The use of live fluorescence staining techniques in surgery: a review.
Roberts Harry W,Donati-Bourne Jack F,Wilson Victoria L F,Wilton Joanne C
Journal of investigative surgery : the official journal of the Academy of Surgical Research
Intraoperative fluorescence may allow improvements to existing surgical procedures or offer scope for new operations. Despite articles describing its use dating back more than a decade, its emergence as a commonly used adjunct is still anticipated. While awareness and availability of special equipment may limit the uptake of these techniques, intraoperative fluorescence could represent a key innovation in the future of surgery. Further awareness of techniques and more clinical trials are needed to promote a wide base of clinical expertise from which further innovations can be made. This literature review begins with a discussion of the physics and chemistry of fluorophores and the properties needed for use in clinical practice. Uses in the majority of surgical specialties will be considered and the current literature addressed. Common uses include delineating hollow visci such as blood vessels or demonstrating pathology such as tumors. Fluorescent stains used have been safe, effective, and often easier to use than the established methods. Finally, novel materials such as antibodies and nanoparticles will be mentioned as new developments on the horizon of intraoperative fluorescent staining.
10.3109/08941939.2013.778923
Intraoperative indocyanine green imaging as an adjunctive technique to reduce any circumflex artery damage during mitral valve surgery: a feasibility study.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery
Iatrogenic injuries to the circumflex coronary artery during mitral valve surgery are probably underestimated (reported rates of 0.3-1.8%). This complication arises from the artery's close proximity to the mitral annulus, particularly at the anterolateral commissure. The study aimed to assess this risk in a patient group prone to such injury. The surgical procedure utilized a minimally invasive approach and indocyanine green-based fluorescence imaging. This technique allows a real-time visualization of the circumflex artery, aiding precise placement of annular sutures and minimizing the risk of injury. The method, applied in 6 patients, integrates preoperative assessments with intraoperative fluorescence imaging, ensuring accurate arterial depiction and preventing iatrogenic damage. The study highlights the safety and efficacy of fluorescence imaging, especially in identifying vessel anomalies, indicating potential applications in various cardiac procedures.
10.1093/ejcts/ezae043
A novel fluorescent cardiac imaging system for preclinical intraoperative angiography.
Mashalchi Sara,Pahlavan Sara,Hejazi Marjaneh
BMC medical imaging
BACKGROUND:Intraoperative coronary angiography can tremendously reduce early coronary bypass graft failures. Fluorescent cardiac imaging provides an advanced method for intraoperative observation and real-time quantitation of blood flow with high resolution. METHODS:We devised a system comprised of an LED light source, special filters, lenses and a detector for preclinical coronary artery angiography. The optical setup was implemented by using two achromatic doublet lenses, two positive meniscus lenses, a band-pass filter, a pinhole and a CCD sensor. The setup was optimized by Zemax software. Optical design was further challenged to obtain more parallel light beams, less diffusion and higher resolutions to levels as small as arterioles. Ex vivo rat hearts were prepared and coronary arteries were retrogradely perfused by indocyanine green (ICG). Video angiography was employed to assess blood flow and plot time-dependent fluorescence intensity curve (TIC). Quantitation of blood flow was performed by calculating either the gradient of TIC or area under curve. The correlation between blood flow and each calculated parameters was assessed and used to evaluate the quality of flow. RESULTS:High-resolution images of flow in coronary arteries were obtained as precise as 62 µm vessel diameter, by our custom-made ICG angiography system. The gradient of TIC was 3.4-6.3 s, while the area under curve indicated 712-1282 s values which ultimately gained correlation coefficients of 0.9938 and 0.9951 with relative blood flow, respectively. CONCLUSION:The present ICG angiography system may facilitate evaluation of blood flow in animal studies of myocardial infarction and coronary artery grafts intraoperatively.
10.1186/s12880-021-00562-y
Targeted Near-Infrared Fluorescence Imaging of Atherosclerosis: Clinical and Intracoronary Evaluation of Indocyanine Green.
Verjans Johan W,Osborn Eric A,Ughi Giovanni J,Calfon Press Marcella A,Hamidi Ehsan,Antoniadis Antonios P,Papafaklis Michail I,Conrad Mark F,Libby Peter,Stone Peter H,Cambria Richard P,Tearney Guillermo J,Jaffer Farouc A
JACC. Cardiovascular imaging
OBJECTIVES:This study sought to determine whether indocyanine green (ICG)-enhanced near-infrared fluorescence (NIRF) imaging can illuminate high-risk histologic plaque features of human carotid atherosclerosis, and in coronary atheroma of living swine, using intravascular NIRF-optical coherence tomography (OCT) imaging. BACKGROUND:New translatable imaging approaches are needed to identify high-risk biological signatures of atheroma. ICG is a U.S. Food and Drug Administration-approved NIRF imaging agent that experimentally targets plaque macrophages and lipid in areas of enhanced endothelial permeability. However, it is unknown whether ICG can target atheroma in patients. METHODS:Eight patients were enrolled in the BRIGHT-CEA (Indocyanine Green Fluorescence Uptake in Human Carotid Artery Plaque) trial. Five patients were injected intravenously with ICG 99 ± 25 min before clinically indicated carotid endarterectomy. Three saline-injected endarterectomy patients served as control subjects. Excised plaques underwent analysis by intravascular NIRF-OCT, reflectance imaging, microscopy, and histopathology. Next, following ICG intravenous injection, in vivo intracoronary NIRF-OCT and intravascular ultrasound imaged 3 atheroma-bearing coronary arteries of a diabetic, cholesterol-fed swine. RESULTS:ICG was well tolerated; no adverse clinical events occurred up to 30 days post-injection. Multimodal NIRF imaging including intravascular NIRF-OCT revealed that ICG accumulated in all endarterectomy specimens. Plaques from saline-injected control patients exhibited minimal NIRF signal. In the swine experiment, intracoronary NIRF-OCT identified ICG uptake in all intravascular ultrasound-identified plaques in vivo. On detailed microscopic evaluation, ICG localized to plaque areas exhibiting impaired endothelial integrity, including disrupted fibrous caps, and within areas of neovascularization. Within human plaque areas of endothelial abnormality, ICG was spatially related to localized zones of plaque macrophages and lipid, and, notably, intraplaque hemorrhage. CONCLUSIONS:This study demonstrates that ICG targets human plaques exhibiting endothelial abnormalities and provides new insights into its targeting mechanisms in clinical and experimental atheroma. Intracoronary NIRF-OCT of ICG may offer a novel, clinically translatable approach to image pathobiological aspects of coronary atherosclerosis. (Indocyanine Green Fluorescence Uptake in Human Carotid Artery Plaque [BRIGHT-CEA]; NCT01873716).
10.1016/j.jcmg.2016.01.034
Indocyanine green angiography for intra-operative assessment in vascular surgery.
Yamamoto M,Orihashi K,Nishimori H,Wariishi S,Fukutomi T,Kondo N,Kihara K,Sato T,Sasaguri S
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery
OBJECTIVES:Indocyanine green (ICG) angiography is used for the intra-operative assessment of the graft vessel in coronary artery bypass grafting to enable immediate revision if necessary. We report the feasibility and implications of an ICG colour imaging system, HyperEye Medical System (HEMS), in surgeries for arteriosclerosis obliterans (ASO) and abdominal aortic aneurysm (AAA) which carry risk of mesenteric ischaemia. METHODS:HEMS ICG angiography was used for the intra-operative assessment of 12 ASO patients and 10 AAA patients. RESULTS:In the ASO patients, HEMS angiography enabled visualisation of the graft and native artery. The fluorescent lucent region in the artery distal to the anastomosis was shown in 1 of 12 ASO patients. There was a 3-s time lag in the increase of intensity between the proximal artery and distal stenotic region. In AAA patients, HEMS angiography clearly showed the perfusion in the mesenteric arteries and intestinal wall as opaque. One AAA patient had segmental ischaemia due to thromboembolism and another one had diffuse ischaemia due to systemic malperfusion. The ischaemic region of the intestine was visualised as a fluorescent lucent area by HEMS angiography. CONCLUSION:HEMS angiography can accurately assess peripheral arterial perfusion in surgical cases with ASO and AAA.
10.1016/j.ejvs.2011.12.030
Intraoperative quality control in vascular surgery.
Wipper S,Detter C,Lohrenz C,Debus E S
The Journal of cardiovascular surgery
Since graft patency is the predominant predictor of long-term survival after vascular surgery, intraoperative graft patency control is of major importance for improving quality assurance. Intraoperative quality control is of major importance to obtain good short- and longterm results and to eliminate the need for reoperation. Currently there is no standardized approach and intraoperative quality control is not performed routinely by most surgeons. The most commonly used intraoperative assessment techniques include arteriography, duplex ultrasonography, angioscopy and transit-time flow measurement (TTFM). Fluorescent angiography (FA) using the dye indocyanine green (ICG) is a novel noninvasive technology for intraoperative visualization and documentation of vessels, bypass grafts, and perfusion with an infrared sensitive imaging device, so far validated for quality control in coronary bypass surgery. FA and TTFM are methods for quantitative assessment of blood flow measurement, which are currently exclusively used as intraoperative quality control in cardiac bypass surgery. Up to now, there are no experiences published for peripheral vascular reconstructions. However, transposition and implementation of these techniques seem to be valuable and useful. Therefore further studies for intraoperative quality control in vascular surgery are necessary.
Intraoperative Coronary Artery Imaging for Planning.
Feins Eric N,Si Ming-Sing,Baird Christopher W,Emani Sitaram M
Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual
A clear understanding of coronary anatomy is critical in congenital heart surgery, especially when a ventriculotomy is planned, as in right ventricular outflow tract reconstructions and biventricular repairs. Typically, major epicardial coronary arteries are easily identified during first-time operations. However, in reoperative surgery, epicardial adhesions can obscure coronary vessels making their identification challenging. This paper describes the application of intraoperative fluorescence imaging in congenital heart surgery to obtain real-time coronary artery visualization for operative planning in order to avoid coronary injury. The fluorescence imaging utilizes indocyanine green (ICG). ICG is diluted to 0.28 mg/mL, and 0.1-1.0 mL of ICG solution is delivered via the cardioplegia cannula into the coronaries. A handheld imaging probe illuminates the field with near-infrared laser light, which excites ICG fluorescence. The fluorescence is captured by a camera, and the signal is transmitted to a monitor for real-time viewing. The imaging probe shows the precise coronary anatomy, enabling identification of the optimal ventriculotomy site. Intraoperative fluorescence imaging is a safe and effective technique for characterizing coronary anatomy. This technique enhances procedural planning and helps minimize the risk of coronary injury during reoperative congenital heart surgery.
10.1053/j.pcsu.2020.02.001
Real-time vessel navigation using indocyanine green fluorescence during robotic-assisted gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery.
Asian journal of endoscopic surgery
Injury to the right gastroepiploic artery (RGEA) graft during gastrectomy after coronary artery bypass grafting (CABG) can cause critical coronary failure. A man in his 60s with advanced gastric cancer and a history of CABG was admitted to our hospital. His cardiac blood flow was dependent on RGEA, and a gastrectomy with RGEA preservation was necessary. Robot-assisted distal gastrectomy with real-time vessel navigation using indocyanine green (ICG) fluorescence imaging and Da Vinci Firefly technology was planned. Intraperitoneal observation revealed severe adhesions around the graft. Two milliliters ICG (2.5 mg/mL) was injected intravenously, and RGEA was visualized. An RGEA-preserving robot-assisted distal gastrectomy was successfully performed. The operation time was 279 minutes, and the blood loss was 5 mL. The postoperative course was good and there were no complications.
10.1111/ases.13161