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Laser-Assisted Indocyanine Green Angiography: A Critical Appraisal

Wu, Cindy MD; Kim, Sendia MD; Halvorson, Eric G. MD, FACS

doi: 10.1097/SAP.0b013e31827565f3
Research Papers

Background Laser-assisted indocyanine green angiography (ICG-A) has been promoted to assess perfusion of random skin, pedicled, and free flaps. Few studies address its potential limitations.

Methods Thirty-seven patients who underwent reconstructive procedures with ICG-A were studied retrospectively to determine the correlation between clinical findings and ICG-A. Indocyanine green angiography underestimated perfusion when areas of less than or equal to 25% uptake were not debrided and remained perfused. Indocyanine green angiography overestimated perfusion when areas with greater than 25% uptake developed necrosis.

Results Of 14 random skin flaps, ICG-A underestimated perfusion in 14% and overestimated in 14%. In 16 patients undergoing perforator flap breast reconstruction, ICG-A correlated with computed tomographic angiogram (CTA) in 85%. Indocyanine green angiography underestimated perfusion in 7% and overestimated in 7%. In 8/11 patients undergoing fasciocutaneous flaps, ICG-A aided in donor site selection. In 3/6 ALT flaps, a better unilateral blush was found that correlated with Doppler. In all 3, a dominant perforator was found. In 11 patients, there was a 9% underestimation of flap perfusion. In 3 pedicled flaps, there was a 66% underestimation and 33% overestimation of perfusion.

Conclusions Indocyanine green angiography often confirmed our clinical/radiologic findings in abdominal perforator and fasciocutaneous flaps. It tended to underestimate perfusion in pedicle and skin flaps. When clinical examination was obvious, ICG-A rendered clear-cut findings. When clinical examination was equivocal, ICG-A tended to provide ambiguous findings, demonstrating that a distinct cutoff point does not exists for every patient or flap. Indocyanine green angiography is a promising but expensive technology that would benefit from standardization. Further research is needed before ICG-A can become a reliable tool for surgeons.

From the Division of Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, NC.

Received September 18, 2012, and accepted for publication, after revision, September 20, 2012.

Presented at the 55th Annual Southeastern Society of Plastic Surgeons, June 6, 2012, Amelia Island, FL.

Conflicts of interest and sources of funding: none declared.

Reprints: Eric G. Halvorson, MD, FACS, Division of Plastic and Reconstructive Surgery, University of North Carolina, 7040 Burnett-Womack Building CB #7195, Chapel Hill, NC 27599-7195. E-mail:

© 2013 by Lippincott Williams & Wilkins