Editor's Choice – The Prognostic Value of the WIfI Classification in Patients with Chronic Limb Threatening Ischaemia: A Systematic Review and Meta-Analysis

Abstract

classification has been developed as a tool to help clinical decision making in patients with CLTI. This systematic review shows that the WIfI classification can, to some extent, predict major amputation after one year. However, the current evidence is not sufficient for the instrument to be helpful in clinical decision making for patients with CLTI. Objectives: The Society for Vascular Surgery has proposed the Wound, Ischaemia, and foot Infection (WIfI) classification system as a prognostic tool for the one year amputation risk and the added value of revascularisation in patients with chronic limb threatening ischaemia (CLTI). This systematic review summarises the current evidence on the prognostic value of the WIfI classification system in clinical practice. Design: Systematic review and meta-analysis following the PRISMA guidelines. Materials: The Embase, MEDLINE, and Cochrane databases were searched up to June 2018. Methods: All studies using the WIfI classification for patients with CLTI were eligible. Outcomes of interest were major amputation, limb salvage, and amputation free survival in relation to WIfI clinical stage. The methodological quality of studies was appraised with the Quality in Prognosis Studies (QUIPS) tool. If possible, data were pooled and analysed using a random effects model. Study selection, quality assessment, and data extraction were carried out by two authors independently. Results: The search yielded 12 studies comprising 2669 patients, most of whom underwent endovascular or open revascularisation. Overall study quality was moderate. All but one were retrospective studies, including a variety of subpopulations of patients with CLTI, such as only haemodialysis dependent, diabetic or non-diabetic patients. The WIfI classification was derived from chart data or prospectively maintained databases, both documented before the WIfI classification was published. Estimated one year major amputation rates from four studies comprising 569 patients were 0%, 8% (95% CI 3e21%), 11% (95% CI 6e18%) and 38% (95% CI 21e58%), for WIfI stages IeIV, respectively. Conclusions: The likelihood of an amputation after one year in patients with CLTI increases with higher WIfI stages, which is important prognostic information. Prospective evaluations are needed to determine its role in clinical practice.

A Comparison Between Diabetic Foot Classifications WIfI, Saint Elian, and Texas: Description of Wounds and Clinical Outcomes

“…2 WIfI gives information about prognosis and revascularization benefit and has been validated in various studies with different results. [12][13][14][15][16][17][18][19][20][21] Stages 1 and 2 behave in the same way as it was shown in our study and in the study of Zhan et al, 18 so these 2 stages could be unified. Although the information given by this classification is more complete than that of Texas, it is more difficult to implement because it requires an Android application or a table to calculate the stage.…”

“…A systematic review and meta-analysis was published in 2019 with the aim of summarizing the current evidence on the prognostic value of WIfI classification system in clinical practice. 19 This study shows that WIfI can predict major amputation after 1 year but is not sufficient for helping in clinical decision-making. The search yielded 12 studies comprising 2669 patients and included diabetic and nondiabetic patients.…”

Chronic Limb-Threatening Ischemia (CLTI) in Diabetic Patients: Looking at the Big Picture beyond Wound, Ischemia and Foot Infection (WIfI) Classification System

“…This could, partly, explain the statistical heterogeneity that they found. Although the concept of the WIfI classification is well designed, it only considers the status of the affected limb with neither additional information related to vascular anatomy involved nor patients' comorbidities [20] (see Tables 13 and 14).…”

“…In a recent meta-analysis published in 2019 regarding the prognostic value of the WIfI classification in patients with CLTI and where 12 studies comprising 2669 patients were evaluated, the authors conclude that "the likelihood of an amputation after 1 year in patients with CLTI increases with higher WIfI stages". But, "the current evidence is not sufficient for the instrument to be helpful in clinical decision making for patients with CLTI and prospective studies are needed to determine its role in clinical practice" [20]. We are aware that the risk of amputation increases as the WIfI clinical stage progresses from stage 1 to stage 4.…”

A limb is a peninsula and no clinician is an island: Introducing the American Limb Preservation Society (ALPS)

“…1 In 2014 the Society for Vascular Surgery published the WIfI (Wound, Ischemia, and foot Infection) classification system for staging lower extremities at-risk for amputation 2 and a subsequent metaanalysis of WIfI publications confirmed it to be predictive of one-year amputation risk. 3 The three risk-factors of WIfI inherently suggest the need for interprofessional collaborative efforts if at-risk limbs are to be preserved. In fact, before the publication of the WIfI classification system, several of its authors initiated concerted efforts to promote a podiatric and vascular surgery ('Toe and Flow') team approach to limb preservation.…”