Angiosome-targeted vs non-targeted endovascular revascularization in diabetic foot ischemia: A retrospective cohort study

Table 1 Overall cohort characteristics (n = 142)

Variable	Non-missing (n)	Overall (n = 142)
Demographics
Age, years	142	65.4 ± 12.0
Male sex	142	99 (69.7)
Cardiovascular risk factors
Ever smoker	142	28 (19.7)
Hypertension	142	123 (86.6)
ESRD	142	69 (48.6)
Dyslipidemia	142	82 (57.7)
Clinical severity
Rutherford class 5	142	139 (97.9)
Rutherford class 6	142	3 (2.1)
Wagner grade	142	3.0 (3.0–4.0)
Grade 1	142	1 (0.7)
Grade 2	142	27 (19.0)
Grade 3	142	68 (47.9)
Grade 4	142	42 (29.6)
Grade 5	142	3 (2.1)
Wagner multiple/ambiguous entry flag	142	1 (0.7)
Procedural characteristics
Procedure group: Targeted-only	142	33 (23.2)
Procedure group: Non-targeted-only	142	74 (52.1)
Procedure group: Combined	142	35 (24.6)
Procedure level: BTK only	141	47 (33.1)
Procedure level: ATK only	141	47 (33.1)
Procedure level: ATK + BTK	141	47 (33.1)
Stent adjunct	142	8 (5.6)
Follow-up duration, months	139	6.0 (4.0–6.0)
Clinical outcomes
Technical success	142	123 (86.6)
Wound healing	139	67 (48.2)
Limb salvage	141	109 (77.3)
Major amputation	141	16 (11.3)
Complications	142	7 (4.9)
Re-intervention	141	18 (12.8)

Data are presented as n (%), mean ± SD, or median (interquartile range). ATK: Above the knee; BTK: Below the knee; ESRD: End-stage renal disease.

Table 2 Baseline characteristics by procedure group

Variable	Targeted only, n = 33	Non-targeted only, n = 74	Combined, n = 35	P value	Test
Age, years	64.0 (58.0–74.0)	65.5 (59.0–74.0)	68.0 (56.0–75.0)	0.891	KW
Male sex	20/33 (60.6)	51/74 (68.9)	28/35 (80.0)	0.215	χ2
Ever smoker	2/33 (6.1)	15/74 (20.3)	11/35 (31.4)	0.031a	χ2
Hypertension	32/33 (97.0)	60/74 (81.1)	31/35 (88.6)	0.077	FE
ESRD	15/33 (45.5)	35/74 (47.3)	19/35 (54.3)	0.728	χ2
Dyslipidemia	16/33 (48.5)	44/74 (59.5)	22/35 (62.9)	0.444	χ2
Rutherford class 6	1/33 (3.0)	2/74 (2.7)	0/35 (0.0)	0.602	FE
Wagner grade	3.0 (3.0–4.0)	3.0 (3.0–4.0)	3.0 (3.0–4.0)	0.396	KW
Follow-up, months	6.0 (2.0–6.0)	6.0 (6.0–6.0)	6.0 (2.0–6.0)	0.102	KW
Stent adjunct	1/33 (3.0)	5/74 (6.8)	2/35 (5.7)	0.742	FE

^aP < 0.05.

Data are presented as n/N (%) or median (interquartile range). ESRD: End-stage renal disease; FE: Fisher’s exact test; KW: Kruskal–Wallis test.

Table 3 Clinical outcomes by procedure group

Outcome	Targeted only, n = 33	Non-targeted only, n = 74	Combined, n = 35	P value	Test
Technical success	23/33 (69.7)	68/74 (91.9)	32/35 (91.4)	0.005a	FE
Wound healing	16/33 (48.5)	37/72 (51.4)	14/34 (41.2)	0.617	χ2
Limb salvage	25/33 (75.8)	56/73 (76.7)	28/35 (80.0)	0.903	χ2
Major amputation	3/33 (9.1)	9/73 (12.3)	4/35 (11.4)	0.888	FE
Complications	3/33 (9.1)	2/74 (2.7)	2/35 (5.7)	0.359	FE
Re-intervention	4/33 (12.1)	11/73 (15.1)	3/35 (8.6)	0.634	FE

^aP < 0.05.

Data are presented as n/N (%). Denominators vary because of missing outcome data in some patients. FE: Fisher’s exact test.

Table 4 Strict binary subgroup analysis: Targeted-only vs non-targeted-only (n = 107; combined procedures excluded)

Variable	Targeted only, n = 33	Non-targeted only, n = 74	P value	Test
Baseline characteristics
Age, years	64.0 (58.0–74.0)	65.5 (59.0–74.0)	0.741	MWU
Male sex	20/33 (60.6)	51/74 (68.9)	0.536	χ2
Ever smoker	2/33 (6.1)	15/74 (20.3)	0.116	χ2
Hypertension	32/33 (97.0)	60/74 (81.1)	0.034a	FE
ESRD	15/33 (45.5)	35/74 (47.3)	1.000	χ2
Dyslipidemia	16/33 (48.5)	44/74 (59.5)	0.398	χ2
Rutherford class 6	1/33 (3.0)	2/74 (2.7)	1.000	FE
Wagner grade	3.0 (3.0–4.0)	3.0 (3.0–4.0)	0.312	MWU
Follow-up, months	6.0 (2.0–6.0)	6.0 (6.0–6.0)	0.084	MWU
Stent adjunct	1/33 (3.0)	5/74 (6.8)	0.664	FE
Clinical outcomes
Technical success	23/33 (69.7)	68/74 (91.9)	0.006a	FE
Wound healing	16/33 (48.5)	37/72 (51.4)	0.947	χ2
Limb salvage	25/33 (75.8)	56/73 (76.7)	1.000	χ2
Major amputation	3/33 (9.1)	9/73 (12.3)	0.750	FE
Complications	3/33 (9.1)	2/74 (2.7)	0.169	FE
Re-intervention	4/33 (12.1)	11/73 (15.1)	0.773	FE

^aP < 0.05.

Data are presented as n/N (%) or median (interquartile range). ESRD: End-stage renal disease; FE: Fisher’s exact test; MWU: Mann–Whitney U test.

Table 5 Logistic regression analysis: Predictors of limb salvage

Predictor	n	OR	95%CI	P value
Univariable analysis
Age	141	1.01	0.97–1.04	0.690
Male sex	141	1.05	0.45–2.45	0.916
Ever smoker	141	1.10	0.40–2.99	0.858
Hypertension	141	1.26	0.42–3.80	0.686
ESRD	141	1.31	0.59–2.89	0.505
Dyslipidemia	141	1.07	0.48–2.36	0.876
Rutherford class 6	141	0.14	0.01–1.58	0.112
Wagner grade	141	0.58	0.34–0.99	0.044a
Procedure: Targeted vs non-targeted	141	0.95	0.36–2.49	0.915
Procedure: Combined vs non-targeted	141	1.21	0.45–3.27	0.701
Procedure level: ATK + BTK vs ATK only	141	1.38	0.53–3.55	0.509
Procedure level: BTK only vs ATK only	141	1.61	0.61–4.25	0.332
Stent adjunct	141	0.46	0.10–2.06	0.313
Follow-up, months	139	1.17	0.97–1.42	0.110
Multivariable analysis (n = 139; AUC = 0.661; LR P = 0.359)
Age	139	1.01	0.97–1.05	0.682
Male sex	139	1.18	0.45–3.07	0.733
ESRD	139	1.45	0.60–3.51	0.411
Wagner grade	139	0.59	0.33–1.05	0.075
Procedure: Targeted vs non-targeted1	139	1.16	0.40–3.32	0.787
Procedure: Combined vs non-targeted1	139	1.64	0.54–4.93	0.379
Stent adjunct	139	0.43	0.09–2.14	0.303
Follow-up, months	139	1.19	0.97–1.47	0.099

^aP < 0.05.

¹Reference group: Non-targeted-only.

ATK: Above the knee; AUC: Area under the receiver-operating characteristic curve; BTK: Below the knee; ESRD: End-stage renal disease; LR: Likelihood ratio; OR: Odds ratio; 95%CI: 95% confidence interval.

Table 6 Logistic regression analysis: Predictors of wound healing

Predictor	n	OR	95%CI	P value
Univariable analysis
Age	139	1.05	1.02–1.08	0.003a
Male sex	139	0.69	0.33–1.42	0.309
Ever smoker	139	1.20	0.52–2.78	0.673
Hypertension	139	1.71	0.63–4.65	0.290
ESRD	139	0.69	0.35–1.34	0.269
Dyslipidemia	139	0.94	0.48–1.83	0.847
Rutherford class 6	139	2.18	0.19–24.67	0.527
Wagner grade	139	0.51	0.32–0.81	0.004a
Procedure: Targeted vs non-targeted	139	0.89	0.39–2.03	0.782
Procedure: Combined vs non-targeted	139	0.66	0.29–1.51	0.327
Procedure level: ATK + BTK vs ATK only	139	1.04	0.46–2.37	0.919
Procedure level: BTK only vs ATK only	139	0.96	0.43–2.17	0.922
Stent adjunct	139	1.85	0.43–8.08	0.411
Follow-up, months	137	1.42	1.16–1.74	< 0.001a
Multivariable analysis (n = 137; AUC = 0.770; LR P = 0.0001)
Age	137	1.05	1.02–1.09	0.004a
Male sex	137	1.05	0.45–2.44	0.908
ESRD	137	1.03	0.47–2.24	0.950
Wagner grade	137	0.52	0.32–0.86	0.010a
Procedure: Targeted vs non-targeted1	137	1.38	0.52–3.71	0.519
Procedure: Combined vs non-targeted1	137	0.86	0.34–2.21	0.759
Stent adjunct	137	1.49	0.30–7.35	0.622
Follow-up, months	137	1.41	1.13–1.76	0.002a

^aP < 0.05.

¹Reference group: Non-targeted-only.

ATK: Above the knee; AUC: Area under the receiver-operating characteristic curve; BTK: Below the knee; ESRD: End-stage renal disease; LR: Likelihood ratio; OR: Odds ratio; 95%CI: 95% confidence interval.

Table 7 Literature summary of angiosome-targeted vs non-targeted endovascular revascularization in diabetes

Reference	Design	Procedure	Results/comment
Alexandrescu et al[27], 2020	Prospective, 167 patients with diabetes, CLTI, and foot wounds	Endovascular	Wound healing (1 year): 70% (targeted) vs 20% (non-targeted). Healing time: 6.8 months vs 9.8 months
Pinelo et al[21], 2025	Retrospective, 114 patients with diabetes and neuroischemic ulcers	Endovascular and open surgery	Wound healing (12 months): No significant difference. Healing time: Shorter with targeted approach
Kreider-Stempfle et al[24], 2025	Retrospective, 68 patients with diabetes and CLTI	Endovascular	Positive outcome (6 months): 92.6% (targeted) vs 90.5% (complete revascularization). Indirect-only outcomes: 33.3%–40.0% (worse unless collaterals present: 66.7% with collaterals)
Ji et al[22], 2018	Retrospective, 102 patients with diabetes and Fontaine IV critical limb ischemia undergoing infrapopliteal PTA	Endovascular	Wound healing (6 months): 85.1% (40/47, DR) vs 60.0% (33/55, IR), P = 0.005. Limb salvage (6 months): 100% (47/47) vs 90.1% (50/55), P = 0.035
Biancari and Juvonen[7], 2014	Meta-analysis of 9 studies, 715 limbs (targeted) vs 575 limbs (non-targeted)	Endovascular and open surgery	Risk of unhealed wound: HR = 0.64 (95%CI: 0.52–0.80); favors targeted. Risk of major amputation: HR = 0.44 (95%CI: 0.26–0.75); favors targeted. Limb salvage at 1 year: 86.2% vs 77.8%
Schaper et al[23], 2024	IWGDF guideline	Angiosome-guided revascularization	Restoring in-line flow to at least 1 pedal artery, preferably the vessel supplying the anatomical region of the wound, while selecting the revascularization technique according to PAD morphology, conduit availability, comorbidity, and operator expertise
Moysidis et al[25], 2025	Review	Angiosome-guided direct revascularization	Improved wound healing and limb salvage rates following angiosome-guided direct revascularization (if in-line flow could be restored). Comparable outcomes were reported with indirect revascularization in the presence of robust collateral circulation
Present study	Retrospective; 142 patients with diabetes	Angiosome-targeted vs non-targeted endovascular revascularization	No significant differences in wound healing, limb salvage, or major amputation rates were observed across the 3 procedure groups

CLTI: Chronic limb-threatening ischemia; DR: Direct revascularization; HR: Hazard ratio; IR: Indirect revascularization; IWGDF: International Working Group on the Diabetic Foot; PAD: Peripheral artery disease; PTA: Percutaneous transluminal angioplasty; 95%CI: 95% confidence interval.