Cannulation Indocyanine Green Method for Strategic Management of Postoperative Arterial Thrombosis after Free Jejunal Flap Transfer

Abstract

Summary: Indocyanine green (ICG) angiography is widely used in reconstructive surgery to confirm the perfusion of the flap. Here, we report a case in which the use of the “cannulation ICG method” was useful for strategic management of postoperative arterial thrombosis after free jejunal flap transfer. A 64-year-old woman underwent cervical esophagectomy followed by a free jejunal transfer. On postoperative day 3, ischemia of the free jejunum was suspected, and takeback was performed. In the reoperation, re-anastomosis of the artery was planned after the removal of arterial thrombus. However, before re-anastomosis, it was unclear whether there was venous thrombus and whether this jejunum flap was salvageable. To resolve these two questions, we performed the cannulation ICG method. In this method, we injected a mixture of 1.0 mL of ICG and 20 mL of blood into the jejunal artery via 24-gauge cannula. We then evaluated the perfusion of the jejunal flap and monitoring jejunum, and the patency of the venous anastomosis site using a near-infrared fluorescence imaging device (LIGHTVISION; Shimadzu Corporation, Kyoto, Japan). In this case, the whole jejunal flap (including the monitoring jejunum) and venous anastomosis site were highlighted. We determined that there were no venous thrombi and that the entire jejunum was salvageable. After the arterial re-anastomosis, ICG angiography showed good perfusion of the whole jejunum. The postoperative course was uneventful, and the free jejunal flap survived completely. The cannulation ICG method may be effective for determining the surgical method for reoperation due to arterial thrombosis after reconstruction of the free jejunum.