Patients with critical limb-threatening ischemia with chronic forefoot wounds often need transmetatarsal amputation (TMA). Lower extremity revascularization improves healing and prevents major amputation. Additionally, the condition of the pedal arch plays an important role in the healing process and is, therefore, possibly associated with major amputation conversion. The aim of this study was to investigate the relation between TMA healing and distal angiographic arterial patterns using two anatomic classification systems. Cases were selected from a single-center retrospective review conducted among patients who had all of the following: TMA, endovascular revascularization intervention, and available angiographic imaging of the leg including the ankle and foot. All patients were included from the University of California San Francisco Medical Center from January 1, 2008, to December 31, 2016. A total of 38 cases with TMA, endovascular revascularization intervention and available imaging was obtained. All angiographic images were scored using two anatomic classifications—the Pedal Outflow Modifier of the Global Anatomic Staging System and the Pedal Arch Classification developed by Kawarada et al (Table I). Scoring was done separately by two observers who reached consensus on all scores. The primary end point was TMA healing after 6 months. A clear trend was seen when it comes to TMA healing in relation to both the Pedal Outflow Modifier and Pedal Arch Classification (Table II). However, owing to the small number of cases there was no statistical significance (P = .078). There seems to be a clear trend in the correlation between the condition of the pedal arch and wound healing after TMA. To achieve statistical significance, additional cases as well as bypass surgery will be added. Anatomic classification of the pedal arch in the future may become an adjunct to the clinical decision making process on determining amputation level.Table IPedal outflow modifier and pedal arch classificationMeasureDescriptionPedal outflow modifier P0Target artery crosses ankle into foot, with intact pedal arch P1Target artery crosses ankle into foot; absent or severely diseased pedal arch P2No target artery crossing ankle into footPedal arch classification Type 1Both dorsalis pedis and plantar artery patent Type 2AOnly dorsalis pedis patent Type 2BOnly plantar artery patent Type 3Both dorsalis pedis and plantar artery not patent Open table in a new tab Table IITransmetatarsal amputation (TMA) healing rates by anatomic class after 6 monthsTMA healedPedal outflow modifier P02/3 (67%) P15/26 (19%) P21/9 (11%)Pedal arch classification Type 12/3 (67%) Type 2A4/15 (27%) Type 2B1/8 (13%) Type 31/12 (8%) Open table in a new tab