Intraoperative Fluorescence Angiography: A Review of Applications and Outcomes in War-Related Trauma

In the recent Iraq and Afghanistan conflicts, survival rates from complex battlefield injuries have continued to improve. The resulting war-related wounds are challenging, with confounding issues making assessment of tissue perfusion subjective and variable. This review discusses the utility of intraoperative fluorescence angiography, and its usefulness as an objective tool to evaluate the perfusion of tissues in the face of complex war-related injuries.A retrospective review of all war-related traumatic and reconstructive cases employing intraoperative indocyanine green laser angiography (ICGLA) was performed. Data analyzed included indication for use, procedure success/failure rates, modifications performed, and perfusion-related complications. Anatomical regions assessed were extremity, head and neck, truncal, and intra-abdominal viscera. The endpoint of specific interest involved the decision for additional debridement of poorly perfused tissue, as based on the ICGLA findings.Over a 3-year period, this study examined 123 extremity soft tissue flaps, 41 extremity injuries including amputation and/or amputation revision cases, 13 craniofacial flaps, and 9 truncal/abdomen/gastrointestinal cases in which ICGLA was utilized to assess tissue perfusion and viability. A total of 35 (18.8%) of cases employing ICGLA required intraoperative modifications to address perfusion-related issues.Intraoperative fluorescent angiography is an objective, useful tool to assess various war-related traumatic injuries. This study expands on prior cited indications for ICGLA to include (1) guiding debridement in heavily contaminated wounds, (2) providing improved assessment of avulsion soft tissue injuries, (3) allowing for rapid detection of vascular and/or microvascular compromise in soft tissue and osseous flap reconstructions, (4) reducing and preventing perfusion-related complications in trauma, amputation closures, and reconstruction procedures, (5) contributing to better outcomes in certain complex orthopedic and composite tissue injuries, and (6) enabling improved postoperative wound and reconstruction assessment in those cases of perfusion-related issues that arise within a delayed setting.