Weaver M Libby, Hicks Caitlin W, Canner Joseph K, Sherman Ronald L, Hines Kathryn F, Mathioudakis Nestoras, Abularrage Christopher J
Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, Md.
J Vasc Surg. 2018 Nov;68(5):1473-1481. doi: 10.1016/j.jvs.2018.01.060. Epub 2018 May 24.
Previous studies show conflicting results in wound healing outcomes based on angiosome direct perfusion (DP), but few have adjusted for wound characteristics in their analyses. We have previously shown that the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification correlates with wound healing in diabetic foot ulcers (DFUs) treated by a multidisciplinary team. The aim of this study was to compare WIfI classification vs DP and pedal arch patency as predictors of wound healing in patients presenting with DFU and peripheral arterial disease.
We performed a retrospective review of a prospectively maintained database of all patients with peripheral arterial disease presenting to our multidisciplinary DFU clinic who underwent angiography. An angiosome was considered directly perfused if the artery feeding the angiosome was revascularized or was completely patent. Wound healing time at 1 year was compared on the basis of DP vs indirect perfusion, Rutherford pedal arch grade, and WIfI classification using univariable statistics and Cox proportional hazards models.
Angiography was performed on 225 wounds in 99 patients (mean age, 63.3 ± 1.2 years; 62.6% male; 53.5% black) during the entire study period. There were 33 WIfI stage 1, 33 stage 2, 51 stage 3, and 108 stage 4 wounds. DP was achieved in 154 wounds (68.4%) and indirect perfusion in 71 wounds (31.6%). On univariable analysis, WIfI classification was significantly associated with improved wound healing (57.2% for WIfI 3/4 vs 77.3% for WIfI 1/2; P = .02), whereas DP and pedal arch patency were not (both, P ≥ .08). After adjusting for baseline patient and wound characteristics, WIfI stage remained independently predictive of wound healing (WIfI 3/4: hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.67-0.88), whereas DP (HR, 0.82; 95% CI, 0.55-1.21) and pedal arch grade (HR, 0.85; 95% CI, 0.70-1.03) were not.
In our population of patients treated by a multidisciplinary diabetic foot service, the Society for Vascular Surgery WIfI classification system was a stronger predictor of diabetic foot wound healing than DP or pedal arch patency. Our results suggest that a measure of wound severity should be included in all future studies assessing wound healing as an outcome, as differences in patients' wound characteristics may be a strong contributor to the variation of angiosome-directed perfusion results previously observed.
以往研究显示，基于血管体直接灌注（DP）的伤口愈合结果存在相互矛盾的结论，而且很少有研究在分析中对伤口特征进行校正。我们之前已经表明，血管外科学会伤口、缺血和足部感染（WIfI）分类与多学科团队治疗的糖尿病足溃疡（DFU）的伤口愈合相关。本研究的目的是比较WIfI分类与DP以及足弓通畅情况，以此作为DFU和外周动脉疾病患者伤口愈合的预测指标。
我们对前瞻性维护的所有到我们多学科DFU门诊就诊并接受血管造影的外周动脉疾病患者数据库进行了回顾性分析。如果为血管体供血的动脉实现了血运重建或完全通畅，则认为该血管体得到了直接灌注。使用单变量统计和Cox比例风险模型，比较基于DP与间接灌注、卢瑟福足弓分级以及WIfI分类的1年时伤口愈合时间。
在整个研究期间，对99例患者（平均年龄63.3±1.2岁；62.6%为男性；53.5%为黑人）的225处伤口进行了血管造影。有33处WIfI 1期、33处2期、51处3期和108处4期伤口。154处伤口（68.4%）实现了DP，71处伤口（31.6%）为间接灌注。单变量分析显示，WIfI分类与伤口愈合改善显著相关（WIfI 3/4为57.2%，WIfI 1/2为77.3%；P = 0.02），而DP和足弓通畅情况则不然（两者P≥0.08）。在对基线患者和伤口特征进行校正后，WIfI分期仍然是伤口愈合的独立预测指标（WIfI 3/4：风险比[HR]，0.77；95%置信区间[CI]，0.67 - 0.88），而DP（HR，0.82；95% CI，0.55 - 1.21）和足弓分级（HR，0.85；95% CI，0.70 - 1.03）则不是。
在我们由多学科糖尿病足服务团队治疗的患者群体中，血管外科学会WIfI分类系统比DP或足弓通畅情况更能预测糖尿病足伤口愈合情况。我们的结果表明，在所有未来评估伤口愈合作为结局的研究中都应纳入伤口严重程度的衡量指标，因为患者伤口特征的差异可能是先前观察到的血管体定向灌注结果差异的重要原因。
