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6 The Use ofUltrasound Technology inPlanning Perforator Flaps andLymphatic Surgery
technology for diagnosis and treatment purposes. To do so,
specic training is needed to understand the technology and
its potential and to correctly use it daily.
Plastic surgery remains one of the few specialties in which
the use of ultrasound is still not common and when needed is
delegated to radiologist. However, in our specialty we can benet a lot from ultrasound, from general plastic surgery patient
check and follow-up (postoperative scan of any surgical site
when in doubt of seroma, uid accumulation, hematoma) up to
very sophisticated preoperative planning in microsurgery.
Even though many plastic surgeons may believe that in
case the ultrasound examination is needed it is better to delegate it to radiologists to save time for other specic works,
this attitude is not far-sighted. In fact, once the ultrasound
skills are acquired, basic postoperative checkups may take
few minutes to be performed. This will enhance a lot patients’
compliance, adherence, and esteem.
When used in preoperative planning for sophisticated
microsurgical procedures such as perforator ap and lymphatic surgery, ultrasound examination allows to save intraoperative time needed for exploration leaving energy for
creativity and other important aspect of the surgery. In lymphatic surgery, ultrasound is the quintessence to perform
LVA in an effective and efcient way.
49
6.3 Color-Coded Duplex Sonography
(CCDS)
CCDS using high-resolution ultrasound allows to have
detailed information on microvascular and soft tissue anatomy
of any donor site [12–16]. In the eld of plastic surgery, linear
probes from 4 to 19 MHz are the most indicated. Highfrequency ultrasound (>15MHz) allows to expand knowledge
on more supercial plane, thus allowing a further analysis of
the perforator vessels and supercial microanatomy.
The anatomical details can be studied using B-mode, and
information on microvascular network are better studied using
color Doppler and power Doppler (Figs.6.3, 6.4, and 6.5).
In literature, different studies have demonstrated a high
sensitivity of color-coded ultrasound in preoperative perforator evaluation [12–16].
Compared to other imaging technology, such as multidetector CT (MDCT) scan angiography and magnetic resonance angiography (MRA) [17], US allows a live evaluation
of the perforators which gives the possibility to mark their
location precisely on the skin. Moreover, high-frequency
probes allow a resolution up to 100μm with the possibility to
visualize microvessels up to 0.2mm in caliber, which goes
beyond the ability of other imaging modalities (Fig.6.2).
Moreover, a dynamic evaluation of ow and velocity can
be performed along with measuring its caliber, which helps
Fig. 6.3 Comparison of B-mode ultrasound scan of anterolateral thigh
area taken with conventional (above) and high-frequency (below) ultrasound using same depth and focus point of the same spot. The anterolateral thigh (ALT) is a very common donor site for perforator aps.
The gross differences between conventional and high-frequency ultrasound are clear: the rst gives clearer detail of deeper structures compared to the second. The intramuscular septum between rectus femoris
(RF) muscle and vastus lateralis (VL) muscle is highlighted by yellow
spots. Down to the septum, into the virtual space below RF and above
vastus intermedius (VI) muscle, it is visible the descending branch of
the lateral circumex femoral artery (DB-LCFA)
in selecting the perforator preoperatively. The precise subfascial course of the perforator is available (septal/intramuscular/mixed course) up to the source vessel, thus precisely
delineating the dissection route that will be performed intraoperatively (Fig.6.4).
When planning local perforator aps, the exact axis of a
perforator within the subcutaneous tissue can be delineated,
which helps to precisely include the perforator tree within
ap design [18].
In LVA surgery, high-frequency ultrasound is useful in
preoperative evaluation of recipient venules, whereas it gives
limited information on lymphatic channels compared to
ultrahigh-frequency [19].
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Fig. 6.4 DB-LCFA
perforator course. (Above)
Perforator visualization using
the color ow mapping
(CFM) just after piercing the
muscular fascia. It is evident
that the perforator has a strict
suprafascial course for half
centimeter and then enters the
subcutaneous tissue. (Center)
At the point when the
perforator pierces the
muscular fascia. It is visible
an intrafascial branch. (Below,
left) Perforator intramuscular
course through VL muscle. At
CFM, the perforator course
from the muscular fascia
perforator point to the
intramuscular branch is not
clear. (Above, right) To
improve the sensibility of the
signal, it is possible to switch
to power Doppler mode which
clearly highlights a strict
subfascial course of the
perforator for 0.5cm before
piercing the fascia. Compared
to CFM, we do not have the
ow direction information.
Figure gives an idea of the
most common information
that can be acquired from a
preoperative planning of an
ALT ap. The perforator
caliber, position, and course
are already very clear before
starting surgery
G. Visconti et al.
6 The Use ofUltrasound Technology inPlanning Perforator Flaps andLymphatic Surgery
planning a thin, superthin, or pure skin perforator (PSP)
ap, we further evaluate the identied perforators using the
UHFUS.In fact, UHFUS allows to expand the knowledge
of subcutaneous tissue anatomy and its microvascular network. We recently proposed a practical classication for
harvesting thin, superthin, and PSP aps based on UHFUS
information [21].
Perforators are classied as type 1 perforators, when the
perforator shows a direct course from the muscular fascia to
dermis. Its caliber is preserved up to the supercial fascia
(Camper’s fascia), where it can branch or proceed directly to
the dermis. One to three dermis entry points are identiable
and the intradermal plexus (for the arterial and venous component) is visible.
The microanatomical features of type 1 perforators make
them very favorable when a superthin or PSP is planned. In
fact, for superthin aps, the main important step during the
surgery is the identication of the proper supercial fascia
(Camper’s fascia). Once this plane is identied, the dissection proceeds along this plane up to the perforator, without
needing explorative approach and/or microdissection. There
is no fear to jeopardize ap vascularity by ligation of further
microvessels that are encountered during elevation, because
the chosen perforator has no branches below this level. For
PSP, the dissection is similar with the difference that the
Fig. 6.5 The same perforator of Fig.6.4 was scanned with ultrahigh-
frequency ultrasound (UHFUS) linear probe (70MHz). This technology allows to obtain very supercial details. The scale on the right is in
millimeter compared to the scale of the high frequency which is in centimeter. (Above) With UHFUS, it is possible to identify the exact perforator dermis entry point as well as intradermal plexus. This information
is particularly useful when planning thin and pure skin perforator aps.
This is a type 2 perforator, and the image above shows the left branch,
barely appreciable with the high-frequency ultrasound (below)
elevation is made just below the dermis, as when a fullthickness skin graft is raised.
Conversely, type 2 perforators start to arborize in different collaterals within the subcutaneous tissue, after piercing
the Scarpa’s fascia. The perforator cannot be easily followed
within the subcutaneous tissue with 48 and 70MHz probes.
Compared to type 1 perforator, it is not possible to detect a
direct perforator course from muscular fascia to the dermis
in type 2 perforators.
6.4 Ultrahigh-Frequency Ultrasound
(UHFUS)
Type 2 perforators are thus chosen when a thin ap is
planned (elevated on the Scarpa’s fascia plane). If those perforators are chosen for superthin or PSP ap elevation,
The latest evolution in ultrasound technology has been the
introduction of ultrahigh-frequency probes (48 and 70MHz)
available for use in humans. These frequencies allow a resolution up to 30μm (70MHz) and 50 μm (48 MHz) which
enables clear and detailed visualization of very tiny structures and details, not possible before. The main disadvantages of such frequency is the depth analysis related to the
microdissection of all the tiny subcutaneous collaterals is
needed not to jeopardize ap vascularity.
This classication does not apply for conventional supraor subfascial perforator ap elevation, because in both cases,
the perforator vascular tree is included in the ap.
In our experience, there are two main advantages of proposed UHFUS perforator classication:
low penetration. Accurate analysis down to 1cm from the
skin is possible with 70MHz probes and down to 2cm with
the 48MHz probes.
For these features, UHFUS should be seen as an
upgrade of HF-US for some specific application in plastic surgery, especially for perforator and lymphatic imaging [20–28].
For perforator aps, we usually proceed rst with CCDS
to delineate all features of the perforator. In case we are
• Safer, faster elevation of PSP and superthin ap. The pre-
cise knowledge of the perforator subcutaneous anatomy
allows the surgeon to concentrate more on correctly nding the plane of elevation, which is sometimes hard, and
to proceed with a precise superthin elevation.
• Choose the perforators on which the ap is based. In fact,
we can choose the best perforator for our needs within the
same donor site or choose the donor site based on perfora-
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Fig. 6.6 Ultrahigh-frequency
ultrasound scan of lower limb
lymphedema using a 48MHz
linear probe. ICG
lymphography did not show
clear linear patterns. UHFUS
allowed to identify an incision
point with two lymphatic
channels (yellow arrows) and
a favorable recipient venule
with a branch (blue arrows)
G. Visconti et al.
tor features. To give an example, ALT donor site is the
most used for soft tissue reconstruction. It is not uncommon to nd two to three sizeable and appropriate perforators on which we can harvest our ap. With the information
given by US, we can choose the simplest, the leastinvasive, and most appropriate perforator for our needs in
case of thin aps (type 1 or type 2).
UHFUS has also application in capillary perforator ap
planning and in supermicrosurgical eld [20].
In LVA surgery, UHFUS is the quintessence of preopera-
tive planning [20, 23–28] that can be resumed in these points:
• Identication of functional lymphatic channels in dermal
backow areas (Fig.6.6)
• Evaluation of lymphatic channels seen as linear pattern at
the indocyanine green lymphography (ICG-L)
• Intraoperative selection of lymphatic channels
• Entire preoperative study in iodine-allergy patients that
cannot undergo ICG-L
• Differentiation between functional and less-functional
lymphatic channels as the UHFUS provides details comparable to those of histology
• Functional and static evaluation of favorable recipient
venules
• Planning alternative methods in incisions devoid of
venules
6.5 Conclusions
Ultrasound technology is largely available in all hospitals
and small clinics as this technology represents the stethoscope for many specialties. Plastic surgeons should acquire
sonographic skills to incorporate this tool in their practice,
either this includes microsurgery or not.
CCDS allows to preoperatively study perforator anatomy,
comprehensively. Information on size, hemodynamics, and
anatomical course of a perforator allows to preoperatively
plan the surgery, allowing to avoid time wasted for intraoperative exploration and frustration related to unknown microanatomy. This energy can be saved for improving creativity
and to focus on other reconstructive needs. The patient will
benet from a safer, faster, and less destructive surgery.
UHFUS is advisable when planning superthin and PSP
aps. It represents the quintessence in LVA surgery.
Lastly, it is our opinion that ultrasonographic examination
should be performed by the operating surgeon and not delegated to other colleagues or other specialists. It is only in this
way that the operating surgeon can really feel to have preoperative knowledge of the microanatomy. This may have innite potentials for further development of microsurgery.
Disclosure Giuseppe Visconti and Akitatsu Hayashi are
Medical Advisors for Fujilm Japan. Alessandro Bianchi
and Marzia Salgarello have no interest in any of the products,
devices, or drugs mentioned in this manuscript.
6 The Use ofUltrasound Technology inPlanning Perforator Flaps andLymphatic Surgery
53
Conict of Interest None.
Funding None.
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Novel Microscopic Technologies
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inReconstructive Microsurgery/
Microvascular Surgery
MichalisHadjiandreou andGeorgiosPatanis
7
Abbreviations
3D Three-dimensional
ALT Anterolateral thigh
AR Augmented reality
CGAP Cranial gluteal artery perforator
CVAs Cerebrovascular accidents
DIEP Deep inferior epigastric perforator
DOF Depth of eld
ENT Ear, nose and throat
ETE End-to-end
FOV Field of view
HMM Head-mounted microscope
HR High resolution
HSI Hyperspectral imaging
ICG Indocyanine green
IMV Internal mammary vein
iOCT Integrated optical coherence tomography
LSCI Laser speckle contrast imaging
MBARS Microscope-based augmented reality system
MBVRS Microscope-based virtual reality system
MIOCT Microscope-integrated optical coherence
tomography
MSI Multispectral imaging
NIRF Near-infrared uorescence
OCT Optical coherence tomography
OM Operating microscope
OMiHSI Operating microscope-integrated hyperspec-
tral imaging
M. Hadjiandreou (*)
Centre for Plastic Surgery and Burns, St John’s Hospital,
Livingston, Scotland, UK
UCL Division of Surgery and Interventional Science, Royal Free
Hospital, London, UK
G. Patanis
London Reconstructive Microsurgery Unit (LRMU), Emergency
Care and Trauma Division (ECAT), The Royal London Hospital,
Barts Health NHS Trust, London, UK
OM-NIRF Operating microscope-near infrared
uoroscopy
PAL Photoacoustic lymphangiography
PAM Photoacoustic microscopy
PRDOCT Phase-resolved Doppler optical coherence
tomography
PU Perfusion units
RM Reconstructive microsurgery
VR Virtual reality
7.1 Introduction
7.1.1 The Evolution ofOperating Microscopy
Operating microscopy has gone through remarkable development over the last centuries. Technical advancements in
the eighteenth and nineteenth centuries focused on improving the resolution of the monocular microscope. Amongst
those, the placement of several low-powered lenses in a row
with a certain distance between them by Joseph Jackson
Lister and the proposal for a formula to calculate the numerical aperture by Ernst Abbe led to the enhancement of microscopy resolution [1].
Although the compound microscope had been invented in
1590 by two Dutch opticians, Zacharias and Hans Janssen,
its several limitations including size and weight did not allow
it to enter the operating theatre. Its limitations coupled with
advancements in ophthalmology led to the development of
binocular vision that was introduced by spectacle mounted
magnifying systems. Head-worn magnication dominated
the eld of microscopy and preceded the operating microscope (OM) [2]. Devices were categorised into single-lens
magniers (Figs.7.1 and 7.2), prismatic magniers (Figs.7.3
and 7.4) and telescopic systems [3]. In their simplest form,
single-lens magniers were magnifying spectacles with convex lenses suspended at the end of the nose. Prismatic magniers were binocular magniers that used prism oculars and
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_7
55
56
M. Hadjiandreou and G. Patanis
lenses and were rst introduced in 1912 by the Carl Zeiss
Company, offering a magnication in the range of 0.75–3.0×.
It is of particular interest that the limitation of magnication
and inexibility in working distance paved the way for tele-
Fig. 7.1 Biconvex lenses on extended arm (single-lens magnier)
Fig. 7.2 Berger loupe (single-lens magnier)
scopic systems. The open Galilean loupes were the rst
device to offer this, followed by the rst closed Galilean system that achieved focus of 15cm and magnication of 3×.
Finally, in 1952, the introduction of the Keeler Galilean tele-
scopic system (Fig.7.5) opened the door to modern micro-
surgery by providing a wide range of magnication
(1.75–9×), working distance (34–16.5cm) and the ability to
adjust the interpupillary distance [3].
The need for stability in focusing and surgeon’s discomfort with addition of a light source shifted the need to more
stable devices such as monocular and, subsequently, binocular microscopes with tripod support and light attachment [3].
In 1921, the rst monocular microscope was used intraoperatively by Carl Olof Nylén. The lack of depth perception led
to the development of a binocular Zeiss microscope on a tri-
pod with external light source in 1922 (Fig.7.6). The operating microscope was widely adopted in the eld of ENT
surgery [1, 4]. However, several issues required improvements including image vibration at high magnication, xed
magnication insufcient illumination and single surgeon
surgical eld view.
In 1938, P.Tullio and P.Calicetti constructed a heavy tripod with counterweights that stabilised the image and
allowed the optical unit to hang freely above the surgical
table. Prisms were also mounted between the oculars to
allow assistant to view the surgical eld [5]. In 1952, Hans
Littmann invented and introduced magnication change
without changing focal length, in the form of Zeiss-Opton
(Fig.7.7) (working distance 200mm, magnications of 4, 6,
10, 16, 25, 40 or 63 as a rotary Galilean system) [4, 5]. In
1953, Littmann adopted improvements in manoeuvrability
Fig. 7.3 Zeiss Prism binocular loupe (prismatic magnier)
Fig. 7.4 Zeiss Prism binocular loupe on face frame (prismatic
magnier)
Fig. 7.5 Keeler Galilean telescopic system
Fig. 7.6 The binocular Zeiss microscope modied by Holmgren
7 Novel Microscopic Technologies inReconstructive Microsurgery/Microvascular Surgery
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7.2 Novel Microscopic Technologies
7.2.1 Visualisation Technologies
7.2.1.1 HD Displays and3D Visualisation
Visualisation is one of the most important technical characteristics of the modern OM.Stereopsis is a key feature of the
binocular microscope that has enhanced visualisation by
Fig. 7.7 Zeiss Opton microscope by Hans Littman
providing depth perception under magnication. This offered
the microsurgeon a 3D impression of the surgical eld. The
depth information is clinically relevant in aiding diagnosis
via recognition of anatomical location and morphology of
tissue structures [4].
FusionOptics™ technology is a sophisticated optical
approach technology that enhances stereo visualisation for
surgical microscopes by providing simultaneous high depth
of eld (DOF) and high resolution (HR). This is achieved by
one light path received by observer with higher resolution
and lower DOF and, simultaneously, the other light path
Fig. 7.8 The Zeiss OPMI 1
received by observer with lower resolution and higher DOF
[10]. The human brain combines the images into a HR, high
by Horst L.Wullstein and introduced the Zeiss OPMI 1, a
milestone in the evolution of microscopy (Fig.7.8), which
offered more stability, easier operation and superior coaxial
lighting than other microscopes available at the time (10–
40.5cm working distance and magnications 2.5 and 50).
Finally, in 1956, the OM had some signicant innovations
such as knee-controlled focusing lever and foot-controlled
x–y coordinate system. These two developments allowed surgeons to operate in a hands-free manner and established the
position of the OM in modern surgical practice [5].
DOF optical spatial image.
High-denition (HD) display and 3D visualisation have
transformed microsurgical practice and training and show
potential in improving ergonomics. In 2010, TrueVision
Systems developed a ‘heads-up 3D microscopy’ system
which transmits the image on a HD 3D monitor to improve
position of the microsurgeon. Mendez et al. evaluated the
feasibility of using heads-up 3D microscopy to perform rat
femoral artery anastomoses comparing the technique to traditional microscopy (Fig.7.9). 3D visualisation was found to
be equally safe to traditional technique with 100% patency
rate and no signicant difference in operative time. In addi-
7.1.2 Operating Microscopy
inReconstructive Microsurgery
tion, the 3D system was assessed by the majority of participants as equivalent or superior in-depth perception, image
resolution and FOV.It is worth noting that all the participants
The OM has numerous applications in the eld of reconstructive microsurgery (RM). From nger replantation to
lymphatic reconstruction, the OM offers unique capabilities
to the reconstructive microsurgeon such as powerful magnication and unparalleled illumination. Numerous studies
have highlighted the superiority of the OM compared to
other means of magnication in the reconstructive outcome
and safety of ap design [6–9].
Current limitations of the OM such as manoeuvrability,
found the 3D system to be a more valuable educational and
interactive experience [11]. High-denition displays can
show overlaid radiological or other images that can provide
surgical guidance and intraoperative planning. A feasibility
study by Belykh etal. presented the capabilities of the robotic
visualisation platform, ZEISS KINEVO 900, including 3D
display through polarising glasses for microvascular anasto-
moses on rat carotid arteries [12]. Further details on KINEVO
900 can be found in Sect. 7.2.3.2 (Fig.7.10).
large volume, high cost and absence of three-dimensional
(3D) vision remain the challenges that need to be addressed
7.2.1.2 Immersive Microscopy
via technological advancements, namely, robotics and imaging modalities. This chapter will focus on presenting novel
microscopic technologies for reconstructive microsurgery in
three parts: (1) current novel microscopic technologies, (2)
clinical applications of these technologies in the reconstructive eld and (3) future directions of operative microscopy.
Augmented Reality
Augmented reality (AR) overlays digital information on
real-world objects to enhance user experience or capabilities
[13]. AR has gained momentum in the eld of RM due to its
potential benets and technical advancements of the OM.A
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M. Hadjiandreou and G. Patanis
recent systematic review by Vles etal. identied AR applications in preoperative planning for osteotomies in different
plastic surgery procedures and perforator vessel identication; however, there was no utilisation of a microscope-based
AR system (MBARS) in these applications [14]. Similarly, a
systematic review by Al Omran etal. focusing on AR in RM
identied ve studies that incorporated three types of AR:
head-mounted devices, hand-held devices and spatial augmentation reality. None of the studies identied involved the
use of microscope-based AR system [15]. Despite the fact
that MBARS is not popular within RM, it has been used in
the eld of neurosurgery. The MBARS allows overlaying 3D
projections of preoperative surgical images into the bilateral
eyepieces of the binocular optics with surgical eld alignment [16].
Fig. 7.9 (Left) 3D dimensional microscopy using 3D goggles.
(Reproduced from Mendez etal. [11])
There are a number of technical considerations prior to
utilisation of MBARS.These can be categorised into calibration of optical system, tracking, registration and display.
Table7.1 summarises the technical interventions and their
aim. Although not studied in RM directly, a MBARS has the
potential to be used with near-infrared guided indocyanine
green (NIR-ICG) technique in identication of lymphatic
vessels for lymphaticovenous anastomosis (LVA) [17, 18].
Watson etal. demonstrated how real-time overlay of brighteld and NIR uorescence images can be achieved. The
objective lens receives both NIR and bright-eld images of
the specimen simultaneously. The augmentation module
separates the NIR image from the bright-eld image, and the
NIR image is processed to generate a synthetic image. The
synthetic image is then redirected to a single ocular piece.
Equivalently, two cameras can capture the NIR image, and
after processing, this is superimposed on the FOV, and the
integrated image is projected to both ocular pieces [19].
Figure7.11 shows a schematic of the MBARS reproduced
from Watson etal. [19].
Table 7.1 Summary and aim of MBARS technical interventions
(adapted from Ma L etal. [4])
MBARS
technical
interventions
Calibration (of
optical system)
Tracking Pose estimation of
Registration Relating 2 or more
Display Image injection into
Summary of
intervention Aim
Determination of all
camera parameters
including optical
errors
objects in real time
data sets to each
other to match their
content
microscope oculars
and monitors
Production of projection
matrix generating pixel
position in the injected image
of any 3D point relative to
the frame of reference of
microscope
Accuracy
Essential as system very
sensitive to misalignment of
virtual image and real
environment
Accurate superposition of
real and virtual image
Fig. 7.10 (a, b) (Right) Overlaid image (picture-in-picture) feature of the robotic visualisation platform ZEISS KINEVO 900. (Reproduced from
Belykh etal. [12])
Specimen
7 Novel Microscopic Technologies inReconstructive Microsurgery/Microvascular Surgery
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59
LED
780 nm
Excitation
source
f=20 mm
793SP
Ocular
L
VIS
700SP
50/50
Augmetation
module
VIS/NIR 50/50
780 nm VIS+NIR VIS+NIR
Ocular
R
VIS+GRN
Augmented image
live observation
700SP
840BP50
NIR
GRN
Nir image
0.5x
f=100 mmf=100 mm
capture
CMOS
OLED
Synthetic
image display
Image processing
unit
1x Objective
Fig. 7.11 MBARS illustration with augmented image projected to right eyepiece. (Reproduced from Watson etal. [19])
There are several obstacles in the design of AR before it is
safely incorporated in routine RM practice: registration error
RM purposes such as planning, intraoperative navigation or
training [22].
from compounded sources, system latency resulting in visual
asynchrony, obstruction of area of interest by virtual component and time consumption for registration and verication.
7.2.2 Optical Imaging Modalities
Depth in AR refers to the understanding of spatial relationships between perspective, object in view and overlaid information. Incorrect depth interpretation is the most common
perceptual problem in AR applications and can potentially
have serious clinical implications [20]. The future of AR
applications includes renement and improvement of AR
systems to allow seamless integration in the challenging
microsurgical environment.
7.2.2.1 Near-Infrared Fluorescence Imaging
Near-infrared uorescence (NIRF) imaging modality is one of
the most promising imaging techniques for image-guided surgery. Contrast agents with uorescent characteristics (i.e. uorophores including indocyanine green (ICG)) in the
near- infrared spectrum (700–900nm) can be visualised using
dedicated NIR camera systems. A systematic review by
Cornelissen etal. presents the multiple applications of NIRF
Virtual Reality
Virtual reality (VR) is a simulated, immersive experience
that presents digital information in a 3D environment [21]. A
review by Kim etal. identied VR applications in plastic surgery planning and training; however, none of the studies presented a microscopy-based VR system (MBVRS) used for
imaging in plastic and reconstructive surgery including assessment of tissue perfusion in free ap surgery, perioperative
assessment of mastectomy skin ap perfusion, bone perfusion
and abdominal wall perfusion in abdominal wall reconstruction, planning of LVA and assessment of perfusion after revascularisation of upper limb extremity ischaemia [23].
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