Acta Neurochirurgica

, Volume 154, Issue 1, pp 67–73 | Cite as

An innovative method for detecting surgical errors using indocyanine green angiography during carotid endarterectomy: a preliminary investigation

  • Chang-Hyun Lee
  • Young Sub Jung
  • Hee-Jin Yang
  • Young-Je Son
  • Sang Hyung Lee
Clinical Article

Abstract

Background

Carotid endarterectomy (CEA) is the most effective treatment method of carotid stenosis or occlusion. Surgeons typically check the blood flow in each vessel using Duplex Doppler ultrasonography or radiocontrast angiography in order to prevent postoperative complications. Embolic cerebral infarction on the ipsilateral side has been reported in 4–7% of patients undergoing CEA despite a tolerable blood flow reported by Duplex ultrasonography. This study was designed to evaluate a new intraoperative method for detecting technical errors during CEA using indocyanine green (ICG) angiography.

Methods

Six consecutive patients with severe carotid stenosis or occlusion underwent CEA. Both ICG angiography and Doppler ultrasonography were performed before the carotid arterial incision and after the carotid arterial suture. After injecting ICG dye via an intravenous route, the internal surface, atheroma, and flow defect were visualized with a microscope.

Results

In ICG angiography, stenotic lesions could be identified as regions of relatively dark signal intensity. Magnified real-time images could be created using a microscope with an infrared filter, including three-dimensional images and detailed images of the inner lumen. These images could then be compared with the results of Doppler ultrasonography. In the six cases assessed by both ICG angiography and Doppler ultrasonography, all Doppler results were acceptable. However, one patient underwent revision surgery because a fluttering atheroma was detected by ICG angiography. ICG angiography could assume the extent of severe stenotic area. ICG angiography could also detect mobile lesions such as a fluttering atheroma.

Conclusions

Intraoperative ICG angiography before arteriotomy is useful to determine the precise stenotic area and the shape of the associated plaque. ICG angiography after an arteriotomy site is sutured is also useful for detecting residual stenosis or fluttering atheroma. ICG angiography could be an alternative method to Doppler ultrasonography for ensuring a complete and successful operation and preventing complications.

Keywords

Indocyanine green Carotid stenosis Carotid endarterectomy Doppler Angiography 

Supplementary material

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References

  1. 1.
    Barnes RW, Nix ML, Wingo JP, Nichols BT (1986) Recurrent versus residual carotid stenosis. Incidence detected by Doppler ultrasound. Ann Surg 203:652–660PubMedCrossRefGoogle Scholar
  2. 2.
    Blaisdell FW, Lim R Jr, Hall AD (1967) Technical result of carotid endarterectomy. Arteriographic assessment. Am J Surg 114:239–246PubMedCrossRefGoogle Scholar
  3. 3.
    Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF (2010) Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 363:11–23PubMedCrossRefGoogle Scholar
  4. 4.
    Fox IJ, Wood EH (1960) Indocyanine green: physical and physiologic properties. Proc Staff Meet Mayo Clin 35:732–744PubMedGoogle Scholar
  5. 5.
    Garski TR, Staller BJ, Hepner G, Banka VS, Finney RA Jr (1978) Adverse reactions after administration of indocyanine green. JAMA 240:635PubMedCrossRefGoogle Scholar
  6. 6.
    Levi CR, O'Malley HM, Fell G, Roberts AK, Hoare MC, Royle JP, Chan A, Beiles BC, Chambers BR, Bladin CF, Donnan GA (1997) Transcranial Doppler detected cerebral microembolism following carotid endarterectomy. High microembolic signal loads predict postoperative cerebral ischaemia. Brain 120(Pt 4):621–629PubMedCrossRefGoogle Scholar
  7. 7.
    Linfante I, Hirsch JA, Selim M, Schlaug G, Caplan LR, Reddy AS (2004) Safety of latest-generation self-expanding stents in patients with NASCET-ineligible severe symptomatic extracranial internal carotid artery stenosis. Arch Neurol 61:39–43PubMedCrossRefGoogle Scholar
  8. 8.
    Mays BW, Towne JB, Seabrook GR, Cambria RA, Jean-Claude J (2000) Intraoperative carotid evaluation. Arch Surg 135:525–528, discussion 528–529PubMedCrossRefGoogle Scholar
  9. 9.
    Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO (1999) Ischemic stroke subtypes: a population-based study of incidence and risk factors. Stroke 30:2513–2516PubMedCrossRefGoogle Scholar
  10. 10.
    Rockman CB, Halm EA (2007) Intraoperative imaging: does it really improve perioperative outcomes of carotid endarterectomy? Semin Vasc Surg 20:236–243PubMedCrossRefGoogle Scholar
  11. 11.
    Roh HG, Byun HS, Ryoo JW, Na DG, Moon WJ, Lee BB, Kim DI (2005) Prospective analysis of cerebral infarction after carotid endarterectomy and carotid artery stent placement by using diffusion-weighted imaging. AJNR Am J Neuroradiol 26:376–384PubMedGoogle Scholar
  12. 12.
    Silver FL, Mackey A, Clark WM, Brooks W, Timaran CH, Chiu D, Goldstein LB, Meschia JF, Ferguson RD, Moore WS, Howard G, Brott TG (2011) Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 42:675–680PubMedCrossRefGoogle Scholar
  13. 13.
    Winkler GA, Calligaro KD, Kolakowski S, Doerr KJ, McAffee-Bennett S, Muller K, Dougherty MJ (2006) Comparison of intraoperative completion flowmeter versus duplex ultrasonography and contrast arteriography for carotid endarterectomy. Vasc Endovascular Surg 40:482–486PubMedCrossRefGoogle Scholar
  14. 14.
    Zierler RE, Bandyk DF, Thiele BL (1984) Intraoperative assessment of carotid endarterectomy. J Vasc Surg 1:73–83PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Chang-Hyun Lee
    • 1
  • Young Sub Jung
    • 2
    • 3
  • Hee-Jin Yang
    • 2
  • Young-Je Son
    • 2
  • Sang Hyung Lee
    • 2
    • 3
  1. 1.Department of NeurosurgerySeoul National University Bundang HospitalSeongnam cityKorea
  2. 2.Department of Neurosurgery, SMG-SNU Boramae Medical CenterSeoul National University College of MedicineSeoulKorea
  3. 3.Department of NeurosurgerySeoul National University College of MedicineSeoulKorea

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