Usefullness Of Icg Direct Injection Method Using Spy System
Masao Takahashi1, Keisuke Miyajima1, Hirotaro Sugiyama1, Toshihiro Ishikawa2, Kazuyoshi Hatada2.
1Hiratsuka Kyosai Hospital, Hiratsuka, Japan, 2Odawara Municipal Hospital, Odawara, Japan.
OBJECTIVE: The SPY System is the first commercially available fluorescence angiographic device which allows surgeons to assess the bypassed graft during the surgery. The prototype of SPY System (SP1000) was introduced in 2002. The second generation (SP2000) had been used from 2002 to 2015. And the latest version with color mode (SP3000) was initiated from July 2015. In our institute, 100 % of isolated coronary patients was performed off pump CABG. SPY intraoperative graft validation was routinely done in more than 700 cases. Since May 2016, new technique has been initiated for the free graft.
METHODS: 1. Identification of the target coronary using SPY System. 2. ICG-DIM (Indocyanine Green Direct Injection Method): After distal anastomosis is completed, diluted ICG mixed with heparinized blood is injected directly into the free graft while SPY is recording. 3. Routine SPY imaging: After proximal anastomosis, SPY imaging with natural flow was performed, injecting diluted ICG via central venous line.
RESULTS: 1. Before anastomosis, target coronary artery can be identified using SPY System. It is very helpful especially in totally occluded branches. 2. Just after completion of anastomosis, visual confirmation of the patency of the graft can be obtained. ICG-DIM was very useful, especially when the target artery is very small around 1mm diameter and the operator has concern about the patency of the anastomosis, or when the anastomosis is performed by an inexperienced resident. Four cases could be avoided the sequential bypass grafting, because the neighbor coronary could be stained just after ICG-DIM. 3. All bypass grafts including in-situ one were routinely evaluated using SPY system. All areas of LAD, CX, distal RCA and aortic proximal site could be accessed.
CONCLUSIONS: Using the SPY system, technical error can be avoided intra-operatively while the chest is open. Distal anastomotic patency of the free graft can be convinced using ICG-DIM. It may be useful for surgeon’s training period. ICG-DIM may have the potential to reduce unnecessary sequential bypass grafting.
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