Clinical application effects of indocyanine green angiography combined with color Doppler ultrasound in perforator localization of anterolateral thigh perforator flaps
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摘要:
目的 探讨吲哚菁绿血管造影（ICGA）联合彩色多普勒超声（CDU）在股前外侧穿支皮瓣穿支定位中的临床应用效果。 方法 该研究为回顾性观察性研究。2024年1—8月,苏州瑞华骨科医院手外科收治21例、创面修复科收治35例符合入选标准的采用CDU和ICGA辅助设计的股前外侧穿支皮瓣修复四肢皮肤软组织缺损的患者,其中男44例、女12例,年龄16~71岁,清创后创面面积为7.0 cm×5.5 cm~40.0 cm×10.0 cm。术前均采用CDU和ICGA定位股前外侧穿支皮瓣穿支,皮瓣切取面积为8.0 cm×6.0 cm~40.5 cm×11.0 cm。将皮瓣供区创面直接缝合或移植对侧大腿全厚皮修复。记录术前CDU、ICGA定位到的穿支数量,术中探查到的穿支数量、来源、类型、口径,皮瓣厚度。比对术前CDU、ICGA定位结果与术中探查结果一致性,测量术前CDU、ICGA定位到的穿支位置分别与术中探查到的穿支位置的误差距离。以术中探查到穿支为金标准,计算术前CDU和ICGA定位穿支的敏感度、特异度、阳性预测值、阴性预测值、准确性。筛选56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者CDU、ICGA定位结果与术中探查结果一致性的独立影响因素。 结果 术前CDU定位到131条穿支,ICGA定位到130条穿支。术中探查到132条穿支,其中64条穿支来自斜支,49条穿支来自降支,9条穿支来自横支,10条穿支来自前支；46条穿支为肌间隔穿支,86条穿支为肌皮穿支；穿支口径为（0.72±0.21）mm。皮瓣厚度为（1.5±0.6）cm。术前CDU定位结果与术中探查结果一致性和ICGA定位结果与术中探查结果一致性比较,差异无统计学意义（P>0.05）。术前CDU定位到的穿支位置与术中探查到的穿支位置的误差距离和ICGA定位到的穿支位置与术中探查到的穿支位置的误差距离比较,差异无统计学意义（P>0.05）。术前ICGA、CDU定位穿支的敏感度、特异度、阳性预测值、阴性预测值、准确性分别为92.42%、92.00%、93.85%、90.20%、92.24%,84.09%、80.00%、84.73%、79.21%、82.33%。皮瓣厚度为56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者术前ICGA穿支定位结果与术中探查结果一致性的影响因素（比值比为0.20,95%置信区间为0.06~0.66,P<0.05）,穿支类型为56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者术前CDU穿支定位结果与术中探查结果一致性的影响因素（比值比为3.07,95%置信区间为1.11~8.46,P<0.05）。调整了性别、年龄、体重指数、穿支类型、穿支口径后,皮瓣厚度为56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者术前ICGA穿支定位结果与术中探查结果一致性的独立影响因素（比值比为0.15,95%置信区间为0.03~0.73,P<0.05）。调整了性别、年龄、体重指数、皮瓣厚度、穿支口径后,穿支类型为56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者术前CDU穿支定位结果与术中探查结果一致性的独立影响因素（比值比为4.25,95%置信区间为1.39~12.98,P<0.05）。 结论 在临床股前外侧穿支皮瓣穿支定位中联合应用ICGA和CDU可优势互补提高定位精度,其中皮瓣厚度显著影响ICGA定位准确性,穿支类型显著影响CDU定位准确性。 Abstract:Objective To investigate the clinical application effects of indocyanine green angiography (ICGA) combined with color Doppler ultrasound (CDU) in perforator localization of anterolateral thigh perforator flaps. Methods This study was a retrospective observational study. From January to August 2024, the Department of Hand Surgery admitted 21 patients and the Department of Wound Repair Surgery of Suzhou Ruihua Orthopedic Hospital admitted 35 patients that met the inclusion criteria. These patients underwent surgical repair of the extremity skin and soft tissue defects using anterolateral thigh perforator flaps designed under the assistance of CDU and ICGA. Among them, there were 44 males and 12 females, aged 16 to 71 years. After debridement, the wound area ranged from 7.0 cm×5.5 cm to 40.0 cm×10.0 cm. Before surgery, CDU and ICGA were used to locate the perforators of anterolateral thigh perforator flap. The area of harvested flap ranged from 8.0 cm×6.0 cm to 40.5 cm×11.0 cm. The wounds in flap donor sites were closed directly or covered with the full-thickness skin graft from the contralateral thigh. The number of perforators located by preoperative CDU or ICGA, and the number, origin, type, and caliber of perforators in intraoperative exploration, and flap thickness were recorded. The consistency between preoperative CDU or ICGA localization results and intraoperative exploration findings was assessed. The error distances between preoperative CDU or ICGA localization and intraoperative exploration of perforator, respectively, were measured. Using intraoperative exploration of perforator as the gold standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of preoperative CDU and ICGA for perforator localization were calculated. The independent influencing factor for the consistency between CDU or ICGA localization results and intraoperative exploration findings of 56 patients who had anterolateral thigh perforator flap designed under the assistance of CDU and ICGA were screened. Results A total of 131 perforators were located by CDU and 130 perforators were located by ICGA preoperatively. Intraoperatively, 132 perforators were explored, including 64 perforators from the oblique branch, 49 perforators from the descending branch, 9 perforators from the transverse branch, and 10 perforators from the anterior branch. Among them, 46 perforators were septocutaneous perforators and 86 perforators were musculocutaneous perforators, with a mean caliber of (0.72±0.21) mm. The flap thickness was (1.5±0.6) cm. There was no statistically significant difference in the consistency between preoperative CDU localization results and intraoperative exploration findings and ICGA localization results and intraoperative exploration findings (P>0.05). There was no statistically significant difference in the error distance between preoperative CDU localization and intraoperative exploration of perforator and preoperative ICGA localization and intraoperative exploration of perforator (P>0.05). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ICGA and CDU in locating perforators were 92.42%, 92.00%, 93.85%, 90.20%, and 92.24%, 84.09%, 80.00%, 84.73%, 79.21%, and 82.33%, respectively. Flap thickness was an influencing factor for the consistency between preoperative ICGA localization results and intraoperative exploration findings of 56 patients who had anterolateral thigh perforator flap designed under the assistance of CDU and ICGA (with odds ratio of 0.20, 95% confidence interval of 0.06-0.66, P<0.05). Perforator type was an influencing factor for the consistency between preoperative CDU localization results and intraoperative exploration findings of 56 patients who had anterolateral thigh perforator flap designed under the assistance of CDU and ICGA (with odds ratio of 3.07, 95% confidence interval of 1.11-8.46, P<0.05). After adjusting for sex, age, body mass index, perforator type, and perforator caliber, flap thickness was an independent influencing factor for the consistency between preoperative ICGA localization results and intraoperative exploration findings of 56 patients who had anterolateral thigh perforator flap designed under the assistance of CDU and ICGA (with odds ratio of 0.15, 95% confidence interval of 0.03-0.73, P<0.05). After adjusting for sex, age, body mass index, flap thickness, and perforator caliber, perforator type was an independent influencing factor for the consistency between preoperative CDU localization results and intraoperative exploration findings of 56 patients who had anterolateral thigh perforator flap designed under the assistance of CDU and ICGA (with odds ratio of 4.25, 95% confidence interval of 1.39-12.98, P<0.05). Conclusions The combined application of ICGA and CDU for perforator localization in anterolateral thigh perforator flaps in clinic can complete each other to improve the accuracy of localization. Flap thickness significantly affects the accuracy of ICGA localization, while perforator type significantly affects the accuracy of CDU localization. -
参考文献
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图 1 联合应用ICGA和CDU辅助设计的游离股前外侧穿支皮瓣修复患者左足创面的效果。1A.清创后可见左足背软组织缺损伴骨骼和肌腱外露；1B.术前CDU定位股前外侧穿支皮瓣穿支；1C.根据CDU定位穿支结果预设计皮瓣；1D.ICGA定位股前外侧穿支皮瓣穿支,3个高亮点从近端向远端依次显影,呈条带状分布,初步判断为下行穿支且3条穿支为同一来源；1E.根据CDU和ICGA定位穿支结果调整皮瓣设计；1F.术中探查到ICGA定位的3条穿支,3条穿支为下行穿支且均来自斜支；1G.术后12 d,供区创面愈合良好；1H.术后12 d,皮瓣顺利成活
注：ICGA为吲哚菁绿血管造影,CDU为彩色多普勒超声
Table 1. 影响56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者ICGA穿支定位结果与术中探查结果一致性的单因素logistic回归分析结果
自变量 比值比 95%置信区间 P值 女性 0.51 0.12~2.14 0.360 年龄（岁） 1.02 0.98~1.06 0.324 体重指数（kg/m2） 0.98 0.81~1.18 0.832 肌间隔穿支 1.14 0.28~4.64 0.857 皮瓣厚度（cm） 0.20 0.06~0.66 0.008 穿支口径（mm） 41.11 0.93~1 807.74 0.054 注：CDU为彩色多普勒超声,ICGA为吲哚菁绿血管造影；性别中男性为参照,穿支类型中肌皮穿支为参照 
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Table 2. 影响56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者CDU穿支定位结果与术中探查结果一致性的单因素logistic回归分析结果
自变量 比值比 95%置信区间 P值 女性 0.79 0.24~2.64 0.703 年龄（岁） 1.02 0.99~1.06 0.172 体重指数（kg/m2） 1.03 0.90~1.19 0.643 肌间隔穿支 3.07 1.11~8.46 0.030 皮瓣厚度（cm） 0.64 0.28~1.48 0.297 穿支口径（mm） 3.04 0.25~36.48 0.381 注：CDU为彩色多普勒超声,ICGA为吲哚菁绿血管造影；性别中男性为参照,穿支类型中肌皮穿支为参照
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Table 3. 影响56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者ICGA穿支定位结果与术中探查结果一致性的多因素logistic回归分析结果
自变量 模型1 模型2 模型3 比值比 95%置信区间 P值 比值比 95%置信区间 P值 比值比 95%置信区间 P值 皮瓣厚度 0.20 0.06~0.66 0.008 0.15 0.03~0.70 0.015 0.15 0.03~0.73 0.019 注：CDU为彩色多普勒超声,ICGA为吲哚菁绿血管造影；模型1未调整协变量；模型2调整了性别、年龄、体重指数；模型3调整了性别、年龄、体重指数、穿支类型、穿支口径
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Table 4. 影响56例采用CDU和ICGA辅助设计股前外侧穿支皮瓣患者CDU穿支定位结果与术中探查结果一致性的多因素logistic回归分析结果
自变量 模型1 模型2 模型3 比值比 95%置信区间 P值 比值比 95%置信区间 P值 比值比 95%置信区间 P值 肌间隔穿支 3.07 1.11~8.46 0.030 3.96 1.34~11.66 0.013 4.25 1.39~12.98 0.011 注：CDU为彩色多普勒超声,ICGA为吲哚菁绿血管造影；穿支类型中肌皮穿支为参照；模型1未调整协变量,模型2调整了性别、年龄、体重指数,模型3调整了性别、年龄、体重指数、皮瓣厚度、穿支口径
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