Major lower limb amputations are often performed by orthopedic surgeons and other surgeons in the clinical setting. In cases of chronic gangrene due to diabetes and/or arteriosclerosis obliterans, the amputation level is planned based on the preoperative angiography findings and the detection of necrosis on visual inspection. Amputation is performed above or below the knee. Fine adjustment of the amputation level is conducted intraoperatively upon checking the skin findings and evaluating for bleeding. This report shows the application of near-infrared (NIR) fluorescence imaging, using indocyanine green (ICG), to determine the amputation level in a patient with femoral artery occlusion. In the present case, the amputation level was difficult to determine based on visual examination and computed tomography angiography (CTA) findings. This is a case of an 80-year-old woman, who was successfully resuscitated from cardiac arrest caused by acute myocardial infarction.

This case showed three utility points for the application of NIR-ICG imaging in emergency extremity amputation. First, NIR-ICG imaging accurately assesses soft tissue blood flow. It assesses the peripheral small vessels proximal to the skin, rather than the large vessels. In this respect, ICG is superior to CTA. Second, NIR-ICG imaging is performed can be performed instantly at any location. It is easy to use and does not expose the patient to radiation.  Thirdly, ICG is contraindicated for a few patients only, and it is safe for children and the elderly. NIR-ICG is a useful imaging tool for accurately determining the amputation level, especially in patients with acute arterial occlusion.

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