Postoperative Monitoring of Local and Free Flaps with Contrast-Enhanced Ultrasound (CEUS) – Analysis of 112 Patients

Abstract

Purpose: Tissue defects are a common problem in trauma surgery and oncology. Flap transplantation is often the only therapy to cover such defects. Several monitoring systems are currently available but none has made it to the clinical routine. The aim of this study was to assess perfusion disturbances of local and free flaps using contrast-enhanced ultrasound (CEUS).

Materials and Methods: 112 patients were examined during the first 72 hours after operation. CEUS was performed by one experienced examiner with a linear transducer (6 – 9 MHz, LOGIQE9/GE) after a bolus injection of 2.4 ml sulfohexa-fluoride microbubbles (SonoVue^®, Bracco, Italy). Retrospective vascular perfusion was quantified by evaluating the stored DICOM cine loops using the perfusion software QONTRAST^® (Bracco, Italy). Over a total penetration depth of 3 cm, every centimeter was analyzed separately. 27 complications were observed. Complete flap loss was only seen in 4 cases, while 23 flaps had to undergo minor revision and survived.

Results: Regarding the complete flap size, quantitative analysis showed significantly higher perfusion values in patients without complications compared to patients with complications: PEAK 16.5 vs. 10.0 (p = 0.001), TTP 32.6 vs. 22.2 (p = 0.001), RBV: 738.8 vs. 246.2 (p < 0.001), RBF 17.5 vs. 10.1 (p < 0.001) and MTT 43.1 vs. 29.5 (p = 0.001). Analysis of the correlation of the different flap types, age, sex and etiology of the tissue defect to the complication rate showed no statistical correlation.

Conclusion: CEUS was capable of detecting vascular disturbances after flap transplantation. TTP, RBV and MTT seem to be the most accurately parameters and are not susceptible to malfunction during measurement.

Zusammenfassung

Ziel: Weichteildefekte sind häufige Komplikationen in der Unfallchirurgie oder der Onkologie. Oftmals können derartige Defekte nur mit Hilfe eines Gewebetransfers gedeckt werden. Es existieren diverse Systeme zur Beurteilung der Lappenvitalität, aber kein Verfahren hat sich im klinischen Alltag etabliert. Ziel dieser Studie war die Detektion von vaskulären Komplikationen nach lokalem oder freiem Gewebetransfer mit Kontrastmittelultraschall (CEUS).

Material und Methoden: 112 Patienten wurden innerhalb der ersten 72 postoperativen Stunden untersucht. Nach einer Bolus Injektion (2,4 ml) des Kontrastmittels SonoVue^® (Bracco, Italien) wurde die Untersuchung von einem erfahrenen Radiologen mittels eines Linearschallkopfs (6 – 9 MHz, LOGIQE9/GE) durchgerührt. Retrospektiv wurden die gespeicherten Video Sequenzen mit Hilfe der Perfusionssoftware QONTRAST^® (Bracco, Italien) quantitative ausgewertet. Über eine Eindringtiefe von 3 cm wurde jeder cm separat ausgewertet. 27 Komplikationen wurden beobachtet. Ein kompletter Lappenverlust trat in 4 Fällen auf. In 23 Fällen konnten nach kleinen Revisionsreingriffen das Transplantat gerettet werden.

Ergebnisse: Bezogen auf die komplette Lappendicke wurden signifikant höhere Perfusionswerte in der Gruppe ohne Komplikationen im Vergleich zur Komplikationsgruppe beobachtet: PEAK 16,5 vs. 10,0 (p = 0,001), TTP 32,6 vs. 22,2 (p = 0,001), RBV: 738,8 vs. 246,2 (p < 0,001), RBF 17,5 vs. 10,1 (p < 0,001) und MTT 43,1 vs. 29,5 (p = 0,001). Es zeigte ich keine statistische Korrelation zwischen Alter, Geschlecht, Lappentyp, Ätiologie des Weichteildefektes und der Komplikationsrate.

Schlussfolgerung: Mit Hilfe von CEUS war es möglich Durchblutungsstörungen nach Gewebetransfer zu detektieren. TTP, RBV und MTT scheinen die exaktesten Messdaten zu liefern und scheinen im Vergleich zu den restlichen Messparametern gegenüber Messfehlern nicht so anfällig zu sein.

Key words

skin - soft tissues - ultrasound - contrast-enhanced ultrasound (CEUS) - perfusion monitoring

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