Why diabetes-related foot ulcers fail to heal despite successful revascularization: closing the patency-to-healing gap: a narrative review.

Revascularization is central to limb salvage when a diabetes-related foot ulcer is complicated by peripheral artery disease. However, an open artery does not guarantee wound healing. This patency-to-healing gap arises because repair requires regional perfusion, infection control, mechanical protection, viable tissues, physiological reserves, and coordinated care. This focused narrative review searched PubMed/MEDLINE through June 30, 2026, and supplemented the search with guidelines, landmark trials, and citation chaining. The BEST-CLI and BASIL-2 studies showed that the results depended on the population, anatomy, and endpoints studied. Neither technical success nor composite limb endpoint confirmed adequate wound-territory perfusion. This review separates technical, hemodynamic, regional tissue, and clinical success and offers a time-linked approach to reassessment. A decrease of approximately 50% in the wound area by 4 weeks may signal the need to revisit the plan; however, the threshold was derived largely from nonischemic neuropathic ulcers and has not been validated as a decision rule after revascularization. It is particularly unreliable after major debridement, in dry gangrene, or when the baseline is unstable. PIPPP (perfusion, infection, pressure, patient, and plan) is presented as an unvalidated, hypothesis-generating checklist that overlaps with, rather than replaces, the International Working Group on the Diabetic Foot; wound, ischemia, and foot infection; Global Limb Anatomic Staging System; and Global Vascular Guideline structures. Prospective validation is required before clinical effectiveness can be achieved. Durable healing requires more than a patent vessel; tissue perfusion must be confirmed, recurrent ischemia monitored, infection controlled, pressure relieved, systemic problems addressed, and responsibility for follow-up made clear.