Leitthema

Gefässchirurgie 2018 · 23:580–585https://doi.org/10.1007/s00772-018-0477-6Published online: 26 November 2018© Springer Medizin Verlag GmbH, ein Teil vonSpringer Nature 2018

P. Vikatmaa · A. AlbäckDepartment of vascular surgery, Helsinki University Hospital, HUS, Helsinki, Finland

Intraoperative quality controlwith transit time flowmeasurementMethods in peripheral vascular surgery

Introduction

Early graft failure after a vascular recon-struction leads to reoperations and mayhave catastrophic consequences for thepatient, especially in cases of delayed di-agnosis. It is thus crucial to control pa-tency related issues and quality of thereconstruction intraoperatively. Variousoptions are available but the scientific ba-sis to support the choice of one methodover another is weak. At the end ofa vascular reconstruction the end organshould be perfused, the flow in a graftshould be sufficient and the reconstruc-tion should be free of technical errors.There is no gold standard for intraop-erative quality control and all availablemethods have their pros and cons. Sim-ple pulse palpation and inspection arenot sufficientmethods. Continuouswavedoppler monitoring gives an idea aboutthe local flow velocity but gives almostno information about the flow volume.All intraoperative assessment methodsshould therefore be used carefully andthe information given by the differentmethods should be summarized by ex-perienced clinicians. In a large registry-based study, completion imaging couldnot be shown to improve primary graftpatency at 1 year; however, several con-founding factors could not be controlled[1].

Intraoperative digital subtraction an-giography (DSA)maybe the bestmethodto visualize the graft quality and distalrun-off after a bypass but is often consid-ered too cumbersome to use on a routinebasis in all vascular operations. Some

locations, such as the proximal superiormesenteric artery (SMA) may be diffi-cult to visualize with angiography. It ispossible to miss flap remnants and spotlesions. Althoughgivingagoodanatomi-cal picture angiography shows little aboutthe flow and perfusion if not combinedwith advanced techniques [2]. It is alsoresource intensive, has the need for radi-ation protection and may unnecessarily

Table 1 Roughestimatesoflow,normalandhighflowvaluesindifferentarteriesandreconstruc-tions (ml/min). There is no high-quality scientific evidence to support these values.These figuresshould be seen as a suggestion developed in clinical practice after routine use of TTFM at the endof nearly all open arterial operations in this unit since the early 1990s

Low flow (ml/min) Normal (ml/min) High (ml/min)

ICA <100 100–300 500

Axillary artery <100 100–500 >500

Radiocephalic FAV <200 >300 >1000

A. hepatica/lienalis <100 >150 >500

SMA <200 >400 1000

A. renalis <150 200–400 >500

Iliac arteries <300 500–2000 >1000

CFA <200 300–1000 >700

Popliteal bypass <100 >100 >300

Crural bypass <80 80–200 >200

Inframalleolar bypass <50 >50 >200

ICA internal carotid artery, SMA superior mesenteric artery, CFA common femoral artery, FAV arte-riovenous fistula

Table 2 Different reasons for early graft failure and an estimation of the capacity of three dif-ferent completion controlmethods.+=moderate, ++=good, +++=excellent in diagnosing theproblem

Anastomotic er-ror or thrombus

Embolus Flap remnant Kinking/twist

Ultrasound +++ + +++ ++

Angiography ++ +++ ++ +++

Transit time flow + ++ ++ +++

prolong theoperation. Ontheotherhandthe new role of hybrid reconstructionsbrings more and more patients to highqualityhybrid suiteswithpossibilitiesnotonly for completion angiographybut alsoadjunctive procedures, such as inflow oroutflow percutaneous transluminal an-gioplasty (PTA) or stenting [3].

High quality intraoperative ultra-sound (IUS) should be readily available

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Fig. 18 Simultaneousmeasurement of arterial and venous flow from left groin, during reperfusionphaseafter isolated limbperfusiontreatment (andradical lymphnodedissection). In thishealthymalevascular bed a high flowof>1l/min can be seen.The upper curve shows a normal arterial curvewithagoodsystolic inflowand lowdiastolic resistance (>500ml/minflowduringdiastole).The lowercurveshows venous flowwith suboptimal contact (yellowbox, acoustic contact indicator, ACI 31%).The ve-nous flow curve shape is typically rounded venous and reaches zero during inhalation.A peripheralmanualmuscle compressionwould give a high peak of flow.The values are negative, because of theprobe orientation. Sometimes it is technically easier not to use the correct orientation and absolutevalues should be used

Fig. 28 Measurements after groin reconstructionwith veins (infected grafts) from the superficial(above) anddeep (below) femoral artery. Figure a shows low flows during vasospasmwith high pul-satility index (PI) and negative flowduring diastole.The spasmhas been releasedwithpapaverinehydrochloride inb showing higher flows and low PI values. If the flow volume andPIwould not haveimproved, further investigationswith ultrasound and/or angiographywould have been necessary

in all operating theatres performing vas-cular surgery. With a high frequency(>15MHz) superficial transducer thevisibility of anastomoses, dissectionflaps and other anatomical structuresis excellent in the simple B-mode. Byadding pulsed wave Doppler and flowvelocity measurements, local stenosiscan be accurately detected. Volume flowmeasurement programs are prone toerrors due to the fact that the calcula-tion is based on measurement of vesseldiameter or estimation of the vesselcross-sectional area and correct meanflow velocity is also highly dependent

on the measurement angulation of in-sonation. Use of ultrasound requiresspecial training, is operator dependentand it may be difficult to visualize someparts of the vessels in the intraoperativesetting; for example, deeply tunnelledgrafts or air and edema in the opera-tive field can cause problems. With thevery high capability to detect flaps andsmall irregularities, there is a clear riskfor over diagnosis and the criteria forintervention remain to be solved, e. g.when to reclamp and open a finalizedcarotid reconstruction. There are somecase series where excellent patency after

distal bypass has been obtained usingintraoperative duplex scanning [4] butno robust randomized or comparativedata are available to prove the benefitsof this strategy. In a series of 2032 lowerextremity bypasses, no differences in1-year patency could be seen when thesurgeon used completion imaging (an-giography or duplex ultrasound) eitherroutinely or selectively [5].

Angioscopy has been proposed asa quality control method and seems towork well in carotid endarterectomy(CEA) [6] but despite promising earlystudies, as the field under inspectionmust be blood free at the time of theangioscopy, it has limited potential inother areas, such as distal bypass surgeryand has not become widely acceptedroutine practice despite some promisingearly results [7].

In carotid surgery intraoperative tran-scranial doppler (TCD)andnear infraredspectroscopy have a role when evaluat-ing if the patient tolerates carotid clamp-ing and in detecting intraoperative em-bolization, but these methods seem to berelatively insensitive when searching fortechnical errors.

For reconstructions of critical limb is-chemia it may seem appealing to imme-diately evaluate the perfusion of the footand it is possible to bring a toe pressuremeasurement device into the theatre foron-line toe pressure measurements. Itmay, however, take some time for the toepressure to increase even after success-ful bypass surgery, a fact that limits theuse of all intraoperative perfusion mea-surement methods. Indocyanine greendye can be used for intraoperative flu-orescent angiography [8] but has beenmore extensively studied and standard-ized for postoperative ulcer healing pre-diction purposes [9].

Transit time flow measurement(TTFM) using ultrasound-based probesis specifically designed to measure in-traoperative flow in vessels and grafts.The measurement is somewhat invasive,as the probe needs to be put aroundthe vessel. The TTFM probe sends twoultrasound beams, one upstream andanother downstream. The two piezo-electric crystals are on the same side ofthe vessel and ametal reflector on the op-

Gefässchirurgie 8 · 2018 581

posite side of the vessel. The ultrasoundpropagation time is longer upstreamand the flow velocity can be calculatedfrom the difference of the propagationtimes of these two ultrasound beams.The transmitted wide ultrasonic beamcovers the whole width of the vessellumen and the transducer integrates allvelocity components in the vessel. Sincenon-moving parts within the beam areado not contribute to the flow velocity,the difference between upstream anddownstream transit time is proportionalto the volume flow and the shape of thevessel is not essential [10, 11].

TheTTFM technique has been shownto be very accurate under optimal con-ditions, the error of measurement be-ing only in the range of 1–4% [11, 12]and TTFM was validated for intraop-erative use for popliteal and crural by-passes in the 1990s. Probably due tothe ease of use TTFM is in routine dailyuse in many clinics for a variety of pur-poses and thousands of measurementsare performed every week. Most experi-ence comes from cardiac bypass surgery.The pulsatility index (PI) and flow vol-umes aremore variable in peripheral vas-cular surgery, which makes standardiza-tion difficult. Normal values are unclearinmany situations and the intraoperativevariability is high (. Table 1).

The transit time flow measurement(TTFM) gives a picture of the bloodflow to the end organ but is prone tofast changes caused by vasoactive anddilatative medications and changes afterreperfusion. The pulsatility index (PI)describes the amplitude of the curve andquantifies the difference between systolicand diastolic flow, thus reflecting bothinflow and outflow (resistance of the pe-ripheral arterial bed).

PI = Vsystole − Vdiastole/Vmean

The(TTFM)method is fast andeasy touse and abnormal findings should lead tofurther investigations. Probes are avail-able in different sizes: (1.5–16mm) andthe reliability of the measurement is en-hanced with correct probe size, goodcontact and avoiding measuring froma curved part of the vessel (. Fig. 1). Ster-ile ultrasound gel can be used to improve

Abstract · Zusammenfassung

Gefässchirurgie 2018 · 23:580–585 https://doi.org/10.1007/s00772-018-0477-6© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

P. Vikatmaa · A. Albäck

Intraoperative quality control with transit time flowmeasurement. Methods in peripheral vascular surgery

AbstractVascular reconstructions carry a high riskof early and late failure, leading potentiallyto major problems. Therefore, it is crucialto ensure the quality of reconstructions atthe end of every operation. No method hasbeen shown to be superior to others andit is beneficial for the vascular surgeons tomaster many techniques. Transit time flowmeasurement (TTFM) is a fast and easy way todirectly evaluate the desired end result; blood

flow to the end organ. It is not problem-free nor totally reliable. In addition to TTFMdifferent quality control methods includingtheir pros and cons are discussed.

KeywordsPeripheral arterial disease · Quality assurance ·Vascular patency · Ultrasound · TTFM, graftflow

Intraoperative Qualitätssicherungmit laufzeitbasierterFlussmessung. Methoden in der peripheren Gefäßchirurgie

ZusammenfassungGefäßrekonstruktionen gehen mit einemhohen Risiko des frühen und spätenVersagens einher, was zu erheblichenSchwierigkeiten führen kann. Entsprechendist es äußerst wichtig, am Ende jedesEingriffs die Qualität der Rekonstruktionensicherzustellen. Kein dabei eingesetztesVerfahren war in Studien anderen Verfahrenüberlegen. Gefäßchirurgen profitieren daherdavon, viele Verfahren sicher zu beherrschen.Die laufzeitbasierte Flussmessung (TTFM) isteine schnelle und einfache Methode, um auf

direktemWeg das gewünschte Endergebnis,nämlich den Blutstrom zum Endorgan, zubeurteilen. Das Verfahren ist allerdings nichtfrei von Schwierigkeiten und auch nichtgänzlich zuverlässig. Neben der TTFM werdenweitere Methoden der Qualitätssicherungmitihren Vor- und Nachteilen erörtert.

SchlüsselwörterPeriphere arterielle Verschlusskrankheit · Qua-litätssicherung · Vaskuläre Durchgängigkeit ·Ultraschall · Ausbreitungszeit

contact. Air e. g. in newly implantedprotheses makes the measurement unre-liable as the ultrasound-based measure-ment is disturbed.

Basedoncurrentevidenceit isnotpos-sible to draw definite cut-off values onwhen to intervene when flow values aretoo low. In clinical practice further imag-ing would be considered after all “low-flow” values in . Table 1. The secondimaging after TTFMcould be eitherDSAor IUS depending on the operation, e. g.afterCEAthe routineuseof IUS is recom-mended and routine DSA after extremeand high-risk bypass surgery should beconsidered but TTFM is considered suf-ficient after femoral endarterectomy orroutinebypasssurgery. Theprosandconsof DSA, IUS and TTFM are summarizedin . Table 2.

Lower limb disease

The flow after finalized reconstructionis greatly dependent on spasms in thearteries. This is true in many arterialbeds and has been studied in the lowerlimb bypasses. The maximum flow ca-pacity can be studied by injecting pa-paverinhydrochloride,with its strongan-tispasmodic capacity, intra-arterially tothe graft resulting in transient vasodilata-tion and drop in the PI ([13]; . Fig. 2).In a series with 172 crural and pedalbypasses from this clinic the maximumflow increased by 53% in crural and by38% in pedal bypasses. A cut-off valueof 90ml/min for maximum flow capac-ity had a significant predictive value on1-year patency [14]. Other vasodilata-tive drugs may also be used. Alprostadil,a prostacyclin analogwas studied byThul

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Fig. 38 Results ofmeasurements in 8173 bypasses performed inHelsinki University Hospital during 2001–2015.No exactconclusion on cut-off values can be drawn from these registeredmeasurements asmedication, timing after declamping andbloodpressureamongotherfactorsarenotstandardizedandfollow-updatahavenotbeencomparedtothesevalues. Thepinkboxhighlights the lowvalues in this population that couldbea trigger for further investigationsbut shouldnotbe consideredscientific evidence. (x-axis = TTFMflow inml/min, y-axis = number of patients)

Gefässchirurgie 8 · 2018 583

Leitthema

et al. and they found a 103% increase offlow in crural and popliteal bypass grafts.Popliteal grafts had a bigger change inflow and decrease in the PI [15]. Logi-cally, themoremuscleandvesselsdistal tothe bypass, the greater flowand change inthe flow after maximum vasodilatation.The flow volume is dependent on the sta-tus of run-off vessels and collaterals andthe result should be judged against thepreoperative angiogram. . Fig. 3 showsthedistributionofflowvolumeafter threedifferent level bypasses in Helsinki Uni-versity Hospital in more than 8000 pa-tients during 2001–2015.

Carotid surgery

In carotid surgery the change of inter-nal carotid artery flow has been inves-tigated and a median 160ml/min flowprior to the endarterectomy changed to240ml/min after declamping. In thisstudy of 1000 carotid stenoses, also theproportion of flow directed to the exter-nal carotid artery decreased with higherICA flow showing a redistribution pat-tern [16]. It has also been shown thatthe increase in ICA flow correlates to thedegree of stenosis, the higher the steno-sis, the bigger the change [17, 18]. Onthe other hand too high flowmay also bea predictor of hyperperfusion risk [19].Some clinics routinelywait for some timeinorder for the cerebral autoregulation toreact and diminish the flow and Ascheret al. in a small series suggested cut-offvalues (100ml/min, with intraoperativeduplex scanning) for performing intra-operative control angiography [20]. Ourclinical experience supports these prac-tices, as often the immediate ICA flowmay be very high and then level off aftersome minutes and problems seem morelikely when the flow volume is less than100ml/min. The flow volume can guidethepostoperative targetedbloodpressureand if immediate reperfusion values areused, itmay lead to unnecessarily aggres-sive blood pressure control. The availablescience to guide these decisions is scarce.

Abdominal vascular surgery

Quality control methods are vital, butevenmore difficult to standardize in vas-

cular reconstructions in the abdominalcavity. Afteraortobi-iliacorbifemoral re-constructions it is crucial that potentialproblems causing lower limb ischemiaare detected as soon as possible in or-der to avoid major muscle ischemia andits typical consequences, fasciotomy, re-nal failure and amputation. The TTFMis a fast and easy method to ensure theflow in almost any artery immediatelyafter performing the anastomosis whena segment of native artery is free. Mea-surement through a prothesis is also pos-sible but includes some problems and isless reliable. A polytetrafluoroethylene(PTFE) graft has to be heavily pinchedor clamped with a soft vascular clamp inorder to push the air from the prothesiswall, a practice that might damage theprothesis and therefore should be ques-tioned. A polyethylene prothesis has lessair in the wall and typically a signal is de-tectable some15minafterbloodhasbeenreleased to the prothesis. It is thus pos-sible to monitor for example the flow ina temporary axillary artery graft used toperfuse visceral arteries while perform-ing more extensive reconstructions [21].Also, after renal artery reconstructions itis crucial to know that the flow has beenrestored to the kidneys. Inmost cases it isfast and easy to ensure this with a TTFMbut perioperative ultrasound is a valu-able tool as well. Routine measurementof SMA flow after thrombectomy maybe life saving and if not routine, at leasta low threshold to confirm the vesselswith a perioperative angiography shouldbe practiced [22].

Conclusion

There is no single optimal method forperioperative quality control and the in-formation from several methods is ad-ditive. The practical recommendation isthat TTFM completion control can andshould be utilized at the end of virtuallyeveryopenorhybridvascularsurgicalop-eration. It is the only method that easilyand relatively reliably measures the de-sired endpoint with reconstructions andflow to the end organ. It’s capacity todetect low flow states is good, althoughno clear cut-off values are available. Fur-ther diagnosis should oftenbe performed

with other methods, such as re-exposi-tion, perioperative ultrasound or angiog-raphy. There is a clearpaucityof scientificdata to guide clinical decisions.

Corresponding address

Prof. Dr. P. VikatmaaDepartment of vascularsurgery, Helsinki UniversityHospital, HUSPB 340, 00019 Helsinki,FinlandPirkka.Vikatmaa@hus.fi

Compliance with ethicalguidelines

Conflict of interest. P. Vikatmaa is the treasurer ofthe European Society for Vascular Surgery. P. VikatmaaandA. Albäckdeclare that theyhave no competinginterests.

This article does not contain any studieswith humanparticipants or animals performedby anyof the au-thors.

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