Effect of Direct or Indirect Revascularization of the Below-The-Knee Lesions on Clinical Outcomes in Patients with Chronic Limb Threatening Ischemia Treated Based on the Angiosome Concept

Aim: To investigate the impact of direct and indirect revascularization, based on the angiosome concept, on major amputation, minor amputation, and wound healing outcomes after endovascular intervention in patients with critical limb ischemia.Material and Methods: A total of 121 patients with critical limb ischemia and foot ulcer (Rutherford stage 5–6) were evaluated. During follow-up, 3 patients died, and successful revascularization could not be achieved in 29 patients. The remaining 89 patients were classified according to successful restoration of blood flow to the affected angiosome as direct revascularization (DR, n=59) or indirect revascularization (IR, n=30). Patients were followed for three months for major amputation, minor amputation, and wound healing outcomes.Results: Among 89 successfully revascularized patients (mean age 63.9 ± 10.2 years, 81.6% male), direct angiosome-targeted flow was achieved in 59 patients (66.3%). During follow-up, the DR group had a significantly lower major amputation rate compared to the IR group (10.2% vs 30%, p=0.018). Minor amputation rates were similar between groups (23.7% vs 23.3%, p=0.967), while wound healing was significantly better in the DR group (61% vs 36.7%, p=0.030).Conclusion: Angiosome-guided direct revascularization may reduce major amputation risk and improve wound healing in isolated below-knee lesions. Whenever feasible, direct revascularization should be considered the preferred treatment strategy.