A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy

J Dalli; C L Nguyen; A Jindal; J P Epperlein; N P Hardy; C Pulitano; S Warrier; R A Cahill

doi:10.1016/j.jpra.2024.01.012

A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy

JPRAS Open. 2024 Jan 26:40:32-47. doi: 10.1016/j.jpra.2024.01.012. eCollection 2024 Jun.

Authors

J Dalli¹, C L Nguyen^{2

3

4}, A Jindal¹, J P Epperlein⁵, N P Hardy¹, C Pulitano^{3

4}, S Warrier^{2

3

4}, R A Cahill^{1

6}

Affiliations

¹ UCD Centre for Precision Surgery, School of Medicine, UCD, Dublin, Ireland.
² Department of Breast Surgery, Chris O'Brien Lifehouse, Camperdown, Australia.
³ Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia.
⁴ Department of Surgery, The University of Sydney, Camperdown, Australia.
⁵ IBM Research Europe, Dublin, Ireland.
⁶ Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.

Abstract

Introduction: Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications.

Methods: ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data.

Results: The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity.

Conclusion: Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.

Keywords: Fluorescence angiography; ICG; ICGFA; Immediate breast reconstruction; Indocyanine green; Oncoplastic.