The “Woundosome” Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia

Fowkes FG Rudan D Rudan I , et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329–1340. doi:10.1016/S0140-6736(13)61249-0.

Nakama T Watanabe N Haraguchi T , et al. Clinical outcomes of pedal artery angioplasty for patients with ischemic wounds: results from the multicenter RENDEZVOUS registry. JACC Cardiovasc Interv. 2017;10(1):79–90. doi:10.1016/j.jcin.2016.10.025.

Jung HW Ko YG Hong SJ , et al. Editor’s choice—impact of endovascular pedal artery revascularisation on wound healing in patients with critical limb ischaemia. Eur J Vasc Endovasc Surg. 2019;58(6):854–863. doi:10.1016/j.ejvs.2019.07.034.

Machin M Younan HC Guéroult AM , et al. Systematic review of inframalleolar endovascular interventions and rates of limb salvage, wound healing, restenosis, rest pain, reintervention and complications. Vascular. 2022;30(1):105–114. doi:10.1177/17085381211004246.

Meloni M Izzo V Giurato L , et al. Below-the-ankle arterial disease severely impairs the outcomes of diabetic patients with ischemic foot ulcers. Diabetes Res Clin Pract. 2019;152:9–15. doi:10.1016/j.diabres.2019.04.031.

Conte MS Bradbury AW Kolh P , et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019;69(6S):3S–125S.e40. doi:10.1016/j.jvs.2019.02.016. Erratum in: J Vasc Surg. 2019;70(2):662.

TASC Steering Committee; Jaff MR White CJ Hiatt WR , et al. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II). Vasc Med. 2015;20(5):465–478. doi:10.1177/1358863X15597877.

Bradbury AW Moakes CA Popplewell M , et al. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. Lancet. 2023;401(10390):1798–1809. doi:10.1016/S0140-6736(23)00462-2.

Farber A Menard MT Conte MS , et al. Surgery or endovascular therapy for chronic limb-threatening ischemia. N Engl J Med. 2022;387(25):2305–2316. doi:10.1056/NEJMoa2207899.

Attinger CE Evans KK Bulan E , et al. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg. 2006;117(suppl 7):261S–293S.

Dilaver N Twine CP Bosanquet DC. Editor’s choice—directvs. Indirect angiosomal revascularisation of infrapopliteal arteries, an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2018;56(6):834–848.

Biancari F Juvonen T. Angiosome-targeted lower limb revascularization for ischemic foot wounds: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2014;47(5):517–522.

Kabra A Suresh KR Vivekanand V , et al. Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia. J Vasc Surg. 2013;57(1):44–49. doi:10.1016/j.jvs.2012.07.042.

Alexandrescu VA Brochier S Limgba A , et al. Healing of diabetic neuroischemic foot wounds with vs without wound-targeted revascularization: preliminary observations from an 8-year prospective dual-center registry. J Endovasc Ther. 2020;27(1):20–30. doi:10.1177/1526602819885131.

Ballotta E Da Giau G Gruppo M , et al. Infrapopliteal arterial revascularization for critical limb ischemia: is the peroneal artery at the distal third a suitable outflow vessel? J Vasc Surg. 2008;47(5):952–959. doi:10.1016/j.jvs.2008.01.002.

Mohapatra A Boitet A Malak O , et al. Peroneal bypass versus endovascular peroneal intervention for critical limb ischemia. J Vasc Surg. 2019;69(1):148–155. doi:10.1016/j.jvs.2018.04.049.

Söderström M Albäck A Biancari F , et al. Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers. J Vasc Surg. 2013;57(2):427–435. doi:10.1016/j.jvs.2012.07.057.

Spillerova K Biancari F Leppäniemi A , et al. Differential impact of bypass surgery and angioplasty on angiosome-targeted infrapopliteal revascularization. Eur J Vasc Endovasc Surg. 2015;49(4):412–419. doi:10.1016/j.ejvs.2014.12.023.

Neville RF Attinger CE Bulan EJ , et al. Revascularization of a specific angiosome for limb salvage: does the target artery matter? Ann Vasc Surg. 2009;23(3):367–373. doi:10.1016/j.avsg.2008.08.022.

Alexandrescu VA Hubermont G Philips Y , et al. Selective primary angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1-4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service. J Endovasc Ther. 2008;15(5):580–593. doi:10.1583/08-2460.1.

Varela C Acín F de Haro J , et al. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model. Vasc Endovascular Surg. 2010;44(8):654–660.

Zheng XT Zeng RC Huang JY , et al. The use of the angio- some concept for treating infrapopliteal critical limb ischemia through interventional therapy and determining the clinical significance of collateral vessels. Ann Vasc Surg. 2016;32:41–49.

Kawarada O Fujihara M Higashimori A , et al. Predictors of adverse clinical outcomes after successful infrapopliteal intervention. Catheter Cardiovasc Interv. 2012;80:861–871. doi:10.1002/ccd.24370.

Alexandrescu VA Brochier S Schoenen S , et al. Grades of below-the-ankle arterial occlusive disease following the angiosome perfusion: a new morphological assessment and correlations with the inframalleolar GVG stratification in CLTI patients. Ann Vasc Surg. 2022;81:358–377. doi:10.1016/j.avsg.2021.09.031.

van den Berg JC . Angiosome perfusion of the foot: an old theory or a new issue? Semin Vasc Surg. 2018;31(2–4):56–65. doi:10.1053/j.semvascsurg.2018.12.002.

Troisi N Turini F Chisci E , et al. Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia. Int Angiol. 2017;36(5):438–444. doi:10.23736/S0392-9590.17.03809-3.

Mustapha JA Saab FA Martinsen BJ , et al. Digital subtraction angiography prior to an amputation for critical limb ischemia (CLI): an expert recommendation statement from the CLI Global Society to Optimize Limb Salvage. J Endovasc Ther. 2020;27(4):540–546. doi:10.1177/1526602820928590.

Schreuder SM Nieuwdorp M Koelemay MJW , et al. Testing the sympathetic nervous system of the foot has a high predictive value for early amputation in patients with diabetes with a neuroischemic ulcer. BMJ Open Diabetes Res Care. 2018;6(1):e000592. doi:10.1136/bmjdrc-2018-000592.

Liu IH Wu B Krepkiy V , et al. Pedal arterial calcification score is associated with the risk of major amputation in chronic limb-threatening ischemia. J Vasc Surg. 2022;75(1):270–278.e3. doi:10.1016/j.jvs.2021.07.235.

Misra S Shishehbor MH Takahashi EA , et al. Perfusion assessment in critical limb ischemia: principles for understanding and the development of evidence and evaluation of devices: a scientific statement from the American Heart Association. Circulation. 2019;140(12):e657–e672. doi:10.1161/CIR.0000000000000708.

Menard MT Farber A Assmann SF , et al. Design and rationale of the best endovascular versus best surgical therapy for patients with critical limb ischemia (BEST-CLI) trial. J Am Heart Assoc. 2016;5(7):e003219. doi:10.1161/JAHA.116.003219.

Chuter V Schaper N Hinchliffe R , et al. Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: a systematic review. Diabetes Metab Res Rev. 2024;40(3):e3701. doi:10.1002/dmrr.3701.

Teso D Sommerset J Dally M , et al. Pedal acceleration time (PAT): a novel predictor of limb salvage. Ann Vasc Surg. 2021;75:189–193. doi:10.1016/j.avsg.2021.02.038.

Montero-Baker MF Au-Yeung KY Wisniewski NA , et al. The First-in-Man “Si Se Puede” Study for the use of micro-oxygen sensors (MOXYs) to determine dynamic relative oxygen indices in the feet of patients with limb-threatening ischemia during endovascular therapy. J Vasc Surg. 2015;61(6):1501–1509.e1. doi:10.1016/j.jvs.2014.12.060.

Awopetu AI Gohel MS Sadat U , et al. Clinical feasibility of diffuse speckle contrast analysis for real-time tissue perfusion monitoring. Int Angiol. 2022;41(1):82–89. doi:10.23736/S0392-9590.21.04740-4.

Ikeoka K Watanabe T Shinoda Y , et al. Below-the-ankle arrival time as a novel limb tissue perfusion index: two-dimensional perfusion angiography evaluation. J Endovasc Ther. 2020;27(2):198–204. doi:10.1177/1526602820905527.

de Castro-Santos G Gonçalves PEO Procópio RJ , et al. Accuracy of the pedal acceleration time to diagnose limb ischemia in patients with and without diabetes using the WIfI classification. Vasc Med. 2023;28(1):36–44. doi:10.1177/1358863X221150453.

Trihan JE Mahé G Croquette M , et al. Accuracy of acceleration time of distal arteries to diagnose severe peripheral arterial disease. Front Cardiovasc Med. 2022;8:744354. doi:10.3389/fcvm.2021.744354.

Tehan PE , et al. Diagnostic accuracy of pedal acceleration time for detecting peripheral arterial disease. PowerPoint presentation at 38th Western Vascular Society Annual Meeting; September 10, 2023; Kauai, HI.

Mills JL Conte MS Armstrong DG , et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on Wound, Ischemia, and foot Infection (WIfI). J Vasc Surg. 2014;59(1):220–234.e1–e2.

van Reijen NS Ponchant K Ubbink DT , et al. Editor’s choice—the prognostic value of the WIfI classification in patients with chronic limb threatening ischaemia: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2019;58(3):362–371. doi:10.1016/j.ejvs.2019.03.040.

Ferraresi R Clerici G Casini A , et al. Foot angiosomes: instructions for use. Int J Low Extrem Wounds. 2020;19(4):293–304. doi:10.1177/1534734620954745.

Manzi M Cester G Palena LM , et al. Vascular imaging of the foot: the first step toward endovascular recanalization. Radiographics. 2011;31(6):1623–1636. doi:10.1148/rg.316115511.

Akturk A van Netten JJ Vermeer M , et al. Improved outcomes in patients with diabetic foot ulcers despite of differences in baseline characteristics. Wound Repair Regen. 2021;29(6):912–919. doi:10.1111/wrr.12976.