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Table 1 Methods for evaluation of tissue perfusion, by setting

From: Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use

Method/Setting use Advantages Limitations Sources
ICG intraoperative laser angiography* →Visualize perforator perfusion zone in real time →Visualizes perforator perfusion zones →Requires administration of contrast media Phillips et al., 2012 [12]
→Confirm patency of arterial and venous anastomoses →No exposure to ionizing radiation →Does not identify precise vessel location or course through muscle and fascia when lipodystrophy exists Francisco et al., 2010 [52]
→Confirm perfusion of tissue prior to incision, after elevation of flaps, and prior to final closure →Strong safety profile and short half-life of ICG Komorowska-Timek & Gurtner, 2010 [1]
→Permits re-evaluation during same surgery Murray et al., 2010 [16]
Tamburrino et al., 2010 [17]
Newman et al., 2009 [11]
Jones et al., 2009 [14]
Azuma et al., 2008 [18]
Prantl et al., 2008 [19]
De Lorenzi et al., 2005 [20]
Mothes et al., 2004 [8]
Holm, Tegeler, et al., 2002 [21]
Holm, Mayr, et al., 2002 [22]
Still et al. 1999 [23]
Doppler – handheld →Identification of perforator vessel location →Easy to use →Provides information on discrete area below probe Yu & Youssef, 2006 [29]
→Widely available →Requires direct skin contact
→Inexpensive →Does not identify perforator perfusion zone
→Provides confirmatory information →Provides limited data and accuracy for flap design,
→especially in heavier patients
→Difficult to quantify
→Does not stratify perforators
Fluorescein →Visualization of perforator perfusion zone →Visualization of perforator perfusion zone →Single use only Phillips et al., 2012 [12]
→Widely available →No venous information Losken et al., 2008 [51]
→Long delay time
→Toxicity concerns
→Use of ultraviolet Woods lamp
→High sensitivity, low specificity
Clinical judgment →Estimation of tissue perfusion and flap viability →Familiarity, ease of use →Poor reliability when used alone Phillips et al., 2012 [12]
→Dependent on surgeon experience Mothes et al., 2004 [8]
→Inferior to imaging modalities for estimation of flap survival Olivier et al., 2003 [9]
Holm, Tegeler et al., 2002 [21]
Doppler Ultrasound (duplex, color, power) →Identification of perforator vessel location →No exposure to ionizing radiation or contrast media →Inferior to CT angiography for identification of vessel location Rozen et al., 2008 [24]
→Estimate of vessel flow rate →Provides estimation of perforator location, caliber, and flow →Considered operator-dependent Khalid et al., 2006 [25]
→Does not identify perforator perfusion zone Giunta et al., 2000 [26]
→High rate of false-positive findings reported Hallock, 2003 [27]
Blondeel et al., 1998 [28]
Laser Doppler flowmetry →Identification of vessel location and tissue perfusion →No exposure to ionizing radiation or contrast media →May underestimate flap survival Schlosser et al., 2010 [30]
→Identifies ischemia in flaps →Poor ability to detect perforator vessels Holzle et al., 2006 [31]
→Sensitive to small movements Heller et al., 2001 [32]
Heden et al.1986 [33]
CT angiography →Visualization of location and course of vessels through muscles and fascia →Accurate detection of anatomic location and course of vessels →Does not assess vascular flow Ghattaura et al.,2010 [34]
→Greater accuracy than Doppler ultrasound →Does not show perforator perfusion zones Smit et al., 2009 [35]
→Potential for reduced surgical time →May have poor resolution for vessel caliber; Rozen et al., 2008 [24]
→Exposure to ionizing radiation Cina et al., 2010 [36]
→Potential toxicity of contrast media Scott et al., 2010 [37]
Phillips et al., 2008 [38]
Rosson et al., 2007 [39]
Masia et al., 2006 [40]
MR angiography →Visualization of location and course of vessels through muscles and fascia →Greater accuracy than Doppler ultrasound →Does not assess vascular flow Schaverien et al., 2011 [42]
→Detection of small caliber vessels →Does not show perforator perfusion zones Newman et al., 2010 [43]
→Potential for reduced surgical time →Less spatial resolution compared to CT angiography Greenspun et al., 2010 [45]
→No exposure to ionizing →Potential toxicity of contrast Chernyak et al., 2009 [41]
→radiation →media Neil-Dwyer et al., 2009 [44]
Rozen et al., 2009 [46]
Transcutaneous oxygen monitoring** →Assessment of tissue oxygen saturation →Useful for postoperative monitoring →Limited to discrete 1 cm2 area under probe Steele, 2011 [47]
   →Accurately detects vascular compromise →Numeric output only Lin et al., 2011 [48]
   →Improves flap salvage rate in postoperative setting →Used primarily for postoperative monitoring Keller, 2009 [49]
    →Time consuming, cumbersome for intraoperative mapping Keller, 2007 [50]
  1. * Includes evidence from use of ICG intraoperative perfusion assessment devices available outside the United States.
  2. ** Used intraoperatively by some surgeons.
  3. CT: computed tomography.
  4. MR: magnetic resonance.
  5. ICG: indocyanine green.