Indocyanine Green Fluorescence Angiography as a Navigational Adjunct in Focused Parathyroidectomy: Does It Contribute to Surgical Outcomes?

AbstractIntroduction: Indocyanine green (ICG) fluorescence angiography enables real-time visualization of hypervascular parathyroid tissue and has shown promise as an intraoperative navigational tool. However, its specific additive value in focused parathyroidectomy—beyond preoperative localization and naked-eye exploration—remains unclear, particularly regarding surgical cure rates.Materials and Methods: This retrospective cohort study analyzed 35 consecutive patients with primary hyperparathyroidism undergoing focused parathyroidectomy at a single center between January 2024 and May 2025. Patients were stratified by intraoperative ICG use (ICG group, n=17) versus no ICG (non-ICG group, n=18). Preoperative localization (ultrasonography and sestamibi scintigraphy), naked-eye exploration (NEE), intraoperative PTH monitoring, surgical approach, and outcomes were compared. Cure was defined as normocalcemia and normal PTH levels at 6 months.Results: Baseline characteristics were comparable except for higher ultrasonography positivity and transoral approaches in the ICG group. Overall cure rate was 97.1% (94.1% ICG vs. 100% non-ICG, p=0.486). Among 17 ICG cases, 15 glands showed positive fluorescence. ICG identified the adenoma in one NEE-negative case despite concordant preoperative imaging, while one ICG-negative case resulted in persistent disease. No significant additive benefit of ICG on cure rates was observed across preoperative localization subgroups (all p>0.05).Conclusion: In focused parathyroidectomy with adequate preoperative localization, routine ICG fluorescence angiography does not significantly improve cure rates. However, it may serve as a valuable “rescue” tool for intraoperative navigation in selected cases where naked-eye identification is challenging, independent of preoperative imaging.Keywords: Primary hyperparathyroidism, Focused parathyroidectomy, Indocyanine green, Near-infrared fluorescence, Intraoperative navigation