Revascularization Is Not The Finish Line: The Wound That Remains After Perfusion

By Ned Swanson, MD, President & Chief Medical Officer, PolarityBio

Roughly half of people with diabetes and a foot ulcer have peripheral artery disease.[1] For a diabetic foot ulcer complicated by peripheral arterial disease, restoring blood flow is the right priority. Revascularization succeeds in roughly nine of ten cases,[2] yet a meaningful share of those feet still do not heal. The wound does not close because the angiogram looks good. It closes because, after perfusion is restored, someone keeps doing the work of healing it.

Perfusion is necessary, not sufficient

Adequate inflow is a precondition for healing an ischemic wound. Without it, most interventions fail, and failed revascularization is itself an independent predictor of nonhealing and amputation.[2] But restoring inflow does not, by itself, close a wound. Surgeons long ago described “islands of ischemia”: ulcers that refused to heal even after a technically adequate bypass, where tissue oxygen at the wound edge stayed low despite improved perfusion to the foot overall. The pattern still holds, and it is measurable at the level of the foot itself: in a series of ischemic diabetic foot ulcers with below-the-ankle disease, healing reached 89.3% where foot perfusion was successfully restored but only 9.1% where it was not, and failed foot revascularization was an independent predictor of nonhealing, minor amputation, and major amputation.[3] Inflow to the leg is not the same thing as perfusion at the wound. In one cohort followed for six months after revascularization, about 71% of ulcers healed, roughly 14% went on to a major amputation, and the rest remained open.[4] The gap between a successful and a failed procedure is real and large: in a 314-patient single-center series of endovascular revascularization for diabetic foot ulcers, the procedure succeeded in 285 patients (90.8%), and those patients went on to complete wound healing in 53.7% of cases with a major amputation rate of 3.9%, compared to 20.7% healing and 24.1% amputation when revascularization failed.[2] Even among successful revascularization, roughly half the wounds had not closed. Revascularization moved the odds substantially; however, it did not guarantee closure. This likely comes down to the advanced wound healing therapies used for those individual patients.

Why the wound still needs the work

An ischemic ulcer that has finally been re-perfused is still a chronic wound, and it still carries the biology of one: a stalled, inflammatory bed, frequently colonized or infected, often sitting over a pressure point that has not gone anywhere. Restoring flow removes one major obstacle to healing. It does not remove the others. Offloading, debridement, infection control, glycemic management, and advanced wound care are as necessary the day after revascularization as the day before.

Restoring blood flow removes one obstacle to healing. It does not remove the others.

Measure the result, don’t infer it

Guidance is explicit that perfusion should be objectively remeasured after revascularization, and the tools that do this best are the ones that read the microcirculation rather than the vessel. In a prospective multicenter study of ischemic and neuroischemic ulcers assessed four weeks after endovascular revascularization, transcutaneous oxygen pressure and toe pressure were the two tests that best predicted six-month healing, with sensitivities of 0.89 at a TcPO2 cut-off of 24 mmHg and 0.70 at a toe pressure cut-off of 46 mmHg.[4] A number at the wound bed, taken after the procedure and compared with the number before it, is what tells you whether the intervention changed the biology the ulcer actually experiences.

The follow-through gap

This is where handoffs often fail. Guidance is explicit that healing should be tracked from the moment perfusion is restored, and that wound care, offloading, and infection control remain essential to that healing.[1] A re-perfused foot with a wound that no one is actively managing is a limb still at risk. The vascular result was necessary to create the opportunity for wound healing.

Patency is not permanent

The other reason follow-through matters is that the vascular result itself can fade. Reintervention is common: in a one-year series of Rutherford 6 patients treated endovascularly, 48.8% required reintervention within six months.[5] A wound that stalls after an initially good result is not necessarily a wound-care failure; it may be the first clinical sign that perfusion has fallen off again. That is an argument for scheduled reassessment of both the wound and the circulation, not a single post-procedure check.

What “then what” looks like

Confirm perfusion improved with an objective measurement rather than a good-looking angiogram. Reassess the wound on the same trajectory logic that applies to any diabetic foot ulcer, meaning is it moving.  Keep offloading and infection control in place and treat a stalled wound as a prompt to re-examine perfusion rather than only the dressing. Finally, keep the wound owned by someone until it closes.  This is what determines whether saved circulation becomes a saved limb.

Revascularization earns its place at the center of limb salvage. But blood flow is the beginning of healing, not the end of it. The wound that remains after perfusion is restored is still a wound, and it still has to be closed by the patient work of advanced wound care, offloading, and follow-through. Restore the flow, then finish the job.

References

1. Fitridge R, Chuter V, Mills J, et al. Editor's Choice — The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. Eur J Vasc Endovasc Surg. 2023;66(4):454–483. doi:10.1016/j.ejvs.2023.07.020.

2. Caetano AP, et al. Successful revascularization has a significant impact on limb salvage rate and wound healing for patients with diabetic foot ulcers: single-centre retrospective analysis with a multidisciplinary approach. CardioVasc Intervent Radiol. 2020;43(10):1449–1459.

3. Meloni M, Morosetti D, Giurato L, et al. Foot revascularization avoids major amputation in persons with diabetes and ischaemic foot ulcers. J Clin Med. 2021;10(17):3977. doi:10.3390/jcm10173977.

4. Lázaro-Martínez JL, et al. Determining the best noninvasive test for peripheral arterial disease diagnosis to predict diabetic foot ulcer healing in patients following endovascular revascularization. Healthcare (Basel). 2024;12(16):1664. doi:10.3390/healthcare12161664.

5. Lee RE, Patel A, Soon SXY, et al. One year clinical outcomes of Rutherford 6 chronic limb threatening ischemia patients undergoing lower limb endovascular revascularisation from Singapore. CVIR Endovasc. 2022;5(1). doi:10.1186/s42155-022-00306-1.2016;5(7):279–287.