Perfusion Assessment with the SPY System after Arterial Venous Reversal for Upper Extremity Ischemia

Abstract

Background: The timing and pattern of reperfusion following arterial- venous reversal (AVR) in patients with terminal ischemia of an upper extremity is not well understood.

Methods: The current case series describes the timing and pattern of reperfusion observed in patients with terminal upper extremity ischemia who underwent AVR and repeated postoperative indocyanine green (ICG) angiography between 2004 and 2009. For all included patients, the SPY Near-Infrared Perfusion Assessment System permitted visualization of ICG-labeled blood flow for 60-second sampling periods at scheduled postoperative time points; outflow and rate and amplitude of inflow were objectively quantified with SPY-Q Analysis Toolkit image analysis software.

Results: The series comprised 6 male patients (mean age, 46 years) who presented with upper extremity ischemia related to hypothenar hammer syndrome (n = 2), embolism with patent foramen ovale (n = 2), atherosclerosis (n = 1), and avulsion amputation of the thumb (n = 1); the patient with the avulsion amputation was diagnosed with thromboangiitis obliterans at the time of replantation. AVR was successful in all 6 patients. In 5 of 6 patients, ICG angiography and SPY-based visualization/quantification showed that venous outflow and arterial inflow gradually normalized (versus unaffected digits) between postoperative days (PODs) 0 and 3 and was maintained at long-term follow-up (≥3 months); for the patient who underwent thumb replantation, perfusion normalized between POD 3 and month 5 follow-up.

Conclusions: AVR effectively reestablished blood flow in patients with terminal upper extremity ischemia. ICG angiography with SPY technology revealed that, in most cases, kinetic curves, timing, and patterns of perfusion gradually normalized over several PODs.

Conflict of interest statement

Disclosure: Editorial support for this article was provided by Peloton Advantage, LLC, Parsippany, N.J., and funded by LifeCell Corp., Branchburg, N.J. The opinions expressed in this article are those of the author. The author received no honoraria/fee for service or other form of financial support related to the development of this article. The article processing charge was paid for by LifeCell Corp.

Figures

Fig. 1.

Diagrammatic representation of an AVR. Note that the ulnar artery is occluded from the forearm to the distribution of the digital arteries at the fourth and fifth digits. The dotted line illustrates the region of poor arterial flow (A). Noncontributory veins or those whose flow are outside of the region requiring arterialization are ligated (B). A valvulotome is used to disrupt valves and allow retrograde flow (C). The dorsal vein is then transposed and repaired to a healthy artery proximal to the occlusion arterializing the venous system and providing flow to the ischemic capillary beds (D).

Fig. 2.

Average kinetic curves for ICG detected at the control and treatment fingertips at POD 0, POD 1, POD 3, and long-term follow-up. Broken line triangles represent the slope or rate of inflow (orange) and outflow (pink) for the control kinetic curve. The average kinetic curves of the treatment fingertips illustrate arterial insufficiency or lack of inflow at POD 0. This is followed by progressive improvement in the rate of arterial inflow at POD 1 and 3 with normalization approximating the control on long-term follow-up. Venous insufficiency or lack of outflow marks POD 1 but begins to resolve in 5 of 6 patients by POD 3. The increased rate of outflow noted at POD 3 is associated with the trend toward improved inflow rate and amplitude. Rate of inflow, outflow, and amplitude normalize by 3 months.

Fig. 3.

Case 1. Left fifth cyanotic finger (A) and angiogram revealing significant ulnar artery and deep and superficial arch occlusion without sufficient compensation from the superficial arch from the radial artery to support the fifth digit (B). The fourth digit is perfused by flow from the radial artery to the residual superficial arch. There is no target for potential bypass grafting.

Fig. 4.

Case 1. ICG fluorescent angiograms illustrating the 60-second perfusion of the hand prearterialization (A), 30 seconds postarterialization (showing improvement in the level of inflow; B), and 60 seconds postarterialization (showing continued improvement but persistent arterial insufficiency at the fingertip at POD 0; C). Note the persistent fifth finger arterial insufficiency at 60 seconds.

Fig. 5.

Case 1. Three months after AVR, no signs or symptoms of arterial or venous insufficiency have returned.

Video Graphic 1.

See video, Supplemental Digital Content 1. Case 1: Video shows arterial insufficiency resolved at POD 1. ICG fluorescence now reaches the fifth fingertip at approximately 15 seconds and peaks at 45 seconds. This video is available in the “Related Videos” section of the Full-Text article on PRSGo.com or available at http://links.lww.com/PRSGO/A42.

Video Graphic 2.

See video, Supplemental Digital Content 2. Case 1: Video shows continued increase in the rate and amplitude of inflow and peak amplitude similar to the unaffected control area. These trends persisted at long-term follow-up, with normalization of rate of inflow and rate and amplitude of outflow, with amplitude approximating control digit values. This video is available in the “Related Videos” section of the Full-Text article on PRSGo.com or available at http://links.lww.com/PRSGO/A43.

Fig. 6.

Case 2. Hematoxylin and eosin stain of a representative histological section of the digital arteries revealing fibroluminal stenosis with central vascular recanalization consistent with late thromboangiitis obliterans.

Fig. 7.

Case 2. Two weeks after replantation by AVR, the thumb has complete soft-tissue survival, good color, and resolution of swelling.

Fig. 8.

Case 2. Kinetic curves obtained 5 months after AVR for the control index finger (A) and the thumb (B) replanted by AVR. Yellow boxes define the study area for each digit. Note the comparable inflow and outflow rates. Real-time visual appreciation of the pattern and timing of the inflow and outflow circuits not only illustrates the normalization of flow kinetics in the arterialized thumb but also demonstrates the utility of the SPY technology.

Video Graphic 3.

See video, Supplemental Digital Content 3. Case 2: Video shows that Doppler evaluation of the arterialized dorsal vein revealed patency. This video is available in the “Related Videos” section of the Full-Text article on PRSGo.com or available at http://links.lww.com/PRSGO/A44.

Video Graphic 4.

See video, Supplemental Digital Content 4. Case 2: Video shows similar peak amplitudes and simultaneous rates of arterial inflow and venous outflow consistent with normalization of the kinetic curves and maturation of the vascular circuits. This video is available in the “Related Videos” section of the Full-Text article on PRSGo.com or available at http://links.lww.com/PRSGO/A45.