The angiosome and woundosome concepts in guiding revascularization for chronic limb-threatening ischemia and diabetic foot ulcers-a narrative review.

Background and Objective: The angiosome concept, introduced by Taylor et al. and further applied by Neville et al., divides the body into three-dimensional blocks of tissue supplied by specific source arteries. This anatomical framework has been instrumental in guiding targeted revascularization strategies, thus enhancing blood flow to ischemic wounds. Building upon this, the woundosome concept was recently introduced, which focuses on individualized perfusion targeting, based on (I) anatomic variations; (II) the presence and extent of collateral circulation; and (III) wound characteristics. The woundosome concept may offer a potentially more tailored approach, paving the way for more thoughtful tissue revascularization. This review aims to investigate the role of angiosome- and woundosome-directed endovascular revascularization for the improvement of outcomes in patients with chronic limb-threatening ischemia (CLTI). Methods: We conducted a systematic search in PubMed, Web of Science, and Cochrane Library from 1990 to February 2025 using combinations of the terms "angiosome", "woundosome", "critical limb ischemia", "diabetic foot ulcer", "direct revascularization", and "indirect revascularization". After screening 480 records, 14 studies were included in our analysis. Data were extracted regarding study design, patient population, revascularization strategy, and outcomes (wound healing, limb salvage). Findings were narratively synthesized with respect to study methodology and limitations. Key Content and Findings: Most retrospective studies reported improved wound healing and limb salvage rates following angiosome-guided direct revascularization (DR), particularly when inline flow could be restored. However, comparable outcomes were observed with indirect revascularization (IR) in the presence of robust collateral circulation. Evidence for woundosome-guided revascularization remains limited but suggests that a perfusion-oriented, individualized strategy may be especially valuable in anatomically complex cases. Conclusions: Incorporating angiosome- and woundosome-based strategies in CLTI management may improve limb- and patient-related outcomes. The decision on which particular territory needs primary attention and how many vessels require revascularization largely depends on the patency of feeding arteries in the wound area. In the future, a standardized way to measure the intra- and post-procedural arterial flow to the wound would be necessary, to study the clinical applications of the mentioned strategies. Future studies should therefore prospectively validate woundosome-guided strategies and integrate standardized perfusion assessment tools to guide individualized treatment decisions.