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Indocyanine green angiography guidance for vascular preservation in skin and nipple sparing mastectomy

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Abstract

Purpose

The skin and/or nipple-sparing approach has become an oncologically sound and desirable choice for women choosing mastectomy. Indocyanine green (ICG) perfusion imaging has been shown to reduce ischemic complications in mastectomy skin flaps. Immediate reconstruction requires a well-vascularized skin flap capable of tolerating full expansion. Identification of the perforating subcutaneous vessels to the skin envelope may allow for better and more consistent blood vessel preservation and flap perfusion.

Methods

The authors conducted an institutional review board-approved prospective study with 41 patients to assess the feasibility of using ICG perfusion imaging to visualize, cutaneously map, and preserve the vessels that supply the skin flap and nipple-areolar complex. For each patient, the number of vessels initially mapped, the number of vessels preserved, the extent to which each vessel was preserved, and the proportion of the flap with adequate perfusion (as defined by the SPY-Q > 20% threshold) was recorded and analyzed.

Results

Vessels were able to be identified and marked in a high majority of patients (90%). There was a moderate linear relationship between the number of vessels marked and the number preserved. Successful mapping of vessels was associated with lower rates of wound breakdown (p = 0.036). Mapping and preserving at least one vessel led to excellent flap perfusion (> 90%). No increase in complications was observed from utilizing ICG angiography preoperatively.

Conclusion

This prospective study using preoperative ICG perfusion mapping demonstrated safety, feasibility, and good prognostic outcomes.

Level of evidence

III.

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Data availability

Data utilized in this manuscript was collected, verified, and analyzed solely by the manuscript authors and is available upon reasonable request from the corresponding author.

Notes

  1. As stated by Diagnostic Green: "a patient with a known allergy to macromolecular iodide/iodine containing compounds will not be at risk of an allergic reaction to ICG where the salt sodium iodide is incorporated." Joanne Renew. (2020, August 25). Indocyanine Green and Iodine/Iodide allergies. Diagnostic Green RoW. https://diagnosticgreen.com/row/news/indocyanine-green-and-iodine-iodide-allergies/

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Acknowledgements

This project was done with the support of the Department of Women’s Oncology, Department of Research, and surgical staff at Women and Infants Hospital of Rhode Island.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Breast Health Center, Department of Women’s Oncology, Women and Infants Hospital of Rhode Island, Providence, RI, USA

    Thor S. Stead, Connie Y. Lu, Abby Geletzke, Elizabeth Butler, Ashley Stuckey, David A. Edmonson & Jennifer S. Gass

  2. The Warren Alpert Medical School of Brown University, Providence, RI, USA

    Thor S. Stead

  3. Portsmouth Regional Hospital, Portsmouth, NH, USA

    Connie Y. Lu

  4. UPMC Pinnacle Health, Lancaster, PA, USA

    Abby Geletzke

  5. AdventHealth Shawnee Mission, Merriam, KS, USA

    Elizabeth Butler

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Contributions

CYL, AG, EB, AS, DE, JG gathered data, TSS and CYL performed data analysis, and TSS, CYL, and JG wrote the main manuscript text. All authors reviewed the manuscript.

Corresponding author

Correspondence to Thor S. Stead.

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Competing interests

Dr. Edmonson - Advisory Board, Impedimed. All other authors report no financial or commercial relationships that have a special interest in this study and received no financial or material support in conducting this work.

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The authors have no conflict of interest to declare.

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Stead, T.S., Lu, C.Y., Geletzke, A. et al. Indocyanine green angiography guidance for vascular preservation in skin and nipple sparing mastectomy. Breast Cancer Res Treat (2024). https://doi.org/10.1007/s10549-024-07326-6

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