Systematic review and meta-analysis on the diagnostic accuracy of indocyanine green angiography for skin viability assessment: Evaluation in post-mastectomy flaps

Background Indocyanine green angiography (ICGA) is frequently used to assess skin viability; however, there is no clear overview of its diagnostic accuracy. This systematic review and meta-analysis aimed to synthesize evidence on the diagnostic accuracy of ICGA for skin viability assessment, compare quantification methods, and identify clinically relevant cut-off values. Methods A literature search was conducted in the PubMed, Embase, Web of Science, and Cochrane Library databases up to October 2025. Studies were included if raw diagnostic ICGA data for skin viability assessment were retrievable. Study quality was assessed using the QUADAS-2 tool. Pooled sensitivity, specificity, predictive values, and cut-off values were identified for absolute and relative perfusion using the bivariate random-effects and multiple-threshold models. Results Twelve studies were included, of which 10 were pooled in the quantitative synthesis. All 10 studies evaluated post-mastectomy flaps. The reference standard was the postoperative clinical evaluation of skin necrosis. Using multiple-threshold analysis, the pooled sensitivity for absolute perfusion cut-offs (6 studies) was 85.1% (95% CI: 61.9–95.2%) and pooled specificity was 61.4% (95% CI: 43.2–77.0%), with an area under the curve (AUC) of 0.77. For relative perfusion (5 studies), the pooled sensitivity was 68.4% (95% CI: 32.2–90.8%) and pooled specificity was 69.1% (95% CI: 45.2–85.8%), with an AUC of 0.74. The pooled negative predictive value was high (94.7–97.1%), whereas the pooled positive predictive value was low (21.3%) at the observed necrosis rate of 10.9%. The identified cut-off values were 18.3 for absolute perfusion and 31.7% for relative perfusion. Conclusions ICGA demonstrated moderate diagnostic accuracy for assessing skin viability of post-mastectomy flaps. Its diagnostic performance for the skin in other locations and procedures is yet to be established.