title: Post-operative monitoring of tissue transfers: advantages using contrast enhanced ultrasound (CEUS) and contrast enhanced MRI (ceMRI) with dynamic perfusion analysis?
abstract: BACKGROUND
  The immediate evaluation of microvascular tissue flaps with respect to microcirculation after transplantation is crucial for optimal monitoring and outcome. The purpose of our investigation was to evaluate the clinical value of contrast-enhanced ultrasound (CEUS) and contrast-enhanced MRI (ceMRI) for monitoring the integrity of tissue flaps in plastic surgery.
  
  
  METHODS
  To this end, we investigated 10 patients (47 ± 16 a) between postoperative day 7 and 14 who underwent flap surgery in order to cover tissue defects in various body regions. For CEUS we utilized the GE LOGIQ E9 equipped with a linear transducer (6-9 MHz). After application of 2.4 ml SonoVue, the tissue perfusion was detected in Low MI-Technique (MI < 0.2). The perfusion curves were quantitatively analyzed using digital video sequences (QONTRAST, Bracco, Italy) regarding peak % and relative blood flow (RBF). Furthermore, we investigated all tissue flaps using contrast-enhanced MRI (Magnetom Symphony TIM, Siemens) with a 3D-VIBE sequence and a time resolution of 7s. Thus, the transplants were completely captured in all cases. As perfusion parameters, the positive enhancement integral (PEI) as well as the maximum intensity projection time (MIP-time) were collected. For comparison of both applications, all parameters were displayed in color-coded resolution and analyzed by three independent readers. Depending on the flap thickness, 1-3 regions of interest (ROI) were investigated. Each ROI measured 1 × 3 cm.
  
  
  RESULTS
  The subcutaneous ROI-1 showed a significantly lower rating regarding RBF in the ceMRI compared to CEUS (Mann-Whitney Rank-Sum test, p < 0.05). ROI-2 and -3 did not show any significant differences between the two applications. The frequency distribution showed good accordance in both modalities. Both imaging techniques detected 1 partial flap necrosis within the random area of cutaneous and subcutaneous layers, 1 hematoma as well as 1 insufficient perfusion over all tissue layers. After subsequent reoperation, graft loss could be prevented.
  
  
  CONCLUSIONS
  At present, both technologies provide an optimal assessment of perfusion in cutaneous, subcutaneous and muscle tissue layers, whereby the detection of fatty tissue perfusion is currently more easily detected using CEUS compared to ceMRI.
authors.affiliation: Center of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany. philipp.lamby@klinik.uni-regensburg.de
authors.forename: P
authors.initials: P
authors.lastname: Lamby
authors.forename: L
authors.initials: L
authors.lastname: Prantl
authors.forename: C
authors.initials: C
authors.lastname: Fellner
authors.forename: S
authors.initials: S
authors.lastname: Geis
authors.forename: E M
authors.initials: EM
authors.lastname: Jung
mesh_terms: D000293:Adolescent; D000368:Aged; D003287:Contrast Media; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010477:Perfusion / Q000379:methods; D010865:Pilot Projects; D011182:Postoperative Care; D012867:Skin / Q000098:blood supply*; D016038:Skin Transplantation / Q000379:methods*; D013524:Surgical Flaps / Q000098:blood supply*; D018615:Ultrasonography, Doppler, Color
chemical_list: D003287:Contrast Media