Intraoperative Techniques to Quantitatively Assess Tissue Perfusion in Patients with Peripheral Artery Disease: A Systematic Review

Objectives Intraoperative tissue perfusion assessment for peripheral artery disease (PAD) has gained importance in recent years. Its perceived benefit encompasses the ability for surgeons to evaluate the need for additional intervention and predict patient outcomes before the patient leaves the operating room (OR). The aim of this systematic review is to provide an overview of the applicability and availability of current perfusion techniques and to determine their potential for predicting clinical outcomes. Design A systematic review was performed, following the PRISMA-guidelines. Data sources MEDLINE (via PubMed), Embase and the Cochrane Central Register of Controlled Trials Review methods The electronic databases were searched from 1 January 2010 to 16 July 2026. Articles were deemed eligible if they evaluated an intraoperative perfusion assessment technique in patients with PAD in the OR. The QUADAS-2 tool was used to assess the risk of bias and applicability of the studies. Results In total, 56 articles describing 14 distinct intraoperative perfusion assessment techniques were included. The included techniques were categorised into four categories: macrovascular level perfusion assessment, microvascular level perfusion assessment, oxygenation assessment and hybrid techniques. All studies were evaluated according to the QUADAS-2 guidelines, which yielded mostly poor-quality research. Nonetheless, the two most extensively researched techniques, 2D-perfusion assessment (macrovascular level technique) and fluorescence angiography (hybrid technique), demonstrated correlation of quantified parameters to clinical outcomes in numerous studies. Conclusions This systematic review identified 14 intraoperative perfusion assessment techniques. To date, 2D-perfusion assessment and fluorescence angiography have been researched most extensively. Future research in larger cohorts and randomized controlled trials should focus on assessing the accuracy in predicting clinical outcomes and preventing re-intervention.