Ramanan Bala, Ahmed Ayman, Wu Bian, Causey Marlin W, Gasper Warren J, Vartanian Shant M, Reyzelman Alexander M, Hiramoto Jade S, Conte Michael S
Division of Vascular Surgery, University of Texas Southwestern Medical Center, Dallas, Tex.
Center for Limb Preservation, Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, Calif.
J Vasc Surg. 2017 Dec;66(6):1765-1774. doi: 10.1016/j.jvs.2017.05.102. Epub 2017 Aug 18.
The objective of this study was to assess midterm functional status, wound healing, and in-hospital resource use among a prospective cohort of patients treated in a tertiary hospital, multidisciplinary Center for Limb Preservation.
Data were prospectively gathered on all consecutive admissions to the Center for Limb Preservation from July 2013 to October 2014 with follow-up data collection through January 2016. Limbs were staged using the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification scheme at the time of hospital admission. Patients with nonatherosclerotic vascular disorders, acute limb ischemia, and trauma were excluded.
The cohort included 128 patients with 157 threatened limbs; 8 limbs with unstageable disease were excluded. Mean age (±standard deviation [SD]) was 66 (±13) years, and median follow-up duration (interquartile range) was 395 (80-635) days. Fifty percent (n = 64/128) of patients were readmitted at least once, with a readmission rate of 20% within 30 days of the index admission. Mean total number of admissions per patient (±SD) was 1.9 ± 1.2, with mean (±SD) cumulative length of stay (cLOS) of 17.1 (±17.9) days. During follow-up, 25% of limbs required a vascular reintervention, and 45% developed recurrent wounds. There was no difference in the rate of readmission, vascular reintervention, or wound recurrence by initial WIfI stage (P > .05). At the end of the study period, 23 (26%) were alive and nonambulatory; in 20%, functional status was missing. On both univariate and multivariate analysis, end-stage renal disease and prior functional status predicted ability to ambulate independently (P < .05). WIfI stage was associated with major amputation (P = .01) and cLOS (P = .002) but not with time to wound healing. Direct hospital (inpatient) cost per limb saved was significantly higher in stage 4 patients (P < .05 for all time periods). WIfI stage was associated with cumulative in-hospital costs at 1 year and for the overall follow-up period.
Among a population of patients admitted to a tertiary hospital limb preservation service, WIfI stage was predictive of midterm freedom from amputation, cLOS, and hospital costs but not of ambulatory functional status, time to wound healing, or wound recurrence. Patients presenting with limb-threatening conditions require significant inpatient care, have a high frequency of repeated hospitalizations, and are at significant risk for recurrent wounds and leg symptoms at later times. Stage 4 patients require the most intensive care and have the highest initial and aggregate hospital costs per limb saved. However, limb salvage can be achieved in these patients with a dedicated multidisciplinary team approach.
本研究旨在评估在一家三级医院的多学科肢体保全中心接受治疗的前瞻性队列患者的中期功能状态、伤口愈合情况及住院资源利用情况。
前瞻性收集了2013年7月至2014年10月期间所有连续入住肢体保全中心的患者的数据，并通过2016年1月进行随访数据收集。入院时使用血管外科学会伤口、缺血和足部感染（WIfI）肢体威胁分类方案对肢体进行分期。排除患有非动脉粥样硬化性血管疾病、急性肢体缺血和创伤的患者。
该队列包括128例患者，共157条受到威胁的肢体；排除8条无法分期的肢体。平均年龄（±标准差[SD]）为66（±13）岁，中位随访时间（四分位间距）为395（80 - 635）天。50%（n = 64/128）的患者至少再次入院一次，在首次入院后30天内的再入院率为20%。每位患者的平均入院总数（±SD）为1.9 ± 1.2，平均（±SD）累计住院时间（cLOS）为17.1（±17.9）天。在随访期间，25%的肢体需要进行血管再干预，45%出现复发性伤口。根据初始WIfI分期，再入院率、血管再干预率或伤口复发率无差异（P > 0.05）。在研究期结束时，23例（26%）存活但不能行走；20%的患者功能状态缺失。单因素和多因素分析均显示，终末期肾病和既往功能状态可预测独立行走能力（P < 0.05）。WIfI分期与大截肢（P = 0.01）和cLOS（P = 0.002）相关，但与伤口愈合时间无关。4期患者每挽救一条肢体的直接医院（住院）费用显著更高（所有时间段P < 0.05）。WIfI分期与1年及整个随访期的累计住院费用相关。
在一家三级医院肢体保全服务收治的患者群体中，WIfI分期可预测中期免于截肢的情况、cLOS和住院费用，但不能预测行走功能状态、伤口愈合时间或伤口复发情况。患有肢体威胁性疾病的患者需要大量住院治疗，再住院频率高，后期出现复发性伤口和腿部症状的风险很大。4期患者需要最 intensive care，每挽救一条肢体的初始和总住院费用最高。然而，通过专门的多学科团队方法，这些患者可以实现肢体保全。
