The authors acknowledge Neff Sherri and Jan Ivey for their help during the study. Kannan, Tharakan, and Upendran acknowledge the Mizzou Advantage Grant, Ellis Fischel Cancer Center Grant, and Coulter Foundation for providing financial support.

Animal studies were performed following approval from the University of Missouri Animal Care and Use Committee. The University of Missouri is USDA-licensed and AAALAC-International accredited.
1. Pre-operation procedure
<ol>
	<li>Obtain a domestic Yorkshire/large white pig (4 months old; 57 kg) one day prior to the study and provide water ad libitum.</li>
	<li>Sedate the pig with 5 mg/kg Telazol and 2.2 mg/kg xylazine. Provide 3-4% isoflurane by nose cone until the pig can be intuba...

<ol>
	<li>Detter, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fluorescent+cardiac+imaging:+a+novel+intraoperative+method+for+quantitative+assessment+of+myocardial+perfusion+during+graded+coronary+artery+stenosis.">Fluorescent cardiac imaging: a novel intraoperative method for quantitative assessment of myocardial perfusion during graded coronary artery stenosis.</a> Circulation. 116, 1007-1014 (2007).</li><li>Urbanavicius, L., Pattyn, P., de Putte, D. V., Venskutonis, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+to+assess+intestinal+viability+during+surgery:+A+review+of+techniques.">How to assess intestinal viability during surgery: A review of techniques.</a> World J Gastrointest Surg. 3, 59-69 (2011).</li><li>Mack, M. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Results+of+graft+patency+by+immediate+angiography+in+minimally+invasive+coronary+artery+surgery.">Results of graft patency by immediate angiography in minimally invasive coronary artery surgery.</a> Ann Thorac Surg. 68, 383-389 (1999).</li><li>Lin, J. C., Fisher, D. L., Szwerc, M. F., Magovern, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+graft+patency+during+minimally+invasive+coronary+artery+bypass+grafting+with+Doppler+flow+analysis.">Evaluation of graft patency during minimally invasive coronary artery bypass grafting with Doppler flow analysis.</a> Ann Thorac Surg. 70, 1350-1354 (2000).</li><li>Amin, S., Pinho-Gomes, A. C., Taggart, D. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relationship+of+Intraoperative+Transit+Time+Flowmetry+Findings+to+Angiographic+Graft+Patency+at+Follow-Up.">Relationship of Intraoperative Transit Time Flowmetry Findings to Angiographic Graft Patency at Follow-Up.</a> Ann Thorac Surg. , (2016).</li><li>Gwozdziewicz, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cardiomed+coronary+flow+meter+for+prevention+of+early+occlusion+in+aortocoronary+bypass+grafting.">Cardiomed coronary flow meter for prevention of early occlusion in aortocoronary bypass grafting.</a> Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 148, 59-61 (2004).</li><li>Succi, J. 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J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+Characterization+of+Coronary+Atherosclerosis+With+Dual-Modality+OCT+and+Near-Infrared+Autofluorescence+Imaging.">Clinical Characterization of Coronary Atherosclerosis With Dual-Modality OCT and Near-Infrared Autofluorescence Imaging.</a> JACC Cardiovasc Imaging. , (2016).</li><li>Takami, Y., Masumoto, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transit-time+flow+measurement+cannot+detect+wrong+anastomosis+of+an+internal+thoracic+artery+with+the+cardiac+vein+in+coronary+artery+surgery.">Transit-time flow measurement cannot detect wrong anastomosis of an internal thoracic artery with the cardiac vein in coronary artery surgery.</a> J Thorac Cardiovasc Surg. 128, 629-631 (2004).</li><li>Hope-Ross, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adverse+reactions+due+to+indocyanine+green.">Adverse reactions due to indocyanine green.</a> Ophthalmology. 101, 529-533 (1994).</li><li>Alander, J. 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S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Indocyanine+green:+observations+on+its+physical+properties,+plasma+decay,+and+hepatic+extraction.">Indocyanine green: observations on its physical properties, plasma decay, and hepatic extraction.</a> J Clin Invest. 39, 592-600 (1960).</li><li>Sander, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Peri-operative+plasma+disappearance+rate+of+indocyanine+green+after+coronary+artery+bypass+surgery.">Peri-operative plasma disappearance rate of indocyanine green after coronary artery bypass surgery.</a> Cardiovasc J Afr. 18, 375-379 (2007).</li><li>Takahashi, M., Ishikawa, T., Higashidani, K., Katoh, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=SPY:+an+innovative+intra-operative+imaging+system+to+evaluate+graft+patency+during+off-pump+coronary+artery+bypass+grafting.">SPY: an innovative intra-operative imaging system to evaluate graft patency during off-pump coronary artery bypass grafting.</a> Interact Cardiovasc Thorac Surg. 3, 479-483 (2004).</li><li>Sevick-Muraca, E. 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Development of NAVI for ICG Imaging Applications
NIR-based fluorescence imaging is emerging as a simple alternative procedure for intraoperative imaging, demonstrating significant benefits by: (1) eliminating the radiation exposure required by fluoroscopy and computed tomography and (2) reducing the surgical time, thus decreasing per-patient costs while maintaining efficacy and increasing safety. In this paper, we demonstrated the procedure for using NAVI to perform fluorescence imaging (using IC...

Intraoperative assessments of blood flow following arterial or venous grafting, as well as direct visualization methods evaluating anastomosis, allow surgeons to make immediate decisions on the likelihood of success or failure, allowing for repair, if needed1,2. Techniques frequently employed are fluoroscopic angiography3, direct visualization, palpation of pulsatile flow, pulse oximetry2, Doppler ultrasound4, transit time flowmetry5,6,7, computed tomography angiography8, and visible light and near-infrared spectrophotometry9. As the evaluation of surgical outcomes continues, improvements in equipment and an increasing availability of technology allow for the more widespread use of these methods. Challenges exist in many of these techniques; while they are excellent at evaluation, some limitations include cumbersome equipment, a lack of proper anatomical definition, and exposure to radiation10. One technique that avoids many of these drawbacks and that has been tested across a wide variety of surgical repairs is the use of near-infrared (NIR) fluorescence imaging, specifically with FDA-approved indocyanine green (ICG)11. ICG fluoresces brightly at low concentrations and is well confined to the vasculature due to its high plasma protein binding capabilities12. Additionally, the liver clears it from blood circulation within minutes, allowing for multiple injections13,14.
Fluorescence image-guided surgery is an optical imaging procedure that allows surgeons to visualize real-time tissue images and to evaluate circulation and perfusion intraoperatively. Capturing real-time images improves surgical outcomes by allowing the rapid identification and repair of graft failures15. ICG is injected intravenously and visualized under an NIR wavelength range (700-900 nm). ICG visualization in this wavelength range results in high contrast against a black background due to minimal tissue absorbance and scattering,meaning minimal auto-fluorescence. While frequently used to measure hepatic function and ophthalmic angiography11, this dye has shown promise for several procedures that include but are not limited to: lymphatic mapping16,17,18,19, hepatobiliary surgery20, dermal vasculature mapping for burn wound severity21, cerebral aneurysm repair22,23, gastrointestinal anastomosis verification24, and venous and arterial grafting12. A recent, encompassing review of the usage of ICG in surgical procedures revealed the need for improvements in the image processing, portability of the instrumentation, and economic viability12.
A portable and economical fluorescence imaging system that could serve as an alternative to the costly and unwieldy existing fluorescence imaging modality is desired to assist surgeons in intraoperatively evaluating the success of the vascular grafting process. We used a portable NIR navigation system (NAVI), which has the capability of visualizing ICG in deep tissues and recording real-time images with high sensitivity. The ability of the NAVI system to visualize selected regions of interest, confirm blood flow, and detect leaks from sites of anastomosis has been demonstrated by in vivo arteriovenous grafting procedures in a swine study.
The integral components and assembly of NAVI (Figure 1) for the visualization of florescence emitted from ICG are listed and briefly described below. The source is five 770-nm NIR LEDs assembled onto a battery DC power supply, with a 775-nm short pass filter. The short pass filter allows only 770-nm emitted light to reach the imaging site while reducing any possible stray radiation above 770 nm. The camera is an NIR imaging camera with an added band pass filter. The width of the pass region is 37 nm, centered at 832 nm, and is employed for the purpose of rejecting radiation collected by the NIR imaging camera that does not emanate from ICG fluorescence or from stray light. The NIR imaging camera has an RCA analog output for the image signal. The interface is the composite video image from an NIR imaging camera that is interfaced to a USB port on a computer via an analog-to-video interface designed to translate composite video to digital for the purpose of capturing, storing, processing, and providing the output of the digital signal to an image display unit. The interface system accepts the analog output. The computer is a single-board with a USB input that has the processing capabilities necessary to store and process images. The monitor is a conventional video monitor of any size and is used to display the images generated by the computer. The stands are two mechanical arms for suspending the source and NIR camera over selected tissue areas, as well as a foot control that aids in the movement of the NIR camera.

<table border="0" cellpadding="0" cellspacing="0" width="1181">
	<tbody>
		<tr height="39">
			<td height="39" style="height:39px;width:321px;">Telazol</td>
			<td style="width:471px;">Zoetis</td>
			<td style="width:119px;"></td>
			<td style="width:271px;">Reconstitute with sterile water prior to use</td>
		</tr>
		<tr height="24">
			<td height="24" style="height:24px;width:321px;">Xylazine (AnaSed)</td>
			<td style="width:471px;">AKORN Animal Health</td>
			<td style="width:119px;"></td>
			<td style="width:271px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">0.9% NaCl</td>
			<td style="width:471px;">Abbott</td>
			<td style="width:119px;"></td>
			<td style="width:271px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">Indocyanine green</td>
			<td style="width:471px;">AKRON</td>
			<td style="width:119px;"></td>
			<td style="width:271px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">Heparin</td>
			<td style="width:471px;">Baxter</td>
			<td style="width:119px;"></td>
			<td style="width:271px;"></td>
		</tr>
		<tr height="19">
			<td height="19" style="height:19px;width:321px;">Visipaque (iodixanol)</td>
			<td style="width:471px;">GE Healthcare</td>
			<td>564v</td>
			<td style="width:271px;"></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;width:321px;">Guide catheter</td>
			<td style="width:471px;">Boston Scientific</td>
			<td style="width:119px;"></td>
			<td style="width:271px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">LED 770-03AU, 18 mW</td>
			<td style="width:471px;">Roithner Laser Technik GmbH, Wiedner Hauptstrasse, Austria</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">Short pass filter</td>
			<td style="width:471px;">Edmund optics, Barrington, NJ, USA</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="22">
			<td height="22" style="height:22px;width:321px;">NIR imaging&#160; camera (Igen NV20/20-IC)</td>
			<td style="width:471px;">B&#38;H optics, New york, NY, USA</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">Micropac USB-AVCPT interface</td>
			<td style="width:471px;">Sabrent, USA</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="22">
			<td height="22" style="height:22px;width:321px;">CT instrument</td>
			<td style="width:471px;">Varian Medical System manufactured by Omega Medical Imaging</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">TS420 Perivascular Flow Module&#160;</td>
			<td style="width:471px;">Transonic Systems Inc., Ithaca, NY</td>
			<td style="width:119px;">TS420 &#38; T402</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">PR Series Flow Probes&#160;</td>
			<td style="width:471px;">Transonic Systems Inc., Ithaca, NY</td>
			<td style="width:119px;">3PSB</td>
			<td style="width:271px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">Digital Board to Flow module</td>
			<td>ADInstruments Inc., Colorado Springs, CO</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:321px;">Lab Chart</td>
			<td>ADInstruments Inc., Colorado Springs, CO</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
	</tbody>
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near-infrared navigation system for real-time visualization of blood flow in vascular grafts

Vascular grafting failures are often attributed to inadequate anastomotic perfusion assessments. If successful, vascular anastomosis can be rapidly confirmed through the visualization of continuous blood flow upon completion of the grafting process. Surgeons can then minimize graft failures, thus decreasing morbidity in a cost-effective manner. Fluorescence image-guided surgery using near-infrared (NIR) dye is one of the methods that can be performed to monitor grafting success. To address the current logistical challenges and costs of these systems, a compact camera system was used for intraoperative fluorescence real-time NIR imaging. Combined with benchtop experiments, a swine model was used to demonstrate the procedure of using a near-infrared navigation system (NAVI) to visualize grafted vessels in vivo. This was done by performing bilateral arteriovenous grafts and imaging intravenously injected ICG as it circulated through the grafted vessels. The fluorescent images obtained by NAVI were corroborated with Doppler flow measurements and cine-angiography, the current gold standard for the evaluation of vascular grafts.

Optimization of the Concentration of ICG
The concentration of ICG required to produce optimal fluorescent images was determined using the following procedure. Different concentrations of ICG solutions ranging from 1.29 to 258 &#181;M were prepared in microcentrifuge tubes and placed on a stand. The NIR light source and the camera were placed at a constant distance from the dye (i.e., 18 and 31 in, respectively, from the st...

We describe the procedure for real-time monitoring of blood flow in vascular grafts using indocyanine green (ICG), a near-infrared (NIR) dye, and a portable near-infrared navigation (NAVI) detectible camera system. The flow of dye in vascular grafts and the camera efficiency have been compared with Doppler and cine-angiography procedures.

Near-infrared Navigation System for Real-time Visualization of Blood Flow in Vascular Grafts

Vascular grafting failures are often attributed to inadequate anastomotic perfusion assessments. If successful, vascular anastomosis can be rapidly ...

Near-infrared Navigation System for Real-time Visualization of Blood Flow in Vascular Grafts

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