Clinical Applications of Indocyanine Green Fluorescence Imaging in Vascular Malformations: A Systematic Review

Background/Objectives: The use of near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) has gained increasing attention in the management of vascular malformations, offering real-time visualization of vascular and lymphatic structures that may improve surgical precision and outcomes. Methods: A systematic review was conducted in accordance with PRISMA guidelines, searching PubMed, Web of Science, CINAHL, and EMBASE databases for studies evaluating the intraoperative use of ICG in vascular malformations, which was prospectively registered in PROSPERO (CRD420251131951). Two independent reviewers screened all records based on predefined eligibility criteria. Extracted data included study design, patient characteristics, ICG administration protocols, clinical applications, and perioperative outcomes. Results: A total of 33 studies comprising 433 patients treated between 2014 and 2025 were included for qualitative synthesis. Nineteen (57.6%) were case reports, seven (21.2%) retrospective descriptive studies, two (6.1%) retrospective comparative studies, three (9.1%) prospective comparative trials, and two (6.1%) prospective descriptive studies. Clinical indications for ICG included capillary and venous malformations (5 studies), arteriovenous malformations (9 studies), and lymphatic malformations (19 studies). Quality assessment with the MINORS tool showed that most studies scored < 17, while only seven reached 18-24, reflecting higher methodological quality. Conclusions: Intraoperative ICG fluorescence imaging represents a promising adjunct in the treatment of vascular malformations, providing real-time visualization that may facilitate lesion delineation, guide resection, and support minimally invasive techniques such as lymphaticovenous anastomosis. However, current evidence is largely descriptive, with very limited comparative outcome data, and high-quality studies are needed to determine whether these technical advantages translate into improved long-term clinical outcomes.