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Hyperbaric Oxygen Therapy in Management of Diabetic Foot Ulcers: Indocyanine Green Angiography May Be Used as a Biomarker to Analyze Perfusion and Predict Response to Treatment

Mohammad, Arbab; Saha, Shivangi M.B.B.S., M.S., M.Ch.; Escandón, Joseph M. M.D.

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Plastic and Reconstructive Surgery: February 2022 - Volume 149 - Issue 2 - p 346e-347e
doi: 10.1097/PRS.0000000000008758
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We read with great interest the article entitled “Hyperbaric Oxygen Therapy in Management of Diabetic Foot Ulcers: Indocyanine Green Angiography May Be Used as a Biomarker to Analyze Perfusion and Predict Response to Treatment,” by Hajhosseini et al.1 The article describes the authors’ experience of using indocyanine green angiography to assess the effects of hyperbaric oxygen therapy as well as its efficacy as a potential biomarker to predict healing of chronic wounds. The authors concluded that hyperbaric oxygen therapy improves the perfusion in chronic wounds, as it ameliorates hypoxia in addition to improving angiogenesis. According to their study, indocyanine green angiography demonstrated an efficient tool to assess hyperbaric oxygen therapy–induced recovery of chronic wounds, interestingly proposing an additional theory that states indocyanine green angiography efficiency in deciding which patient group can benefit most from hyperbaric oxygen therapy.

This prospective nonrandomized clinical trial included 21 patients (chronic wounds patients: n = 11, study group; healthy subjects: n = 10, control group). All but two patients (soft-tissue radionecrosis) in the study group had Wagner grade 3 diabetic foot ulcers. Each participant was injected with 2.5 mg/ml indocyanine green before and after hyperbaric oxygen therapy sessions. After injection, a near-infrared laser camera was used to capture images.

We believe the use of indocyanine green angiography can be substituted with forward-looking infrared thermography technology, which is available as a handheldt camera capable of measuring skin infrared emissivity and capturing pictures that can later be analyzed via associated software. Evidence of forward-looking infrared utility in assessment of diabetic foot ulcers has been demonstrated in the current literature.2,3 Indocyanine green angiography proves to be an expensive tool requiring invasive procedures and is associated with cumbersome mechanics. In contrast, smartphone-attached forward-looking infrared is a relatively cheaper and less-invasive solution, with the added advantage of bedside convenience owing to its time-saving nature of application. In addition, indocyanine green angiography dye usage is associated with several limitations, such as hypersensitivity reactions and lack of safety information in pregnant women. In advanced diabetes with reduced renal clearance, its use warrants caution.4

Although forward-looking infrared (69.90 percent) has been demonstrated to have lesser sensitivity than indocyanine green angiography (97.80 percent) in experimental studies, it can still be acknowledged as a good monitoring tool due to its increased user-friendliness in repeated evaluation, which is usually required after hyperbaric oxygen therapy sessions.3,5 Both of these apparatuses are routinely being used for intraoperative flap perfusion assessment by our surgeons. After taking into account the superior user interface, safety index, and economic background, we are of the opinion that forward-looking infrared is a better and cost-effective alternative that can elicit adequate standards of patient care without outcome assessment compromise in diabetic foot ulcer and chronic wound evaluation.

Despite these differences in opinions, we believe the authors’ efforts are commendable. Their conclusions will certainly pave the way to further investigations that could benefit the chronic wound patient population. We anticipate a prospective multicenter study to compare the economic and reliability parameters of indocyanine green angiography and forward-looking infrared in chronic wound assessment after hyperbaric oxygen therapy to obtain high-level evidence in the future.


The authors have no financial interest to declare in relation to the content of this communication.

Arbab Mohammad
Aarupadai Veedu Medical College and Hospital
Puducherry, India

Shivangi Saha, M.B.B.S., M.S., M.Ch.
Department of Plastic Reconstructive and Burns Surgery
All India Institute of Medical Sciences
New Delhi, India

Joseph M. Escandón, M.D.
Division of Plastic Surgery
Department of Surgery
Strong Memorial Hospital
University of Rochester Medical Center
Rochester, N.Y.


1. Hajhosseini B, Chiou GJ, Virk SS, et al. Hyperbaric oxygen therapy in management of diabetic foot ulcers: Indocyanine green angiography may be used as a biomarker to analyze perfusion and predict response to treatment. Plast Reconstr Surg. 2021;147:209–214.
2. Kanazawa T, Nakagami G, Goto T, et al. Use of smartphone attached mobile thermography assessing subclinical inflammation: A pilot study. J Wound Care. 2016;25:177–180, 182.
3. van Doremalen RFM, van Netten JJ, van Baal JG, Vollenbroek-Hutten MMR, van der Heijden F. Validation of low-cost smartphone-based thermal camera for diabetic foot assessment. Diabetes Res Clin Pract. 2019;149:132–139.
4. U.S. Food and Drug Administration. Indocyanine green. March 21, 2021. Available at: Accessed March 4, 2021.
5. Han T, Khavanin N, Wu J, et al. Indocyanine green angiography predicts tissue necrosis more accurately than thermal imaging and near-infrared spectroscopy in a rat perforator flap model. Plast Reconstr Surg. 2020;146:1044–1054.


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