Shintani Tsunehiro, Obara Hideaki, Matsubara Kentaro, Hayashi Masanori, Kita Hidenori, Ono Shigeshi, Watada Susumu, Kikuchi Naoya, Sekimoto Yasuhito, Torizaki Yukiko, Asami Atsunori, Fujii Taku, Hayashi Keita, Harada Hirohisa, Fujimura Naoki, Hosokawa Kyousuke, Nakatani Eiji, Kitagawa Yuko
Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan.
Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
J Vasc Surg. 2024 Mar;79(3):632-641.e3. doi: 10.1016/j.jvs.2023.11.003. Epub 2023 Nov 7.
There is no established consensus or guidelines for wound management after revascularization for patients with chronic limb-threatening ischemia (CLTI) without severe infection. This study is designed to evaluate the clinical effect of the wound management strategy on toe wounds after revascularization for CLTI.
This retrospective cohort study was performed at eight institutions affiliated with Keio University School of Medicine in Japan and included 261 patients who underwent revascularization for CLTI between April 2019 and July 2021. We identified 132 patients with toe wounds from the database who had restored in-line blood flow to the foot. Patients were divided into two groups by the timing of toe resection after revascularization, which dictated the wound management policy. Group A (62 patients) underwent early toe amputation for suspected osteomyelitis, whereas group B (70 patients) underwent watchful waiting. The primary outcome was wound healing after revascularization; the secondary outcome was major amputation. We compared outcomes between groups A and B after propensity score matching.
Using propensity score matching, each patient in group A (33 patients) was matched with a patient in group B (33 patients). Wound healing in matched group A was significantly better than that in matched group B (respectively: 1-year wound healing rate: 90.0% vs 68.2%, P < .001; median wound healing time: 65 days vs 258 days, P < .01). Although five major amputations were necessary in matched group B, none were required in matched group A (P = .05). The high rate of major amputations in group B was attributed to the sudden exacerbation of infection. Limb salvage rate in matched group A exceeded matched group B (100.0% vs 90.5%: 1-year limb salvage rate, P = .02).
Early toe amputation for highly suspected osteomyelitis in patients with CLTI with toe wounds may expedite wound healing compared with watchful waiting, potentially avoiding unnecessary major amputation. Considering the wound management strategy is crucial when evaluating wound healing outcomes in patients with CLTI with revascularization.
对于无严重感染的慢性肢体威胁性缺血（CLTI）患者，血管重建术后的伤口处理尚无既定的共识或指南。本研究旨在评估CLTI血管重建术后伤口处理策略对趾部伤口的临床效果。
这项回顾性队列研究在日本庆应义塾大学医学院附属的8家机构进行，纳入了2019年4月至2021年7月期间接受CLTI血管重建术的261例患者。我们从数据库中识别出132例足部恢复直线血流的有趾部伤口的患者。根据血管重建术后趾部切除的时间将患者分为两组，这决定了伤口处理策略。A组（62例患者）因怀疑骨髓炎而早期行趾部截肢术，而B组（70例患者）则进行观察等待。主要结局是血管重建术后伤口愈合；次要结局是大截肢。我们在倾向评分匹配后比较A组和B组的结局。
采用倾向评分匹配法，A组的每例患者（33例患者）与B组的1例患者（33例患者）进行匹配。匹配后的A组伤口愈合情况明显优于匹配后的B组（分别为：1年伤口愈合率：90.0%对68.2%，P <.001；伤口愈合中位时间：65天对258天，P <.01）。尽管匹配后的B组有5例需要进行大截肢，但匹配后的A组无一例需要（P =.05）。B组大截肢率高归因于感染的突然加重。匹配后的A组肢体挽救率超过匹配后的B组（100.0%对90.5%：1年肢体挽救率，P =.02）。
对于有趾部伤口的CLTI患者，对于高度怀疑骨髓炎的情况早期行趾部截肢术与观察等待相比，可能会加快伤口愈合，有可能避免不必要的大截肢。在评估接受血管重建术的CLTI患者的伤口愈合结局时，考虑伤口处理策略至关重要。
