Don t You Want To Know the Flow in Your Micro-vessels?

Transcription

1 Microvascular Surgery Don t You Want To Know the Flow in Your Micro-vessels? Quantify restored flow in the smallest vessels Improve reattachment and flap outcomes Measure flow quickly and easily

2 Microvascular Surgery Microsurgical Flowprobes take the guesswork out of knowing volume flow... Transonic Microsurgical Flowprobes work with HT350 and HT360-Series Flowmeters to measure volume flow in mm blood vessels and grafts. The non-constrictive Flowprobes use gold standard transit time ultrasound technology to measure volume blood flow directly within these small blood vessels. TTFV (Transit-time Flow Volume) provides novel physiologic flap data and identifies flow anastomoses and higher-flow venae comitantes. These data have clinical value in microsurgery and hold the potential to reduce microvascular complications and improve outcomes. JC Selber, MD, MPH et al Including flow in my surgical approach gives me a high degree of control over surgical outcomes. When I close the patient, I know the patient will recover without ischemic surprises. This translates into peace of mind for the patient and for me. F Charbel, MD, FACS The new line of microvascular Flowprobes now offer the surgeon a quantitative tool with which they can objectively assess the quality of the reconstruction or replantation. Unseen blood flow obstructions can be detected intraoperatively and repaired before leaving the operating room. No longer will a micro-vascular surgeon have to rely solely on clinical impressions to assess the quality of the surgery during the procedure. This on-the-spot volume flow technology produces flow information quickly, accurately, and non-intrusively. The ability to immediately correct otherwise undetectable flow restrictions provides the surgeon with a unique opportunity to improve their patients outcomes. Accurate flow measurements can be of great assistance during vascular reconstructive surgery. The primary aim with these intraoperative measurements is to obtain information on the immediate result of the reconstruction, where a technical failure may jeopardize an otherwise successful operation. A Lundell, MD, FACS TRANSIT-TIME ULTRASOUND TECHNOLOGY MEASURES VOLUME FLOW, NOT VELOCITY Two transducers pass ultrasonic signals, alternately intersecting the vessel in upstream and downstream directions. The difference between the two transit times yields a measure of volume flow. Transonic Systems Inc. is a global manufacturer of innovative biomedical measurement equipment. Founded in 1983, Transonic sells gold standard transit-time ultrasound flowmeters and monitors for surgical, hemodialysis, pediatric critical care, perfusion, interventional radiology and research applications. In addition, Transonic provides pressure and pressure volume systems, laser Doppler flowmeters and telemetry systems. AMERICAS Transonic Systems Inc. 34 Dutch Mill Rd Ithaca, NY U.S.A. Tel: Fax: support@transonic.com EUROPE Transonic Europe B.V. Business Park Stein MB Elsloo The Netherlands Tel: Fax: europe@transonic.com ASIA/PACIFIC Transonic Asia Inc. 6F-3 No 5 Hangsiang Rd Dayuan, Taoyuan County Taiwan, R.O.C. Tel: Fax: support@transonicasia.com JAPAN Transonic Japan Inc. KS Bldg 201, Kita-Akitsu Tokorozawa Saitama Japan Tel: Fax: info@transonic.jp Microvascular Cover sheet (CV-100-fly) Rev. A 6/13

3 Microvascular Microsurgical Flowprobes Transonic Microsurgical Flowprobes work with HT350- and HT360-Series Flowmeters to measure volume flow in vessels or grafts from 0.4 to 3.7 mm diameter. Flow measurement in these vessels during microvascular procedures can guide better surgical decisions and give the surgeon the opportunity to correct otherwise undetectable flow restrictions before closing the patient. 3.0 mm Probe body Flexible neck 2.0 mm 1.5 mm Handle 1.0 mm 0.7 mm Fig. 1: Ultrasonic sensing windows of Microvascular Flowprobe Series. Reflector Fig. 3: 2 mm Microvascular Flowprobe showing handle and flexible probe neck for easy positioning of the Flowprobe around a vessel. Fig. 2: Side-by-side comparison of a 0.7 mm Microvascular Flowprobe with a tip of a 25 gauge needle. Fig. 4: Microvascular Flowprobe Series including 0.7 mm, 1 mm, 1.5 mm, 2 mm, 3 mm Flowprobes. VESSEL SIZES FOR MICROVASCULAR FLOWPROBES PROBE SIZE (mm) VESSEL OD (mm) MAXIMUM FLOW (ml/min) MicrosurgeryFlowprobesAureflo(CV-101-ds)RevC2016USltr

4 Microvascular The AureFlo Transonic s AureFlo system and Microvascular Flowprobes use transit-time ultrasound technology to measure volume flow in micro-vessels with unprecedented accuracy and resolution. Even lymph flows can be measured directly. Used with single or dual-channel Optima Flowmeters, the AureFlo s unprecedented resolution is accompanied by lower offsets, and higher low-flow accuracy. The AureFlo features an easy-to-read, high contrast display on a touch screen PC. The display can be projected to an OR monitor. Data entry to capture, store and retrieve flow information is quick and easy. Operative notes can be easily augmented and 8-second snapshots of recorded measurements can be reviewed from a remote location. Waveforms for reference, analyzing, teaching or, for the patient record, can be selected and printed. The AureFlo s small footprint allows for easy mobility within the OR. A stable cart securely holds the system components and a convenient writing surface and storage drawer is also provided. The AureFlo s immediate, quantitative flow measurements provide unsurpassed accuracy and resolution to ensure vessel patency in micro-vessels. The AureFlo system accommodates Transonic s new Microsurgical Flowprobes to continuously measure, display, record and document absolute volume flow and other derived parameters. In the photo on the right, the AureFlo is shown with a HT354 singlechannel Optima Flowmeter, and displays the flow profile of a popilteal artery. Transonic Systems Inc. is a global manufacturer of innovative biomedical measurement equipment. Founded in 1983, Transonic sells gold standard transit-time ultrasound flowmeters and monitors for surgical, hemodialysis, pediatric critical care, perfusion, interventional radiology and research applications. In addition, Transonic provides pressure and pressure volume systems, laser Doppler flowmeters and telemetry systems. AMERICAS Transonic Systems Inc. 34 Dutch Mill Rd Ithaca, NY U.S.A. Tel: Fax: support@transonic.com EUROPE Transonic Europe B.V. Business Park Stein MB Elsloo The Netherlands Tel: Fax: europe@transonic.com ASIA/PACIFIC Transonic Asia Inc. 6F-3 No 5 Hangsiang Rd Dayuan, Taoyuan County Taiwan, R.O.C. Tel: Fax: support@transonicasia.com JAPAN Transonic Japan Inc. KS Bldg 201, Kita-Akitsu Tokorozawa Saitama Japan Tel: Fax: japan@transonic.com

5 Microvascular Surgery Publication Brief A Prospective Study of Transit Time Flow Volume (TTFV) Measurement for Intraoperative Evaluation and Optimization of Free Flaps OBJECTIVE To determine if transit-time volume flow measurements improve decision-making in microvascular free tissue transfer procedures. STUDY Transit-time volume flow was measured in 52 consecutive free flaps (five types) by five surgeons. Thirty-eight (73.1%) of the flaps were harvested to reconstruct head and neck defects, while the remaining 14 (26.9%) (all TRAMs) were harvested for breast reconstruction. Flow measurements were performed: In Situ, after flap elevation and isolation on its pedicle; Immediately following anastomosis and reperfusion; Thirty minutes following anastomosis and reperfusion. Intra-operative decisions based on transit-time volume flow measurements were documented. RESULTS Arterial inflow was, on average, 1.5 times greater than venous outflow, and arterial resistance was 3.59 times greater than venous resistance (arterial: 9.04 ml/min; venous: 7.24 ml/min) Free transverse rectus abdominis musculocutaneous (TRAM) flaps had the highest arterial and venous flows (14.2 ml/min; venous: 11.3 ml/min), and free radial forearm flaps (RFF) had the lowest (arterial: 6.33 ml/min; venous 5.29 ml/min). Compared to the baseline (In Situ) measurement, all flaps had higher flows immediately after transfer (Time 1) (p<0.0001), but no significant differences were seen 30 minutes later (Time 2) (p=0.68). Arterial resistance, however, increased during that interval (p=0.006). In more than a third of the cases (19 out of 52), operative decisions and when to revise an anastomosis, were modified on the basis of transit-time volume flow findings. CONCLUSION Transit-time volume flow measurements provide novel physiologic flap data and identify flawed anastomoses and higher-flow venae comitantes. These data have clinical value in microsurgery and hold the potential to reduce microvascular complications and improve outcomes. TAKE HOME POINTS This publication from a microvascular surgeon key opinion leader provides proof that volume flow measurements can provide quantifiable measurements of one of the most critical pieces of microvascular reconstruction: inflow and outflow. The author notes that perhaps the most compelling finding of the study is that flow measurements could alter or augment surgical decision making as it had in 36% of the cases in the study. These quantitative measurements fill a knowledge gap in microsurgery. Reference: Selber JC, Garvey PB, Clemens MW, Chang EI, Zhang H, Hanasono MM, A Prospective Study of Transit Time Flow Volume (TTFV) Measurement for Intraoperative Evaluation and Optimization of Free Flaps, Plast Reconstr Surg (Transonic Reference # 9762AHM) CV-9762AHM-pb Selber RevA

6 Microvascular Surgery Publication Brief Refining Perforator Selection for DIEP Breast Reconstruction Using Transit-time Flow Volume Measurements OBJECTIVE To examine the usefulness of transit-time ultrasound volume flow measurements in assessing perforator vessels in deep inferior epigastric artery perforator (DIEP) flap harvesting and to evaluate their correlation with computed tomographic angiography (CTA) and hand-held Doppler signals in identifying perforators. STUDY CTA was used to identify abdominal wall perforators for ten consecutive free DIEP breast reconstructions in eight women (two with bilateral mastectomies, six with unilateral). Abdominal wall perforating vessels >1 mm in diameter were evaluated intraoperatively with a conventional hand-held 8-MHz Doppler and a transit-time ultrasound flowmeter. The location of the vessels was correlated with preoperative CTA. Information about arterial versus venous flow patterns and mean flow values were recorded for each vessel typically, with a 2 mm flowprobe, but occasionally, with a 3 mm flowprobe. Flow values were correlated with both CTA and hand-held Doppler signals. Information about arterial versus venous flow patterns and mean flow values were recorded for each perforator. Perforators with high volume flows and an arterial waveform were selected to supply the flap. RESULTS Of the 54 eligible perforators identified, transit-time flow measurements showed arterial flow waveforms in 15 of 16 perforators identified by CTA and in 2 of the remaining 38 vessels. Mean flow for the 16 arterial vessels was 5.3 ml/min. Mean flows for the remaining 38 dissected vessels was 2.1 ml/min. Transit-time flow measurement sensitivity in identifying arterial perforators was 94%; specificity was 95%. Hand-held Doppler was misleading in 70% of vessels. CONCLUSION Transit-time flow measurements distinguished arterial from venous waveforms in vessels that appear arterial by hand-held Doppler signals. CTA and transit-time flow measurements had high correlation. The use of transit-time flow measurements may prevent poor perfusion seen in some DIEP flaps. DISCUSSION This group from the University of Toronto tested the use of transit-time ultrasound flowmetry to identify optimal deep inferior epigastric arterial perforators to harvest for breast reconstruction. Moreover, they suggest that transit-time flowmetry may be able to predict early patency in completed microvascular anastomoses, as is the case in CABG surgery. Reference: Visscher K, Boyd K, Ross DC, Amann J, Temple C, Refining perforator selection for DIEP breast reconstruction using transit time flow volume measurements, J Reconstr Microsurg. 2010; 26(5): (Transonic Reference # 9953VM) CV-9953VM-pbVisscherRevA2014USltr

7 Surgery Transonic Perivascular Flowprobes The widest selection of Flowprobes available Transonic s application-customized Flowprobes measure volume flow in blood vessels and grafts from 0.5 mm to 36 mm to: Quantify blood flow Identify technical problems early Improve patient outcomes FlowprobeFlyer(CV-500-fly)RevB 2014

8 Microvascular Flowprobes Flaps Reattachments Transonic Microvascular Flowprobes measure volume flow in blood vessels or grafts from 0.5 to 4.0 mm diameter. Flow measurement in these vessels during microvascular procedures quantify flows in the smallest vessels in order to objectively assess the quality of the reconstruction or replantation, guide better surgical decisions and give the surgeon the opportunity to correct otherwise undetectable flow restrictions before closing the patient. Due to extreme accuracy requirements, this Microvascular Flowprobe Series is only available with the Optima Flowmeter. Probe body Flexible neck Reflector Flowprobe handle Microvascular Flowprobe (2 mm) showing handle and flexible probe neck for easy positioning of the Flowprobe around a vessel. 0.7 mm 1.0 mm 1.5 mm 2.0 mm 3.0 mm Ultrasonic sensing windows of Microvascular Flowprobe (MU) Series. Side-by-side comparison of a 0.7 mm Flowprobe with a tip of a 25g. needle. Microvascular Flowprobe (-MU) Series including 0.7 mm, 1 mm, 1.5 mm, 2 mm, and 3 mm Flowprobes.

9 Cardiac Flowprobes Coronary Artery Grafts Ascending Aorta Transonic Cardiac Flowprobes include FMC-Series Flowprobes for coronary artery bypass grafting surgery and COnfidence Flowprobes for continuous measurement on great vessels with turbulent flows. Coronary Flowprobes Elongated curved neck Probe body Flexible neck segment Probe handle FMC-Series Coronary Handle Flowprobes are available in sizes 1.5 mm to 4 mm. They feature a J-style reflector, designed for spot flow checks of coronary artery bypass grafts and an extended neck with a flexible end to reach coronary grafts even behind the heart. COnfidence Flowprobes Probe shell Ultrafit liner COnfidence Flowprobes consist of a Flowprobe shell and a single-use soft, flexible Ultrafit liner. This novel concept for ultrasonic signal coupling enables immediate, accurate beat-to-beat flow measurements with a minimum of ultrasonic coupling gel. The form-fitting Ultrafit Liner slips into the transducer shell to encircle the vessel and keep the vessel in place. The liner cushions and protects the vessel during a flow measurement. Liners are incrementally sized for optimal fit on the target vessel. Pictured, from left to right, are 1.5 mm, 2 mm, 3 mm and 4 mm coronary Flowprobes showing their blue Probe bodies, J reflectors and ultrasonic sensing windows. 8 mm 10 mm 12 mm 14 mm 16 mm 20 mm 24 mm 28 mm COnfidence Flowprobes (-AU-Series), designed with four transducers, provide highly accurate measurements in vessels with highly turbulent flows such as the ascending aorta. The Flowprobe s slim, ergonomic profile creates a minimal footprint that fits in tight anatomical sites. The soft, pliable liner cushions and protects the vessel. Available in 15 sizes from 8 mm to 36 mm. Port-Access Flowprobes Port-Access Flowprobes, a customer-driven innovation, feature a long endoscopic handle to extend through robotic ports and measure flows on coronary grafts. They are available in three sizes: 2 mm, 3 mm, and 4 mm.

10 Vascular Flowprobes Peripheral Vascular Carotid Endarterectomy Transonic s spectrum of Vascular Flowprobes measure volume flows intraoperatively in vessels and grafts from 0.5 mm to 20 mm to detect blood flow obstructions before leaving the operating room. This ability to correct otherwise undetectable flow restrictions provides the surgeon with a unique opportunity to improve the outcome for his or her patient. Handle Vascular Flowprobes Probe body J Reflector Flexible neck Handle Short Handle Vascular Flowprobes: The FMV-Series features a short handle and a J reflector designed for spot flow checks. Available in a wide range of sizes from 1.5 mm to 14 mm. Carotid Flowprobes Non-handle Flowprobes Sliding cover Probe body L reflector L reflector Flexible neck FME-Series Flowprobes feature an L-shaped reflector to protect against dislodging of plaque (such as during carotid endarterectomy) as the Flowprobe is applied. The L reflector design allows the probe to be slipped on and off a carotid artery easily, facilitating quick pre- and post-procedure measurements. Available in 1.5 mm to 10 mm sizes. Non-Handle Flowprobes (FSB-Series) feature an ultrasonic flowsensing window defined by an L reflector with a sliding cover so that the Flowprobe can remain positioned around the vessel for extended measurements. FSB-Series Flowprobes are available in sizes from 2 mm to 14 mm. OptiMax Flowprobes The OptiMax family with J reflectors (shown) and L reflectors (not shown) are available in 4, 6, 8, 10 and 12 mm. OptiMax Flowprobes two reflector shapes and multiple probe sizes accommodate different surgical preferences and patient anatomies. The skin tabs secure the Flowprobe so that continuous measurements can guide vascular constructions, banding or revisions until a target flow is achieved.

11 Cerebrovascular Flowprobes Aneurysm Clipping EC-IC Bypass AVMs Fistulas Transonic Cerebrovascular (Charbel) Flowprobes measure volume flow in intracranial and extracranial vessels during cerebrovascular flow preservation or flow augmentation surgeries. Intraoperative measurements of volume flow assure the integrity of flow in cerebral vessels or they alert the surgeon to dangerous flow deficits at a time when every minute counts. Intracranial Flowprobes Flexible neck Probe body Long bayonet neck Reflector Probe head Close-up Extracranial Flowprobes Long bayonet neck Long bayonet neck intracranial Charbel Micro-Flowprobes are available in three sizes, 1.5 mm, 2 mm and 3 mm, for aneurysm clipping, AVM and dural fistula obliteration surgeries. -MB & -MR-Series Charbel Micro-Flowprobes are designed to measure flow in major intracranial vessels of the Circle of Willis. Their long bayonet neck permits use under a surgical microscope and a flexible neck segment permits bending the Flowprobe as needed to most easily position the probe around the vessel. Short bayonet neck Short bayonet neck extracranial Charbel Probes are available in three sizes, 3 mm, 4 mm and 6 mm, for extracranial vessels such as the superior temporal artery during extracranial-intracranial (EC-IC) bypass surgeries. Their short bayonet neck permits use under a surgical microscope and a flexible neck segment permits bending the Flowprobe as needed to most easily position the probe around the vessel. Side-by-side comparison between intracranial Charbel Micro-Flowprobes and shorter neck extracranial Charbel Flowprobes used during EC-IC bypass surgery.

12 Surgery Transplant Flowprobes Liver Renal Heart/Lung Pancreas Transonic Flowprobes work with HT300-Series Flowmeters to measure volume flow in blood vessels and grafts from 0.5 to 36.0 mm. In critical transplant surgeries, intraoperative measurement of flow in vessels can guide surgical decisions to ensure vessel patency prior to closing. Probe body Flexible neck Reflector Handle FMV-Series 4 and 6 mm Vascular Flowprobes recommended for measuring hepatic arterial flow. Picture shows Flowprobe handle with size of Probe in mm, the Probe s flexible neck for optimal positioning of the Probe around the vessel, the Probe body that houses the ultrasonic transducers, and the Probe reflector. Vessel is positioned within the Probe sensing window that is defined by the Probe body and its stationary reflector. Vascular Flowprobes (FMV-Series) in sizes 8 mm to 14 mm are used for spot portal venous flow measurements. COnfidence Flowprobes (-AU-Series) can also be used for continuous portal venous flow measurements. Transonic Systems Inc. is a global manufacturer of innovative biomedical measurement equipment. Founded in 1983, Transonic sells gold standard transit-time ultrasound flowmeters and monitors for surgical, hemodialysis, pediatric critical care, perfusion, interventional radiology and research applications. In addition, Transonic provides pressure and pressure volume systems, laser Doppler flowmeters and telemetry systems. AMERICAS Transonic Systems Inc. 34 Dutch Mill Rd Ithaca, NY U.S.A. Tel: Fax: support@transonic.com EUROPE Transonic Europe B.V. Business Park Stein MB Elsloo The Netherlands Tel: Fax: europe@transonic.com ASIA/PACIFIC Transonic Asia Inc. 6F-3 No 5 Hangsiang Rd Dayuan, Taoyuan County Taiwan, R.O.C. Tel: Fax: support@transonicasia.com JAPAN Transonic Japan Inc. KS Bldg 201, Kita-Akitsu Tokorozawa Saitama Japan Tel: Fax: info@transonic.jp

13 Surgery Flowprobe Selection Guide CARDIAC SURGERY CABG: ON OR OFF PUMP Probe Size (mm) Probe Series Arterial conduits 1.5, 2, 3, 4 -FMC Saphenous vein 2, 3, 4 -FMC Port access - coronary arteries 1.5, 2, 3, 4 -FD CARDIAC OUTPUT Ascending aorta 28, 32, 36 -AU Pulmonary artery 24, 28, 32 -AU Pediatric heart PERIVASCULAR FLOWPROBE SERIES & AVAILABLE SIZES SUFFIX DESCRIPTION SIZES (mm) -FMC Coronary (J-reflector, extended neck) 1.5, 2, 3, 4 -FMV Vascular (J-reflector, standard handle) 1.5, 2, 3, 4, 6, 8, 10, 12, 14 -FME Carotid (L-reflector, standard handle) 4, 6, 8, 10 -FTV OptiMax (J-reflector, hands-free butterfly wings) 4, 6, 8, 10, 12 -FTE OptiMax (L-reflector, hands-free butterfly wings) 4, 6, 8, 10, 12 -MU Microvascular (L-reflector, standard handle) 0.7, 1, 1.5, 2, 3 -AU -MB; -MR -MB-S -MR-R Cardiac Output COnfidence Flowprobe (C-shaped design, no handle) Intracranial Charbel Micro-Flowprobe (L-reflector, long bayonet handle) -MB: single use; -MR: resposable Extracranial EC-IC Bypass: Micro-Flowprobe (L-reflector, short bayonet handle): -MB-S: single use; -MR-S: resposable 4, 6, 8, 10, 12, 14, 16, 20 -AU 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 26, 28, 30, 32, 34, , 2, 3 3, 4, 6 -FSB Basic (L-reflector with sliding cover, no handle) 1.5, 2, 3, 4, 6, 8, 10, 12, 14 -P -FD Port Access (J-reflector, long port-access handle) Port Access (J-reflector, long port-access handle) TRANSPLANT SURGERY LIVER Probe Size (mm) Probe Series Hepatic artery 4, 6, 8 -FMV -AU Portal vein 10, 12, 14 -FMV -AU KIDNEY Renal artery 4, 6 -FMV -FSB Renal vein 10 -FMV -FSB External iliac artery 6, 8 -FMV -FSB Hypogastric artery 4, 6 -FMV -FSB PANCREAS Common iliac artery 8 -FMV -FSB 2, 3, 4 1.5, 2, 3, 4 Recommended Sizes and/or Flowprobe Series for Specific Vessels or Applications CAROTID ENDARTERECTOMY VASCULAR SURGERY Probe Size (mm) Probe Series Common carotid artery 8, 10 -FTE -FME -FSB External carotid artery 6 -FTE -FME -FSB Internal carotid artery 6 -FTE -FME -FSB AV FISTULAS & GRAFTS Radial artery 2, 3 -FMV -FSB Brachial artery 3, 4, 6 -FMV -FTV -FSB Graft venous outflow 4, 6 -FMV -FTV -FSB ABDOMINAL Renal bypass 4, 6 -FMV -FTV -FSB Aorta 16, 20 -AU -FSB Common iliac 10, 12 -FMV -FTV -AU -FSB Portocaval shunt 10, 12, 14 -FMV -FTV -AU -FSB Splenorenal shunt 10, 12, 14 -FMV -FTV -AU -FSB LOWER EXTREMITY BYPASS Profunda femoris 8 -FMV -FTV -AU -FSB Common femoral 8, 10 -FMV -FTV -AU -FSB Popliteal 4, 6 -FMV -FTV -FSB Tibial 3, 4 -FMV -FTV -FSB CEREBROVASCULAR SURGERY ANEURYSM CLIPPING Probe Size Probe Series mm 1 x use resposable Cerebral arteries 1.5, 2, 3 -MB -MR EC-IC BYPASS Extracranial 3, 4, 6 -MB-S MR-S Intracranial 1.5, 2, 3 -MB -MR AVM, TUMOR RESECTION, DURAL FISTULA Outflows variable -MB, -MR MICROVASCULAR SURGERY REATTACHMENTS/FLAPS Probe Size (mm) Probe Series Microvessels in hand, wrist 0.7, 1, 1.5, 2, 3 -MU