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c d

J. Luck

Fig. 4.2 Transit time volume owmetry using the Medistim system (reproduced with permission from Medistim). (a) Each probe contains two transducers that re ultrasound pulses in opposite directions. The time taken for the ultrasound beam to pass upstream (tu) is slightly longer than downstream (td), and this delay is proportional to blood ow. (b) Medistim QuickFit™ vascular probes. (c) Quantitative mean ow values should be interpreted in the context of vessel size and blood pressure. The pulsatility index is calculated by dividing the difference

between the maximum and minimum ow by the mean ow: a high pulsatility index (caused by turbulence or vasospasm) may suggest that the measurements are unreliable or may indicate the need for anastomotic revision. Before using the Medistim system, a baseline acoustic coupling index is recorded: to ensure that the measurements taken intraoperatively are reliable, this should remain >30%. (d) Medistim MiraQ™ vascular system

4 Assessment ofFlap Perfusion: Microvascular Flowmetry

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4.3 Post-operative Flowmetry

4.3.1 Non-invasive

4.3.1.1 Laser Doppler

What Is It?

Laser Doppler owmetry (LDF) provides a continuous and non-invasive measurement of blood ow within a small (1mm3) volume of tissue located 0.5–8mm beneath a surface probe [1]. The probe is held in place using either adhesive material or sutures, and it is connected to a 5mW diode laser via a breoptic cable [37]. The target tissue is illuminated with coherent laser light, and the frequency shift of backscattered light reects the average velocity of erythrocytes. It provides a real-time reection of tissue perfusion expressed as a relative velocity (Fig. 4.3). Although measurements are typically given in mL/min/100g tissue, they are often considered as arbitrary units [38, 39] and may be normalised to ow values before ap elevation [40]. Although tissue penetration is affected by skin pigmentation and probe geometry, LDF is particularly useful in muscle aps and darker skin where clinical evaluation is more challenging [41].

How Is It Used?

Importantly, relative perfusion values vary between tissues and patients. As a result, it is the trend that is informative, as opposed to any absolute values. When arterial inow is lost, ow values typically steeply decline towards zero [42]. This means that LDF may be used intraoperatively during ap inset when the pedicle may be compromised by kinking, stretching or excessive pressure [43]. In the post-operative surveillance period, a decline in normalised ow values should prompt close clinical review and possibly reexploration [40, 43]. Some authors use a decrease in perfusion value of over 50% for >20min as their threshold for clinical review [41] although there are no widely accepted standards across the literature [44]. With conventional LDF, venous obstruction is more subtle—here, there is a slower decline in ow values as blood is still able to enter the ap until the capacitance of the system is exceeded [42, 45]. To address this issue, more modern LDF devices (such as the Oxygen to See (O2C, LEA Medizintechnik, Germany) system) combine conventional LDF with white light spectrophotometry to better differentiate between arterial and venous insufciency [46]. Similarly, some LDF probes have integrated surface temperature sensors to provide additional information about ap perfusion.

Fig. 4.3 Laser Doppler owmetry system (reproduced with permission from BIOPAC). Various different breoptic surface probes (pictured) and invasive needle probes (not pictured) are compatible with the BIOPAC laser Doppler owmetry system. Flow values are usually treated as arbitrary units, and it is the trend in relative perfusion (rather than any absolute value) that is informative

J. Luck

Technical Considerations andLimitations

Although LDF is highly sensitive and relatively easy to use [2], ow values may be falsely elevated by movement or vibration artefacts [39], and positive ow values have been observed even in ‘no ow’ conditions [47]. Furthermore, LDF calculations are inuenced by erythrocyte density— hence laser Doppler techniques may be inaccurate in the context of anaemia or haemodilution, both of which are not uncommon following free tissue transfer. From a practical perspective, it can be difcult to maintain probe contact on moist or bloody surfaces, and probe dislodgement may produce falsely low readings [38]. On some devices, the last recorded value may still be displayed with an ‘out of range’ alert. As a result, inexperienced medical or nursing personnel could miss this warning and be falsely reassured [48]. It is also worth highlighting that the probe is only able to monitor a small tissue area and hence the anastomoses indirectly. Finally, as with any new technology, there are expensive start-up costs [43] that require rigorous cost-benet evaluation in each clinical setting.

4.3.1.2 Near-Infrared Spectroscopy

What Is It?

Near-infrared spectroscopy (NIRS) uses the selective light absorption characteristics of haemoglobin to provide continuous, non-invasive monitoring of tissue perfusion [49]. A probe attached to the ap surface emits calibrated nearinfrared wavelengths that penetrate up to 20 mm [50] (Fig.4.4). Backscattered light is then collected by a receiver photodiode, and the ratio of oxyhaemoglobin to deoxyhaemoglobin is used to calculate tissue oxygen saturation (StO2) levels [4]. In principle, NIRS is not signicantly different from traditional white/visible light spectroscopy; however, the absorption of visible light is 100 times greater than nearinfrared wavelengths, meaning that NIRS is particularly useful in thick aps [51]. Unlike other modalities (such as LDF), NIRS is not signicantly inuenced by movement artefact or temporary probe detachment [50], making it a practical adjunct in ward-based settings. Furthermore, StO2 is not affected by common confounding physiological (e.g. blood

Fig. 4.4 Near-infrared spectroscopy T.Ox™ system (reproduced with permission from ViOptix). A probe attached to the ap surface emits calibrated near-infrared wavelengths and measures backscattered light.

The ratio of oxyhaemoglobin to haemoglobin is then used to provide a continuous trace of tissue oxygen saturation

4 Assessment ofFlap Perfusion: Microvascular Flowmetry

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Table 4.2 Commercially available NIRS systems (adapted from Kagaya etal. [51])

O2C T.Ox Tissue Oximeter T-Stat VLS TOS-OR Measurement depth 2–8mm Update interval 2s 4s 1s 1s Measurement item(s) StO2 StO2 StO2 StO2

Device cost (USD) Device: 27,000 Device: 40,000 Device: 32,500 Not currently in production

Manufacturer LEA Medizintechnik GmbH, Germany ViOptix, USA Spectros, USA Fujita, Japan

USD US dollars, StO2 tissue oxygen saturation, Hb haemoglobin, rHb relative amount of haemoglobin, THI tissue haemoglobin index, HbI haemoglobin index, THB total haemoglobin concentration

Different depth probes available

rHb THB HbI

Flow velocity

Probe: 2240 Probe: 1600 Probe: 660–760

3–6mm 2mm 8–16mm

pressure and supplemental oxygen) and ap (e.g. perforator number and size) variables [52].

How Is It Used?

Various proprietary NIRS systems are commercially available (see Table 4.2)—all of these measure StO2, and the majority provide additional information about tissue haemoglobin (Hb) which helps to differentiate between arterial and venous compromise. In general, arterial insufciency is indicated by a reduction in both StO2 and Hb levels, whereas venous congestion is usually characterised by a transient increase in StO2 followed by a steady decline with rising Hb values. Although there is no widely accepted consensus as to the thresholds that prompt surgical re-exploration, StO2 levels below 30% (or falling by >15% per hour) should raise concerns about the status of the ap [51, 53]. To help in the interpretation of the NIRS data recorded, some authors advocate the use of a second probe on native, healthy tissue (e.g. the contralateral breast) to provide patient-specic reference values [54].

Technical Considerations andLimitations

While NIRS is able to act as an early warning system for impending ap failure, it is of limited use in the rst 8–12h post-operatively when a physiological decrease in StO2 is expected [49, 51, 55]. Commercially available NIRS monitors differ with respect to their hardware capabilities and proprietary algorithms, meaning that experience with one device may not be readily transferable to another system [49]. Traditionally, NIRS monitors need to be afxed to a cutaneous paddle, although there is emerging evidence that NIRS may be used with buried muscle or visceral organ aps [55,

56]. Finally, while NIRS is associated with high upfront

costs [50, 57] some studies have demonstrated that the routine use of NIRS is cost-effective overall [58].

4.3.1.3 Dynamic Infrared Thermography

What Is It?

Conventional surface temperature monitoring is often used as an adjunct in post-operative free ap monitoring. The

primary mechanism of cutaneous heat loss is via infrared (IR) radiation; hence a heat-sensing camera may be used to generate a colour-coded representation of blood ow. In static IR thermography, ‘hot’ and ‘cold’ regions are shown on a single image; however, the information gained from a single image is relatively limited and may be subject to interference from complex vascular patterns [59]. As a result, dynamic IR thermography (DIRT) techniques have been developed to monitor the response of a ap to thermal stress—typically a transient cold challenge. To achieve physiological cooling, a conductive metal plate is applied to the area for 30s [59], or a high-speed portable fan is used to accelerate the evaporation of topically applied isopropyl alcohol spray [60]. The rate and pattern of homeostatic temperature changes is then monitored to provide a visual and non-invasive representation of tissue perfusion (see Fig.4.5).

How Is It Used?

DIRT may be used both intraoperatively and post- operatively. Several authors have described the use of DIRT in perforator selection [61–63], corroborated by handheld acoustic Doppler. Following completion of the anastomosis, DIRT may then be used to identify on-table issues with the pedicle [64]. Using this technique, it is possible to differentiate between arterial and venous insufciency: if the entire ap fails to rewarm, this suggests an inow problem; conversely, venous congestion manifests as adequate rewarming but without characteristic ‘hot spots’ [10]. Importantly, these features can reliably be identied using IR thermography before macroscopic changes are visible [63]. DIRT may also be used to interrogate ap perfusion post-operatively [65]— here, smartphone-compatible, portable thermographic cameras (such as the Forward Looking Infrared One (FLIR ONE®) device (FLIR Systems, Wilsonville, OR)) may be of particular benet.

Technical Considerations andLimitations

Early IR thermographic cameras were limited in their ability to detect subtle (<0.1°C) temperature changes. Since then, improvements in IR technologies mean that DIRT can be

38.0ºC

22.0ºC

38.0ºC

J. Luck

Fig. 4.5 Post-operative dynamic IR thermography images conrming DIEP ap viability in breast reconstruction (reproduced from de Weerd etal. [59] with permission). The thermogram in (a) shows the DIEP in

used to simply and non-invasively evaluate free ap perfusion. However, DIRT is not able to continuously monitor blood ow and, as the observer is required to make their own assessment of the topographic map displayed, it lacks true objectivity [60]. It is also important that clinicians are aware of this impact of external factors on ap temperature [66]; for example, room temperature, clothing and humidity can generate skin temperature uctuations of up to 8 °C [67]. Dedicated thermal cameras are less likely to be misled by background thermal interference (such as ‘heat hollows’ or cutaneous veins [68]), although these are typically more

situ before gentle cooling with a metal plate (b). The effect of cooling is demonstrated in (c) before reperfusion is conrmed by rapid return of thermal hot spots (d)

wrapped in a silastic sleeve. This sleeve is wrapped around the vascular pedicle and held in place using sutures [70], microclips [71], brin sealant [72] or an elongated soft silicone cuff [73]. When positioned correctly, the pulsed 20MHz ultrasonic probe reects ow as a qualitative ‘all-ornothing’ phenomenon. A thin wire exiting through the wound connects the probe to a portable monitor via an intermediary extension cable that is sutured to the patient by a series of retention tabs [74]. The wire is then safely removed at between Day 5 and 10 [7] by applying gentle (50 g)

tension. expensive and less portable than their smartphone counterparts.

How Is It Used?

The implantable Doppler provides continuous monitoring of

blood ow across the pedicle. The probe may be placed on

4.3.2 Invasive

either the artery or vein and, as yet, there is no universal con-

sensus as to which approach is superior [75]. In principle,

4.3.2.1 Implantable Doppler

arterial placement leads to a higher false negative rate as the

probe is less able to detect early venous thrombosis [76]. In

What Is It?

The Cook-Swartz implantable Doppler probe was rst developed in 1988 [69]. It consists of a 1mm3 piezoelectric crystal

contrast, venous monitoring is able to promptly identify both

inow and outow issues [56]. However, venous probes are

more easily dislodged and poorly discriminate between true

4 Assessment ofFlap Perfusion: Microvascular Flowmetry

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thrombosis and technical malfunction [76]. Given that implantable Dopplers are especially useful in buried aps when clinical correlation is challenging, these false positives can lead to unnecessary re-exploration. To some extent, the development of a wireless implantable Doppler system may mitigate against the risk of inadvertent probe dislodgment [77]. In addition, the Cook-Swartz Doppler may be useful during ap inset when it provides valuable information about on-table pedicle compromise [1].

Technical Considerations andLimitations

By design, the implantable Doppler is only able to measure blood ow across the pedicle and provides only limited information about tissue perfusion [1]. It is necessarily invasive and requires the permanent placement of a foreign body, theoretically increasing the risk of anastomotic rupture or thrombosis [56]. This may be particularly problematic in anatomical areas with challenging geometry, such as the head and neck [76], or when multiple probes are used [74]. In addition, its introduction into routine clinical practice involves a surgical learning curve, and, to some extent, the widely variable false positive and false negative rates seen across the literature may reect operator experience [7]. Finally, as with all owmetry technologies, rigorous nancial evaluation is needed to justify its additional upfront costs in each clinical setting [76].

4.4 Future Directions

4.4.1 Characteristics ofanIdeal Flowmetry

Device

The ideal monitoring device should be non-invasive and provide real-time, objective measurements of tissue perfusion both intraoperatively and post-operatively [78]. It should

Quantitative

Buried and

non-buried flaps

Arterial vs

venous

compromise

Intra- and

post-operative

Fig. 4.6 Characteristics of an ideal owmetry device (created with

BioRender)

Ideal characteristics

use

Cost-effective

Non-invasive

Continuous

Minimal

learning curve

respond to subtle changes in blood ow and be able to distin-

guish arterial from venous compromise [37]. It should be

applicable to all types of aps, including those without a

cutaneous paddle, and provide quantitative data that can be

interpreted by even inexperienced personnel [1]. It should

not put either the ap or patient at risk, and it should be cost-

effective at scale (Fig.4.6). Crucially, any owmetry device

must be sufciently sensitive and specic to meaningfully

improve clinical outcomes [4]. For example, post-operative

monitoring devices should signicantly increase ap salvage

rates without an unnecessarily high number of false positive

take backs [7]. The key features of each monitoring device

discussed in this chapter are outlined in Table4.3.

Table 4.3 Monitoring characteristics of different owmetry techniques

Flowmetry technique Invasive Timing Data Frequency Pedicle assessment Buried aps? Fluorescence angiography Yes Intra-op Transit time volume owmetry Yes Intra-op Quantitative Single use A and V Yes Laser Doppler No Intra- and post-op Quantitative Continuous A and V Ye s Near-infrared spectroscopy No Post-op Quantitative Continuous A and V Yes Dynamic infrared thermography No Intra- and post-op Semiquantitative Intermittent A and V No Implantable Doppler Yes Intra- and post-op Qualitative Continuous A and V Yes

A arterial, V venous

Can be used post-operatively

May be able to indirectly demonstrate venous insufciency

Emerging evidence in buried aps

Semiquantitative Single use A

J. Luck

Table 4.4 Additional microvascular owmetry techniques in clinical studies

Non-invasive Invasive Colour Doppler Microdialysis Pulse oximetry Contrast-enhanced ultrasound Photoplethysmography Nuclear medicine (PET) Spatial frequency domain imaging White/visible light spectroscopy Sidestream dark eld imaging

4.5 Conclusions

This chapter reviews the role of microvascular owmetry in free tissue transfer with a focus on understanding the key features of the most commonly encountered owmetry techniques. It aims to describe how each modality may be most effectively used with an appreciation of each technique’s relative advantages and disadvantages. However, many other emerging owmetry techniques not discussed here have been trialled in clinical settings (Table4.4).

Although clinical assessment remains the gold standard method of evaluating free ap perfusion, we anticipate that owmetry devices will enter widespread clinical use as important intraoperative and post-operative adjunct technologies. At present, there is an unmet clinical need for objective, quantitative tools that are able to accurately predict and monitor free ap outcomes. When appraising the effectiveness of any ap monitoring tool in your own practice, we recommend that you consider the following framework set out by Lineaweaver [79]:

1. False positive rate

2. Sensitivity to true vascular complications

3. Clinical outcomes, including ap failure and ap salvage

rates

4.6 Selected Readings

• Chae MP, Rozen WM, Whitaker IS, Chubb D, Grinsell D,

Ashton MW, et al. Current Evidence for postoperative

monitoring of microvascular free aps: a systematic

review. Ann Plast Surg. 2015;74:621–32.

• Comprehensive review of post-operative owmetry tech-

nologies with an emphasis on clinically relevant out-

comes. In particular, it highlights which monitoring tools

lead to improvements in ap salvage without unaccept-

ably high false positive rates.

• Hanasano MM. Chapter 4 - Emerging technology in

reconstructive surgery. In: Wei F-C, Mardini S, editors.

Flaps and reconstructive surgery. 2nd ed. Amsterdam:

Elsevier; 2016. p. e11.

• Detailed narrative review of how ICG angiography can

be used intraoperatively to improve outcomes in both free tissue transfer and lymphatic surgery. However, no other microvascular owmetry technologies are discussed.

• Lohman RF, Ozturk CN, Ozturk C, Jayaprakash V, Djohan R.An analysis of current techniques used for intraoperative ap evaluation. Ann Plast Surg. 2015;75:679–85.

• Quantitative systematic appraisal of the sensitivity and

specicity of intraoperative ICG angiography, dynamic IR thermography and photospectrometry with an attempt to correlate owmetry data with clinically relevant outcomes (e.g. revision, re-exploration and ap loss).

• Newton E, Butskiy O, Shadgan B, Prisman E, Anderson DW. Outcomes of free ap reconstructions with nearinfrared spectroscopy (NIRS) monitoring: a systematic review. Microsurgery. 2020;40:268–75.

• PRISMA-compliant systematic review demonstrating the

benet of additional NIRS monitoring post-operatively. Based upon ten articles included in the nal analysis, the detection of vascular compromise with NIRS preceded clinical changes, leading to higher salvage rates and reduced partial ap loss.

• Patanis G, Raveendran M, Myers S, Ghanem AM. Flowmetry evolution in microvascular surgery: a systematic review. J Plast Reconstr Aesthet Surg. 2017;70:1242–51.

• Systematic review of the preclinical and clinical micro-

vascular owmetry literature with an appraisal of the quality of evidence provided by each study. The article concludes with a discussion of how owmetry monitoring changes surgical decision-making in both intraoperative and post-operative settings.

• Smit JM, Zeebregts CJ, Acosta R, Werker PMN.Advancements in free ap monitoring in the last decade: a critical review. Plast Reconstr Surg. 2010;125(1):177–85.

• Narrative review of commonly encountered owmetry

technologies with an overview of the scientic rationale underpinning each approach. It also assesses to what extent each technique conforms to the criteria for an ideal monitoring device.

• Smit JM, Negenborn VL, Jansen SM, Jaspers MEH, de Vries R, Heymans MW, etal. Intraoperative evaluation of perfusion in free ap surgery: a systematic review and meta-analysis. Microsurgery. 2018;38:804–18.

• Well-executed PRISMA-compliant systematic review and

meta-analysis of intraoperative owmeter devices, demonstrating that the use of uorescence angiography and laser Doppler improves ap survival outcome; insufcient evidence to support the use of oxygen saturation monitoring, dynamic IR thermography, microdialysis and ultrasound-based approaches.

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4 Assessment ofFlap Perfusion: Microvascular Flowmetry

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

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