ABSTRACT
Despite a lack of solid evidence in applying the angiosome concept (AC) in current chronic limb threatening ischemia (CLTI) treatment, several encouraging results for improved wound healing and less for limb preservation were reported in various consistency studies. Direct revascularization (DR) following the foot angiosomes distribution (whenever feasible) may afford better clinical results compared to angiosome indifferent, or indirect revascularization (IR), however without clear benefit on survival and for major adverse limb events (MALE). Inside this interrogation, the notable influence of the remnant collaterals, the foot arches, the wound characteristics, and the type of revascularization (bypass versus endovascular) still remain ardent topics. Current evidence suggests that applying DR in daily vascular practice requires practitioners to be committed to every individual hemodynamic variable in a thorough macro- and micro-vascular evaluation of the ischemic foot. It becomes clearer nowadays that not all CLTI foot ulcers hold same ischemic burden and seemingly need specific DR. In the same setting, a novel wound targeted revascularization (WTR) design was proposed assembling wider circulatory targets than genuine DR notion, as used by some authors. Beyond specific angiosomal artery reperfusion, WTR associates the available arches, the large- and medium-sized collaterals, and the arterial-arterial communicants, in an intentional “source artery” and “collateral” topographic foot revascularization. However, up to date, the notion of angiosome wound-guided revascularization (DR and WTR) detains only a reserved level of confirmation. As for DR, the WTR equally needs higher levels of evidence allowed by standardized definition, uniform indications, and pertinent results from multicenter larger prospective analysis, before large application.