Impact of Woundsome Revascularization on the Outcomes of Endovascular Intervention in Patients With Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI) represents the most advanced stage of lower-extremity peripheral artery disease (PAD) and is a major global health concern with escalating prevalence and significant health-care costs. Fortunately, technological advancements, evolving revascularization strategies, as well as refinement and expansion of the skill set of surgical and endovascular specialists have successfully reduced the number of patients previously deemed inappropriate for revascularization. The recent Global Vascular Guidelines on the management of CLTI acknowledge limitations about incorporating the terminal circulation into its algorithmic framework. In 2006, Attinger et al introduced the concept of the 6 Angiosomes in the foot and ankle, originating from the 3 main infrapopliteal arteries, as a dependable method to guide revascularization procedures and ensure direct blood flow to trophic lesions. However, doubts about the utility of the "Angiosome" concept have emerged over time. One significant limitation lies in its reliance on standard anatomy, disregarding potential anatomical variations, possible collateralized vessel contributions, such as from peroneal artery branches supplying anterior and/or posterior circulation patterns, and the role of a patent and non-significantly diseased pedal arch. In addition, the frequent involvement of more than one angiosome in cases of larger wounds clouds its application. Here comes the concept "Woundsome," a term that encapsulates the dynamic impact of increasing the direct arterial blood flow to the wound area in patients with Chronic Limb-Threatening Ischemia (CLTI) and tissue loss. Existing literature focusing on CLTI patients with tissue loss has consistently indicated that the presence of direct arterial flow to the wound is associated with superior outcomes in terms of limb salvage and wound healing. Conversely, the presence and quality of foot collaterals following indirect revascularization procedures have also shown to be important in predicting clinical success, often yielding results comparable to direct revascularization.