Bayesian network meta-analysis and systematic review of endovascular revascularization strategies for infrapopliteal arteries in chronic limb-threatening ischemia.

BACKGROUND: In 2024, several researchers introduced the concept of "woundosome" in an editorial, highlighting the need to prioritize perfusion and microcirculation function within patient wound areas. Building upon this foundation, we systematically compared this concept with the previously established angiosome theory.

METHODS: A comprehensive search was performed across the Cochrane Central Register of Controlled Trials, Embase, and PubMed. Twenty-five relevant studies met the inclusion criteria, including four investigations using wound blush (WB). We implemented a Bayesian network meta-analysis to evaluate angiosome-related studies and reviewed the literature on WB. Within the framework of the network meta-analysis, therapeutic efficacy was compared among direct revascularization (DR), indirect revascularization (IR), and indirect revascularization with collateral vessels (IRc). Primary outcome measures encompassed wound healing rate (WHR), amputation-free survival (AFS), and limb salvage rate (LSR).

RESULTS: The network meta-analysis revealed that DR was significantly better than IR in WHR outcomes at 3, 6, and 12 months, as well as in the overall analysis. In addition, IRc demonstrated a significant advantage over IR in both the 12-month and overall analyses. The surface under the cumulative ranking curves (SUCRA) values for WHR indicated that DR achieved the highest ranking at 3, 6, and 12 months after surgery. IRc SUCRA values at 6 months, 12 months, and in the overall analysis were comparable to those of DR. In terms of AFS, DR showed significantly better results than IR at 6 months, 12 months, and in the overall analysis. LSR analysis indicated that both DR and IRc were significantly superior to IR at 12 months and in the overall analysis. The SUCRA curves for AFS and LSR revealed that DR and IRc had similar SUCRA values and higher compared with IR. In the second part of the study, we reviewed research related to WB. Our findings indicated that WHR, LSR, and AFS were significantly higher in the WB+ group compared with the WB- group. The benefit of LSR in WB+ patients persisted for over 3 years, whereas there was no significant difference in DR/IR between the two groups. Notably, the proportion of DR patients in the WB+ group was higher than that in the WB- group, suggesting that DR may increase the likelihood of WB+.

CONCLUSIONS: For endovascular treatment of critical limb-threatening ischemia disease, DR and IRc exhibit comparable efficacy across all three end points and are both superior to IR. WB reflects a focus on wound microcirculation and appears to better inform intraoperative decision-making and predict favorable clinical outcomes.