{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T20:40:15Z","timestamp":1784234415848,"version":"3.55.0"},"reference-count":64,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2023,8,4]],"date-time":"2023-08-04T00:00:00Z","timestamp":1691107200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Diabetes Metabolism Res"],"published-print":{"date-parts":[[2024,3]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Introduction<\/jats:title><jats:p>Peripheral artery disease (PAD) is associated with an increased likelihood of delayed or non\u2010healing of a diabetes\u2010related foot ulcer, gangrene, and amputation. The selection of the most effective surgical technique for revascularisation of the lower limb in this population is challenging and there is a lack of conclusive evidence to support the choice of intervention. This systematic review aimed to determine, in people with diabetes and tissue loss, if direct revascularisation is superior to indirect revascularisation and if endovascular revascularisation is superior to open revascularisation for the outcomes of wound healing, minor or major amputation, and adverse events including mortality.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Title and abstract searches of Medline, Embase, PubMed, and EBSCO were conducted from 1980 to 30th November 2022. Cohort and case\u2010control studies and randomised controlled trials reporting comparative outcomes of direct (angiosome) revascularisation (DR) and indirect revascularisation (IR) or the comparative outcomes of endovascular revascularisation and open or hybrid revascularisation for the outcomes of healing, minor amputation, and major amputation in people with diabetes, PAD and\u00a0tissue loss (including foot ulcer and\/or gangrene) were eligible. Methodological quality was assessed using the Cochrane risk\u2010of\u2010bias tool for randomised trials, the ROBINS\u2010I tool for non\u2010randomised studies, and Newcastle\u2010Ottawa Scale for observational and cohort studies where details regarding the allocation to intervention groups were not provided.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>From a total 7086 abstracts retrieved, 26 studies met the inclusion criteria for the comparison of direct angiosome revascularisation (DR) and indirect revascularisation (IR), and 11 studies met the inclusion criteria for the comparison of endovascular and open revascularisation. One study was included in both comparisons. Of the included studies, 35 were observational (31 retrospective and 4 prospective cohorts) and 1 was a randomised controlled trial. Cohort study quality was variable and generally low, with common sources of bias related to heterogeneous participant populations and interventions and lack of reporting of or adjusting for confounding factors. The randomised controlled trial had a low risk of bias. For studies of DR and IR, results were variable, and it is uncertain if one technique is superior to the other for healing, prevention of minor or major amputation, or mortality. However, the majority of studies reported that a greater proportion of participants receiving DR healed compared with IR, and that IR with collaterals may have similar outcomes to DR for wound healing. For patients with diabetes, infrainguinal PAD, and an adequate great saphenous vein available for use as a bypass conduit who were deemed suitable for either surgical procedure, an open revascularisation first approach was superior to endovascular therapy to prevent a major adverse limb event or death (Hazard Ratio: 0.72; 95% CI 0.61\u20130.86). For other studies of open and endovascular approaches, there was generally no difference in outcomes between the interventions.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>The majority of available evidence for the effectiveness of DR and IR and open and endovascular revascularisation for wound healing and prevention of minor and major amputation and adverse events\u00a0including mortality in people with diabetes, PAD and tissue loss is inconclusive, and the certainty of evidence is very low. Data from one high quality randomised controlled trial supports the use of open over endovascular revascularisation to prevent a major limb event and death in people with diabetes, infrainguinal disease and tissue loss who have an adequate great saphenous vein available\u00a0and who are deemed suitable for either approach.<\/jats:p><\/jats:sec>","DOI":"10.1002\/dmrr.3700","type":"journal-article","created":{"date-parts":[[2023,8,4]],"date-time":"2023-08-04T04:44:17Z","timestamp":1691124257000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":20,"title":["Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review"],"prefix":"10.1002","volume":"40","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4793-5340","authenticated-orcid":false,"given":"Vivienne","family":"Chuter","sequence":"first","affiliation":[{"name":"School of Health Sciences Western Sydney University  Campbelltown Sydney Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicolaas","family":"Schaper","sequence":"additional","affiliation":[{"name":"Division of Endocrinology Department Internal Medicine MUMC+  Maastricht The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph","family":"Mills","sequence":"additional","affiliation":[{"name":"Baylor College of Medicine  Houston Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Hinchliffe","sequence":"additional","affiliation":[{"name":"Bristol Centre for Surgical Research University of Bristol  Bristol UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Russell","sequence":"additional","affiliation":[{"name":"Leeds Teaching Hospitals NHS Trust  Leeds UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nobuyoshi","family":"Azuma","sequence":"additional","affiliation":[{"name":"Asahikawa Medical University  Asahikawa Hokkaido Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian\u2010Alexander","family":"Behrendt","sequence":"additional","affiliation":[{"name":"Department of Vascular and Endovascular Surgery Asklepios Clinic Wandsbek Asklepios Medical School  Hamburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3695-192X","authenticated-orcid":false,"given":"Edward J.","family":"Boyko","sequence":"additional","affiliation":[{"name":"University of Washington  Seattle Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael S.","family":"Conte","sequence":"additional","affiliation":[{"name":"San Francisco (UCSF) Medical Centre University of California  San Francisco California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Misty D.","family":"Humphries","sequence":"additional","affiliation":[{"name":"UC Davis Health  Sacramento California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lee","family":"Kirksey","sequence":"additional","affiliation":[{"name":"The Cleveland Clinic  Cleveland Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0706-159X","authenticated-orcid":false,"given":"Katharine C.","family":"McGinigle","sequence":"additional","affiliation":[{"name":"University of North Carolina  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sigrid","family":"Nikol","sequence":"additional","affiliation":[{"name":"Clinical and Interventional Angiology Asklepios Klinik  St Georg Hamburg Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joakim","family":"Nordanstig","sequence":"additional","affiliation":[{"name":"Department of Molecular and Clinical Medicine at the Institute of Medicine University of Gothenburg  Gothenburg Sweden"},{"name":"Department of Vascular Surgery Sahlgrenska University Hospital  Gothenburg Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincent","family":"Rowe","sequence":"additional","affiliation":[{"name":"David Geffen School of Medicine UCLA  Los Angeles California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jos C.","family":"van den Berg","sequence":"additional","affiliation":[{"name":"CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano sede Civico and Universit\u00e4tsinstitut f\u00fcr Diagnostische Interventionelle und P\u00e4diatrische Radiologie Inselspital Universit\u00e4tsspital  Bern Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maarit","family":"Venermo","sequence":"additional","affiliation":[{"name":"Helsinki University Hospital University of Helsinki  Helsinki Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6258-5997","authenticated-orcid":false,"given":"Robert","family":"Fitridge","sequence":"additional","affiliation":[{"name":"Faculty of Health and Medical Sciences University of Adelaide  Adelaide South Australia Australia"},{"name":"Vascular and Endovascular Service Royal Adelaide Hospital  Adelaide South Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2023,8,4]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.27.12.2843"},{"key":"e_1_2_12_3_1","doi-asserted-by":"publisher","DOI":"10.1056\/nejmra1615439"},{"key":"e_1_2_12_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/s1078\u20105884(96)80044\u2010x"},{"key":"e_1_2_12_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejvs.2014.06.041"},{"key":"e_1_2_12_6_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13643\u2010017\u20100488\u20105"},{"key":"e_1_2_12_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.diabres.2015.02.008"},{"key":"e_1_2_12_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/0007\u20101226(87)90185\u20108"},{"key":"e_1_2_12_9_1","doi-asserted-by":"publisher","DOI":"10.1155\/2014\/270539"},{"key":"e_1_2_12_10_1","doi-asserted-by":"publisher","DOI":"10.1177\/1526602819885131"},{"key":"e_1_2_12_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.avsg.2020.11.031"},{"key":"e_1_2_12_12_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.avsg.2015.09.021"},{"key":"e_1_2_12_13_1","doi-asserted-by":"publisher","DOI":"10.1583\/08\u20102460.1"},{"key":"e_1_2_12_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2012.01.037"},{"key":"e_1_2_12_15_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2012.10.129"},{"key":"e_1_2_12_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2013.06.075"},{"key":"e_1_2_12_17_1","doi-asserted-by":"publisher","DOI":"10.1155\/2014\/672897"},{"key":"e_1_2_12_18_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2016.10.100"},{"key":"e_1_2_12_19_1","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.24.8.1433"},{"key":"e_1_2_12_20_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41569\u2010021\u201000663\u20109"},{"key":"e_1_2_12_21_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2018.09.078"},{"key":"e_1_2_12_22_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(05)67704-5"},{"key":"e_1_2_12_23_1","doi-asserted-by":"publisher","DOI":"10.1161\/circinterventions.117.005531"},{"key":"e_1_2_12_24_1","doi-asserted-by":"publisher","DOI":"10.1002\/dmrr.3279"},{"key":"e_1_2_12_25_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2019.02.016"},{"key":"e_1_2_12_26_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2021.04.026"},{"key":"e_1_2_12_27_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.l4898"},{"key":"e_1_2_12_28_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.i4919"},{"key":"e_1_2_12_29_1","unstructured":"WellsGA SheaB O\u2019ConnellD et\u00a0al.The Newcastle\u2010Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta\u2010Analyses;2000."},{"key":"e_1_2_12_30_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.323.7308.334"},{"key":"e_1_2_12_31_1","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.28.9.2206"},{"key":"e_1_2_12_32_1","doi-asserted-by":"publisher","DOI":"10.1093\/ehjci\/ehaa946.2382"},{"key":"e_1_2_12_33_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejvs.2017.01.008"},{"key":"e_1_2_12_34_1","doi-asserted-by":"publisher","DOI":"10.1583\/10\u20103260.1"},{"key":"e_1_2_12_35_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0172023"},{"key":"e_1_2_12_36_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejvs.2019.09.413"},{"key":"e_1_2_12_37_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2019.07.094"},{"key":"e_1_2_12_38_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.avsg.2020.07.049"},{"key":"e_1_2_12_39_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00270\u2010012\u20100544\u20104"},{"key":"e_1_2_12_40_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.avsg.2022.02.012"},{"key":"e_1_2_12_41_1","doi-asserted-by":"publisher","DOI":"10.7547\/18\u2010130"},{"key":"e_1_2_12_42_1","doi-asserted-by":"publisher","DOI":"10.5152\/dir.2015.15129"},{"issue":"3","key":"e_1_2_12_43_1","first-page":"176","article-title":"Evaluation of angiosome\u2010targeted infrapopliteal endovascular revascularization in critical diabetic limb ischemia","volume":"1","author":"Ji D","year":"2018","journal-title":"J Interv Med"},{"key":"e_1_2_12_44_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.avsg.2013.08.026"},{"key":"e_1_2_12_45_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.avsg.2018.01.061"},{"key":"e_1_2_12_46_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.avsg.2008.08.022"},{"key":"e_1_2_12_47_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2012.07.057"},{"key":"e_1_2_12_48_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2018.01.060"},{"issue":"1","key":"e_1_2_12_49_1","first-page":"4","article-title":"Comparison between primary minor amputations and minor amputations with previous revascularization in diabetic foot pathology","volume":"73","author":"Del Carmen DTM","year":"2021","journal-title":"Angiologia"},{"key":"e_1_2_12_50_1","doi-asserted-by":"publisher","DOI":"10.23736\/s0392\u20109590.17.03809\u20103"},{"key":"e_1_2_12_51_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2012.07.042"},{"issue":"4","key":"e_1_2_12_52_1","first-page":"783","article-title":"Comparison between direct and indirect revascularization of below\u2010the\u2010knee arterial occlusive diseases based on foot angiosome concept","volume":"38","author":"Khalefa S","year":"2019","journal-title":"Egypt J Surg"},{"issue":"6","key":"e_1_2_12_53_1","first-page":"1","article-title":"Pedal revascularization: extending the limits of endovascular or surgical means to prevent amputation","volume":"16","author":"Neville R","year":"2019","journal-title":"Vasc Dis Manage"},{"key":"e_1_2_12_54_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.avsg.2018.06.007"},{"key":"e_1_2_12_55_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2018.01.055"},{"key":"e_1_2_12_56_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2021.11.063"},{"key":"e_1_2_12_57_1","doi-asserted-by":"publisher","DOI":"10.1056\/nejmoa2207899"},{"key":"e_1_2_12_58_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2022.12.035"},{"key":"e_1_2_12_59_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2020.09.016"},{"key":"e_1_2_12_60_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2016.07.107"},{"key":"e_1_2_12_61_1","doi-asserted-by":"publisher","DOI":"10.1024\/0301\u20101526.29.3.207"},{"key":"e_1_2_12_62_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2012.05.025"},{"key":"e_1_2_12_63_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2017.10.076"},{"key":"e_1_2_12_64_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejvs.2006.11.022"},{"key":"e_1_2_12_65_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2013.08.003"}],"container-title":["Diabetes\/Metabolism Research and Reviews"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/dmrr.3700","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,17]],"date-time":"2025-09-17T04:39:53Z","timestamp":1758083993000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/dmrr.3700"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,8,4]]},"references-count":64,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2024,3]]}},"alternative-id":["10.1002\/dmrr.3700"],"URL":"https:\/\/doi.org\/10.1002\/dmrr.3700","archive":["Portico"],"relation":{},"ISSN":["1520-7552","1520-7560"],"issn-type":[{"value":"1520-7552","type":"print"},{"value":"1520-7560","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,8,4]]},"assertion":[{"value":"2023-07-08","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2023-07-10","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2023-08-04","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e3700"}}