstract BACKGROUND Vascularized intranasal flaps are the primary reconstructive option for endoscopic skull base defects. Flap vascularity may be compromised by injury to the pedicle or prior endonasal surgery. There is currently no validated technique for intraoperative evaluation of intranasal flap viability. OBJECTIVE To evaluate the efficacy of indocyanine green (ICG) near-infrared angiography in predicting the viability of pedicled intranasal flaps during endoscopic skull base surgery through a pilot study. METHODS ICG near-infrared fluorescence endoscopy was performed during endoscopic endonasal surgery for skull base tumors. Intraoperative and postoperative data were collected regarding enhancement of the flap body and pedicle. Fluorescence was rated qualitatively. Postoperatively, flap perfusion was evaluated via MRI-contrast enhancement in addition to clinical outcomes (cerebrospinal fluid leak and endoscopic flap appearance). RESULTS Thirty-eight patients underwent ICG fluorescence angiography. Both the body and pedicle enhanced in 20 patients (53%), while the pedicle only enhanced for 12 patients (32%), the body only for 3 (8%), and neither for 3 (8%). When both the pedicle and body enhanced with ICG, the rate of postoperative MRI contrast enhancement was 100% and the rate of flap necrosis was 0%. The sensitivity and specificity of flap pedicle ICG enhancement for predicting postoperative flap MRI enhancement were 97% and 67%, respectively. Two of 3 patients without enhancement developed flap necrosis. CONCLUSION 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.

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Indocyanine Green Fluorescence Angiography of the Transverse Cervical Arterial Supply to Clavicle Flaps: An Anatomical Study

Otolaryngology ◽

10.1177/01945998211000432 ◽

2021 ◽

pp. 019459982110004

Author(s):

Pichtat Muangsiri ◽

Rungkit Tanjapatkul ◽

Papat Sriswadpong ◽

Pojanan Jomkoh ◽

Supasid Jirawatnotai

Keyword(s):

Indocyanine Green ◽

Near Infrared ◽

Fluorescence Angiography ◽

Head And Neck Reconstruction ◽

Green Fluorescence ◽

Indocyanine Green Fluorescence ◽

Cervical Artery ◽

Indocyanine Green Fluorescence Angiography ◽

Vascularized Bone ◽

Transverse Cervical Artery

Objective To describe the anatomy of the transverse cervical artery and to prove its perfusion to the clavicle using indocyanine green fluorescence angiography as an alternative vascularized bone for head and neck reconstruction. Study Design Cadaveric dissection. Setting Anatomy lab. Methods Twenty-two necks and shoulders from 11 fresh-frozen cadavers were dissected. The transverse cervical artery diameter, length, emerging point, and the length of clavicle segment harvested were described. Photographic and near-infrared video recordings of the bone’s medial and longitudinal cut surfaces were taken prior to, during, and after indocyanine green injection. Results The transverse cervical artery originated from the thyrocervical trunk and emerged at the level of the medial one-third of the clavicle in 22 of 22 (100%) specimens. The average length of the pedicle was 3.6 cm (range, 2.2-4.4 cm), and the mean diameter was 2.5 mm (range, 1.8-3.4 mm). The harvested bone had a mean length of 5.1 cm (range, 4.3-5.8 cm). After injecting the indocyanine green, 22 of 22 (100%) specimens showed enhancement in the periosteum, bony cortex, and medulla. Conclusion The middle third of the clavicle can be reliably harvested as a vascularized bone with its perfusion solely from the transverse cervical artery pedicle, as shown by the near-infrared fluorescence imaging. The pedicle was sizable and constant in origin.

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Influence of vessel stenosis on indocyanine green fluorescence intensity assessed by near-infrared fluorescence angiography

Surgery Today ◽

10.1007/s00595-016-1453-y ◽

2016 ◽

Vol 47 (7) ◽

pp. 877-882 ◽

Cited By ~ 2

Author(s):

Masaki Yamamoto ◽

Hideaki Nishimori ◽

Takashi Fukutomi ◽

Takemi Handa ◽

Kazuki Kihara ◽

...

Keyword(s):

Indocyanine Green ◽

Fluorescence Intensity ◽

Near Infrared ◽

Fluorescence Angiography ◽

Green Fluorescence ◽

Near Infrared Fluorescence ◽

Indocyanine Green Fluorescence ◽

Vessel Stenosis

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Intraoperative near-infrared indocyanine green fluorescence angiography (NIR-ICG AG) can predict delayed small bowel stricture after ischemic intestinal injury: Report of a case

Journal of Pediatric Surgery ◽

10.1016/j.jpedsurg.2013.03.067 ◽

2013 ◽

Vol 48 (5) ◽

pp. 1123-1128 ◽

Cited By ~ 11

Author(s):

Yasushi Iinuma ◽

Yutaka Hirayama ◽

Naoyuki Yokoyama ◽

Tetsuya Otani ◽

Kohjyu Nitta ◽

...

Keyword(s):

Small Bowel ◽

Indocyanine Green ◽

Near Infrared ◽

Intestinal Injury ◽

Fluorescence Angiography ◽

Green Fluorescence ◽

Indocyanine Green Fluorescence ◽

Small Bowel Stricture ◽

Bowel Stricture ◽

Indocyanine Green Fluorescence Angiography

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Use of Indocyanine Green and Fluorescence Angiography in Parathyroid Surgery: A Feasibility Study

Surgical Innovation ◽

10.1177/1553350620956437 ◽

2020 ◽

pp. 155335062095643

Author(s):

Christina Maser ◽

Amanda H. Kohlbrenner ◽

Rachel Dirks

Keyword(s):

Indocyanine Green ◽

Near Infrared ◽

Parathyroid Tissue ◽

Surrounding Tissue ◽

Fluorescence Angiography ◽

Clinical Settings ◽

Capillary Networks ◽

Nir Fluorescence ◽

Parathyroid Adenomas ◽

Control Study

Background. Indocyanine green (ICG) with near-infrared (NIR) fluorescence is an established method for assessing vascularity in various clinical settings. We hypothesized that parathyroid adenomas, with increased capillary networks, may demonstrate a fluorescence which could aid intraoperative identification and confirmation of the abnormal parathyroid tissue. Methods. This prospective case–control study compared patients with primary hyperparathyroidism undergoing parathyroidectomy (cases) to normal parathyroid in thyroidectomy patients (controls). After exposing the parathyroid gland, ICG was injected and the fluorescence of parathyroid and thyroid was recorded and graded in comparison to the surrounding tissue and vasculature (0 = nonfluorescent and 5 = vasculature). Results. The intensity of parathyroid fluorescence was more in cases (4 ± 2) than controls (2 ± 1) when graded intraoperatively ( P = .001). Thyroid fluorescence did not differ (3 vs 3, P = .072); however, parathyroid fluorescence was more intense than thyroid in cases (parathyroid = 4 ± 2 and thyroid = 3 ± 1, P = .018). Conclusions. ICG fluorescence in diseased parathyroid was more intense than normal parathyroid and thyroid, suggesting the ICG/NIR technology may be a useful intraoperative tool for identification of abnormal parathyroid.

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Integration of Indocyanine Green Videoangiography With Operative Microscope: Augmented Reality for Interactive Assessment of Vascular Structures and Blood Flow

Operative Neurosurgery ◽

10.1227/neu.0000000000000681 ◽

2015 ◽

Vol 11 (2) ◽

pp. 252-258 ◽

Cited By ~ 17

Author(s):

Nikolay L Martirosyan ◽

Jesse Skoch ◽

Jeffrey R Watson ◽

G Michael Lemole ◽

Marek Romanowski ◽

...

Keyword(s):

Blood Flow ◽

Indocyanine Green ◽

Real Time ◽

Femoral Artery ◽

White Light ◽

Near Infrared ◽

Field Of View ◽

Fluorescence Angiography ◽

Indocyanine Green Videoangiography ◽

Operative Microscope

Abstract BACKGROUND Preservation of adequate blood flow and exclusion of flow from lesions are key concepts of vascular neurosurgery. Indocyanine green (ICG) fluorescence videoangiography is now widely used for the intraoperative assessment of vessel patency. OBJECTIVE Here, we present a proof-of-concept investigation of fluorescence angiography with augmented microscopy enhancement: real-time overlay of fluorescence videoangiography within the white light field of view of conventional operative microscopy. METHODS The femoral artery was exposed in 7 anesthetized rats. The dissection microscope was augmented to integrate real-time electronically processed near-infrared filtered images with conventional white light images seen through the standard oculars. This was accomplished by using an integrated organic light-emitting diode display to yield superimposition of white light and processed near-infrared images. ICG solution was injected into the jugular vein, and fluorescent femoral artery flow was observed. RESULTS Fluorescence angiography with augmented microscopy enhancement was able to detect ICG fluorescence in a small artery of interest. Fluorescence appeared as a bright-green signal in the ocular overlaid with the anatomic image and limited to the anatomic borders of the femoral artery and its branches. Surrounding anatomic structures were clearly visualized. Observation of ICG within the vessel lumens permitted visualization of the blood flow. Recorded video loops could be reviewed in an offline mode for more detailed assessment of the vasculature. CONCLUSION The overlay of fluorescence videoangiography within the field of view of the white light operative microscope allows real-time assessment of the blood flow within vessels during simultaneous surgical manipulation. This technique could improve intraoperative decision making during complex neurovascular procedures.

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