Corbin Cleary, MD, Ziyad Nasrawi, MD, Angelo Reyes, Raffaelle Borriello. New York Presbyterian Brooklyn Methodist Hospital
Pulmonary arteriovenous malformations are rare pathological conditions resulting from an atypical connection between arterial and venous systems within the pulmonary vasculature. These lesions bypass the capillary beds and can grow over time, leading to right-to-left shunts, possibly causing hypoxia or bleeding. Standard treatment consists of angiography and embolization, but for our patient, due to anatomical difficulties, this option was not available. Given the associated risks of pulmonary arteriovenous malformations, she was admitted and prepared for surgical resection.
On the day of her admission, she underwent a robotic assisted right sided thorascopic surgery. After mobilization of the lung through division of the inferior pulmonary ligament, the ICG dye (25mg diluted w/ 10cc of normal saline) was injected intravenously. Within seconds of its injection, the area within the right lower lobe containing the pulmonary arteriovenous malformation demonstrates substantial uptake of the dye. Sequential firing of the robotic Endo-GIA stapler allowed for complete resection of the pulmonary arteriovenous malformation. A single chest tube was left, and she was extubated at the culmination of the procedure. The chest tube was removed on POD1, and she was discharged on POD2.
ICG dye is utilized with near-infrared (NIR) fluorescence to provide detailed anatomic information for a variety of cases in conjunction with the Intuitive/DaVinci Xi robotic surgical platform and its Firefly capability. A water-soluble tricarbocyanine dye, ICG binds readily to plasma proteins before being excreted in bile. NIR fluorescence is poorly absorbed by humans but has deep tissue penetration – allowing it to be used as a valuable intraoperative tool. Such technology has been used for a variety of thoracic surgical procedures, including sentinel node mapping, lung segmental plane identification, identification of pulmonary nodules and pulmonary bullae, vascular evaluation of conduit viability, and thoracic duct evaluation; however, there has not been a reported case where such an approach was utilized in the surgical management of a PAVM.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 98718
Program Number: ETP724
Presentation Session: Emerging Technology Poster Session (Non CME)
Presentation Type: Poster