Quantitative Assessment of Free Flap Viability with CEUS Using an Integrated Perfusion Software

Abstract

Purpose: New treatment strategies in oncology and trauma surgery lead to an increasing demand for soft tissue reconstruction with free tissue transfer. In previous studies, CEUS was proven to detect early flap failure. The aim of this study was to detect and quantify vascular disturbances after free flap transplantation using a fast integrated perfusion software tool.

Material and Methods: From 2011 to 2013, 33 patients were examined by one experienced radiologist using CEUS after a bolus injection of 1–2.4 ml of SonoVue^®. Flap perfusion was analysed qualitatively regarding contrast defects or delayed wash-in. Additionally, an integrated semi-quantitative analysis using time-intensity curve analysis (TIC) was performed. TIC analysis of the transplant was conducted on a centimetre-by-centimetre basis up to a penetration depth of 4 cm. The 2 perfusion parameters “Time to PEAK” and “Area under the Curve” were compared in patients without complications vs. patients with minor complications or complete flap loss to figure out significant differences. TtoPk is given in seconds (s) and Area is given in relative units (rU)

Results: A regular postoperative process was observed in 26 (79%) patients. In contrast, 5 (15%) patients with partial superficial flap necrosis, 1 patient (3%) with complete flap loss and 1 patient (3%) with haematoma were observed. TtoPk revealed no significant differences, whereas Area revealed significantly lower perfusion values in the corresponding areas in patients with complications. The critical threshold for sufficient flap perfusion was set below 150 rU.

Conclusion: In conclusion, CEUS is a mobile and cost-effective opportunity to quantify tissue perfusion and can even be used almost without any restrictions in multi-morbid patients with renal and hepatic failure.

Zusammenfassung

Ziel: Der Bedarf an Weichteilrekonstruktion mit freiem Gewebetransfer ist durch die neuen Behandlungsmöglichkeiten in der Tumorchirurgie und der Trauma Versorgung stark angestiegen. In vorangegangen Experimenten konnte bereits die Sensitivität von CEUS zur postoperativen Lappenperfusionskontrolle bestätigt werden. Ziel dieser Studie war es mithilfe einer integrierten Perfusionssoftware Veränderungen der Durchblutung freier Lappenplastiken zu detektieren und zu quantifizieren.

Material und Methodik: Von 2011 bis 2013 wurden 33 Patienten nach einer Bolus Injektion von 1–2,4 ml SonoVue^® durch einen erfahrenen Radiologen untersucht. Die Lappen-Perfusion wurde qualitativ hinsichtlich eines verzögerten Kontrastmittel Wash-in oder einer Kontrastmittel-Aussparungen und zusätzlich semi-quantitativ mittels einer Geräte integrierten Zeit-Intensität Kurvenanalyse (TIC) analysiert. Die TIC Analyse des Transplantats wurde in 1 cm Schichten bis zu einer maximalen Eindringtiefe von 4 cm durchgeführt. Komplikationslose Verläufe wurden mit Patienten, die keinen regulären postoperativen Verlauf aufwiesen anhand der Perfusionswerte Time to PEAK und Area under the curve verglichen. TtoPk wird in Sekunden (s) und Area in relativen Einheiten (rU) angegeben.

Ergebnisse: Komplikationslose Verläufe wurden in 26 Fällen (79%) beobachtet. In 5 Patienten (15%) zeigte sich eine partielle Lappennekrose, 1 Patient (3%) wies eine komplette Lappennekrose und 1 Patient (3%) ein Lappenhämatom auf. Während der Perusions-Parameter TtoPk keine unterschiedlichen Perfusionswerte beider Gruppen aufwies, zeigten sich beim Perfusionsparameter Area signifikant niedrigere Perfusions-Parameter in der Komplikationsgruppe. Der Grenzwert einer suffizienten Lappendurchblutung konnte auf Werte unter 150 rU festgelegt werden.

Zusammenfassung: CEUS ist eine mobile, kostengünstige Alternative zur Quantifizierung der Gewebedurchblutung und kann beinahe uneingeschränkt bei multi-morbiden Patienten mit eingeschränkter Leber- und Nierenfunktion eingesetzt werden.

Key words

microcirculation - perfusion - free flaps - pedicled flaps - perforator flaps - flap monitoring

Schlüsselwörter

Mikrozirkulation - Perfusion - freie Lappenplastiken - gestielte Lappenplastiken - Perforans-Lappenplastiken - bildgebende Verfahren

• References

• 1 Bruck JC, Buttemeyer R, Grabosch A et al. More arguments in favor of myocutaneous flaps for the treatment of pelvic pressure sores. Ann Plast Surg 1991; 26: 85-88
• 2 Demetri GD, Antonia S, Benjamin RS et al. Soft tissue sarcoma. J Natl Compr Canc Netw 2010; 8: 630-674
• 3 Aksnes LH, Bauer HC, Jebsen NL et al. Limb-sparing surgery preserves more function than amputation: a Scandinavian sarcoma group study of 118 patients. J Bone Joint Surg Br 2008; 90: 786-794
• 4 Smit JM, Zeebregts CJ, Acosta R et al. Advancements in free flap monitoring in the last decade: a critical review. Plast Reconstr Surg 2010; 125: 177-185
• 5 Durnig P, Meier M, Reichert B. Monitoring of free flaps and replantations. Status quo in German-speaking microsurgery units. Handchirurgie, Mikrochirurgie, plastische Chirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse 2008; 40: 392-399
• 6 Talbot SG, Pribaz JJ. First aid for failing flaps. Journal of reconstructive microsurgery 2010; 26: 513-515
• 7 Giunta R, Geisweid A, Lukas B et al. Treatment and outcome of complications after free flap-plasty. Handchirurgie, Mikrochirurgie, plastische Chirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse 2000; 32: 176-180
• 8 Machens HG, Mailander P, Kremer M et al. Techniques for postoperative monitoring of tissue circulation after free microvascular tissue transplantation. Handchirurgie, Mikrochirurgie, plastische Chirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse 1999; 31: 107-112
• 9 Kamolz LP, Schrogendorfer KF, Giovanoli P et al. Continuous free-flap monitoring with tissue-oxygen measurements: experiences of the last years. Handchirurgie, Mikrochirurgie, plastische Chirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie: Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse 2002; 34: 195-200
• 10 Holzle F, Rau A, Loeffelbein DJ et al. Results of monitoring fasciocutaneous, myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases. International journal of oral and maxillofacial surgery 2010; 39: 21-28
• 11 Kamolz LP, Giovanoli P, Haslik W et al. Continuous free-flap monitoring with tissue-oxygen measurements: three-year experience. Journal of reconstructive microsurgery. 2002; 18: 487-491 discussion 92-93
• 12 Piscaglia F, Nolsoe C, Dietrich CF et al. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall Med 2012; 33: 33-59
• 13 Geis S, Prantl L, Dolderer J et al. Postoperative monitoring of local and free flaps with contrast-enhanced ultrasound (CEUS) – analysis of 112 patients. Ultraschall Med 2013; 34: 550-558
• 14 Geis S, Prantl L, Mueller S et al. Quantitative Assessment of Bone Microvascularization After Osteocutaneous Flap Transplantation Using Contrast-Enhanced Ultrasound (CEUS). Ultraschall Med 2013; 34: 272-279
• 15 Geis S, Gehmert S, Lamby P et al. Contrast enhanced ultrasound (CEUS) and time intensity curve (TIC) analysis in compartment syndrome: first results. Clin Hemorheol Microcirc 2012; 50: 1-11
• 16 Geis S, Prantl L, Gehmert S et al. TTP (time to PEAK) and RBV (regional blood volume) as valuable parameters to detect early flap failure. Clin Hemorheol Microcirc 2011; 48: 81-94
• 17 Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases. Plast Reconstr Surg 1999; 104: 97-101
• 18 Quaia E. Assessment of tissue perfusion by contrast-enhanced ultrasound. Eur Radiol 2011; 21: 604-615
• 19 Dietrich CF, Averkiou MA, Correas JM et al. An EFSUMB introduction into Dynamic Contrast-Enhanced Ultrasound (DCE-US) for quantification of tumour perfusion. Ultraschall Med 2012; 33: 344-351
• 20 Tranquart F, Mercier L, Frinking P et al. Perfusion quantification in contrast-enhanced ultrasound (CEUS) – ready for research projects and routine clinical use. Ultraschall Med 2012; 33 (Suppl. 01) S31-S38
• 21 Classen DA, Ward H. Complications in a consecutive series of 250 free flap operations. Ann Plast Surg 2006; 56: 557-561
• 22 Haughey BH, Wilson E, Kluwe L et al. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngology – head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery 2001; 125: 10-17
• 23 Singh B, Cordeiro PG, Santamaria E et al. Factors associated with complications in microvascular reconstruction of head and neck defects. Plast Reconstr Surg 1999; 103: 403-411
• 24 Masoomi H, Clark EG, Paydar KZ et al. Predictive risk factors of free flap thrombosis in breast reconstruction surgery. Microsurgery 2014;
• 25 Khouri RK, Cooley BC, Kunselman AR et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102: 711-721
• 26 Drudi FM, Cantisani V, Gnecchi M et al. Contrast-enhanced ultrasound examination of the breast: a literature review. Ultraschall Med 2012; 33: E1-E7
• 27 Solivetti FM, Elia F, Musicco F et al. Anaphylactic shock induced by sulphur hexafluoride in an individual with no history of heart disease: case report and literature review. Ultraschall Med 2012; 33: 597-598
• 28 Cantisani V, Ricci P, Erturk M et al. Detection of hepatic metastases from colorectal cancer: prospective evaluation of gray scale US versus SonoVue(R) low mechanical index real time-enhanced US as compared with multidetector-CT or Gd-BOPTA-MRI. Ultraschall Med 2010; 31: 500-505
• 29 Seitz K, Bernatik T, Strobel D et al. Contrast-enhanced ultrasound (CEUS) for the characterization of focal liver lesions in clinical practice (DEGUM Multicenter Trial): CEUS vs. MRI – a prospective comparison in 269 patients. Ultraschall Med 2010; 31: 492-499
• 30 Seitz K, Strobel D, Bernatik T et al. Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions – prospective comparison in clinical practice: CEUS vs. CT (DEGUM multicenter trial). Parts of this manuscript were presented at the Ultrasound Dreilandertreffen 2008, Davos. Ultraschall Med 2009; 30: 383-389
• 31 Swartz WM, Jones NF, Cherup L et al. Direct monitoring of microvascular anastomoses with the 20-MHz ultrasonic Doppler probe: an experimental and clinical study. Plast Reconstr Surg 1988; 81: 149-161
• 32 Kind GM, Buntic RF, Buncke GM et al. The effect of an implantable Doppler probe on the salvage of microvascular tissue transplants. Plast Reconstr Surg 1998; 101: 1268-1273 discussion 74-75
• 33 Piscaglia F, Leoni S, Cabibbo G et al. Cost analysis of recall strategies for non-invasive diagnosis of small hepatocellular carcinoma. Digestive and liver disease: official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2010; 42: 729-734
• 34 Sangiovanni A, Manini MA, Iavarone M et al. The diagnostic and economic impact of contrast imaging techniques in the diagnosis of small hepatocellular carcinoma in cirrhosis. Gut 2010; 59: 638-644