Copyright ©2008, 2009, 2013, 2015. Novadaq Technologies Inc. All rights reserved.

Printed in the United State of America. Volume 4

SPY Atlas – Volume 4

PINPOINT Endoscopic, high definition white light with on-demand fluorescence imaging.

SPY EliteReal-time fluorescence imaging system for use in open surgery.

LUNA Fluorescence angiography for wound healing and outpatient clinic procedures.

Dedication

This ATLAS is dedicated to the hundreds of thousands of patients and their physicians who have benefited from the use of NOVADAQ’s fluorescence imaging technology and the hospitals who have realized the associated cost savings.

Open SurgerySPY ELITE Intra-operative Fluorescence Imaging

Cardiovascular SugeryCoronary Artery Bypass Graft Carotid Artery Open EndarterectomyCarotid Artery Bypass GraftTemperal to Cerebral Artery Bypass GraftFemoral Popliteal Bypass GraftAbdominal Aneurysm Repair

Breast SurgerySkin Sparing MastectomyNipple Sparing MastectomyBreast Reduction Inferior T-approach

Breast ReconstructionImmediate Tissue Expander/ImplantDelayed Tissue Expander/ImplantDeep Inferior Epigastric Perforator FlapSuperior Gluteal Artery Perforator FlapTrans Rectus Abdominous Myocutaneous FlapTransverse Upper Gracilis FlapLatissimus Flap

Other Microvascular Surgery & ReconstructionParamedian Forehead Pedicle FlapForearm to Hand Pedicle FlapVertical Rectus Abdominous MuscleAnterior Lateral Thigh FlapScapular FlapFibular FlapForearm to Great Toe FlapGastocnemius Muscle FlapMaxillofacial ReconstructionFacial Reanimation

Colon, Rectal & Abdominal SurgerySigmoid ColectomyRight Hemi-ColectomyIschemic Bowel Ostomy RevisionColon ReattachmentComplex Hernia RepairCompartmental Separation

Trauma & Laceration RepairHand SurgeryThoracic SurgeryLung RespectionEsophagectomySentinel Lymph Node Mapping

Wound HealingLUNA Fluorescence Angiography

Chronic Wound ManagementDiabetic Foot UlcerVenous Stasis UlcerPressure UlcerPyoderma GangrenosumSurgical Wound DehiscenceChronic Wound DebridementLimb Salvage & Level of Amputation

Acute Wound ManagementSoft Tissue Traumatic WoundOrthopedic Traumatic WoundPost Mohs- Surgery WoundComplex Open Abdominal WoundBurnsGangreneFournier GangreneNecrotizing FasciitisAcute Wound DebridementLimb SalvageLevel of Amputation

Wound Procedure AssessmentsPre and Post AmputationPre and Post Vascular InterventionPre and Post Hyperbaric Oxygen TherapyPre and Post Application of Skin SubstitutePre and Post Inset of Skin Graft or Flap

Minimally Invasive Surgery PINPOINT Endoscopic Fluorescence Imaging

Colorectal Laparoscopic SurgeryLow Anterior ResectionTransanal Anastomosis AssessmentSigmoid ColectomyTransverse ColectomyRight Hemi-ColectomyLeft Hemi- ColectomyTrans-total Mesorectal ExcisionTAMIS/TATA/TEMSTotal Colectomy

One Solution, Endless Applications

General SurgeryCholecystectomyColostomy Creation & RevisionIlleostomyIschemic Bowel ResectionInguinal Hernia RepairAbdominal Wall RepairNissan Fundoloplication RevisionParaesophageal HerniaEndocrine Surgery • Parathyroid • Total Thyroid • SNL Mapping of ThyroidBile Duct Sentinel Lymph Node GastrectomyAbdominal Wound Dehiscence & EviscerationHiatal HerniaSmall Intestine CancerVentral HerniaVagotomy

Hepatobiliary SurgeryLiver ResectionLiver MetastasesDistal PancreatectomyWhippleTotal PancreatectomyBile Duct Reconstruction

Thoracic SurgeryLung Resection or VATSEsophagectomySnetinel Node MappingLung Transplant

Pelvic FloorEndometrial Cancer ResectionCervical Cancer ResectionVulvectomySentinel Lymph Node Mapping*Vaginal Cuff DehisanceLaparoscopic HysterectomiesMyomectomyOopherectomy

Bariatric SurgeryGastric Sleeve Gastric BypassGastric Sleeve or Bypass RevisionBiliopancreatic Diversion with a Duodenal SwitchGastric Plication

TransplantLiverKidneyPancreas

Urological SurgeryPartial NephrectomyRadical NephrectomySentinel Lymph Node Mapping of the ProstateRadical NephroureterectomyAdrenalectomyRetroperitoneal Lymph Node DissectionCystectomy

Expanded ApplicationsFracture Repair • talar neck fractures, scaphoid fractures, hip/shoulder/knee fracturesOrthopedic Conditions • slipped capital femoral epiphysis, kienbocks disease, osteochondral defects, idiopathic AVN of knee, humeral headArthritis EvaluationMeniscal/Labral Perfusion AssessmentTendon Perfusion AssessmentRotator Cuff Assessment Orthopedic Oncology & Tumor Margin Assessment • Giant cell tumor • Chondroblastoma • Synovial cell carcinoma • PVNSKnee arthroscopy/Knee reconstruction Shoulder arthroscopy/Shoulder Reconstruction/replacementHip Arthroscopy/Reconstruction/ReplacementAnkle Arthroscopy/Reconstruction/ReplacementTraumaPediatric Orthopedic Applications

Lymph EdemaLymph Channel and Node Mapping*Lymph Node Transfer*

Trauma & Laceration RepairHand SurgeryThoracic SurgeryLung RespectionEsophagectomySentinel Lymph Node Mapping

Wound HealingLUNA Fluorescence Angiography

Chronic Wound ManagementDiabetic Foot UlcerVenous Stasis UlcerPressure UlcerPyoderma GangrenosumSurgical Wound DehiscenceChronic Wound DebridementLimb Salvage & Level of Amputation

Acute Wound ManagementSoft Tissue Traumatic WoundOrthopedic Traumatic WoundPost Mohs- Surgery WoundComplex Open Abdominal WoundBurnsGangreneFournier GangreneNecrotizing FasciitisAcute Wound DebridementLimb SalvageLevel of Amputation

Wound Procedure AssessmentsPre and Post AmputationPre and Post Vascular InterventionPre and Post Hyperbaric Oxygen TherapyPre and Post Application of Skin SubstitutePre and Post Inset of Skin Graft or Flap

Minimally Invasive Surgery PINPOINT Endoscopic Fluorescence Imaging

Colorectal Laparoscopic SurgeryLow Anterior ResectionTransanal Anastomosis AssessmentSigmoid ColectomyTransverse ColectomyRight Hemi-ColectomyLeft Hemi- ColectomyTrans-total Mesorectal ExcisionTAMIS/TATA/TEMSTotal Colectomy *SPY imaging technologies are not yet approved for commercial use for lymph node mapping.

Acknowledgements

NOVADAQ’s global mission supports the extraordinary shift towards accountable care and value based care delivery. NOVADAQ empowers medical professionals and hospitals by providing clinically relevant, point-of-care imaging to enhance the lives of patients and their caregivers, while reducing healthcare costs. NOVADAQ’s mission aligns completely with the goals of todays healthcare environment. By partnering with thought leaders in medicine, NOVADAQ will continue to be the global leader in providing fluorescence imaging solutions. Novadaq acknowledges the following physicians for their contribution to the creation of the SPY fluorescence imaging technology Atlas, Volume 4.

George Andros, MD - Valley Presbyterian HospitalZane Atkins, MD - Veterans Administration Medical CenterChristopher Attinger, MD - Georgetown University HospitalOvunc Bardakcioglu, MD – UMC Hospital, Las Vegas, NevadaRobert Beart, MD – University of Southern CaliforniaW. Douglas Boyd, MD – Cleveland Clinic FloridaBrian Coan, MD - Duke University Medical CenterThomas Davenport, MD - Winthrop University HospitalChristopher Dress, MD - Eglin Air Force BasePatrick B. Garvey, MD – MD AndersonGeoffrey Gurtner, MD - Stanford HospitalChet Hammill, MD – Oregon Clinic, Portland, ORGeorge Hassler, MD– Froedtert Medical College of WisconsinJonathan Isaacs, MD - Virginia Commonwealth University Medical CenterGlyn Jones, MD - University of Illinois College of Medicine at PeoriaDavid Josephson, MD – Maimonides Medical CenterJason Lee, MD - Stanford HospitalL. Scott Levin, MD - Duke University Medical CenterJeff Marcus, MD - Duke University Medical CenterJoseph Martz, MD – Mt. Sinai Beth Israel, New York, NYMarga Massey, MD - Roper HospitalDerek Muehrcke, MD – Flagler HospitalFarzad Nahai, MD - Piedmont HospitalMartin Newman, MD and Michel Samson, MD - Cleveland Clinic FloridaNinh Nguyen, MD, FACS – University of California, Irvine Medical CenterLorenzo Pacelli, MD - Scripps Green HospitalR. Parakh, MD - Medanta Medicity Medical CenterAlessio Pigazzi, MD, San Diego CA Abu-Rustum, MD – Memorial Sloan-Kettering Cancer Center, New York, NYMichel Samson, MD - Cleveland Clinic FloridaSubhro K. Sen, MD - Stanford HospitalDanny Sherwinter, MD, FACS – Maimonides Medical Center, New York, NYVijay Singh, MD, and Lawrence Colen, MD - Sentara HospitalDavid Taggart, MD – John Radcliff HospitalApostolos Tassiopoulos, MD – Stony Brook University Medical CenterMargaret Thompson, MD - Cleveland Clinic FloridaMark T. Villa, MD - MD Anderson Cancer CenterAli Zarrinpar, MD, PhD – Ronald Reagan UCLA Medical Center, Los Angeles, CAMichael Zenn, MD - Duke University Medical Center

State of the art white light with on-demand fluorescence imaging

NOVADAQ technologies enable surgeons to go beyond the visual boundaries of the human eye. With an emphasis on innovation and collaboration with the medical community, NOVADAQ provides clinically relevant technologies that assist physicians in achieving improved patient outcomes and decreased healthcare costs.

Endoscopic Fluorescence Imaging

The PINPOINT Endoscopic Fluorescence Imaging System combines — into a single laparoscopic platform — the latest in high-definition white-light video with SPY Fluorescence Imaging, resulting in bright, clear images that evolve a surgeon’s operating room experience.

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FIREFLY delineation of tumorous tissue versus normal parenchyma

Parenchymal perfusion and tumor excision under white-light

Images copyright David Josephson, MD – Maimonides Medical Center

Clinical Pathway:70-year-old male with an incidental right lower pole renal mass detected on a work-up for abdominal pain and confirmed via CT. Renal function was otherwise normal.

FIREFLY Imaging Interpretation:The first image shows a the renal tumor under normal white-light conditions. The second image depicts the same mass following selective uptake of ICG by the tumorous tissue.

Clinical and Other Considerations:FIREFLY imaging provides three separate functions during the conduct of robotic partial nephrectomy. It first aids in the rapid identification of the renal vessels. It then allows for precise segmental cross-clamping, thereby reducing the warm ischemic injury typically associated with full cross-clamping. It further aids in the real-time identification of the tumor itself, aids in protection of the tumor capsule during dissection and thus may help avoid a positive margin.

Laparoscopic Robotic-Assisted Partial Nephrectomy with FIREFLY Fluorescence Imaging

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FIREFLY confirms adequate perfusion of the staple line, a critical component in the prevention of anastomotic complications

Conventional division of rectum via white-light visualization

Images courtesy Alessio Pigazzi, MD, San Diego CA

Clinical Pathway:63-year-old female with confirmed rectal cancer.

FIREFLY Imaging Interpretation:The first image shows the stapler dividing the rectum below the level of the tumor. The second image displays complete resection of the diseased tissue in the deep pelvis, while simultaneously confirming reduced compression/clamping stress and adequate perfusion into the staple line.

Clinical and Other Considerations:The availability of adequate tissue perfusion through an uncompromised local blood supply is potentially the most critical technical factor in creating a viable colorectal anastomosis. Prior to creating the anastomosis, the divided ends must be definitively assessed for signs of ischemia. Fluorescence angiography via FIREFLY provides confirmation of blood flow to the distal margins of resection lines.

Assessment of Rectal Resection Staple Line in Robotic CRS

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PINPOINT clearly demonstrates poor perfusion

Distal bowel under white-light shows uniform appearance of tissue

Images courtesy of Danny A .Sherwinter, MD FACS, Brooklyn, NY

Clinical Pathway:68-year-old male undergoing a right hemicolectomy for cancer.

PINPOINT Imaging Interpretation:The first image shows extracorporeal bowel under white-light visualization. All tissue appears uniform, healthy and well-perfused. The second image shows the exact same view with PINPOINT fluorescence imaging, clearly demonstrating significant tissue ischemia.

Clinical and Other Considerations:Based on clinical parameters and direct visual appearance, the distal bowel was felt to have normal perfusion. PINPOINT was used to evaluate perfusion and there was a clear hypofluorescence of the distal bowel. As per the observational IRB protocol in place at the time, no change in anastomosis was performed. The patient had a prolonged postoperative course culminating in a frank anastomotic dehiscence, sepsis and emergent return to the OR. He required multiple returns to the OR for washouts, which prolonged his initial hospital course greater than 1 month. He also required subsequent rehab admission for the prolonged deconditioning and intubation. He was readmitted for reversal of his ostomy (necessitated by the leak) and a large ventral hernia closure.

Laparoscopic Colorectal Surgery

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PINPOINT fluorescence clearly identifies an aberrant/anomalous duct, otherwise undetected under conventional visualization

White-light image of standard “Critical View of Safety” dissection

Images contributed by Danny Sherwinter, MD – Maimonides Medical Center

Clinical Pathway:28-year-old female with a history of biliary colic and ultrasonographic evidence of cholelithiasis undergoing laparoscopic cholecystectomy. Prior to induction under general anesthesia, 1cc of ICG was injected intravenously.

PINPOINT Imaging Interpretation:The first image shows a conventional white-light view of dissection. The second image shows the more definitive “Critical View of Safety” achievable via PINPOINT fluorescence.

Clinical and Other Considerations:Common bile duct injury during cholecystectomy ranks among the leading sources of medical malpractice claims against surgeons. Misidentification of biliary structure is a leading cause of major bile duct injury. Anomolous ductal anatomy of the biliary system has been reported in up to 23% of cases. Near-infrared cholangiography via PINPOINT produces an anatomic road map of the hepatocystic triangle superior to conventional white-light dissection and without the cost, complexity and risk of standard intraoperative cholangiography.

Identification of Aberrant/Anomalous Biliary Anatomy During Laparoscopic Cholecystectomy

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Gastric conduit and esophagus post-anastomosis

Mucosal layer of the esophagus

Images contributed by Ninh Nguyen, MD, FACS – University of California, Irvine Medical Center

Clinical Pathway:Anastomotic leaks are not uncommon in esophagectomy and are a devastating, often life-threatening, complication.

PINPOINT Imaging Interpretation:In the top image, PINPOINT gives the surgeon the ability to assess the inner mucosal layer of the esophagus which will be critical to the viability of his finished anastomosis.

The second image shows that the PINPOINT system also allows the surgeon to assess perfusion of the gastric conduit and the esophagus after completion of the anastomosis.

Clinical and Other Considerations:Being able to assess perfusion of the mucosal layer of the esophagus and/or gastric conduit could be critical to a viable anastomosis. PINPOINT provides the surgeon with conventional HD visualization during mobilization and division of the stomach and esophagus; the ability to optimize intraoperative assessment of perfusion to the gastric conduit and mobilized esophagus; a tool to assess perfusion post-anastomosis between the distal esophagus and gastric conduit; and a way to identify various critical landmarks prior to or during mobilization/division of the gastric conduit and esophagus. As a result, assessment of gastric perfusion with PINPOINT may result in fewer anastomotic leaks.

Minimally Invasive EsophagectomyIvor-Lewis Technique

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PINPOINT visualization of Triangle of Calot

Images contributed by Danny Sherwinter, MD, FACS – Maimonides Medical Center, New York, NY

Clinical Pathway:The Triangle of Calot (or Critical View of Safety) is an important landmark that must be identified early in the procedure in order to avoid injury to the common bile duct.

PINPOINT Imaging Interpretation:Since ICG is metabolized in the liver and excreted in the bile, this PINPOINT Mode image clearly shows the Triangle of Calot, made up of the cystic and hepatic ducts.

Clinical and Other Considerations:The ability to toggle between PINPOINT Mode and White Light Mode during dissection/division of the gallbladder enables the surgeon to reduce unintentional damage to critical anatomical structures or tissue due to misidentification. PINPOINT also assists the surgeon in identifying anomalous ducts or structures that may be extremely difficult to identify with standard white light visualization.

Laparoscopic Cholecystectomy

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Triangle of Calot in CSF Mode

Triangle of Calot in PINPOINT Mode

Images contributed by Ali Zarrinpar, MD, PhD – Ronald Reagan UCLA Medical Center, Los Angeles, CA

Clinical Pathway:Although infrequent, common bile duct injury (CBD) can be a devastating complication of laparoscopic cholecystectomy. Intraoperative cholangiography has been shown to assist surgeons in early recognition of CBD injury, but this procedure requires prolonged OR time, exposure to ionizing radiation, and increased procedure costs.

PINPOINT Imaging Interpretation:In the first image, even in PINPOINT mode, the cystic and hepatic ducts are not particularly obvious.

In the second image, by switching to CSF Mode, the bile ducts become more identifiable.

Clinical and Other Considerations:The PINPOINT CSF imaging modality enables surgeons to visualize the degree of perfusion in tissue and anatomical structures through qualitative color mapping.

Laparoscopic CholecystectomyColor Segmented Fluorescence (CSF) Mode

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Transanal PINPOINT Mode

Transanal White Light Mode

Clinical Pathway:Bowel mucosa may be more susceptible than serosa to minor alterations in blood flow, therefore, transanal imaging with PINPOINT can be used as a more sensitive test for bowel ischemia.

PINPOINT Imaging Interpretation:This first image shows a white light image of the LAR anastomosis through Novadaq’s Disposable Rigid Scope Introducer via the transanal cavity.

The second image shows a PINPOINT Mode image of the LAR anastomosis showing good perfusion on the colonic and rectal sides of the anastomosis.

Clinical and Other Considerations:The PINPOINT system and Disposable Rigid Scope Introducer provide the ability to see the rectal mucosa, anastomotic staple line and colonic mucosa in high definition white light, as well as the ability to use near infrared fluorescence imaging to assess perfusion. In this case, the use of the PINPOINT system indicates that the anastomotic site has good perfusion with no indications of ischemia.

Low Anterior ResectionTransanal View of Anastomosis

Images contributed by Joseph Martz, MD – Mt. Sinai Beth Israel, New York, NY

18Images contributed by Chet Hammill, MD – Oregon Clinic, Portland, OR

Liver post-transection

Liver pre-transection

Clinical Pathway:The goal of a liver resection is to remove the tumor(s) and the appropriate surrounding liver tissue without leaving any tumor behind. In this case, the surgeon clamped the vessels into the segment of liver which contained the tumor, then injected indocyanine green (ICG) systemically to show where the well perfused liver tissue stopped.

PINPOINT Imaging Interpretation:In the first image, we see a definite line of demarcation. The surgeon is using a cauterization unit to mark where he will resect.

In the second image we see the liver post-transection. This shows a transmural view of the resected area, and ICG is clearly visible throughout.

Clinical and Other Considerations:Even though the goal of a liver resection is to remove all of the tumor, in an otherwise healthy liver, it is imperative that the surgeon leaves enough functioning liver for the patient to survive. Being able to isolate the affected liver segment and then using PINPOINT to identify well-perfused liver tissue and vasculature, is a valuable tool in this procedure.

Liver ResectionHepatic Cancer

19Images contributed by Joseph Martz, MD – Mt. Sinai Beth Israel, New York, NY

Externalized colon prior to transection

Clinical Pathway:With many laparoscopic colon resections, since the specimen will have to be removed through a small incision in the abdomen anyway, surgeons prefer to externalize the colon prior to the proximal transection in order to examine the area under direct vision.

PINPOINT Imaging Interpretation:This image shows the surgeon holding a bovie at the area of planned transection with the PINPOINT scope held above the abdomen.

Clinical and Other Considerations:If the surgeon prefers to examine the colon extracorporeally prior to the proximal transection, PINPOINT can still be used to indicate the best areas of perfusion. In this case, the surgeon was able to verify that his planned transection margin was at the exact line of demarcation verified by PINPOINT fluorescence imaging.

Low Anterior ResectionExternalized Colon Prior to Proximal Transection

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Left pelvic lymphatic trunks with indocyanine green fluorescence imaging after a cervical injection to map endometrial cancer.

Indocyanine green injected into the cervix, leading into a right external iliac sentinel lymph node

Sentinel lymph node (SLN) mapping after cervical indocyanine green (ICG) injection.

Images contributed by Abu-Rustum, MD – Memorial Sloan-Kettering Cancer Center, New York, New York

Clinical Pathway:Sentinel lymph node (SLN) mapping is an image- guided procedure that is well established in the treatment of cancers, such as melanoma and breast cancer. This approach is based on the concept that lymph drains in an orderly pattern away from the tumor through the lymphatic system; therefore, if the SLN, or first node, is negative for metastasis, then the ensuing nodes should also be negative. SPY and PINPOINT Imaging may be extremely useful in SLN mapping in open and laparoscopic surgeries for endometrial cancer.

PINPOINT Imaging Interpretation:The SLN detection rates using the SPY or PINPOINT imaging technology appear comparable or better than those of blue dye only or radiocolloid.

Clinical and Other Considerations:Many patients will undergo a comprehensive lymphadenectomy despite having disease confined to the uterus, resulting in prolonged operating time, additional cost, and potential side effects, such as lower extremity lymphedema. However, recent studies show that a complete lymphadenectomy may have no therapeutic benefit in patients with early-stage endometrial cancer. Sentinel lymph node mapping, which has been used in other cancer types, may be an acceptable surgical strategy between a complete lymphadenectomy and no nodal evaluation in patients with endometrial cancer.

Sentinel Lymph Node Mapping for Endometrial Cancer

SPY imaging technologies are not yet approved for commercial use for lymph node mapping.

Real-time fluorescence imaging system for use in open surgery.

The SPY Elite Imaging System provides clinically relevant information that empowers surgeons to make better informed critical decisions in the operating room. SPY allows surgeons to capture, review, print and archive high-quality image sequences of blood flow in vessels and micro-vessels, tissue and organ perfusion within minutes and in real-time during the course of performing a wide variety of surgical procedures.

Intra-operative Fluorescence Imaging

NOVADAQ’s SPY fluorescence imaging technology has been shown in more than 150 peer reviewed medical journal articlesto assist surgeons in making more informed informed decisions in the operating room. The use of SPY technologies can add to clinical judgment and may result in lower rates of post-operative complications such as tissue necrosis and anastomotic leaks and lower healthcare costs. SPY Elite is ideal for use in a wide variety of surgeries where the ability to assess the quality of blood flow in vessels and tissue perfusion is critically important and can impact patient outcomes.

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MBF pre-TE

MBF w/TE - No fill volume

MBF w/TE - 250 ml fill volume

MBF 2/TE - 400 ml fill volume

Images contributed by Patrick B. Garvey, MD – MD Anderson

Breast ReconstructionSkin-sparing Mastectomy: Pre and Post Expander

Clinical Pathway:This patient had a unilateral skin-sparing mastectomy followed by an immediate breast reconstruction with a tissue expander and subsequent implant.

SPY Imaging Interpretation:In the first image, the mastectomy has been completed, and the surgeon is using a marking pen to designate the poorly perfused areas along the skin edge which will be debrided prior to insertion of the tissue expander.

The second image was captured after insertion of the expander and closure of skin, but no fill volume had been added to the expander. Good generalized perfusion is noted throughout the mastectomy flap. The dark area along the suture line is caused by the tautly pulled subcuticular suture used for closure.

The third image shows the tissue expander filled with 250 ml of volume, which is a little more than half of the anticipated fill volume. Again, we see good perfusion throughout the tissue.

In this fourth image, the expander has been filled with 400 ml, and the skin of the mastectomy flap continues to look well perfused.

Clinical and Other Considerations:SPY imaging allowed the surgeon to assess perfusion within the mastectomy flap at several critical points during the procedure.

• It is not uncommon in a skin-sparing mastectomy for the skin to be thinned out to the point that perfusion is compromised. SPY, enabled the surgeon the ability to debride poorly perfused areas of the skin flap prior to inserting the expander, thereby helping him optimally fashion his flap early in the procedure.

• Use of SPY after insertion of the expander and the ability to image at different fill volumes also allows the surgeon to evaluate the tissue to be sure the pressure from the expander itself is not compromising perfusion to the skin. If the images reveal that the volume may not be ideal, adjustments can be made and volumes can be reduced.

25Images contributed by Geoffrey Gurtner, MD - Stanford Hospital

Pt. 2 – Nipple-Sparing – Improved perfusion after TE aspiration

Pt. 2 – Nipple-Sparing – Poor perfusion after TE insertion

Pt. 1 – Nipple-Sparing – Pre-op mapping

Clinical Pathway:These two patients were having unilateral nipple-sparing mastectomies with tissue expander and subsequent implant.

SPY Imaging Interpretation:In the first image, we see the surgical oncologist using a marking pen to map the vascularity of the nipple-areolar complex (NAC).

The second image of a different patient was captured after insertion of the expander and closure of skin, and we can see that the amount of fluid in the expander has compromised perfusion to the area.

The third image of the same patient was captured after 30 ml of saline was aspirated from the expander. Note improvement in perfusion.

Clinical and Other Considerations:SPY imaging allowed the surgeon to assess perfusion within the mastectomy !ap at several critical points during the procedure.

• It is not uncommon in a skin-sparing mastectomy for the skin to be thinned out to the point that perfusion is compromised. SPY, enabled the surgeon the ability to debride poorly perfused areas of the skin !ap prior to inserting the expander, thereby helping him optimally fashion his !ap early in the procedure.

• Use of SPY after insertion of the expander and the ability to image at different fill volumes also allows the surgeon to evaluate the tissue to be sure the pressure from the expander itself is not compromising perfusion to the skin. If the images reveal that the volume may not be ideal, adjustments can be made and volumes can be reduced.

Mastectomy FlapNipple-Sparing: Pre and Post Expander

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DIEP Flap Inset

DIEP/Thoraco-dorsal Anastomoses

DIEP Flap Skin Insitu

DIEP Perforator A/V Pedicle Insitu

Images contributed by Michel Samson, MD - Cleveland Clinic Florida

Clinical Pathway:This patient underwent unilateral DIEP flap reconstruction 12 years post-mastectomy and 1 year post gastic bypass procedure with subsequent 75 pound weight loss.

SPY Imaging Interpretation:The first image shows the DIEP flap insitu with direct visualization of excellent perfusion through the artery and vein of the skeletonized pedicle.

The second image of the same insitu flap a few moments later, looking at the skin side showing excellent flow into the subdermal plexus out to the edges of the flap.

The third image shows the completed anastomoses and perfusion through the thoraco-dorsal artery and vein into the DIEP artery and vein.

The fourth image was taken through the skin after closure of incision. Brisk filling of the underlying subdermal plexus was noted throughout the flap, as well as into the surrounding native tissue.

Clinical and Other Considerations:The first two images in this study show not only excellent perfusion through the selected pedicle but also more than adequate perfusion throughout the flap, so there is no question regarding filling of particular zones.

The last two images, showing flow through the completed anastomoses and sequential filling of the flap and surrounding native tissue, help allay any concerns regarding venous stasis.

Breast ReconstructionBreast: Deep Inferior Epigastric Perforator (DIEP)

27Images contributed by Michael Zenn, MD - Duke University Medical Center

SGAP Inset – Skin

SGAP Inset – Gluteal A/V to LIM A/V

SGAP A/V Pedicle Insitu

SGAP – Perforator ID

Clinical Pathway:A SGAP flap is considered when the patient’s body habitus does not lend itself to a DIEP flap. (For example, patients who are very athletic or very thin, as well as patients who have had previous abdominal surgery which would preclude consideration of a DIEP.)

SPY Imaging Interpretation:The first image shows the surgeon identifying the brightest perforators through the skin of the gluteal muscle.

The second image shows excellent flow through the arterial/venous pedicle while the gluteal flap is still insitu.

The third image again shows excellent flow after the anastomoses between the gluteal artery and vein and the left internal mammary artery and vein have been completed.

The fourth image shows perfusion through the skin out to the distal tip of the flap after inset but before skin closure.

Clinical and Other Considerations:In this particular case, the surgeon had marked the skin to design the flap prior to using SPY. Once SPY imaging was used to identify the best perforators, however, a brighter perforator was noted just outside of the marked area. Consequently, the planned incision was altered to incorporate the better perfused tissue.

Breast ReconstructionBreast: Superior Gluteal Artery Perforator (SGAP)

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Lt. Breast Reduction – Complete

Rt. Breast Reduction – Complete

Rt. Breast Reduction Pedicle

Images contributed by Farzad Nahai, MD - Piedmont Hospital

Clinical Pathway:This case shows the use of SPY imaging on a repeat breast reduction surgery on an African-American patient.

SPY Imaging Interpretation:The first image shows immediate perfusion throughout the pedicle and surrounding tissue of the right breast. The surgeon was particularly concerned about the vascularity around the areola area, in light of the previous reduction surgery.

The second image was captured after completion of the right breast reduction. Brisk perfusion is noted throughout the subdermal plexus in the breast and areola.

The third image shows the completed reduction of the left breast. Again, excellent perfusion is noted throughout the areola area, breast, and surrounding tissue.

Clinical and Other Considerations:During this repeat breast reduction, the surgeon found the SPY images to be of the highest quality, even in light of the patient’s darker skin tones. SPY also allowed the surgeon to determine that tissue perfusion had not been compromised by the original breast reduction surgery.

Breast ReconstructionInferior T Approach

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Inset latissimus with TE

Irradiated breast flap post-mastectomy

Images contributed by Mark T. Villa, MD - MD Anderson Cancer Center

Pedicled Flap ReconstructionBreast: Latissimus Flap

Clinical Pathway:A latissimus flap might be considered over other flaps, because the procedure may be safer for some patients who are high-risk candidates for the TRAM procedure (e.g. obese patients, diabetics and smokers), the blood supply is highly dependable, the flap is relatively easy to raise and shape, and this option does not cause weakness of the abdominal muscles.

SPY Imaging Interpretation:The first image shows an irradiated breast flap post-mastectomy.

The second image shows the inset latissimus flap with tissue expander in place..

Clinical and Other Considerations:SPY imaging gave this surgeon the added confidence of seeing good perfusion in the mastectomy flap in a breast that had been previously irradiated.

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TRAM – Post-op photo – necrosis

TRAM – Mastectomy flap

TRAM – Flap insitu

Images contributed by Glyn Jones, MD - University of Illinois College of Medicine at Peoria

Clinical Pathway:The advantages of a pedicled TRAM flap include: an uninterrupted blood supply to the tissue used for reconstruction, no insertion of foreign materials into the body, and a shorter operative time, since the microsurgical techniques necessary for a free flap are not required.

SPY Imaging Interpretation:In this first image the superficial vessels have been dissected and the chosen perforators selected. We see the surgeon’s finger showing the division point where poor perfusion is noted to the right section of the flap. This area will be debrided.

The second image shows the mastectomy flap prior to inset of the TRAM. We see darker areas to the upper right and lower left of the incision.

This third image is a postoperative photograph showing areas of necrosis which directly correlated with the darker areas noted on the post-mastectomy SPY image.

Clinical and Other Considerations:In this case, the surgeon went with his clinical judgment regarding perfusion to the mastectomy flap and did not debride tissue that showed less perfusion on the SPY images. The postoperative photograph shows the end result.

Pedicled Flap ReconstructionBreast: Transverse Rectus Abdominis Myocutaneous (TRAM) Flap

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Completed Paramedian Forehead Flap – Good Flow

Completed Paramedian Forehead Flap – No Flow

Images contributed by Christopher Dress, MD - Eglin Air Force Base

Clinical Pathway:This procedure involved rotating a pedicled paramedian forehead flap to perform a nasal reconstruction.

SPY Imaging Interpretation:

After the first SPY image showed no perfusion to the nasal flap, the surgeon inspected the superior aspect of the flap and noted several stitches impeding arterial flow.

The second image was captured after the surgeon loosened two stitches and showed excellent perfusion throughout the flap.

Clinical and Other Considerations:SPY imaging allowed the surgeon to immediately identify, correct, and document a situation which significantly improved perfusion to the newly fashioned flap while still in the operating room.

Pedicled Flap ReconstructionHead and Neck: Paramedian Forehead

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Pedicled forearm flap – Inset to thumb

Pedicled forearm flap – Insitu

Images contributed by Jonathan Isaacs, MD - Virginia Commonwealth University Medical Center

Clinical Pathway:This was a traumatic injury requiring a pedicled forearm flap to the thumb in a diabetic patient.

SPY Imaging Interpretation:The first SPY image shows the forearm flap insitu.

The second SPY image shows the flap after inset into the thumb.

Clinical and Other Considerations:In this case, the diabetes, as well as the trauma of the injury itself, could potentially compromise perfusion in the surrounding tissue. With SPY, the surgeon was able to verify perfusion throughout the procedure.

Pedicled Flap ReconstructionExtremity: Forearm to Hand

33

Pt. 2 – VRAM – Completed – No Perfusion

Pt. 1 – VRAM – Completed

Pt. 1 – VRAM – Insitu

Images contributed by Martin Newman, MD and Michel Samson, MD - Cleveland Clinic Florida

Clinical Pathway:These images show pedicled Vertical Rectus Abdominus Muscle (VRAM) flaps on two separate patients following Abdominal Perineal Resection.

SPY Imaging Interpretation:The first image of the VRAM flap insitu, shows excellent perfusion through the deep epigastric perforator artery and vein throughout the flap prior to rotation for inset into the perineum.

The follow-up image after inset again shows excellent perfusion throughout the flap and surrounding tissue after skin closure.

The third image shows a different patient who was returned to the operating room several days after initial placement of a VRAM flap. We see perfusion into the surrounding tissue of the buttocks but no perfusion into the flap. It was necessary for this flap to be excised and replaced with a Gracilus flap.

Clinical and Other Considerations:The comparison of these two patients shows how important it is for the surgeon to be completely confident intra-operatively that the flap has good perfusion. We cannot begin to calculate the physical and emotional stress for a patient who is already in a compromised state of health after an Abdominal Perineal Resection to require a second reconstructive procedure because of flap failure. (To say nothing of the financial burden placed on the hospital by a return to the operating room.)

Pedicled Flap ReconstructionExtremity: Vertical Rectus Abdominus Muscle (VRAM)

34

TUG – Inset flap

TUG – Flap insitu

TUG – Perforator ID

Images contributed by Marga Massey, MD - Roper Hospital

Clinical Pathway:The TUG flap uses tissue from the inner upper thigh near the natural groin crease. This is usually done in patients who do not have adequate skin and tissue in the abdomen or buttocks region, or have had previous abdominal surgery that might interfere with vessels that would normally perfuse a DIEP flap. The ideal patient for a TUG flap is someone with small breasts who does not require a significant amount of volume for reconstruction.

SPY Imaging Interpretation:The first image shows perforator identification in order to design the flap.

The second image shows the flap still insitu but well perfused throughout.

The third image shows the inset flap.

Clinical and Other Considerations:It is particularly important in this type of flap to be able to determine the best perfused areas prior to harvest, as the flap area of a TUG is relatively small.

Free Flap with Microvascular ReconstructionBreast: Transverse Upper Gracilis (TUG) Flap

35

Inset ALT Flap – Nose/Lips

Inset ALT Flap Below Eye

ALT Flap Insitu

Images contributed by Brian Coan, MD - Duke University Medical Center

Clinical Pathway:This young woman presented with a parotid gland tumor which had invaded her left orbit. Because the patient refused an enucleation, the surgical plan consisted of soft tissue reconstruction along with a special denture which would replace the excised bone.

SPY Imaging Interpretation:The first SPY image shows the thigh and excellent perfusion throughout the ALT flap while still insitu.

The second and third images were taken within a few seconds of each other showing excellent perfusion of the inset flap, just below the left eye and beside the nose and lips, after skin closure.

Clinical and Other Considerations:The ALT flap is frequently used for facial reconstruction, because it is thin enough and has a large enough surface area that it can be used to cover extensive defects. Variability of thigh vasculature, however, can be a problem. SPY imaging can help avoid this problem by aiding in determination of the most prominent perforator vessels.

Free Flap with Microvascular ReconstructionHead and Neck: Anterior Lateral Thigh (ALT) to Cheek

36

Scapular Flap Inset

Scapular Flap Inset – Anastomoses

Scapular Flap Insitu

Scapular Flap Perforator ID

Images contributed by Michael Zenn, MD – Duke University Medical Center

Free Flap with Microvascular ReconstructionHead and Neck: Scapular Flap to Jaw

Clinical Pathway:In this case a section of scapula was harvested to replace the central portion of the mandible. The corresponding skin paddle attached to the scapula would be used to cover the area at closure.

SPY Imaging Interpretation:The first image shows identification of the brightest perforators as the flap is initially designed.

The second image shows perfusion into a section of scapula which has been chiselled out to be used as a portion of the newly fashioned mandible.

The third image shows excellent flow through the newly anastomosed vessels at inset of the flap and good perfusion into the surrounding tissue.

The fourth image shows the scapula flap in the mandible position with the plate about to be screwed in. Again, good perfusion is seen throughout the newly implanted section, as well as the surrounding area. The skin paddle will cover this entire area at closure.

Clinical and Other Considerations:The corresponding skin paddle associated with this flap will have to cover a relatively large area at closure, so being able to determine prior to incision where the best perforators are is a great advantage for the surgeon. It is also very helpful to be able to see which sections of the scapula seem to have the best perfusion prior to chiselling out the necessary length.

37

Free fibular – Inset flap

Free fibular – Fibula and skin paddle insitu

Images contributed by Lorenzo Pacelli, MD - Scripps Green Hospital

Clinical Pathway:This patient was having a reconstruction associated with a radical neck procedure.

SPY Imaging Interpretation:The first SPY image shows the fibula and skin paddle insitu.

The second SPY image shows the fibula flap after inset. Good perfusion is noted throughout the flap as well as the newly anastomosed vessels.

Clinical and Other Considerations:Whenever it is necessary to take bone and tissue, it is important to image both components of the flap, since it is possible for the bone to be well perfused and the skin paddle not survive.

Free Flap with Microvascular Reconstruction Head and Neck: Fibular

38

Forearm Flap Inset Great Toe - Distal Tip

Forearm Flap Inset Great Toe

Forearm Flap Insitu

Forearm Flap Perforator ID

Images contributed by L. Scott Levin, MD - Duke University Medical Center

Clinical Pathway:This procedure involved harvesting a free forearm flap for reconstruction to a great toe after the patient suffered an infection following bunion surgery.

SPY Imaging Interpretation:The first image shows pre-incision identification of the most prominent perforator vessels in the forearm, thereby assisting the surgeon in designing the flap.

The second image shows verification of adequate perfusion throughout the flap prior to harvesting.

The third image shows verification of adequate perfusion following microvascular reconstruction and inset of the flap; the proximal end being closer to the tip of the great toe.

The fourth image shows less robust filling of the distal tip of the flap after inset into the great toe.

Clinical and Other Considerations:Although the surgeon was comfortable with perfusion throughout the flap, the slightly darker area at the distal tip after inset was noted, and this area was monitored closely postoperatively to verify adequate perfusion.

Free Flap with Microvascular ReconstructionExtremity: Forearm to Great Toe

39

Gastrocnemius Flap Inset w/Skin Graft

Gastrocnemius Flap Inset

Tibial Lesion

Images contributed by Brian Coan, MD - Duke University Medical Center

Clinical Pathway:This patient had a pre-tibial skin lesion which required a wide excision down to the bone. The surgical plan was to replace the excised area with a gastrocnemius muscle flap and cover the flap with a skin graft.

SPY Imaging Interpretation:The first image shows the skin lesion and perfusion into the surrounding tissue.

The second image shows the inset gastrocnemius muscle flap with excellent perfusion throughout the muscle.

The third image was taken after the skin graft was placed at closure. Again, excellent perfusion is noted throughout the underlying muscle.

Clinical and Other Considerations:Since the defect left by this type of excision can vary depending on the type and extent of the lesion in question, it is helpful to the surgeon to be able to use SPY to fashion a flap which will meet the needs of each individual patient.

Free Flap with Microvascular ReconstructionExtremity: Gastrocnemius Muscle

40

Gracilis Flap Inset – A/V Anastomoses

Gracilis Flap Insitu

Gracilis Flap/Pedicle Insitu

Images contributed by Jeff Marcus, MD - Duke University Medical Center

Clinical Pathway:This 11 year old, male patient presented with right sided facial paralysis that occurred secondary to brain tumor excision several years prior. The left side of his face was unaffected. Six months prior to this operation, the child underwent a sural nerve grafting procedure. This extension of the facial nerve from the right side of the face had been placed between the nose and the upper lip.

SPY Imaging Interpretation:The first image shows excellent perfusion throughout the pedicled gracilis flap insitu. The gracilis muscle was dissected out and the pedicle, which included the median cutaneous circumflex femoral artery and vein and the obturator nerve, was identified.

The second image shows the gracilis muscle after it had been split into two sections but was still insitu. Better perfusion was noted into the upper section.

The third image showed excellent perfusion through the newly constructed arterial and venous anastomoses, even though a doppler signal had been questionable and a venous revision was being considered prior to this image.

Clinical and Other Considerations:During this challenging case, SPY imaging was particularly helpful at two critical points:

• The surgeon was able to see better perfusion into the upper section of the gracilis muscle while it was still insitu.

• The surgeon was also able to visualize excellent perfusion through his completed anastomoses, when, moments before, he had been considering revising the venous anastomosis secondary to a questionable doppler signal.

At both of these points in the procedure, SPY imaging played an important role in the surgical decision-making process by helping the surgeon pick the better section of muscle for the flap and by avoiding an unnecessary anastomotic revision.

Myocutaneous Flap ReconstructionGracilis Facial Reanimation

41

SLN – Sentinel Node Insitu

SLN – Axillary Dissection

SLN – Breast – Pre-incision

Images contributed by Margaret Thompson, MD - Cleveland Clinic Florida

Clinical Pathway:In many mastectomy cases a sentinel lymph node biopsy is also performed. Lymph node mapping is done by the patient having a radioactive tracer injected several hours prior to surgery and/or methylene blue injected around the areola prior to incision. The tracer and the dye will travel through the lymph system to the sentinel node. A gamma probe can be used to detect a signal in the axilla and the methylene blue will turn the sentinel node dark blue, thus making it easier to identify.

SPY Imaging Interpretation:This first image was taken through the skin 20 minutes after a concentrated dose of fluorescing agent was injected intradermally around the areola of the left breast. We see very bright fluorescence around the areola and a trail of fluorescence running from the injection site up toward the axilla.

The second image was taken 35 minutes after the initial injection, during the node dissection. We see bright fluorescence in the axilla.

The third image shows the fluorescing sentinel node prior to resection.

Clinical and Other Considerations:To be able to identify a sentinel node intra-operatively without having the patient require a nuclear medicine visit would not only save time and stress for the patient, but would also save the facility the cost associated with injection of a radioactive tracer.

Lymph NodeSentinel Lymph Node Biopsy with Mastectomy - Axilla

SPY Imaging technology is not yet approved for lymph mapping in the United States.

42

Image showing good flow through the SVG graft to native LAD

Image showing no flow through the LIMA graft to native LAD

Images contributed by David Taggart, MD – John Radcliff Hospital

Clinical Pathway:This patient underwent coronary artery bypass surgery (CABG) to revascularize a totally occluded left anterior descending (LAD) artery using the left internal mammary artery (LIMA).

SPY Imaging Interpretation:The first image shows no blood flow through the LIMA graft, because the graft was placed proximal to the LAD occlusion. The second image shows good flow through a saphenous vein graft placed distal to the LAD occlusion. The proximal end of this vein was attached to the previously anastomosed LIMA, which was too short to be repositioned distal to the occlusion.

Clinical and Other Considerations:Successful LIMA to LAD bypass grafts are predictive of survival post CABG. SPY imaging allowed the surgeon to assess blood flow to the graft and native coronary arteries. Since the patient remained stable throughout the CABG procedure, the surgeon would have had no idea that there was no flow through the LIMA graft and, more importantly, that the graft was improperly placed virtually rendering the bypass ineffective.

Coronary Artery Bypass Graft SurgeryLIMA to LAD: Misplaced and Occluded Graft

43Images contributed by W. Douglas Boyd, MD – Cleveland Clinic Florida

Image showing some flow to the distal coronary after the removal of the stents and placement of the LIMA graft

Image shows 11 occluded metal stents leaving no free space for a bypass graft.

Clinical Pathway:49 year old male patient was emergently admitted to the operating room for coronary artery bypass graft (CABG) surgery after a failed attempt to revascularize a totally occluded left anterior descending (LAD) artery in the catherterization laboratory using drug eluding stents (DES). During the interventional procedure, 11 DES were placed in the LAD.

SPY Imaging Interpretation:The first image shows occlusion of the 11 drug eluding stents in the LAD and no distal flow to the native coronary vessels. The image also shows no place in the native LAD free of the stents, which made the placement of a bypass graft impossible without stent removal. The second image shows the LAD distribution after removal of the stents and placement of a LIMA graft.

Clinical and Other Considerations:SPY imaging enabled the surgeon to confirm that it would be necessary to remove the previously placed stents in order to revascularize the LAD distribution with a bypass graft. Post stent removal SPY imaging confirmed blood flow through the bypass graft to the distal coronary artery and heart muscle.

Coronary Artery Bypass Graft SurgeryFollowing failure to revascularize the LAD using 11 drug eluting stents

44

Carotid – Post-endarterectomy

Carotid – Pre-endarterectomy

Images contributed by Derek Muehrcke, MD – Flagler Hospital

Clinical Pathway:Stenosis of the carotid artery is sometimes treated by carotid endarterectomy.

SPY Imaging Interpretation:The first image shows the exposed carotid prior to endarterectomy with a darker area to the right of the silastic band showing the stenotic area.

The second image shows the carotid post-endarterectomy with good flow throughout the vessel.

Clinical and Other Considerations:The use of SPY imaging in carotid cases gives the surgeon documentation of improved flow through this artery, as well as being a useful tool to determine if carotid spasm is an issue post-endarterectomy.

Vascular ProceduresCarotid Artery

45

Completed Temporal to Cerebral Bypass

Middle Cerebral Artery Circulation Prior to Bypass

Images contributed by Vijay Singh, MD, and Lawrence Colen, MD - Sentara Hospital

Clinical Pathway:This patient, who was not a candidate for carotid endarterectomy, had suffered several light strokes, so the temporal artery bypass was done to increase cerebral blood supply.

SPY Imaging Interpretation:This first image shows the native temporal artery circulation.

The second image shows the completed temporal artery to middle cerebral artery bypass.

Clinical and Other Considerations:Since this patient was not a candidate for carotid endarterectomy, it was particularly useful to the surgeons to be able to evaluate the temporal circulation as an alternative therapy. The key in this case is that SPY replaced the use of an intraoperative arteriogram to assess the quality of the end-to-side anastomosis performed.

Vascular ProceduresSuperficial Temporal to Middle Cerebral Artery Bypass

46

Post resection image shows well perfused colon tissue

Image indicates large area of ischemia

Images contributed by Robert Beart, MD – University of Southern California

Clinical Pathway:On the 3rd post operative day, a coronary artery bypass graft surgery patient was emergently admitted to the operating room with symptoms of severe abdominal pain and distention indicative of post-operative ischemic bowel. The surgeon chose to use SPY imaging to assess perfusion throughout the lower GI tract.

SPY Imaging Interpretation:The first image shows a very large area of ischemia surrounded by normally perfused tissue. Using the SPY image to guide the resection, the surgeon was able to resect the entire ischemic area, while preserving as much normal tissue as possible.

The second image was taken post resection and shows evenly, well perfused colon tissue.

Clinical and Other Considerations:SPY imaging enabled the surgeon to remove the diseased tissue, while retaining as much healthy tissue as possible. Preserving healthy tissue is critical in ensuring a return to normal bowel function.

Gastrointestinal Surgery – Post-operative Ischemic Bowel Resection

47

After manipulation of the conduit and anastomosis to the cervical esophagus, excellent perfusion continued to be observed

Excellent perfusion was observed in the gastric conduit

Images contributed by George Hassler, MD– Froedtert Medical College of Wisconsin

Clinical Pathway:65 year old patient presented with a history of a perforated esophagus resulting in an esophagectomy that became contaminated. Four months later, after intense antibiotic therapy and a long hospitalization, the patient underwent a delayed esophageal reconstruction procedure. Because of the significant delay between the original surgery and the reconstruction, the surgeon was concerned that the gastric conduit might not be viable. The surgeon had the plastic surgery team standing by to perform a colon interposition procedure should the conduit not be suitable for use.

SPY Imaging Interpretation:The first image showed a well perfused gastric conduit suitable for use in the reconstruction procedure.

Following manipulation and anastomosis of the conduit to the cervical esophagus, the second SPY image showed excellent perfusion in the conduit and native tissue.

Clinical and Other Considerations:SPY imaging enabled the surgeon to confirm that optimal perfusion continued to be present in the conduit and native tissue; and therefore was able to avert the interposition procedure.

Gastrointestinal Surgery – Delayed Esophageal Reconstruction Following Contamination

48Images contributed by Ovunc Bardakcioglu, MD – UMC Hospital, Las Vegas, Nevada

Proximal transection with anvil in place

Clinical Pathway:The surgeon has already performed the proximal and distal transections, and the anvil is in place in preparation for completion of the anastomosis.

SPY Imaging Interpretation:This image shows the proximal transection line with the anvil already inserted immediately prior to completion of the anastomosis.

Clinical and Other Considerations:The national average for anastomotic leaks after low anterior resection is about 12.6%. Although tension on the staple line and surgical technique contribute to this issue, it is well documented that poor perfusion in the area of the anastomosis is a very significant factor. By using SPY in this procedure, the surgeon is able to document good perfusion to the staple lines prior to anastomosis, which allows him to feel confident that ischemia will not be a problem.

Low Anterior ResectionImmediately Prior to Anastomosis

Fluorescence Angiography for Perfusion Assessment in Wound Management

NOVADAQ technologies enable physicians to go beyond the visual boundaries of the human eye. With an emphasis on innovation and collaboration with the medical community, NOVADAQ provides clinically relevant technologies that assist physicians in achieving improved patient outcomes and decreased healthcare costs.

LUNA Fluorescence angiography provides clinicians with a reliable and comprehensive visual and quantitative assessment of tissue perfusion in the wound-care setting.

Fluorescence Angigography

LUNA is indicated to provide fluorescent images for the visual assessment of blood flow in vessels and related tissue perfusion during cardiovascular surgical procedures. Examples of its use in cardiovascular applications include confirming blood flow through the peripheral vasculature and extremities. LUNA has been shown to provide critical fluorescence angiographic information related to the quality of tissue perfusion that may assist physicians in determining the best treatment in patients who are being treated in an outpatient wound care center.

52

BKA post-op skin closure

BKA pre-amputation SPY Q

BKA pre-amputation

Images contributed by Apostolos Tassiopoulos, MD – Stony Brook University Medical Center

Clinical Pathway:This African-American patient presented with progressing gangrene after previous amputation of toes. The surgeon used SPY imaging to help determine a viable level for a below the knee amputation.

LUNA Imaging Interpretation:The first image is a pre-amputation image of the lower leg.

The second image shows quantification in a color overlay of the previous image displaying relative numerical values associated with perfusion.

The last image shows how the longer posterior flap has been brought up anteriorly to close the wound, and good perfusion is seen throughout the post-amputation stump.

Amputation Secondary to GangreneEvaluation of a Lower Leg on an African-American Patient to Determine Level of Amputation

53

Chest Wound – SPY Q analysis in OR

Chest Wound – Skin closure in OR

Images contributed by Zane Atkins, MD - Veterans Administration Medical Center

Clinical Pathway:The LIMA is generally accepted as the graft of choice for revascularization of the Left Anterior Descending artery during Coronary Artery Bypass Graft (CABG) surgery. Harvesting the LIMA, however, always runs the risk of depleting the blood supply to the sternum enough to delay wound healing postoperatively.

LUNA Imaging Interpretation:This first SPY image was taken prior to leaving the operating room after a CABG procedure. Perfusion on the right side of the chest is brisk and evenly distributed throughout the chest wall. The left side of the chest, however, shows very slow, patchy perfusion by comparison.

The second image is a SPY Q analysis of the first image showing a color overlay and the relative numbers associated with the perfusion on both sides of the closed incision.

Chest WoundPostoperative Evaluation of Perfusion to Chest after Left Internal Mammary Artery (LIMA) Harvest

54

Sternal Incision – 48 hours post-op

Sternal Incision – Skin closure in OR

Images contributed by Zane Atkins, MD - Veterans Administration Medical Center

Clinical Pathway:In another example of perfusion to the chest after CABG surgery, this patient exhibited poor perfusion to the left side of the chest after the sternal skin incision was closed, and the surgeon chose to apply Wound V.A.C. therapy in the immediate post-operative period.

SPY Imaging Interpretation:The first SPY image was taken in the operating room immediately after the skin incision was closed. We see a significant difference between perfusion to the right and left sides of the chest.

The second SPY image was taken 48 hours post-operatively at the patient’s bedside. Based on the intra-operative image taken two days earlier, the surgeon applied a Wound V.A.C. before the patient left the operating room, and we now see a dramatic improvement in perfusion to the left side of the chest.

Post CABG Sternal Incision HealingBefore and After Application of Wound V.A.C.

55

Decubitus – Surrounding skin

Decubitus – Sacral ulcer

Images contributed by Thomas Davenport, MD - Winthrop University Hospital

Clinical Pathway:Care for hospital-acquired pressure ulcers is no longer reimbursed by Medicare. However, many patients are admitted to the hospital, with tissue injury (Stage I) that will soon progress to an open ulcer (Stage II – IV). Since prevention is in large part the best treatment for pressure ulcers, it is to the hospital’s advantage to be able to determine the integrity of the skin of an “at risk” patient upon admission. SPY imaging gives the physician an opportunity to monitor the hyperaemic characteristics of an impending ulcer at any pressure point.

LUNA Imaging Interpretation:The first image shows a sacral ulcer that has lost its eschar and the hyperaemia of the surrounding skin.

The second image is from the same video as the first image, but it has been panned away from the ulcer to show where the perfusion to the skin is starting to normalize.

Decubitus UlcerEvaluation of Sacral Decubitus Ulcer

56

Diabetic Foot – SPY Q medial view

Diabetic Foot – before further debridement

Images contributed by Christopher Attinger, MD - Georgetown University Hospital

Clinical Pathway:This African-American patient, with longstanding diabetes, was brought back to the operating room for debridement of necrotic tissue after a previous amputation of toes. The surgeon requested LUNA imaging in an effort to determine the level of viable tissue.

LUNA Imaging Interpretation:The first image shows the sole of the foot with good perfusion up to the level of the previous amputation.

The second image is a SPY Q analysis of the foot from a more medial view. The red and yellow areas show good perfusion throughout the remaining skin of the foot, but the surgeon’s concern involved the underlying tissue from the previous amputation. His concern was verified by the blue areas and associated numbers showing significantly poorer perfusion.

Diabetic Foot Debridement of Diabetic Foot after Previous Amputation of Toes

57

Post-stenting – SPY Q Image dorsal area of R foot – marked improvement of perfusion R foot except the 4th metatarsal

Pre-stenting – R foot poorly perfused dorsal area including 4th metatarsal - no perfusion. Medial plantar view - poor perfusion

Images contributed by R. Parakh, MD - Medanta Medicity Medical Center

Clinical Pathway:This 56-year old female presented with right foot ischemia, with notable ulceration to the tip of the right great toe. She has a medical history of Type II Diabetes, hypertension, and claudication of right leg with complaints of pain and simultaneous numbness and tingling with difficulty in walking. She was referred to the vascular surgeon and podiatrist for further consultation and was then admitted to the hospital for an angioplasty of the right leg. The surgeon requested fluorescence imaging using LUNA technology in an effort to determine the adequacy of perfusion to the surrounding tissues immediately prior to the intervention and post-stent placement, to determine the level of improvement.

LUNA Imaging Interpretation:

For the first image, 5ml of indocyanine green (ICG) was injected through a peripheral IV. As the sequence was being captured, the surgeon was able to mark the ischemic region noted on the dorsal side of the foot – notably the 4th metatarsal area, where no perfusion was seen. Additionally, there was slow filling and ischemia of the medial plantar area of the foot.

After the angioplasty and placement of 2 stents to the right femoral artery, another sequence was captured (using another 5ml injection of ICG through a peripheral IV) to verify perfusion to the right foot. Considerable improvement to the dorsal and plantar region of the foot was noted except for the 4th metatarsal that remained ischemic.

Diabetic Foot StentingEvaluation of Circulation to Diabetic Right Foot

58

Heel Ulcer – Rt. heel ulcer

Heel Ulcer – Rt. lower leg

Images contributed by Christopher Attinger, MD - Georgetown University Hospital

Clinical Pathway:This 66-year old Caucasian male, with a more than 40 year history of diabetes mellitus, presented with a Stage IV heel ulcer on his right foot. Clinical assessment indicated the need for an amputation. Following a traditional angiographic procedure, the surgeon became concerned that perfusion to the patient’s right lower leg might not sustain adequate post-operative perfusion to the stump following a below the knee amputation (BKA), so an above the knee amputation (AKA) was being considered. In an effort to make this determination prior to scheduling the procedure, LUNA imaging was performed at the bedside with the patient awake. The fluorescence agent, indocyanine green, was administered through a peripheral IV.

LUNA Imaging Interpretation:The first 60-second image focused on assessment of fluorescence throughout the posterior right lower leg. The image demonstrated excellent tissue perfusion.

A second image of the Stage IV foot ulcer reveals bone completely exposed in the heel of the foot with good perfusion seen at most wound margins.

Clinical and Other Considerations:Spy imaging provided excellent images of perfusion in the lower leg enabling the surgeon to make a more informed decision. He was able to more confidently perform a BKA instead of an AKA. This outcome could give the patient a much better quality of life, as it is well documented that a BKA will always give the patient the best chance of remaining mobile and walking post-operatively.

Diabetic Heel UlcerEvaluation of Stage IV Heel Ulcer to Determine Level of Amputation

59

Right Femoral Popliteal Post Bypass – SPY Q Image Post Arterial Bypass of right foot

Right Femoral Popliteal Pre Bypass – SPY Q Image Pre Arterial Bypass of right foot

Images contributed by Dr. George Andros - Valley Presbyterian Hospital

Clinical Pathway:This 81 yr old male with Type 1 diabetes was admitted to hospital for right foot ischemia. He was scheduled for a right femoral popliteal bypass to restore circulation to his right leg and foot. The surgeon requested LUNA to capture the images of the patient’s right foot before and after his intervention to assess the difference in perfusion.

LUNA Imaging Interpretation:Separate 5ml injections of ICG were administered through a peripheral IV for the pre-intervention sequence. Blood pressure notations were documented for both sequences. The surgeon attempted to maintain the same orientation of the foot for comparison.

The post operative SPY Q image shows increased perfusion throughout the plantar surface of the right foot.

Diabetic Leg and FootPre and Post Assessment of Perfusion Following Femoral Popliteal Bypass

60

Right Foot Revascularization with Right Femoral Stent Placement – Post Stent SPY Q Image of right foot

Right Foot Revascularization without Right Femoral Stent Placement – Pre Stent SPY Q Image of right foot

Images contributed by Dr. Jason Lee - Stanford Hospital

Clinical Pathway:This 71-year old male, S/P CABG and aorto-bifemoral replacement, was admitted for right foot ischemia. A right femoral stenting in Interventional Radiology was ordered along with LUNA imaging. The surgeon requested LUNA to immediately detect the difference in perfusion after stent placement.

LUNA Imaging Interpretation:SPY sequences were captured prior to and immediately following stent placement. 5 ml of ICG through a peripheral IV were used for both the pre and post sequence. The blood pressure was noted for the pre and post sequence, and orientation of the right foot was maintained for comparison.

The post stent SPY Q image shows improved uniform perfusion to the plantar surface of the right foot.

Great Toe UlcerRight Foot Revascularization with Right Femoral Stent Placement

61

Hand Avulsion – marking for debridement

Hand Avulsion – back of hand

Hand Avulsion – palmar view

Images contributed by Subhro K. Sen, MD - Stanford Hospital

Clinical Pathway:This 23-year old male patient suffered an avulsion of the right hand after an explosion involving fireworks. Besides a large laceration to the central area of his hand, he also lost portions of his thumb, 3rd, 4th, and 5th fingers. The surgeon used LUNA imaging to verify how much debridement would be necessary prior to the reconstruction procedure.

LUNA Imaging Interpretation:The first image shows the surgeon examining the hand before any debridement to verify areas of poor perfusion.

The second image shows the back of the hand and perfusion around the laceration.

The third image shows the surgeon using a marking pen to indicate tissue that will need to be debrided.

Hand AvulsionDebridement and Partial Reconstruction of Right Hand after Traumatic Avulsion

62

Necrotizing Fasciitis – post-debridement

Necrotizing Fasciitis – pre-debridement

Images contributed by Subhro K. Sen, MD - Stanford Hospital

Clinical Pathway:This 42-year old male, in otherwise good health, sustained a small laceration to the right leg and subsequently developed necrotizing fasciitis to the lower leg and foot. The patient had a previous debridement of the medial side of the right lower leg and was admitted to hospital before this procedure for intensive IV antibiotic therapy prior to further debridement of the right ankle and foot. The surgeon requested SPY imaging in an effort to determine the adequacy of perfusion to the surrounding tissues.

SPY Imaging Interpretation:The first image shows the surgeon using a marking pen to outline the dark, poorly perfused area affected by the necrotizing fasciitis.

The second image shows the wound after debridement, verifying that all necrosed areas have been excised and perfusion to the surrounding and underlying tissue is good.

Necrotizing FasciitisEvaluation of Right Lower Leg and Foot for Debridement Secondary to Necrotizing Fasciitis

63

Raynaud’s – After amputation

Raynaud’s – Pre-op – Poor perfusion

Images contributed by Lorenzo Pacelli, MD - Scripps Green Hospital

Clinical Pathway:This patient suffered from Raynaud’s Disease with subsequent impaired perfusion to the tips of the fingers on the right hand.

LUNA Imaging Interpretation:The first LUNA image shows poor perfusion to the tips of the digits on the right hand.

The second LUNA image shows the hand after amputation of the distal tips of the digits.

Clinical and Other Considerations:LUNA imaging can be used to determine the extent of vascular compromise in any number of peripheral vascular problems like Raynaud’s.

Raynaud’s Disease

Cardio-Thoracic Surgery

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6. Coles C; Taggart D; Choudhary B; Abu-Omar Y; Balacumaraswami L; Pigott D. The use of a novel imaging technique to evaluate patency of coronary grafts. Anaesthesia 2003; 58:304.

7. Takahashi M; Ishikawa T; Higashidani K; Katoh H. SPY™: an innovative intra-operative imaging system to evaluate graft patency during off-pump coronary artery bypass grafting; Interactive Cardiovascular and Thoracic Surgery 2004; 3:479-483.

8. Reuthebuch O; Kadner A; Lachat M; Kunzli A; Schurr UP; Turina MI. Early bypass occlusion after deployment of nitinol connector devices. The Journal of Thoracic and Cardiovascular Surgery 2004; 127(5):1421-1426.

9. Reuthebuch O; Haeussler A; Genoni M; Tavakoli R; Odavic D; Kadner A; Turina M. Novadaq Spy* Intraoperative Quality Assessment in Off-Pump Coronary Artery Bypass Grafting. Chest 2004; 125:418-424.

10. Balacumaraswami L; Taggart DP; Digital Tools to Facilitate Intraoperative Coronary Artery Bypass Graft Patency Assessment; Seminars in Thoracic and Cardiovascular Surgery 2004; 16(3):266-271.

11. Balacumaraswami L; Abu-Omar Y; Anastasiadis K; Choudhary B; Pigott D; Yeong SK; Taggart DP. Does off-pump total arterial grafting increase the incidence of intraoperative graft failure? The Journal of Thoracic and Cardiovascular Surgery 2004; 238-244.

12. Yasuda T; Watanabe G; Tomita S. Transaortic injection technique in fluorescence imaging: Novel intraoperative assessment of anastomosis in off-pump coronary artery bypass grafting. The Journal of Thoracic and Cardiovascular Surgery 2005; 130(2):560-561.

13. Desai ND; Miwa S; Kodama D; Cohen G; Christakis GT; Goldman BS; Baerlocher MO; Pelletier MP; Fremes SE. Improving the Quality of Coronary Bypass Surgery with Intraoperative Angiography. Journal of the American College of Cardiology 2005; 46(8):1521-1525.

14. Balacumaraswami L; Abu-Omar Y; Choudhary B; Pigott D; Taggart DP. A comparison of transit-time flowmetry and intraoperative fluorescence imaging for assessing coronary artery bypass graft patency. The Journal of Thoracic and Cardiovascular Surgery 2005; 130(2):315-320.

15. Desai ND; Miwa S; Kodama D; Koyama T; Cohen G; Pelletier MP; Cohen EA; Christakis GT; Goldman BS; Fremes SE. A randomized comparison of intraoperative indocyanine green angiography and transit-time flow measurement to detect technical errors in coronary bypass grafts. The Journal of Thoracic and Cardiovascular Surgery 2006; 132(3):585-594.

16. Balacumaraswami L; Taggart D. Intraoperative Imaging Techniques to Assess Coronary Artery Bypass Graft Patency. Annals of Thoracic Surgery 2007; 83(6):2251-2257.

BibliographySPY Technologies for Open and Minimally Invasive Imaging

17. Waseda K; Ako J; Hasegawa T; Shimada Y; Ikeno F; Ishikawa T; Demura Y; Hatada K; Yock PG; Honda Y; Fitzgerald PJ; Takahashi M. Intraoperative Fluorescence Imaging System for On-Site Assessment of Off-Pump Coronary Artery Bypass Graft. JACC: Cardiovascular Imaging 2009; 2(5):604-612

18. Taggart DP; Balacumaraswami L; Venkatapathy A. Radial Artery Jump Graft from Anterior to Posterior Descending Coronary Artery. Asian Cardiovascular & Thoracic Annals 2009; 17(2):143-146.

19. Kogon B; Fernandez J; Kanter K; Kirshborn P; Vincent B; Maher K; Guzetta N. The Role of Intraoperative Indocyanine Green Fluorescence Angiography in Pediatric Cardiac Surgery. The Annals of Thoracic Surgery 2009; 88(2):632-636.

20. Singh SK; Desai ND; Chikazawa G; Tsuneyoshi H; Vincent J; Zagorski BM; Pen V; Moussa F; Cohen GN; Christakis GT; Fremes SE. The Graft Imaging to Improve Patency (GRIIP) clinical trial results. The Journal of Thoracic and Cardiovascular Surgery 2010; 139(2):294-301.

21. Bir SC, Pattillo CB, Pardue S, Kolluru GK, Docherty J, Goyette D, Dvorsky P, Kevil CG. Nitrite anion stimulates ischemic arteriogenesis involving NO metabolism. Am J Physiol Heart Circ Physiol. 2012 Jul;303(2):H178-88. Epub 2012 May 18. PubMed PMID: 22610173.

22. Ferguson TB, Chen C, Babb JD, Efird JR, Daggubati R, Cahill JM. Fractional flow reserve-guided coronary artery bypass grafting: Can intraoperative physiologic imaging guide decision making? J Thorac Cardiovasc Surg. 146: 4 824-835. October 2013.

23. Pourmoghadam KK, Mills Bunnell AP, O’Brien MC, DeCampli WM. Avoiding Coronary Injury in Congenital Heart Surgery by Laser-Assisted Indocyanine Green Dye Imaging. World J Pedi Cong Heart Surg. Vol. 5(2) 326-329, 2014.

24. Pardolesi A, Veronesi G, Solli P, Spaggiari L. Use of indocyanine green to facilitate intersegmental plane identification during robotic anatomic segmentectomy. J Thorac Cardiovasc Surg. Article in Press – 2014.

25. Cahill RA, Mortensen NJ. Intraoperative augmented reality for laparoscopic colorectal surgery by intraoperative near-infrared fluorescence imaging and optical coherence tomography. Minerva Chir. 2010 Aug;65(4):451-62. Review. PubMed PMID: 20802433.

26. Pineda C, Shelton A, Raju N, Welton M. Use of intraoperative fluorescence vascular angiography to assess intestinal perfusion in the creation of intestinal anastomoses. Abstract - 2nd Biennial Meeting of the Eurasian Colorectal Technologies Association (ECTA) Turin, Italy, 15–17 June 2011. Tech Coloproctol (2011) 15:215–253.

27. Cahill RA, Ris F, Mortensen NJ. Near-infrared laparoscopy for real-time intra-operative arterial and lymphatic perfusion imaging. Colorectal Dis. 2011 Nov;13 Suppl 7:12-7. doi: 10.1111/j.1463-1318.2011.02772.x. PubMed PMID: 22098511.

28. Sherwinter D. Transanal Near-Infrared Imaging of Colorectal Anastomotic Perfusion. Surg Laparosc Endosc Percutan Tech. Volume 22, Number 5, October 2012.

29. Jafari MD, Lee KH, Halabi WJ, Mills SD, Carmichael JC, Stamos MJ, Pigazzi A. The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc. Published online: 13 February 2013.

30. Hellan M, Giuseppe S, Pigazzi A, Lagares-Garcia JA. The influence of fluorescence imaging on the location of bowel transection during robotic left-sided colorectal surgery. Surg Endosc. Published online January 3, 2014.

31. Foppa C, Denoya PI, Tarta C, Bergamaschi R. Indocyanine green fluorescent dye during bowel surgery: Are the blood supply “guessing days” over? Tech Coloproctol. Published online February 21, 2014.

32. Ris M, Hompes R, Cunningham C, Lindsey I, Guy R, Jones O, George B, Cahill R, Mortensen NJ. Near-infrared (NIR) perfusion angiography in minimally invasive colorectal surgery. Surg Endo. Published online Feb 25, 2014.

33. Nachiappan S, Askari A, Currie A, Kennedy RH, Faiz O. Intraoperative assessment of colorectal anastomotic integrity: a systematic review. Surg Endosc. Published online April 10, 2014.

34. Gorgun E. Novel anastomotic techniques. Seminars in Colon and Rectal Surgery 25 (2014) 110–116.

35. Jafari MD, Wexner SD, Martz JE, McLemore EC, Margolin DA, Sherwinter, DA, Lee SW, Senagore AJ, Phelan MJ, Stamos MJ. Perfusion Assessment in Laparoscopic Left Sided/Anterior Resection (PILLAR II): A Multi-Institutional Study. JACS. Vol. 220, No. 1, January 2015.

36. Protyniak B, Dinallo AM, Boyan Jr WP, Dressner RM, Arvanitis ML. Intraoperative Indocyanine Green Fluorescence Angiography – An Objective Evaluation of Anastomotic Perfusion in Colorectal Surgery. The American Surgeon. Vol 81. June 2015.

General Surgery

37. Buchs NC, Hagen ME, Pugin, F, Volonte F, Bucher P, Schiffer E, Morel P. Intra-operative fluorescent cholangiography using indocyanin green during robotic single site cholecystectomy. Int J Med Robotics Comput Assist Surg. Volume 8, Issue 4, Article first published online: 31 May 2012.

38. Wang HD, Singh DP. Case Report: The use of indocyanine green angiography to prevent wound complications in ventral hernia repair with open components separation technique. Hernia. 20 June 2012.

39. Sherwinter DA. Identification of Anomolous Biliary Anatomy Using Near-Infrared Cholangiography. J Gastrointest Surg. 2012 Jul 3. [Epub ahead of print] PubMed PMID: 22752550.

40. Spinoglio G, Priora F, Bianchi PP, Lucido FS, Licciardello A, Maglione V, Grosso F, Quarati R, Ravazzoni F, Lenti LM. Real-time near-infrared (NIR) fluorescent cholangiography in singlesite robotic cholecystectomy (SSRC): a single-institutional prospective study. Surg Endosc. 2012 Dec 28.

41. Patel KM, Bhanot P, Franklin B, Albino F, Nahabedian MY. Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction. J Plast Surg Hand Surg, 2013; Early Online: 1–5 ©2013 Informa Healthcare.

42. Daskalaki D, Fernandes E, Wang X, Bianco FM, Elli EF, Ayloo S, Masrur M, Milone L, Giulianotti PC. Indocyanine Green (ICG) Fluorescent Cholangiography During Robotic Cholecystectomy: Results of 184 Consecutive Cases in a Single Institution. Surgical Innovation. 2014.

43. Colavita PD, Wormer BA, Belyansky I, Lincourt A, Getz SB, Heniford BT, Augenstein VA. Intraoperative indocyanine green fluorescence angiography to predict wound complications in complex ventral hernia repair. Hernia. Published online: 18 August 2015.

44. Sound S, Okoh AK, Bucak E, Yigitbas H, Dural C, Berber E. Intraoperative tumor localization and tissue distinction during robotic adrenalectomy using indocyanine green fluorescence imaging: a feasibility study. Surg Endosc. Published online: 22 July 2015.

General Thoracic Surgery

45. Gilmore DM, Khullar OV, Colson YL. Developing intrathoracic sentinel lymph node mapping with near-infrared fluorescent imaging in non-small cell lung cancer. J Thorac Cardiovasc Surg. 2012 Jun 20. [Epub ahead of print] PubMed PMID: 22726707.

46. Wagner OJ, Louie BE, Vallières E, Aye RW, Farivar AS. Near-infrared fluorescence imaging can help identify the contralateral phrenic nerve during robotic thymectomy. Ann Thorac Surg. 2012 Aug;94(2):622-5. doi: 10.1016/j.athoracsur.2012.04.119.

47. Pacheco PE, Hill SM, Henriques SM, Paulsen JK, Anderson RC. The novel use of intraoperative laser-induced fluorescence of indocyanine green tissue angiography for evaluation of the gastric conduit in esophageal reconstructive surgery. Am J Surg. 205: 349-353. March 2013.

48. Gilmore DM, Khullar OV, Jaklitsch MT, Chirieac LR, Frangioni JV, Colson YL. Identification of metastatic nodal disease in a phase 1 dose-escalation trial of intraoperative sentinel lymph node mapping in non–small cell lung cancer using near-infrared imaging. J Thorac Cardiovasc Surg. 146: 3 562-570. September 2013.

49. Zehetner J, DeMeester SR, Alicuben ET, Oh DS, Lipham JC, Hagen JA, DeMeester TR. Intraoperative Assessment of Perfusion of the Gastric Graft and Correlation With Anastomotic Leaks After Esophagectomy. Published ahead of print. Ann Surg 2014;00: 1-5.

50. Campbell C, Reames MK, Robinson M, Symanowski J, Salo JC. Conduit Vascular Evaluation is Associated with Reduction in Anastomotic Leak After Esophagectomy. J Gastrointest Surg. Published online 20 March 2015.

Gynecology and Gynecologic Oncology Surgery

51. Rossi EC; Ivanova A; Boggess JF. Robotically assisted fluorescence-guided lymph node mapping with ICG for gynecologic malignancies: A feasibility study. Gynecologic Oncology 124 (2012) 78–82.

52. Holloway RW, Molero Bravo RA, Rakowski JA, James JA, Jeppson CN, Ingersoll SB, Ahmad S. Detection of sentinel lymph nodes in patients with endometrial cancer undergoing robotic-assisted staging: A comparison of colorimetric and fluorescence imaging. Gynecologic Oncology 126 (2012) 25-29.

53. Rossi EC, Jackson A, Ivanova A, Boggess JF. Detection of Sentinel Nodes for Endometrial Cancer With Robotic Assisted Fluorescence Imaging: Cervical Versus Hysteroscopic Injection. International Journal of Gynecological Cancer. Vol 23, No 9, November 2013.

54. Ansari M, Ghodsi Rad MA, Hassanzadeh M, Gholami H, Yousefi Z, Dabbagh VR, Sadeghi R. Sentinel node biopsy in endometrial cancer: Systematic review and meta-analysis of the literature. Eur J Gynaec Oncol. 2013.

55. Abu-Rustum NR. Sentinel Lymph Node Mapping for Endometrial Cancer: A Modern Approach to Surgical Staging. JNCCN. Focused Review. Vol 12 Number 2, Feb 2014.

56. Jewell EL, Huang JJ, Abu-Rustum NR, Gardner GJ, Brown CL, Sonoda Y, Barakat RR, Levine DA, Leitao MM. Detection of sentinel lymph nodes in minimally invasive surgery using indocyanine green and near-infrared fluorescence imaging for uterine and cervical malignancies. Gynecologic Oncology 133 (2014) 274-277.

57. Plante M, Touhami O, Trinh XB, Renaud MC, Sebastianelli A, Grondin K, Gregoire J. Sentinel node mapping with indocyanine green and endoscopic near-infrared fluorescence imaging in endometrial cancer. A pilot study and review of the literature. Gynecologic Oncology. Uncorrected proof. 2015.

58. Guan X, Tu Anh Nguyen M, WalshTM, Kelly B. Robotic Single-Site Endometriosis Resection Using Firefly Technology. Journal of Minimally Invasive Gynecology. Accepted: 8/1/2015.

59. Rajanbabu A, Venkatesan R, Chandramouli S, Nitu PV. Sentinel node detection in endometrial cancer using indocyanine green and fluorescence imaging – a case report. ecancer 2015, 9:549.

60. Tanner EJ, Sinno AK, Stone RL, Levinson KL, Long KC, Fader AN. Facts associated with successful bilateral sentinel lymph node mapping in endometrial cancer. Gynecologic Oncology. 2015.

61. How J, Gotlieb WH, Press JZ, Abitbol J, Pelmus M, Ferenczy A, Probst S, Gotlieb R, Brin S, Lau S. Comparing indocyanine green, technetium, and blue dye for sentinel lymph node mapping in endometrial cancer. Gynecologic Oncology 137 (2015) 436-442.

Liver and Hepatobiliary Surgery

62. Sekijima M; Tojimbara T; Sato S; Nakamura M; Kawase T; Kai K; Urashima Y; Nakajima I; Fuchinoue S; Teraoka S. An Intraoperative Fluorescent Imaging System in Organ Transplantation. Transplantation Proceedings 2004; 36(7):2188-2190.

63. Kubota K; Kita J; Shimoda M; Rokkaku K; Kato M; Iso Y; Sawada T. Intraoperative assessment of reconstructed vessels in living-donor liver transplantation, using a novel fluorescence imaging technique. Journal of Hepatobiliary Pancreatic Surgery 2006; 13:100-104.

64. Sanchez EQ; Chinnakotla S; Khan T; Nikitin D; Vasani S; Randall HB; McKenna GJ; Ruiz R; Onaca N; Levy MF; Goldstein RM; Docherty JC; Hurd DK; Klintmalm GB. Intraoperative imaging of pancreas transplant allografts using indocyanine green with laser fluorescence. Proceedings (Baylor University Medical Center) 2008; 21(3):258-260.

Plastic and Reconstructive Surgery

65. Tan BKH; Newman MI; Swartz KA; Samson MC. Subfascial Perforator Dissection for DIEP Flap Harvest. Plastic and Reconstructive Surgery 2009; 124(3):1001-1002 [Letter].

66. Pestana IA; Coan B; Erdmann D; Marcus J; Levin LS; Zenn MR. Early Experience with Fluorescent Angiography in Free-Tissue Transfer Reconstruction. Plastic and Reconstructive Surgery 2009; 123(4):1239-1244.

67. Newman MI; Samson MC. The Application of Laser-Assisted Indocyanine Green Fluorescent Dye Angiography in Microsurgical Breast Reconstruction. Journal of Reconstructive Microsurgery 2009; 25(1):21-26.

68. Murray JD; Jones GE; Elwood ET; Whitty LA; Garcia C. Fluorescent Intraoperative Tissue Angiography with Indocyanine Green: The Evaluation of Nipple-Areolar Vascularity during Breast Reduction Surgery. Plastic and Reconstructive Surgery 2009; 124(4 Suppl):60.

69. Jones GE; Garcia CA; Murray J; Elwood ET; Whitty LA. Fluorescent Intraoperative Tissue Angiography for the Evaluation of the Viability of Pedicled TRAM Flaps. Plastic and Reconstructive Surgery 2009; 124(4 Suppl):53.

70. Francisco, BS; Kerr-Valentic, MA; Agarwal, JP. Laser-Assisted Indocyanine Green Angiography and DIEP Breast Reconstruction. Plastic and Reconstructive Surgery – Viewpoints 2010; 125(3): 116e-118e.

71. Mohebali J; Gottlieb LJ; Agarwal JP. Further Validation for Use of the Retrograde Limb of the Internal Mammary Vein in Deep Inferior Epigastric Perforator Flap Breast Reconstruction Using Laser-Assisted Indocyanine Green Angiography. Journal of Reconstructive Microsurgery 2010; 26(2):131-135.

72. Komorowska-Timek E; Gurtner GC. Intraoperative Perfusion Mapping with Laser-Assisted Indocyanine Green Imaging Can Predict and Prevent Complications in Immediate Breast Reconstruction. Plastic and Reconstructive Surgery 2010; 125(4):1065-1073.

73. Jones EG. Bostwick’s Plastic & Reconstructive Breast Surgery Third Edition: Technologic Advances in Breast Surgery. Quality Medical Publishing, Inc. 2010.

74. Newman MI, Samson MC, Tamburrino JF, Swartz KA., Department of Plastic Surgery, Cleveland Clinic Florida, Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction. J Reconstr Microsurg. 2010 Sep;26(7):487-92. Epub 2010 Jun 10.

75. Newman MI, Samson MC, Tamburrino JF, Swartz KA, Brunworth, L. An investigation of the application of laser-assisted indocyanine green fluorescent dye angiography in pedicle transverse rectus abdominus myocutaneous breast reconstruction. Can J Plast Surg Vol 19 No 1 Spring 2011.

76. Brunsworth LS, Samson MC, Newman, MI, Ramirez JR. Nipple-Areola Complex Evaluation in Long Pedicled Breast Reductions with Real-Time Fluorescent Videoangiography. Vol 128 Number 2 585-587 – Letters. Plastic and Reconstructive Surgery. August 2011.

77. Liu DZ, Mathes DW, Zenn MR, Neligan PC. The Application of Indocyanine Green Fluorescence Angiography in Plastic Surgery. J Reconstr Microsurg 2011;27:355-364.

78. Zenn MR. Fluorescent Angiography. Clin Plastic Surg 38 (2011) 293–300.

79. Howard, RT, Valerio, IL, Basile, PL, Nesti, L. The Use of Intraoperative Fluorescent Angiography to Maximize Fasciocutaneous Flap Coverage of Battle Field Extremity Injuries. Supplement to Plastic and Reconstructive Surgery Vol. 128, No. 4 (2011) 79-80. Abstract.

80. Woodward, CR, Most, SP. Intraoperative Angiography Using Laser-Assisted Indocyanine Green Imaging to Map Perfusion of Forehead Flaps. Arch Facial Plast Surg. Published online February 20, 2012.

81. Losken A, Zenn M, Hammel J, Walsh M, Carlson G. Assessment of Zonal Perfusion Using Intraoperative Angiography during Abdominal Flap Breast Reconstruction. Plastic and Reconstructive Surgery. Volume 129, Number 4, April 2012.

82. Phillips B, Lanier S, Conkling N, Wang E, Dagum A, Ganz J, Khan S, Bui D. Intraoperative Perfusion Techniques Can Accurately Predict Mastectomy Skin Flap Necrosis in Breast Reconstruction: Results of a Prospective Trial. Plastic and Reconstructive Surgery. Volume 129, Number 5, May 2012.

83. Moyer H, Losken A. Predicting Mastectomy Skin Flap Necrosis with Indocyanine Green Angiography: The Gray Area Defined. Plastic and Reconstructive Surgery. Volume 129, Number 5, May 2012.

84. Sacks JM, Nguyen AT, Broyles JM, Yu P, Valerio IL, Baumann DP. Near-Infrared Laser-Assisted Indocyanine Green Imaging for Optimizing the Design of the Anterolateral Thigh Flap. ePlasty. 2012;12:e30. Epub 2012 Jul 5.

85. Christensen JM, Baumann DP, Myers JN, Burett, K, Sacks, JM. Indocyanine Green Near-Infrared Laser Angiography Predicts Timing for the Division of a Forehead Flap. ePlasty. Volume 12. August 31, 2012.

86. Bank J, Pavone LA, Seitz IA, Roughton MC, Schecter LS. Case Report and Review of the Literature: Deep Inferior Epigastric Perforator Flap for Breast Reconstruction After Abdominal Recontouring. ePlasty. Volume 12. December 2012.

87. Gurtner GC, Jones GE, Neligan PC, Newman MI, Phillips BT, Sacks JM, Zenn MR. Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use. Ann Surg Innov Res. 2013 Jan 7;7(1):1.

88. Shah A, Au A. Laser-Assisted Indocyanine Green Evaluation of Paramedian Forehead Flap Perfusion Prior to Pedicle Division. ePlasty. Volume 13, pgs 55-61. Feb 18, 2013.

89. Green JM , Thomas S Sabino J, Howard R, Basile P, Dryden S, Crecelius C, Valerio I. Use of Intraoperative Fluorescent Angiography to Assess and Optimize Free Tissue Transfer in Head and Neck Reconstruction. J Oral Maxillofac Surg -:1-11, 2013.

90. Chatterjee A, Krishnan NM, Phil M, Van Vliet MM, Powell SG, Rosen JM, Ridgway EB. A Comparison of Free Autologous Breast Reconstruction with and without the Use of Laser-Assisted Indocyanine Green Angiography: A Cost-Effectiveness Analysis. Plast. Reconstr. Surg. 131: 693e, 2013.

91. Garvey P, Selber JC, Hobaugh CW, Zhang H, Butler CE, Baumann DP. Abstract – 50 – Tissue expander breast reconstructions experience fewer complications when skin flaps are assessed with laser fluorescent angiography rather than clinical judgement alone. PSRC Abstract Supplement. 131: 5 May 2013.

92. Monahan J, Hwang BH, Kennedy JM, Chen W, Nguyen GK, Schooler WG, Wong AK. Determination of a Perfusion Threshold in Experimental Perforator Flap Surgery Using Indocyanine Green Angiography. Ann Plas Surg. 2013.

93. Sood M, Glat P. Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction. Annals of Surgical Innovation and Research. 2013, 7:9 http://www.asir-journal.com/content/7/1/9.

94. Newman MI, Jack MC, Samson MC. SPY-Q Analysis Toolkit Values Potentially Predict Mastectomy Flap Necrosis. Annals of Plastic Surgery. Vol 70, Number 5, May 2013.

95. Wapnir I, Dua M, Kieryn A, Paro J, Morrison D, Kahn D, Meyer S, Gurtner G. Intraoperative Imaging of Nipple Perfusion Patterns and Ischemic Complications in Nipple-Sparing Mastectomies. Ann Surg Oncol. 21:100-106. January 2014.

96. Janes LE, Hui-Chou HG, Matthews JA, Sabino J, Singh DP. Utilization of Near-infrared Indocyanine Green Angiography for Immediate and Delayed Venous Outflow Assessment in Breast Reconstruction: A Case Report. Plast Reconstr Surg Glob Open 2014;2:e100; Published online 28 January 2014.

97. Duggal CS, Madni T, Losken A. An Outcome Analysis of Intraoperative Angiography for Postmastectomy Breast Reconstruction. Aesthetic Surgery Journal 2014 34: 61.

98. Munabi NCO, Olorunnipa OB, Goltsman D, Rohde CH, Ascherman JA. The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: A prospective trial. J of Plast, Reconstr & Aesthetic Surg (2014).

99. Kanuri A, Liu AS, Guo L. Whom Should We SPY? A Cost Analysis of Laser-Assisted Indocyanine Green Angiography in Prevention of Mastectomy Skin Flap Necrosis during Prosthesis-Based Breast Reconstruction. Plast Reconstr Surg. Volume 133, Number 4, 448e-454e. April 2014.

100. Pestana IA, Crantford JC, Zenn MR. Correlation between Abdominal Perforator Vessels Identified with Preoperative Computed Tomography Angiography and Intraoperative Fluorescent Angiography in the Microsurgical Breast Reconstruction Patient. J Reconstr Microsurg. May 6, 2014. Ahead of print.

101. Lee LN, Smith DF, Boahene KD, Byrne PJ. Intraoperative Laser-Assisted Indocyanine Green Imaging for Objective Measurement of the Vascular Delay Technique in Locoregional Head and Neck Flaps. JAMA Facial Plast Surg. doi:10.1001/jamafacial.2014.106 Published online June 5, 2014.

102. Wyles CC, Taunton MJ, Jacobson SR, Tran NV, Sierra RJ, Trousdale RT. Intraoperative Angiography Provides Objective Assessment of Skin Perfusion in Complex Knee Reconstruction. Clinical Orthopaedics and Related Research®. Published online July 9, 2014.

103. Fourman MS, Phillips BT, Fritz JR, Conkling N, McClain SA, Simon M, Dagum AB. Laser-Assisted Indocyanine Green Dye Angiography Accurately Predicts the Split-Thickness Graft Timing of Integra Artificial Dermis. Annals of Plastic Surgery. Vol 73, No 2, August 2014.

104. Phillips BT, Fourman MS, Rivara A, Dagum AB, Huston TL, Ganz JC, Bui DT, Khan SU. Comparing Quantitative Values of Two Generations of Laser-Assisted Indocyanine Green Dye Angiography Systems: Can We Predict Necrosis? ePlasty. Vol 14: 367-377. December 5, 2014.

105. Monahan J, Hwang BH, Kennedy JM, Chen W, Nguyen GK, Schooler WG, Wong AK. Determination of a Perfusion Threshold in Experimental Perforator Flap Surgery Using Indocyanine Green Angiography. Ann Plast Surg 2014; 73: 602-606.

106. Green JM, Sabino J, Fleming M, Valerio I. Intraoperative Fluorescence Angiography: A Review of Applications and Outcomes in War-Related Trauma. Military Medicine, Vol. 180, March Supplement 2015.

107. Valerio I, Green JM, Sacks JM, Thomas S, Sabino J, Acaturk TO. Vascularized Osseous Flaps and Assessing Their Bipartate Perfusion Pattern via Intraoperative Fluorescence Angiography. J Reconstr Microsurg 2015;31:45-53.

108. Taylor SR, Jorgensen JB. Use of Fluorescent Angiography to Assess Donor Site Perfusion Prior to Free Tissue Transfer. The Laryngoscope. 2015.

109. HagopianTM, Ghareeb PA, Arslanian BH, Moosavi BL, Carlson GW. Case Report – Breast Necrosis Secondary to Vasopressor Extravasation: Management Using Indocyanine Green Angiography and Omental Flap Closure. The Breast Journal. 2015 1-4.

110. Surowitz JB, Most SP. Use of Laser-Assisted Indocyanine Green Angiography for Early Division of the Forehead Flap Pedicle. JAMA Facial Plastic Surgery. Published online April 2015.

111. Dua MM, Bertoni DM, Nguyen D, Meyer S, Gurther GC, Wapnir IL. Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies. Gland Surgery 2015.

112. Harless C, Jacobson SR. Current strategies with 2-staged prosthetic breast reconstruction. Gland Surgery, Vol 4, No 3 June 2015.

113. Beckler AD, Ezzat WH, Seth R, Nabill V, Blackwell KE. Assessment of Fibula Flap Skin Perfusion in Patients Undergoing Oromandibular Reconstruction – Comparison of Clinical Findings, Fluorescein, and Indocyanine Green Angiography. JAMA Facial Plast Surg. Published online September 3, 2015

Surgical Oncology

114. Phillips BT, Jain V, Conkling BA, Pameijer C. Abstract - Sentinel lymph Node detection using laser-assisted indocyanine green dye lymphangiography in melanoma & breast cancer patients. 2011 ASCO Annual Mtg. Citation: J Clin Oncol 29: 2011 (suppl; abstr 8587).

115. Heath CH, Deep NL, Sweeny L, Zinn KR, Rosenthal EL. Use of Panitumumab-IRDye800 to Image Microscopic Head and Neck Cancer in an Orthotopic Surgical Model. Ann Surg Oncol. 2012 Jun 6. [Epub ahead of print] PubMed PMID: 22669455.

116. Jain V, Phillips BT, Conkling N, Pameijer C. Sentinel Lymph Node Detection Using Laser-Assisted Indocyanine Green Dye Lymphangiography in Patients with Melanoma. Int J Surg Oncol. 2013; 2013: 904214. Published online Dec 8, 2013.

117. Xiong L, Gazyakan E, Yang W, Engel H, Hunerbein M, Kneser U, Hirche C. Indocyanine green fluorescence-guided sentinel node biopsy: A meta-analysis on detection rate and diagnostic performance. Article in press Eur J Surg Oncol (2014).

118. Korn JM, Tellez-Diaz A, Bartz-Kurycki M, Gastman B. Indocyanine Green SPY Elite–Assisted Sentinel Lymph Node Biopsy in Cutaneous Melanoma. Plast Reconstr Surg. Volume 133, Number 4, 914-922. April 2014.

119. Liss MA, Farchshchi-Heydari S, Qin Z, Hickey SA, Hall, DJ, Kane CJ, Vera DR. Preclinical Evaluation of Robotic-Assisted Sentinel Lymph Node Fluorescence Imaging. J Nucl Med. Published online July 14, 2014.

120. Cloyd JM, Wapnir IL, Read BM, Swetter S, Greco RS. Indocyanine Green and Fluorescence Lymphangiography for Sentinel Lymph Node Identification in Cutaneous Melanoma. J. Surg. Oncol. 2014.

121. Rosenthal EL, Warram JM, Bland, KI, Zinn KR. The Status of Contemporary Image-Guided Modalities in Oncologic Surgery. Ann Surg 2015; 261: 46-55.

122. Daskalaki D, Aguilera F, PattonK, Giulianoti PC. Fluorescence in Robotic Surgery. J Surg Oncol 2015;9999:1-7.

123. Zelken JA, Tufaro AP. Current Trends and Emerging Future of Indocyanine Green Usage in Surgery and Oncology: An Update. Ann Surg Oncol. Published online: 21 July 2015.

Urology

124. Tobis S, Knopf J, Silvers C, Yao J, Rashid H, Wu G, and Golijanin D. Near Infrared Fluorescence Imaging With Robotic Assisted Laparoscopic Partial Nephrectomy: Initial Clinical Experience for Renal Cortical Tumors. The Journal of Urology. Vol. 186, 47-52, July 2011.

125. Tobis S, Knopf J, Silvers C, Marshall J, Cardin A, Wood R, Reeded J, Erturk E, Madeb R, Yao J, Singer E, Rashid H, Wu G, Messing E, Golijanin D. Near Infrared Fluorescence Imaging After Intravenous Indocyanine Green: Initial Clinical Experience With Open Partial Nephrectomy for Renal Cortical Tumors. Urology. 79:958-964.

126. Tobis S, Knopf J, Silvers C, Messing E, Yao J, Rashid H, Wu G, Golijanin D. Robot-Assisted and Laparoscopic Partial Nephrectomy with Near Infrared Fluorescence Imaging. Journal of Endourology. Volume 26, July 2012.

127. Borofsky MS, Gill IS, Hemal AK, Marien TP, Jayaratna I, Krane LS, Stifelman MD. Near-infrared fluorescence imaging to facilitate super-selective arterial clamping during zeroischaemia robotic partial nephrectomy. BJU Int. 2012 Dec 17. doi: 10.1111/j.1464-410X.2012.11490.x.

128. Manny TB, Patel M, Hemal AK. Fluorescence-enhanced Robotic Radical Prostatectomy Using Real-time Lymphangiography and Tissue Marking with Percutaneous Injection of Unconjugated Indocyanine Green: The Initial Clinical Experience in 50 Patients. European Urology. Published online November 2013.

129. Lee Z, Simhan J, Parker DC, Reilly C, Llukani E, Lee DI, Mydlo JH, Eun DD. Novel Use of Indocyanine Green for Intraoperative, Real-time Localization of Ureteral Stenosis During Robot-assisted Ureteroureterostomy. Urology 82 (3), 2013.

130. Manny TB, Hemal AK. Fluorescence-enhanced Robotic Radical Cystectomy Using Unconjugated Indocyanine Green for Pelvic Lymphangiography, Tumor Marking, and Mesenteric Angiography: The Initial Clinical Experience. Urology (4) 83: 824-830, 2014.

131. McClintock TR, Bjurlin MA, Wysock JS, Borofsky MS, Marien TP, Okoro C, Stifelman MD. Can Selective Arterial Clamping With Fluorescence Imaging Preserve Kidney Function During Robotic Partial Nephrectomy? Article in Press. Urology 2014.

132. Siddighi S, Yune JJ, Hardesty J. Indocyanine green for intraoperative localization of ureter. Am J Obstet Gynecol 2014; 211:436.e1-2.

133. Bjurlin MA, McClintock TR, Stifelman MD. Near-Infrared Fluorescence Imaging with Intraoperative Administration of Indocyanine Green for Robotic Partial Nephrectomy. Curr Urol Rep (2015) 16:20.

134. Lee Z, Moore B, Giusto L, Eun DD. Use of Indocyanine Green During Robot-assisted Ureteral Reconstructions. European Urology 67 (2015) 291-298.

Vascular Surgery and Wound Therapy

135. Lepow BD, Perry D, Armstrong D. The Use of SPY Intra-operative Vascular Angiography as a Predictor of Wound Healing. Podiatry Management 141-148 August 2011.

136. Perry D, Bharara M, Armstrong, DG, Mills, J. Intraoperative Fluorescence Vascular Angiography: During Tibial Bypass. Journal of Diabetes Science and Technology. Volume 6, Issue 1, January 2012.

137. Braun JD, Trinidad-Hernandez M, Perry D, Armstrong DG, Mills JL. Early quantitative evaluation of indocyanine green angiography in patients with critical limb ischemia. J Vasc Surg 2013;-:1-6.

138. Ziegler M, Ditslear J, Turner MK, Szotek P. Poster – Intraoperative fluorescence angiography using indocyanine green may predict and may prevent wound complications in complex AWR. AWR conference – Washington DC. June 2013.

139. Schlanger R. Clinical Case Update – Using Fluorescence Angiography to Help Assess Lower Extremity Wounds. Today’s Wound Clinic. Supplement. 2014.

140. Li WW, Arnold J. Imaging of the Chronic Wound and the Emerging Role of Fluorescence Microangiography. Supplement – Today’s Wound Clinic. 2014.

141. Brooks D. Perfusion Assessment with the SPY System after Arterial Venous Reversal for Upper Extremity Ischemia. PRS GO. 2014.

142. Benitez E, Sumpio BJ, Chin J, Sumpio BE. Contemporary assessment of foot perfusion in patients with critical limb ischemia. Seminars in Vascular Surgery 27 (2014) 3-15

143. Fourman MS, Phillips BT, Crawford L, McClain SA, Lin F, Thode Jr HC, Dagum AB, Singer AJ, Clark RA. Indocyanine green dye angiography accurately predicts survival in the zone of ischemia in a burn comb model. Burns 40 (2014) 940-946.

144. Guthrie SD, Guthrie BR. Utilizing Indocyanine Green Wound Imaging in the Management of Hyperbaric Therapy. Today’s Wound Clinic. Oct 2014.

145. Arnold J. Clinical Case Update - Using Fluorescence Microangiography for Timely Assessment of Wound Area Perfusion. Supplement to Today’s Wound Clinic. 2014.

146. Connolly PH, Meltzer AJ, Spector JA, Schneider DB. Indocyanine green angiography aids in prediction of limb salvage in vascular trauma. Annals of Vascular Surgery (Accepted Manuscript) 2015.

Other

147. Zhou Q, Wood R, Schwarz EM, Wang YJ, Xing L. Near-infrared lymphatic imaging demonstrates the dynamics of lymph flow and lymphangiogenesis during the acute versus chronic phases of arthritis in mice. Arthritis Rheum. 2010 Jul;62(7):1881-9.

148. Li J, Zhou Q, Wood RW, Kuzin I, Bottaro A, Ritchlin CT, Xing L, Schwarz EM. CD23(+)/CD21(hi) B-cell translocation and ipsilateral lymph node collapse is associated with asymmetric arthritic flare in TNF-Tg mice. Arthritis Res Ther. 2011 Aug 31;13(4):R138.

149. Li J, Ju Y, Bouta EM, Xing L, Wood RW, Kuzin I, Bottaro A, Ritchlin CT, Schwarz EM. Efficacy of B cell depletion therapy on joint flare is associated with increased lymphatic flow. Arthritis Rheum. 2012 Sep 22.

150. Levey, K. Use of Fluorescence Imaging Technology to Identify Peritoneal Endometriosis: A Case Report of New Technology. Surg Laparosc Endosc Percutan Tech. Volume 24, Number 2, April 2014.

151. Schols RM, Connell NJ, Stassen LPS. Near-Infrared Fluorescence Imaging for Real-Time Intraoperative Anatomical Guidance in Minimally Invasive Surgery: A Systematic Review of the Literature. World J Surg. Published online: 19 December 2014.

152. Maddox JS, Sabino JM, Buckingham EB, Mundinger GS, Zelken JA, Bluebond-Langner RO, Singh DP, Holton III LH. Utility of Indocyanine Green Fluorescence Lymphography in Identifying the Source of Persistent Groin Lymphorrhea. PRS Global Open. 2014.

153. Dayan JH, Dayan E, Smith ML. Reverse Lymphatic Mapping: A New Technique for Maximizing Safety in Vascularized Lymph Node Transfer. Plast Reconstr Surg. Oct 2014. Accepted Manuscript.

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©2015 Novadaq Technologies Inc. NOVADAQ, SPY, SPY ELITE, SPY Q, PINPOINT and LUNA are registered trademarks of Novadaq Technologies Inc. IMAGING ILLUMINATED and ILLUMINATED BY SPY FLUORESCENCE is a trademark of Novadaq Technologies Inc.MS-0000 Rev A

Indications For Use

PINPOINTPINPOINT is intended to provide real-time endoscopic visible and near infrared fluorescence imaging. PINPOINT enables surgeons to perform routine visible light endoscopic procedures as well as further visually assess vessels, blood flow and related tissue perfusion with near infrared imaging during minimally invasive surgery.

SPY ELITEPlastic, Micro, and Reconstructive SurgeryThe SPY Elite System is an imaging system used in capturing and viewing fluorescence images for the visual assessment of blood flow as an adjunctive method for the evaluation of tissue perfusion, and related tissue-transfer circulation in tissue and free flaps used in plastic, micro-, and reconstructive procedures.

Gastrointestinal SurgeryThe SPY Elite System is intended to provide fluorescence images for the visual assessment of blood flow in vessels and related tissue perfusion during gastrointestinal surgical procedures.

Cardiovascular SurgeryThe SPY Elite System is intended to provide fluorescent images for the visual assessment of blood flow in vessels and related tissue perfusion during cardiovascular surgical procedures. Examples of cardiovascular applications include confirming blood flow through the peripheral vasculature and extremities.

LUNAThe LUNA System is intended to provide fluorescent images for the visual assessment of blood flow in vessels and related tissue perfusion during cardiovascular procedures.

Examples of its use in cardiovascular applications include confirming blood flow through the peripheral vasculature and extremities.

SPY imaging technologies are not yet approved for commercial use for lymph node mapping.