Gabel J, Bianchi C, Possagnoli I, Mehta R, Abou-Zamzam AM Jr, Teruya T, Kiang S, Bishop V, Valenzuela A, et al.
Journal of vascular surgery. Date of publication 2020 Jun 1;volume 71(6):2073-2080.e1.
1. J Vasc Surg. 2020 Jun;71(6):2073-2080.e1. doi: 10.1016/j.jvs.2019.07.103. Epub
2019 Nov 11.
Multidisciplinary approach achieves limb salvage without revascularization in
patients with mild to moderate ischemia and tissue loss.
Gabel J(1), Bianchi C(2), Possagnoli I(3), Mehta R(4), Abou-Zamzam AM Jr(5),
Teruya T(5), Kiang S(5), Bishop V(3), Valenzuela A(3).
Author information:
(1)Department of Vascular Surgery, Loma Linda University Health, Loma Linda,
Calif.
(2)Department of Vascular Surgery, Loma Linda University Health, Loma Linda,
Calif; Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare
System, Loma Linda, Calif. Electronic address: christian.bianchi@va.gov.
(3)Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare
System, Loma Linda, Calif.
(4)Research Consulting Group, Center for Health Research, Loma Linda University,
Loma Linda, Calif.
(5)Department of Vascular Surgery, Loma Linda University Health, Loma Linda,
Calif; Department of Vascular Surgery, Veterans Affairs Loma Linda Healthcare
System, Loma Linda, Calif.
Comment in
J Vasc Surg. 2020 Jun;71(6):2081-2082.
OBJECTIVE: The Society for Vascular Surgery Wound, Ischemia, and foot Infection
(WIfI) classification system has been validated to predict wound healing and
limb salvage of patients with peripheral artery disease (PAD). Our goal was to
evaluate the association between WIfI stage and wound healing, limb salvage, and
survival in a select cohort of patients with PAD and tissue loss undergoing an
attempt of wound healing without immediate revascularization (conservative
approach) in a multidisciplinary wound program.
METHODS: Veterans with PAD and tissue loss were prospectively enrolled in our
Prevention of Amputation in Veterans Everywhere (PAVE) program. Limbs were
stratified to a conservative, revascularization, primary amputation, and
palliative limb care approach based on the patient's fitness, ambulatory status,
perfusion evaluation, and validated pathway of care. Rates of wound healing,
wound recurrence, limb salvage, and survival were retrospectively analyzed by
WIfI clinical stages (stage 1-4) in the conservative group. Cox regression
modeling was used to estimate clinical outcomes by WIfI stage.
RESULTS: Between January 2006 and October 2017, there were 961 limbs
prospectively enrolled in our PAVE program. A total of 233 limbs with 277 wounds
were stratified to the conservative approach. WIfI staging distribution included
19.7% stage 1, 20.2% stage 2, 38.6% stage 3, and 21.5% stage 4. All ischemia
scores were classified as 1 or 2. Advanced wound interventions and minor
amputations were performed on 40 limbs (16.6%) and 57 limbs (23.7%),
respectively. Average long-term follow-up was 41.4 ± 29.0 months. Complete wound
healing without revascularization was achieved in 179 limbs (76.8%) during 4.4 ±
4.1 months. Thirty-four limbs (14%) underwent deferred revascularization because
of a lack of complete wound healing. At long-term follow-up, wound recurrence
per limb was 39%. Overall limb salvage at long-term follow-up was 89.3%.
Stratified by WIfI stage, there was no statistically significant difference
between groups for wound healing (P = .64), wound recurrence (P = .55), or limb
salvage (P = .66) after adjustment for significant patient, limb, and wound
characteristics.
CONCLUSIONS: In select patients with mild to moderate ischemia and tissue loss,
a stratified approach can achieve acceptable rates of wound healing and limb
salvage, with limited need for deferred revascularization. WIfI clinical staging
did not predict wound healing, limb salvage, or survival in this cohort.
Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All
rights reserved.
DOI: 10.1016/j.jvs.2019.07.103
PMID: 31727460 [Indexed for MEDLINE]
