College of Biological Sciences, University of California, Davis, Sacramento, CA.
Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA.
Ann Vasc Surg. 2023 Nov;97:221-235. doi: 10.1016/j.avsg.2023.08.005. Epub 2023 Aug 31.
Objective measures of perfusion such as an ankle-brachial index (ABI) and toe pressure remain important in prognosticating wound healing. However, the use of ABI is limited in patients with incompressible vessels and toe pressure may not be comparable across patients. While a toe arm index (TAI) may be of value in this setting, its role as clinical indicator of perfusion for healing in patients with lower-extremity wounds has not been well established.
A retrospective review was performed of all vascular patients with lower-extremity wounds that underwent peripheral vascular intervention between 2014-2019. Data regarding patient demographics, comorbidities, TAI, ABI, toe pressures, and the wound, ischemia, and foot infection (WIfI) score were collected. Associations between patient variables and wound healing at various time points were evaluated.
A total of 173 patients (67.7 ± 10.9 years; 71.1% male) were identified with lower-extremity wounds. Most patients underwent endovascular intervention (77.5%). Patients were followed for a median of 416 (IQR 129-900) days. Mean postoperative TAI was 0.35 ± 0.19 and mean WIfI score was 2.60 ± 1.17. Nine percent (15) of patients healed within 1 month, 44.8% (69) healed within 6 months, and 65.5% (97) healed within 1 year of revascularization without need for major amputation. Those that healed within 1 year without any major amputation did not differ from those that did not heal based on age, gender, race, comorbidities, periprocedural medications, or procedures performed. However, patients that healed without major amputation had a higher postoperative TAI (0.38 vs. 0.30, P = 0.02), higher toe pressure (53 vs. 40 mm Hg, P = 0.004), and lower WIfI score (2.26 vs. 3.12, P < 0.001). Patients that healed with 1 year without requiring any amputation had similar associations with postoperative TAI, toe pressure, and WIfI. Additionally, they were more likely to be White (P = 0.019) and have an open surgical procedure (P < 0.001) and less likely to have chronic kidney disease (P = 0.001) or diabetes (P = 0.008). A Youden index was calculated and identified a TAI value of 0.30 that optimized sensitivity and specificity for wound healing. The area under the curve for TAI as a predictor of wound healing was 0.62.
Higher postoperative TAI is associated with higher odds of wound healing without need for major amputation. Toe arm index is therefore a useful tool to identify patients with adequate arterial perfusion to heal lower-extremity wounds. However, the area under the curve is poor for TAI when used as a sole predictor of wound healing potential suggesting that TAI should be one of multiple factors to considered when prognosticating wound healing potential.
诸如踝臂指数（ABI）和趾压等灌注的客观测量指标在预测伤口愈合方面仍然很重要。然而，在血管不可压缩的患者中，ABI 的使用受到限制，并且趾压在不同患者之间可能无法进行比较。虽然趾臂指数（TAI）在这种情况下可能具有价值，但它作为下肢伤口患者灌注的临床指标在预测愈合方面的作用尚未得到充分确立。
对 2014-2019 年间接受外周血管介入治疗的下肢有伤口的所有血管患者进行了回顾性分析。收集了患者人口统计学、合并症、TAI、ABI、趾压和伤口、缺血和足部感染（WIfI）评分的数据。评估了患者变量与不同时间点伤口愈合之间的关系。
共确定了 173 名（67.7±10.9 岁；71.1%为男性）下肢有伤口的患者。大多数患者接受了血管内介入治疗（77.5%）。患者的中位随访时间为 416（IQR 129-900）天。术后平均 TAI 为 0.35±0.19，平均 WIfI 评分为 2.60±1.17。9%（15 人）的患者在 1 个月内愈合，44.8%（69 人）在 6 个月内愈合，65.5%（97 人）在 1 年内无需进行主要截肢即可愈合。在不需要任何大截肢的情况下 1 年内愈合的患者与未愈合的患者在年龄、性别、种族、合并症、围手术期药物或进行的手术方面没有差异。然而，无需大截肢即可愈合的患者术后 TAI 较高（0.38 与 0.30，P=0.02），趾压较高（53 与 40 mmHg，P=0.004），WIfI 评分较低（2.26 与 3.12，P<0.001）。1 年内无需任何截肢即可愈合的患者与术后 TAI、趾压和 WIfI 也有类似的关联。此外，他们更有可能是白人（P=0.019），更有可能接受开放手术（P<0.001），而不太可能患有慢性肾病（P=0.001）或糖尿病（P=0.008）。计算了约登指数，并确定 TAI 值为 0.30 可优化伤口愈合的敏感性和特异性。TAI 作为预测伤口愈合的曲线下面积为 0.62。
术后 TAI 较高与无需大截肢即可愈合的几率较高相关。因此，趾臂指数是一种有用的工具，可以识别出具有足够动脉灌注以治愈下肢伤口的患者。然而，当 TAI 被用作预测伤口愈合潜力的唯一指标时，其曲线下面积较差，这表明 TAI 应该是预测伤口愈合潜力时需要考虑的多个因素之一。
