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Wound Healing, Wound-Free Period and Amputation-free Survival in Patients with Wound Ischemia foot Infection (WIfI) Stage 3 & 4 Disease
Cuneyt Koksoy
1, Sydney Browder
2, Ilse Torrez-Ruiz
1, Sai P Manikonda
1, Moussa Shahoud
2, Joseph L Mills, Sr.
1, Zachary S Pallister
1, Katherine L McGinigle
2, Jayer Chung
1 1Baylor College of Medicine, Houston, TX;
2University of North Carolina at Chapel Hill, Chapel Hill, NC
INTRODUCTION: Recent publications in low-stage Wound, Ischemia, and foot Infection (WIfI) chronic limb-threatening ischemia (CLTI) suggest wound-care-first strategies are safe. However, the benefit of early revascularization, especially with respect to wound healing and wound free period (WFP) in high-stage WIfI stage 3-4 patients remains unclear.
METHODS: A two-center, retrospective analysis was performed. Baseline data included demographics, comorbidities, perfusion indices, WIfI, and treatment modality (endovascular, open, hybrid, wound care-only). Outcomes were wound healing time (WHT), WFP, and amputation-free survival (AFS). WHT was defined as the interval from wound presentation until complete healing, major amputation, or death. New non-overlapping wounds were counted as separate episodes. WFP was defined as the healed intervals between recurrences.
RESULTS: Over nine years, 1,483 patients with CLTI were managed, of whom 920 (1,091 limbs) were WIfI stage 3-4 (median follow-up 832 days, IQR 694-970). These contributed 1,158 wound episodes: 213 (18%) managed with wound-care only and 945 (82%) revascularized (endovascular n=713, 62%; open n=196, 17%; hybrid n=36, 3%). Overall, 550 wounds (47.6%) healed. Median WHT was 249 days (IQR 120-443). Rates of wound healing were higher with revascularization versus wound-care alone (51% versus 32%; p < 0.01). Median WHT was longest for wound-care only (462 days, IQR 141-528) and shortest with endovascular revascularization (243 days, IQR 133-505; p<0.001). In multivariable linear regression, younger age predicted shorter healing time (-4.6 days/year, p=0.005), while diabetes (+138 days, p<0.001), ESRD (+111 days, p=0.007), hypertension (+237 days, p=0.041), and cerebrovascular disease (+75 days, p=0.046) increased WHT. Subgroup analysis of the healed wounds revealed a shorter WHT in subset the wound-care only group that had healed (N=11; 2%) which were all WIfI wound grade 1 or 2. Among healed wounds, 70 (12.7%) developed recurrence at median 515 days (IQR 163-1163). Median WFP was 630 (IQR 253-1122) days. On multivariable linear regression, only male sex (p=0.04) and younger age (p=0.03) predicted longer WFP. At last follow-up 569 patients (61.8%) experienced major amputation/death. Univariable analysis showed worse AFS in women (median 635 vs. 1013 days, p=0.013), ESRD (529 vs. 1093 days, p<0.001), and WIfI stage 4 (613 vs. 1255 days, p<0.001). Compared with wound care-only, all revascularization modalities improved AFS (517 vs 834-1300 days, p<.001). On Cox regression (Figure), predictors of major amputation/death included age; female sex; ESRD; cerebrovascular disease; COPD, and WIfI stage 4. Endovascular, open, and hybrid revascularization were protective.
CONCLUSIONS: In high-risk CLTI (WIfI 3-4), fewer than half of wounds healed, with more than half undergoing a major amputation/death at last follow up. Of wounds that heal, recurrence was rare and remained healed for most of follow-up, underscoring the importance of achieving initial healing. WFP was longest in men and younger patients. While there is small subgroup that achieves comparable WHT with wound care only, revascularization increased the likelihood of wound healing by almost 2.5-fold.
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