A Conceptual Wound-Oriented Reinterpretation of Perfusion Heterogeneity in Chronic Limb-Threatening Ischemia

Background/Objectives: The angiosome concept is widely used to guide infrapopliteal revascularization in patients with chronic limb-threatening ischemia (CLTI). However, clinical outcomes are not always fully explained by anatomical target-artery alignment alone. The present study aimed to revisit a previously published angiosome-based cohort through a wound-oriented conceptual perspective and to explore whether perfusion heterogeneity may help contextualize variability in clinical outcomes. Methods: This retrospective secondary analysis included 51 patients with CLTI who underwent infrapopliteal endovascular revascularization. Patients were originally classified as direct, indirect, or mixed revascularization according to angiosome-based criteria. The present study represents an exploratory conceptual reinterpretation of the original dataset. No new variables were introduced, and the woundosome concept was not operationalized as a measurable patient-level variable. Statistical analyses were exploratory and descriptive in nature. Results: High rates of wound healing and limb salvage were observed across all revascularization patterns at 12 months. Within the limitations of this small exploratory cohort, no consistent detectable differences in clinical outcomes were observed across anatomical revascularization patterns. Stratification according to the number of affected angiosomes did not reveal clear outcome differences. The findings suggest that factors beyond anatomical target-artery alignment may contribute to wound healing variability in CLTI. Conclusions: The present study does not establish a validated wound-oriented perfusion model but highlights the limitations of relying exclusively on anatomical angiosome classification when interpreting clinical outcomes in CLTI. In this context, the woundosome may serve as a descriptive and hypothesis-generating conceptual framework for discussing perfusion heterogeneity and wound-level perfusion complexity. Prospective studies integrating objective perfusion assessment and standardized wound evaluation are required.