Introduction: Chronic limb ischemia (CLI) and diabetic foot significantly impact patients’ quality of life, with high rates of amputation and mortality. Angiosome-oriented revascularization represents an anatomically precise approach, targeting the artery that directly supplies the lesion area. Direct revascularization (DR) is increasingly considered superior to indirect revascularization (IR) due to potentially better wound healing and limb salvage outcomes. Methods: A narrative literature review was conducted using PubMed, Cochrane Library, and Google Scholar, with the keywords: angiosome, critical limb ischemia, diabetic foot, direct revascularization, endovascular, bypass surgery. Studies published between 2020 and 2025 were included, focusing on systematic reviews, meta-analyses, and prospective cohort and clinical studies. In addition to clinical studies, anatomical data on the distribution of foot and lower leg angiosomes were analyzed, including a table illustrating the correlation between wound location and target artery. Results: Six main angiosomes of the lower limb were identified, each corresponding to a specific artery. DR was associated with higher rates of wound healing and limb preservation, reducing the risk of amputation by 20–30% compared to IR. Optimal candidates for DR are those with localized lesions, patent distal target arteries, and adequate microcirculation. DR is less effective or technically unfeasible in patients with diffuse microvascular disease, multisegment occlusions, poor distal vessels, or active severe infections. Advanced technologies such as hyperspectral imaging and indocyanine green (ICG) mapping improve intraoperative perfusion assessment. Conclusion: Angiosome-oriented revascularization is a logical and anatomically grounded approach for treating CLI and diabetic foot. When feasible, DR of the target artery provides better clinical outcomes than IR. Success requires precise diagnostics, patient selection, and multidisciplinary collaboration. Further randomized studies are needed to define optimal application algorithms for this concept.
Moakes CA, Bradbury AW, Abdali Z, Bate GR, Hall J, Jarrett H, et al. BASIL-2 Investigators. Vein bypass first vs best endovascular treatment first revascularisation strategy for chronic limb-threatening ischaemia due to infra-popliteal disease: the BASIL-2 RCT. *Health Technol Assess*. 2024;28(65):1–72.
2.
Li X, Liu H, Yang C, Xiong A, He X, Tian X, et al. Application of free anterolateral thigh flap with fascia lata for diabetic foot ulcers with bone exposure. *Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi*. 2022;36(1):86–91.
3.
Felder JM, Nageeb E, Rocha I, Qasawa R, Moltaji S, Fuse Y. The role of flaps in preventing lower extremity amputations. *Semin Vasc Surg*. 2025;38(1):64–73.
4.
Patel RA, Fallon B, Brandis A, Chang K, Demarsico A. Outcomes of a multidisciplinary vascular practice: 12-month amputation-free survival and beyond in patients with chronic limb-threatening ischemia. *J Endovasc Ther*. 2024;31(5).
5.
Abdali Z, Kigozi J, Moakes CA, Bate GR, Hall J. A vein bypass first versus a best endovascular treatment first revascularization strategy for patients with chronic limb-threatening ischaemia who require an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularization procedure to restore limb perfusion: the BASIL-2 within-trial health economic analysis. *Br J Surg*. 2025;112(6).
6.
Gee A, Tarricone A, Lavery LA, Wiley KA, Palmieri N, Sharma S, et al. The role of intravascular ultrasound in limb salvage: a systematic review and meta-analysis. *Vasc Endovascular Surg*. 2024;2025;59(3):288-297.
7.
Vaassen HGM, Lips DJ, Geelkerken RH, Wermelink B. Quantitative intra-arterial fluorescence angiography for direct monitoring of peripheral revascularization effects. *J Vasc Surg Cases Innov Tech*. 2025;11(3).
8.
Meyer A, Rother U, Thamm OC. Revascularization prior to defect reconstruction of the lower limb – essential cooperation between plastic and vascular surgery. *Zentralbl Chir*. 2024;149(5):468–74.
9.
Martinez-Singh K, Chandra V. How to build a limb salvage program. *Semin Vasc Surg*. 2022;35(2):228–33.
10.
Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, et al. Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review. *Diabetes Metab Res Rev*. 2024;40(3).
11.
Yeo C, Jung H, Lee K, Song C. Low frequency oscillations assessed by diffuse speckle contrast analysis for foot angiosome concept. *Sci Rep*. 2020;10(1).
12.
Fujii M, Yamada A, Yamawaki K, Tsuda S, Miyamoto N, Gan K, et al. Predictive factors for limb salvage and foot ulcer recurrence in patients with chronic limb-threatening ischemia after multidisciplinary team treatment: a 6-year Japanese single-center study. *Int J Low Extrem Wounds*. 2021;2023;22(4):722-732.
13.
Adami D. Bifurcated bypass in severe chronic limb threatening ischaemia. *Vascular*. 2022;30(4):552–8.
14.
Pinelo A. Comparative outcomes of targeted versus nontargeted angiosome revascularization for diabetic foot wounds: impact of target arterial path on wound healing. *Ann Vasc Surg*. 2025;
15.
Unno N. The patency of tibial/peroneal arteries affects the increment of regional tissue saturation of oxygen in each angiosome after superficial femoral artery revascularization. *Ann Vasc Dis*. 2022;15(2):161–8.
16.
Croo A, Versyck T, Duinslaeger A, Harth C, Vermassen F, Randon C. The impact of an angiosome-targeted revascularization on healing rate, limb salvage and survival in critical limb threatening ischemia. *Acta Chir Belg*. 2022;122(2):107–15.
17.
Tange FP, Ferrari BR, Hoven P, Schaik J, Schepers A, Rijswijk CSP, et al. Evaluation of the angiosome concept using near-infrared fluorescence imaging with indocyanine green. *Ann Vasc Surg*. 2023;93:283–90.
18.
Ma J, Lai Z, Shao J, Lei J, Li K, Wang J, et al. Infrapopliteal endovascular intervention and the angiosome concept: intraoperative real-time assessment of foot regions’ blood volume guides and improves direct revascularization. *Eur Radiol*. 2020;2021;31(4):2144-2152.
19.
Orrapin S, Siribumrungwong B. Successful revascularization, angiosome concept, and multivessel revascularization: effects on wound healing: an Asian perspective. *Int J Low Extrem Wounds*. 2024;23(1):12–8.
20.
Kirkham AM, Paquet M, Fergusson DA, Graham ID, Presseau J. Clinician underprescription of and patient nonadherence to clinical practice guideline-recommended medications for peripheral artery disease: a systematic review and meta-analysis. *EClinicalMedicine*. 2025;86(103391).
Citation
Copyright
This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The statements, opinions and data contained in the journal are solely those of the individual authors and contributors and not of the publisher and the editor(s). We stay neutral with regard to jurisdictional claims in published maps and institutional affiliations.
