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Uz Z, Dilken O, Milstein DMJ, Hilty MP, de Haan D, Ince Y, Shen L, Houtzager J, Franken LC, van Gulik TM, Ince C. Identifying a sublingual triangle as the ideal site for assessment of sublingual microcirculation. J Clin Monit Comput 2023; 37:639-649. [PMID: 36355276 PMCID: PMC10068634 DOI: 10.1007/s10877-022-00936-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 10/15/2022] [Indexed: 11/11/2022]
Abstract
The sublingual mucosa is a commonly used intraoral location for identifying microcirculatory alterations using handheld vital microscopes (HVMs). The anatomic description of the sublingual cave and its related training have not been adequately introduced. The aim of this study was to introduce anatomy guided sublingual microcirculatory assessment. Measurements were acquired from the floor of the mouth using incident dark-field (IDF) imaging before (T0) and after (T1) sublingual cave anatomy instructed training. Instructions consists of examining a specific region of interested identified through observable anatomical structures adjacent and bilaterally to the lingual frenulum which is next to the sublingual papilla. The anatomical location called the sublingual triangle, was identified as stationed between the lingual frenulum, the sublingual fold and ventrally to the tongue. Small, large, and total vessel density datasets (SVD, LVD and TVD respectively) obtained by non-instructed and instructed measurements (NIN (T0) and IM (T1) respectively) were compared. Microvascular structures were analyzed, and the presence of salivary duct-related microcirculation was identified. A total of 72 video clips were used for analysis in which TVD, but not LVD and SVD, was higher in IM compared to NIM (NIM vs. IM, 25 ± 2 vs. 27 ± 3 mm/mm2 (p = 0.044), LVD NIM vs. IM: 7 ± 1 vs. 8 ± 1mm/mm2 (p = 0.092), SVD NIM vs. IM: 18 ± 2 vs. 20 ± 3 mm/mm2 (p = 0.103)). IM resulted in microcirculatory assessments which included morphological properties such as capillaries, venules and arterioles, without salivary duct-associated microcirculation. The sublingual triangle identified in this study showed consistent network-based microcirculation, without interference from microcirculation associated with specialized anatomic structures. These findings suggest that the sublingual triangle, an anatomy guided location, yielded sublingual based measurements that conforms with international guidelines. IM showed higher TVD values, and future studies are needed with larger sample sizes to prove differences in microcirculatory parameters.
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Affiliation(s)
- Zühre Uz
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands.
- Department of Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands.
| | - Olcay Dilken
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Dan M J Milstein
- Department of Oral & Maxillofacial Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Oral Medicine, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
| | - Matthias Peter Hilty
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - David de Haan
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Yasin Ince
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Lucinda Shen
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Julia Houtzager
- Department of Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lotte C Franken
- Department of Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Location: AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Can Ince
- Department of Translational Physiology, Location: AMC, Amsterdam University Medical Centre (UMC), University of Amsterdam, Amsterdam, The Netherlands
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Rizzoni D, Mengozzi A, Masi S, Agabiti Rosei C, De Ciuceis C, Virdis A. New Noninvasive Methods to Evaluate Microvascular Structure and Function. Hypertension 2022; 79:874-886. [PMID: 35114816 DOI: 10.1161/hypertensionaha.121.17954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The structural and functional alterations of microvessels are detected because of physiological aging and in several cardiometabolic diseases, including hypertension, diabetes, and obesity. The small resistance arteries of these patients show an increase in the media or total wall thickness to internal lumen diameter ratio (MLR or WLR), often accompanied by endothelial dysfunction. For decades, micromyography has been considered as a gold standard method for evaluating microvascular structural alterations through the measurement of MLR or WLR of subcutaneous small vessels dissected from tissue biopsies. Micromyography is the most common and reliable method for assessing microcirculatory endothelial function ex vivo, while strain-gauge venous plethysmography is considered the reference technique for in vivo studies. Recently, several noninvasive methods have been proposed to extend the microvasculature evaluation to a broader range of patients and clinical settings. Scanning laser Doppler flowmetry and adaptive optics are increasingly used to estimate the WLR of retinal arterioles. Microvascular endothelial function may be evaluated in the retina by flicker light stimulus, in the finger by tonometric approaches, or in the cutaneous or sublingual tissues by laser Doppler flowmetry or intravital microscopy. The main limitation of these techniques is the lack of robust evidence on their prognostic value, which currently reduces their widespread use in daily clinical practice. Ongoing and future studies will overcome this issue, hopefully moving the noninvasive assessment of the microvascular function and structure from bench to bedside.
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Affiliation(s)
- Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy (D.R., C.A., C.D.C.).,Division of Medicine, Spedali Civili di Brescia, Montichiari (Brescia), Italy (D.R.)
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Italy (A.M., S.M., A.V.).,Institute of Life Science, Sant'Anna School of Advanced Studies, Pisa, Italy (A.M.)
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Italy (A.M., S.M., A.V.).,Institute of Cardiovascular Science, University College London, United Kingdom (S.M.)
| | - Claudia Agabiti Rosei
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy (D.R., C.A., C.D.C.)
| | - Carolina De Ciuceis
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy (D.R., C.A., C.D.C.)
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Italy (A.M., S.M., A.V.)
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Kiseleva E, Ryabkov M, Baleev M, Bederina E, Shilyagin P, Moiseev A, Beschastnov V, Romanov I, Gelikonov G, Gladkova N. Prospects of Intraoperative Multimodal OCT Application in Patients with Acute Mesenteric Ischemia. Diagnostics (Basel) 2021; 11:705. [PMID: 33920827 PMCID: PMC8071199 DOI: 10.3390/diagnostics11040705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Despite the introduction of increasingly multifaceted diagnostic techniques and the general advances in emergency abdominal and vascular surgery, the outcome of treatment of patients with acute impaired intestinal circulation remains unsatisfactory. The non-invasive and high-resolution technique of optical coherence tomography (OCT) can be used intraoperatively to assess intestine viability and associated conditions that frequently emerge under conditions of impaired blood circulation. This study aims to demonstrate the effectiveness of multimodal (MM) OCT for intraoperative diagnostics of both the microstructure (cross-polarization OCT mode) and microcirculation (OCT angiography mode) of the small intestine wall in patients with acute mesenteric ischemia (AMI). METHODS AND PARTICIPANTS A total of 18 patients were enrolled in the study. Nine of them suffered from AMI in segments II-III of the superior mesenteric artery (AMI group), whereby the ischemic segments of the intestine were examined. Nine others were operated on for adenocarcinoma of the colon (control group), thus allowing areas of their normal small intestine to be examined for comparison. Data on the microstructure and microcirculation in the walls of the small intestine were obtained intraoperatively from the side of the serous membrane using the MM OCT system (IAP RAS, Russia) before bowel resection. The MM OCT data were compared with the results of histological examination. RESULTS The study finds that MM OCT visualized the damage to serosa, muscularis externa, and blood vessels localized in these layers in 100% of AMI cases. It also visualized the submucosa in 33.3% of AMI cases. The MM OCT images of non-ischemic (control group), viable ischemic, and necrotic small intestines (AMI group) differed significantly across stratification of the distinguishable layers, the severity of intermuscular fluid accumulations, and the type and density of the vasculature. CONCLUSION The MM OCT diagnostic procedure optimally meets the requirements of emergency surgery. Data on the microstructure and microcirculation of the intestinal wall can be obtained simultaneously in real time without requiring contrast agent injections. The depth of visualization of the intestinal wall from the side of the serous membrane is sufficient to assess the volume of the affected tissues. However, the methodology for obtaining MM OCT data needs to be improved to minimize the motion artefacts generated in actual clinical conditions.
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Affiliation(s)
- Elena Kiseleva
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603950 Nizhny Novgorod, Russia;
| | - Maxim Ryabkov
- Thermal Injury Group, University Clinic, Privolzhsky Research Medical University, 18/1 Verkhnevolzhskaya Naberezhnaja, 603155 Nizhny Novgorod, Russia;
| | - Mikhail Baleev
- City Clinical Hospital No.30, 85A Berezovskaya St., 605157 Nizhny Novgorod, Russia; (M.B.); (V.B.); (I.R.)
| | - Evgeniya Bederina
- The Department of Pathology, University Clinic, Privolzhsky Research Medical University, 18/1 Verkhnevolzhskaya Naberezhnaja, 603155 Nizhny Novgorod, Russia;
| | - Pavel Shilyagin
- Institute of Applied Physics of the RAS, 46 Ulyanova St., 603950 Nizhny Novgorod, Russia; (P.S.); (A.M.); (G.G.)
| | - Alexander Moiseev
- Institute of Applied Physics of the RAS, 46 Ulyanova St., 603950 Nizhny Novgorod, Russia; (P.S.); (A.M.); (G.G.)
| | - Vladimir Beschastnov
- City Clinical Hospital No.30, 85A Berezovskaya St., 605157 Nizhny Novgorod, Russia; (M.B.); (V.B.); (I.R.)
| | - Ivan Romanov
- City Clinical Hospital No.30, 85A Berezovskaya St., 605157 Nizhny Novgorod, Russia; (M.B.); (V.B.); (I.R.)
| | - Grigory Gelikonov
- Institute of Applied Physics of the RAS, 46 Ulyanova St., 603950 Nizhny Novgorod, Russia; (P.S.); (A.M.); (G.G.)
| | - Natalia Gladkova
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603950 Nizhny Novgorod, Russia;
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Latul YP, Kastelein AW, Beemster PWT, van Trommel NE, Ince C, Roovers JPWR. Noninvasive, in vivo assessment of the cervical microcirculation using incident dark field imaging. Microvasc Res 2021; 135:104145. [PMID: 33571547 DOI: 10.1016/j.mvr.2021.104145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 11/17/2022]
Abstract
AIM This study evaluates the feasibility of handheld vital microscopy for noninvasive, objective assessment of the microcirculation of the human uterine cervix. We qualitatively and quantitatively describe the microcirculation in healthy subjects in order to provide a basis for its application in cervical pathology. METHODS Incident dark field imaging was used to image the microcirculation in four quadrants of the uterine ectocervix in ten healthy participants. If the squamocolumnar junction was visible, measurements were repeated on the endocervical columnar epithelium as well. Image acquisition time was recorded and participants scored the experienced level of discomfort. Angioarchitecture was classified according to Weber's classification. Quantitative parameters included capillary density (CD), total and perfused vessel density (TVD, PVD), proportion of perfused vessels (PPV) and microvascular flow index (MFI). RESULTS Image acquisition was easy, fast and well tolerated. Angioarchitecture was characterized by two distinctive and organized patterns; capillary loops underneath the squamous epithelium of the ectocervix and vascular networks underneath the columnar epithelium. In the image sequences containing capillary loops, mean CD was 33.2 cpll/mm2 (95% CI 28.2-38.2 cpll/mm2). In the image sequences with vascular networks, mean TVD was 12.5 mm/mm2 (95% CI 11.2-13.77 mm/mm2), mean PVD was 12.2 (95% CI 11.0-13.5 mm/mm2), MFI was 3 and PPV was 100%. CONCLUSIONS Incident dark field imaging allows for noninvasive, real time visualization and objective evaluation and quantification of the microcirculation of the uterine cervix. The organized vascular patterns and optimal perfusion observed in healthy subjects allow for comparison with cervical pathology, for example in patients with cervical dysplasia or cervical cancer.
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Affiliation(s)
- Yani P Latul
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Arnoud W Kastelein
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Patricia W T Beemster
- Bergman Clinics, Department of Gynaecology, Bergman Vrouwenzorg, Nijenburg 152, 1081 GG Amsterdam, the Netherlands
| | - Nienke E van Trommel
- Center for Gynecologic Oncology Amsterdam, Location Antoni van Leeuwenhoek Hospital/The Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, the Netherlands
| | - Can Ince
- Erasmus Medical Center, Department of Intensive Care, Laboratory of Translational Intensive Care, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Jan-Paul W R Roovers
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Bergman Clinics, Department of Gynaecology, Bergman Vrouwenzorg, Nijenburg 152, 1081 GG Amsterdam, the Netherlands
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Poor perfusion of the microvasculature in peritoneal metastases of ovarian cancer. Clin Exp Metastasis 2020; 37:293-304. [PMID: 32008138 PMCID: PMC7138772 DOI: 10.1007/s10585-020-10024-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/23/2020] [Indexed: 12/13/2022]
Abstract
Most women with epithelial ovarian cancer (EOC) suffer from peritoneal carcinomatosis upon first clinical presentation. Extensive peritoneal carcinomatosis has a poor prognosis and its pathophysiology is not well understood. Although treatment with systemic intravenous chemotherapy is often initially successful, peritoneal recurrences occur regularly. We hypothesized that insufficient or poorly-perfused microvasculature may impair the therapeutic efficacy of systemic intravenous chemotherapy but may also limit expansive and invasive growth characteristic of peritoneal EOC metastases. In 23 patients with advanced EOC or suspicion thereof, we determined the angioarchitecture and perfusion of the microvasculature in peritoneum and in peritoneal metastases using incident dark field (IDF) imaging. Additionally, we performed immunohistochemical analysis and 3-dimensional (3D) whole tumor imaging using light sheet fluorescence microscopy of IDF-imaged tissue sites. In all metastases, microvasculature was present but the angioarchitecture was chaotic and the vessel density and perfusion of vessels was significantly lower than in unaffected peritoneum. Immunohistochemical analysis showed expression of vascular endothelial growth factor and hypoxia inducible factor 1α, and 3D imaging demonstrated vascular continuity between metastases and the vascular network of the peritoneum beneath the elastic lamina of the peritoneum. We conclude that perfusion of the microvasculature within metastases is limited, which may cause hypoxia, affect the behavior of EOC metastases on the peritoneum and limit the response of EOC metastases to systemic treatment.
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Guven G, Hilty MP, Ince C. Microcirculation: Physiology, Pathophysiology, and Clinical Application. Blood Purif 2019; 49:143-150. [PMID: 31851980 DOI: 10.1159/000503775] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/28/2019] [Indexed: 12/17/2022]
Abstract
This paper briefly reviews the physiological components of the microcirculation, focusing on its function in homeostasis and its central function in the realization of oxygen transport to tissue cells. Its pivotal role in the understanding of circulatory compromise in states of shock and renal compromise is discussed. Our introduction of hand-held vital microscopes (HVM) to clinical medicine has revealed the importance of the microcirculation as a central target organ in states of critical illness and inadequate response to therapy. Technical and methodological developments have been made in hardware and in software including our recent introduction and validation of automatic analysis software called MicroTools, which now allows point-of-care use of HVM imaging at the bedside for instant availability of functional microcirculatory parameters needed for microcirculatory targeted resuscitation procedures to be a reality.
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Affiliation(s)
- Goksel Guven
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands,
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Kastelein AW, Vos LM, de Jong KH, van Baal JO, Nieuwland R, van Noorden CJ, Roovers JPW, Lok CA. Embryology, anatomy, physiology and pathophysiology of the peritoneum and the peritoneal vasculature. Semin Cell Dev Biol 2019; 92:27-36. [DOI: 10.1016/j.semcdb.2018.09.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 08/29/2018] [Accepted: 09/18/2018] [Indexed: 01/25/2023]
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