Woundosome-directed bypass to the medial plantar artery in bilateral chronic limb-threatening ischemia

Angiosome-based revascularization may be insufficient in chronic limb-threatening ischemia when microperfusion network is disrupted by atherosclerosis. The woundosome concept, encompassing in-line flow to the wound and microcirculatory status around the wound, provides a more appropriate revascularization framework. A 65-year-old man with bilateral foot ulcers showed patent ankle vessels, yet selective malperfusion of the medial plantar territory corresponded to the ulceration sites. Woundosome-directed bypass to plantar branches was performed bilaterally despite vessel diameters of less than 1 mm, achieving complete wound healing with sustained patency at 1 year. This case demonstrates that woundosome-directed bypass, guided by microperfusion assessment, is essential for wound healing.