Farbkodierte Duplexsonographie und „Power-Doppler“ in der Perforatorchirurgie – Erhöhung der Patientensicherheit durch effiziente Planung

Zusammenfassung

Einleitung Unterschiedlichste Techniken mit spezifischen Vor- und Nachteilen kommen zur Lokalisation der Gefäße in der Perforatorchirurgie zum Einsatz. Stabdoppler sind handlich aber ungenau bei der exakten Perforatorlokalisation. Die Angio-CT ist teuer, zeitaufwendig, strahlenintensiv und invasiv. Die Duplexsonographie dagegen ist eine zuverlässige, einfach einzusetzende und verfügbare Alternative für die prä-, intra- und postoperative Gefäßdarstellung. Der Powerdoppler bietet eine noch größere Sensitivität und kann Gefäße bis 0,5 mm Durchmesser sicher darstellen.

Material und Methoden Der Einsatz von Farb- und Powerdoppler bei der präoperativen Planung wird anhand von Bildern, die die Identifizierung septaler Gefäße beim ALT, die Darstellung von Empfängergefäßen und die Planung von gestielten Perforatorlappenplastiken zeigen, illustriert. Es wurden konsekutiv 33 freie Lappenplastiken (21 ALT, 5 DIEP, 4 FCI, 2 MSAP, 1 tib. post. perforator Lappen) zur Unterschenkel- und Brustrekonstruktion, sowie 19 gestielte Perforatorlappenplastiken am Rumpf und den Extremitäten zur Defektdeckung nach Tumor und Trauma für die Auswertung eingeschlossen.

Ergebnisse Die Detektionsgenauigkeit für das Verfahren lag bei 100 %, bedeutend, dass der identifizierte Perforator in einem Radius von 0,5 cm um die präoperative Markierung lag. Auch der Gefäßverlauf (septal vs. intramuskulär) wurde zu 100 % korrekt dargestellt. In der Serie trat kein Lappenverlust auf. Es handelt sich um eine nicht invasive, sichere und kostengünstige, aber zeitaufwendige und untersucherabhängige Technik.

Diskussion Durch die Sichtbarmachung von Arterien und Venen und der exakten Lokalisierung des Fasziendurchtritts wird das Lappendesign erleichtert. Perforatoren können zentral in den Lappen gelegt, der Perforatorverlauf speziell bei ALT-Lappen dargestellt und damit aufwendige Präparationen durch den Muskel vermieden werden.

Abstract

Introduction There are many techniques to identify vessels in perforator surgery, each with specific disadvantages. Handheld Dopplers are easy to use, but inaccurate with respect to the exact localisation of the perforator. Angio-CT is invasive, time consuming, and expensive. In contrast, duplex sonography is a reliable, easy-to-use and availabe alternative for pre-, intra-, and postoperative visualisation of vessels. Power Doppler further increases sensitivity and allows visualisation of vessels smaller than 0.5 mm in diameter.

Material and Methods The use of duplex sonography and power Doppler in preoperative planning is illustrated in photographs that show how to identify the course of the septal vessel in free ALT flaps, to ensure that there are competent recipient vessels and to plan pedicled perforator flaps. In all 33 free flaps (21 ALT, 5 DIEAP, 4 FCI, 2 MSAP, 1 tib. post. perf. flap) for lower leg and breast reconstruction and 19 pedicled perforator flaps at the trunk and the extremities were harvested with this technique and used to cover post traumatic and tumour defects.

Results The detection accuracy of duplex sonography was 100 % with reference to the perforator being found within 0.5 cm of the duplexed point and the correct detection of the vessel course (septal vs. intramuscular). No flap loss was observed in this series. This is a non-invasive, reliable, and inexpensive, but time consuming and investigator-dependent technique.

Discussion By direct visualisation of the arteries and veins, the exact localisation of fascia penetration can be detected and flaps can then be better designed. Perforators can be centred in the flaps. The course of perforators can be visualised – especially in ALT flaps – and time consuming dissections through muscle can be avoided.

Schlüsselwörter

freie Lappenplastiken - Mikrochirurgie - gestielte Lappenplastiken - Mikrochirurgie - Perforans-Lappenplastiken - Mikrochirurgie - bildgebende Verfahren - Farbdoppler - Duplex - Sonographie

Key words

colour duplex - power doppler - sonography

• Referenzen

• 1 Anderson T, McDicken WN. The difference between Colour Doppler Velocity Imaging and Power Doppler Imaging. Eur J Echocardiogr 2002; 3: 240-244
• 2 Stevenson TR, Rubin JM, Herzenberg JE. Vascular patency of fibular free graft: assessment by Doppler color-flow imager: a case report. J Reconstr Microsurg 1988; 4: 409-413
• 3 Rand RP, Cramer MM, Strandness Jr DE. Color-flow duplex scanning in the preoperative assessment of TRAM flap perforators: a report of 32 consecutive patients. Plast Reconstr Surg 1994; 93: 453-459
• 4 Chidyllo SA, Jacobs JS. The application of duplex ultrasonography in the preoperative evaluation of patients prior to TRAM flap reconstruction. Plast Reconstr Surg 1993; 92: 174-175
• 5 Chang BW, Luethke R, Berg WA. et al. Two-dimensional color Doppler imaging for precision preoperative mapping and size determination of TRAM flap perforators. Plast Reconstr Surg 1994; 93: 197-200
• 6 Pacifici A, Tinti A, Flamini FO. et al. Colour flow duplex scanning: an accurate, non-invasive technique for preoperative evaluation of the vascular supply of the rectus abdominis myocutaneous flap. Scand J Plast Reconstr Surg Hand Surg 1995; 29: 319-324
• 7 Amerhauser A, Moelleken BR, Mathes SJ. et al. Color flow ultrasound for delineating microsurgical vessels: a clinical and experimental study. Ann Plast Surg 1993; 30: 193-202 discussion 202–193
• 8 Trager S, Pignataro M, Anderson J. et al. Color flow Doppler: imaging the upper extremity. J Hand Surg Am 1993; 18: 621-625
• 9 Dominici C, Pacifici A, Tinti A. et al. Preoperative and postoperative evaluation of latissimus dorsi myocutaneous flap vascularization by color flow duplex scanning. Plast Reconstr Surg 1995; 96: 1358-1365
• 10 Miller JR, Potparic Z, Colen LB. et al. The accuracy of duplex ultrasonography in the planning of skin flaps in the lower extremity. Plast Reconstr Surg 1995; 95: 1221-1227
• 11 Hutchinson DT. Color duplex imaging. Applications to upper-extremity and microvascular surgery. Hand Clin 1993; 9: 47-57
• 12 Hallock GG. Evaluation of fasciocutaneous perforators using color duplex imaging. Plast Reconstr Surg 1994; 94: 644-651
• 13 Rothkopf DM, Chu B, Gonzalez F. et al. Radial and ulnar artery repairs: assessing patency rates with color Doppler ultrasonographic imaging. J Hand Surg Am 1993; 18: 626-628
• 14 Anthony JP, Ritter E, Moelleken BR. Utility of the inferior gluteal vessels in free flap coverage of sacral wounds. Ann Plast Surg 1992; 29: 371-375
• 15 Schwabegger AH, Bodner G, Rieger M. et al. Internal mammary vessels as a model for power Doppler imaging of recipient vessels in microsurgery. Plast Reconstr Surg 1999; 104: 1656-1665
• 16 Hallock GG, Brown CL, DeSantis MJ. Preoperative identification of perforating vessels to the skin by color duplex imaging. J Ultrasound Med 1995; 14: 263-266
• 17 Blondeel PN, Beyens G, Verhaeghe R. et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 1998; 51: 202-209
• 18 Giunta RE, Geisweid A, Feller AM. The value of preoperative Doppler sonography for planning free perforator flaps. Plast Reconstr Surg 2000; 105: 2381-2386
• 19 Loh N, Ch’en IY, Olcott E. et al. Power Doppler imaging in preoperative planning and postoperative monitoring of muscle flaps. J Clin Ultrasound 1997; 25: 465-471
• 20 Hallock GG. Doppler sonography and color duplex imaging for planning a perforator flap. Clin Plast Surg 2003; 30: 347-357 v–vi
• 21 Knobloch K, Reuss E, Gohritz A. et al. [A survey of preoperative perforator mapping in perforator flap surgery]. Handchir Mikrochir Plast Chir 2009; 41: 322-326
• 22 Sites BD, Chan VW, Neal JM. et al. The American Society of Regional Anesthesia and Pain Medicine and the European Society Of Regional Anaesthesia and Pain Therapy Joint Committee recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med 2009; 34: 40-46
• 23 Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg 2010; 63: e674-682
• 24 Masia J, Kosutic D, Cervelli D. et al. In search of the ideal method in perforator mapping: noncontrast magnetic resonance imaging. J Reconstr Microsurg 2010; 26: 29-35
• 25 Neil-Dwyer JG, Ludman CN, Schaverien M. et al. Magnetic resonance angiography in preoperative planning of deep inferior epigastric artery perforator flaps. J Plast Reconstr Aesthet Surg 2009; 62: 1661-1665
• 26 Yang X, Miller MJ, Friel HT. et al. Perforator Phase Contrast Angiography of Deep Inferior Epigastric Perforators: A Better Preoperative Imaging Tool for Flap Surgery than Computed Tomographic Angiography?. Invest Radiol 2017; 52: 334-342
• 27 Pratt GF, Rozen WM, Chubb D. et al. Preoperative imaging for perforator flaps in reconstructive surgery: a systematic review of the evidence for current techniques. Ann Plast Surg 2012; 69: 3-9
• 28 Saber AA, Meslemani AM, Davis R. et al. Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg 2004; 239: 182-185
• 29 Rozen WM, Garcia-Tutor E, Alonso-Burgos A. et al. Planning and optimising DIEP flaps with virtual surgery: the Navarra experience. J Plast Reconstr Aesthet Surg 2010; 63: 289-297
• 30 Masia J, Clavero JA, Larranaga JR. et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 2006; 59: 594-599
• 31 Masia J, Clavero JA, Larranaga J. et al. Preoperative planning of the abdominal perforator flap with multidetector row computed tomography: 3 years of experience. Plast Reconstr Surg 2008; 122: 80e-81e
• 32 Masia J, Larranaga J, Clavero JA. et al. The value of the multidetector row computed tomography for the preoperative planning of deep inferior epigastric artery perforator flap: our experience in 162 cases. Ann Plast Surg 2008; 60: 29-36
• 33 Clavero JA, Masia J, Larranaga J. et al. MDCT in the preoperative planning of abdominal perforator surgery for postmastectomy breast reconstruction. AJR Am J Roentgenol 2008; 191: 670-676
• 34 Hamdi M, Van Landuyt K, Van Hedent E. et al. Advances in autogenous breast reconstruction: the role of preoperative perforator mapping. Ann Plast Surg 2007; 58: 18-26
• 35 Kosutic D, Pejkovic B, Anderhuber F. et al. Complete mapping of lateral and medial sural artery perforators: anatomical study with Duplex-Doppler ultrasound correlation. J Plast Reconstr Aesthet Surg 2012; 65: 1530-1536
• 36 Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med 2007; 357: 2277-2284
• 37 Taylor GI, Doyle M, McCarten G. The Doppler probe for planning flaps: anatomical study and clinical applications. Br J Plast Surg 1990; 43: 1-16
• 38 Figus A, Wade RG, Gorton L. et al. Venous perforators in DIEAP flaps: an observational anatomical study using duplex ultrasonography. J Plast Reconstr Aesthet Surg 2012; 65: 1051-1059
• 39 Gravvanis A, Tsoutsos D, Papanikolaou G. et al. Refining perforator selection for deep inferior epigastric perforator flap: the impact of the dominant venous perforator. Microsurgery 2014; 34: 169-176
• 40 Rozen WM, Phillips TJ, Ashton MW. et al. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and doppler ultrasound. Plast Reconstr Surg 2008; 121: 1-8
• 41 Scott JR, Liu D, Said H. et al. Computed tomographic angiography in planning abdomen-based microsurgical breast reconstruction: a comparison with color duplex ultrasound. Plast Reconstr Surg 2010; 125: 446-453
• 42 Kuekrek H, Muller D, Paepke S. et al. [Preoperative CT angiography for planning free perforator flaps in breast reconstruction]. Handchir Mikrochir Plast Chir 2011; 43: 88-94
• 43 Seidenstucker K, Munder B, Richrath P. et al. A prospective study using color flow duplex ultrasonography for abdominal perforator mapping in microvascular breast reconstruction. Med Sci Monit 2010; 16: MT65-70
• 44 Klasson S, Svensson H, Malm K. et al. Preoperative CT angiography versus Doppler ultrasound mapping of abdominal perforator in DIEP breast reconstructions: A randomized prospective study. J Plast Reconstr Aesthet Surg 2015; 68: 782-786
• 45 Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast Reconstr Surg 2006; 118: 928-933 discussion 934–925
• 46 Stekelenburg CM, Sonneveld PM, Bouman MB. et al. The hand held Doppler device for the detection of perforators in reconstructive surgery: what you hear is not always what you get. Burns 2014; 40: 1702-1706
• 47 Dorfman D, Pu LL. The value of color duplex imaging for planning and performing a free anterolateral thigh perforator flap. Ann Plast Surg 2014; 72 (Suppl. 01) S6-8
• 48 Iida H, Ohashi I, Kishimoto S. et al. Preoperative assessment of anterolateral thigh flap cutaneous perforators by colour Doppler flowmetry. Br J Plast Surg 2003; 56: 21-25
• 49 Tsukino A, Kurachi K, Inamiya T. et al. Preoperative color Doppler assessment in planning of anterolateral thigh flaps. Plast Reconstr Surg 2004; 113: 241-246
• 50 Cheng HT, Lin FY, Chang SC. Diagnostic efficacy of color Doppler ultrasonography in preoperative assessment of anterolateral thigh flap cutaneous perforators: an evidence-based review. Plast Reconstr Surg 2013; 131: 471e-473e
• 51 Ensat F, Babl M, Conz C. et al. The efficacy of color duplex sonography in preoperative assessment of anterolateral thigh flap. Microsurgery 2012; 32: 605-610
• 52 Wei FC, Jain V, Suominen S. et al. Confusion among perforator flaps: what is a true perforator flap?. Plast Reconstr Surg 2001; 107: 874-876
• 53 Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg 1986; 16: 1-19
• 54 Khan UD, Miller JG. Reliability of handheld Doppler in planning local perforator-based flaps for extremities. Aesthetic Plast Surg 2007; 31: 521-525
• 55 Jakubietz RG, Jakubietz MG, Grunert JG. et al. [Propeller flaps: the reliability of preoperative, unidirectional Doppler sonography]. Handchir Mikrochir Plast Chir 2011; 43: 76-80
• 56 Tashiro K, Harima M, Yamamoto T. et al. Locating recipient perforators for perforator-to-perforator anastomosis using color Doppler ultrasonography. J Plast Reconstr Aesthet Surg 2014; 67: 1680-1683
• 57 Li H, Du Z, Xie F. et al. Local Skin Warming Enhances Color Duplex Imaging of Cutaneous Perforators. Ann Plast Surg 2015; 75: 108-111