*3.6. Effects on the Autotransplantation Rate*

DiMarco et al. [68] stated that NIRAF imaging might detect inadvertent parathyroidectomy and allow autotransplantation, even though no difference between the NIRAF imaging and control groups was found. Similarly, Ladurner et al. [58] stated that NI-RAF imaging assisted in identifying several inferior parathyroid glands that otherwise would have been lost for autotransplantation. Bellier et al. [69] found that NIRAF imaging can help detect the accidental removal of parathyroid glands and that 60% of these glands can be spared and autotransplanted during the surgery. In the controlled study of Benmiloud et al. [70], NIRAF imaging appeared to reduce the autotransplantation rate (from 15% to 2.1%) and the inadvertent parathyroid resection rate (from 7.2% to 1.1%) thanks to improved parathyroid gland identification. These findings were confirmed later by the same author [45] in a study utilizing NIRAF imaging to detect a reduction in the inadvertent resection rate (from 11.7 to 2.5; *p* = 0.006) and the autotransplantation rate (from 13.3 to 3.3; *p* = 0.009).

Kim et al. [64] found that the rate of incidental parathyroidectomy was higher in the conventional (14%) versus NIRAF imaging group (6%) (*p* = 0.039) despite similar autotransplantation rates (4% vs 6%, respectively; *p* = 0.562). This was in line with another study [66] reporting that the number of inadvertently resected PGs (in the pathologic specimen) was significantly lower in the NIRAF group (12.8% vs 6.9%; *p* = 0.021), but that the number of autotransplanted PGs in both groups was similar.

The autotransplantation rate based on ICG angiography was approximately 17% [52]; however, some authors [49] found it significantly increased not only in the ICG group compared to the control group (36% vs. 12%; *p* = 0.0001), but also comparing the ICG group with the NIRAF group [54].

Several authors [49,71] have stated that ICG angiography can guide more appropriate autotransplantation without compromising postoperative parathyroid function. This is in contrast with Razavi et al. [48], who assert that ICG angiography may lead to unnecessary parathyroid autotransplantation because low-flow ICG patterns are not associated with postoperative PTH changes or transient hypocalcemia.
