Cheun Tracey J, Hart Joseph P, Davies Mark G
Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Wound Healing Center, Pam Health, San Antonio, TX; Department of Anesthesia, Long School of Medicine, San Antonio, TX.
Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI.
Ann Vasc Surg. 2025 Feb;111:319-330. doi: 10.1016/j.avsg.2024.11.005. Epub 2024 Nov 22.
Wound, ischemia, and foot infection (WIfI) is an important staging system for diabetic patients presenting with chronic limb-threatening ischemia (CLTI) of the lower extremities (LEs). This study examines the clinical implications of restaging WIfI after initial vascular and podiatric interventions.
A prospective database of patients undergoing vascular intervention treatment of the LE for tissue loss between 2018 and 2022 was queried. Cases were reviewed and staged preoperatively according to WIfI and then based on the WIfI restaging after primary vascular and podiatric interventions. Three groups were identified as follows: improvement of WIfI score (improved), WIfI unchanged (no change), and deterioration of WIfI score (worsened) groups. In cases of active infection, patients underwent infection control (drainage and/or amputation) followed by revascularization (endovascular or open intervention). In contrast, patients with no active infection underwent revascularization followed by podiatric intervention. Amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above-ankle amputation of the index limb or significant reintervention [new bypass graft or jump or interposition graft revision]) were evaluated.
One thousand four hundred and four patients (61% male, age 64 ± 12 years, mean ± SD) presented with CLTI underwent initial vascular and/or podiatric LE interventions. On initial presentation, 37% of the patients presented with WIfI stage 3, and 63% presented with WIfI stage 4. The majority of the patients had Global Limb Anatomic Staging System (GLASS) stage III anatomic disease. Fifty-six percent of the patients had a primary infection control procedure, and 78% had a vascular intervention (71% endovascular intervention and 29% open bypass). After completing the primary podiatric and vascular procedures and restaging the WIfI score, 48% of the patients were improved, 32% were unchanged, and 20% were worsened. The postoperative change in WIfI classification impacted both 30-day rate of MALE (5% vs. 9% vs. 24% for the improved, unchanged, and worsened groups, respectively; P = 0.01) and the 30-day rate of major amputation (2% vs. 3% vs. 14% for the improved, unchanged, and upgraded groups, respectively; P < 0.02). At 5 years, freedom from MALE was progressively worse in the improved, unchanged, and worsened groups (47 ± 5% vs. 38 ± 5% vs. 23 ± 9%, respectively; mean ± standard error of the mean (SEM), P = 0.001). The 5-year AFS also deteriorated for the improved, unchanged, and worsened groups (49 ± 5% vs. 33 ± 5% vs. 19 ± 6%, respectively; mean ± SEM, P = 0.001) CONCLUSIONS: Restaging WIfI after primary vascular and podiatric intervention results in significant downgrading of WIfI staging, allows for better differentiation of 30-day outcomes, and influences freedom from MALE and AFS outcomes.
伤口、缺血和足部感染（WIfI）是针对患有下肢慢性肢体威胁性缺血（CLTI）的糖尿病患者的重要分期系统。本研究探讨了在初次血管和足病干预后对WIfI进行重新分期的临床意义。
查询了2018年至2022年间因下肢组织缺损接受血管介入治疗的患者的前瞻性数据库。术前根据WIfI对病例进行评估和分期，然后根据初次血管和足病干预后的WIfI重新分期。确定了三组如下：WIfI评分改善组（改善组）、WIfI评分不变组（无变化组）和WIfI评分恶化组（恶化组）。对于有活动性感染的病例，患者先进行感染控制（引流和/或截肢），然后进行血运重建（血管内或开放干预）。相比之下，无活动性感染的患者先进行血运重建，然后进行足病干预。评估无截肢生存率（AFS；无大截肢的生存）和无主要肢体不良事件（MALE；指数肢体的踝关节以上截肢或重大再次干预[新的旁路移植或跳跃或间置移植修复]）情况。
1404例（61%为男性，年龄64±12岁，均值±标准差）患有CLTI的患者接受了初次血管和/或足病下肢干预。初次就诊时，37%的患者为WIfI 3期，63%的患者为WIfI 4期。大多数患者患有全球肢体解剖分期系统（GLASS）III期解剖疾病。56%的患者进行了初次感染控制程序，78%的患者进行了血管介入（71%为血管内介入，29%为开放旁路）。在完成初次足病和血管手术后并对WIfI评分重新分期后，48%的患者得到改善，32%的患者无变化，20%的患者恶化。WIfI分类的术后变化影响了30天的MALE发生率（改善组、无变化组和恶化组分别为5%、9%和24%；P = 0.01）以及30天的大截肢发生率（改善组、无变化组和升级组分别为2%、3%和14%；P < 0.02）。在5年时，改善组、无变化组和恶化组无MALE的情况逐渐变差（分别为47±5%、38±5%和23±9%；均值±均值标准误（SEM），P = 0.001）。改善组、无变化组和恶化组的5年AFS也变差（分别为49±5%、33±5%和19±6%；均值±SEM，P = 0.001）。结论：初次血管和足病干预后对WIfI进行重新分期可使WIfI分期显著下调，有助于更好地区分30天结局，并影响无MALE和AFS结局。
