Outcomes of Critical Limb Ischemia in an Urban, Safety Net Hospital Population with High WIfI Amputation Scores

Abstract

Background Patients presenting to a public hospital with critical limb ischemia (CLI) typically have advanced disease with significant comorbidities. The purpose of this study was to assess the influence of revascularization on 1-year amputation rate of CLI patients presenting to Los Angeles County USC Medical Center, classified according to the Society for Vascular Surgery Wound, Ischemia and foot Infection (WIfI). Methods A retrospective review of patients who presented to a public hospital with CLI from February 2010 to July 2014 was performed. Patients were classified according to the WIfI system. Only patients with complete data who survived at least 12 months after presentation were included. Results Ninety-three patients with 98 affected limbs were included. The mean age was 62.8 years. Eighty-two patients (84%) had hypertension and 71 (72%) had diabetes. Fifty (57.5%) limbs had Trans-Atlantic Inter-Society Consensus (TASC) C or D femoral–popliteal lesions and 82 (98%) had significant infrapopliteal disease. The majority had moderate or high WIfI amputation and revascularization scores. Eighty-four (86%) limbs underwent open, endovascular, or hybrid revascularization. Overall, one year major amputation (OYMA) rate was 26.5%. In limbs with high WIfI amputation score, the OYMA was 34.5%: 21.4% in those who were revascularized and 57% in those who were not. On univariable analysis, factors associated with increased risk of OYMA were nonrevascularization (P = 0.005), hyperlipidemia (P = 0.06), hemodialysis (P = 0.005), gangrene (P = 0.02), ulcer classification (P = 0.05), WIfI amputation score (P = 0.026), and WIfI wound grade (P = 0.04). On multivariable analysis, increasing WIfI amputation score (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.0–3.39) was associated with increased risk of OYMA while revascularization (OR 0.24, 95% CI 0.07–0.80) was associated with decreased risk of OYMA. Conclusions The OYMA rates in this population were consistent with those predicted by the WIfI classification system. In this population, revascularization significantly reduced the risk of amputation. Comorbidities including diabetes mellitus and TASC classification did not moderate the association of WIfI amputation score with risk of 1-year major amputation.

Ulcer‐free survival days and ulcer healing in patients with diabetic foot ulcers: A prospective cohort study

“…Diabetic foot ulcers are a major complication of diabetes, and timely healing of these ulcers is important . However, measures of healing rate may not provide a complete indication of the effectiveness of overall management of diabetic foot ulcers because of high recurrence rates.…”

“…Diabetic foot ulcers are a major complication of diabetes, and timely healing of these ulcers is important. 9 However, measures of healing rate may not provide a complete indication of the effectiveness of overall management of diabetic foot ulcers because of high recurrence rates. The most important outcome for patients is to remain ulcer-free, yet these ulcer-free survival days have hardly been investigated since they were first introduced.…”

“…Along with costs and increasing prevalence, diabetic foot ulcers come with high disease burden, morbidity and mortality, and reduced health‐related quality of life . Approximately 20% of infected ulcers lead to an amputation, with the presence of peripheral artery disease increasing the risk of an amputation . In patients with diabetes, the risk of death is twice as high in patients with foot ulcers compared with those without .…”

“…6,7 Approximately 20% of infected ulcers lead to an amputation, with the presence of peripheral artery disease increasing the risk of an amputation. [8][9][10] In patients with diabetes, the risk of death is twice as high in patients with foot ulcers compared with those without. 11,12 Around 10% of patients die within 30 days of a major amputation, and more than 70% of the patients with diabetes-related amputations will die within 5 years.…”

Endovascular Devices and Revascularization Techniques for Limb-Threatening Ischemia in Individuals With Diabetes

“…7,8 This article will focus on endovascular therapies.Wound-healing and limb-salvage in LTI is multifactorial, but revascularization is critical. [9][10][11][12] There is no absolute perfusion target threshold, making goals of revascularization difficult to define. A recent review found that skin perfusion pressure ≥ 25 mm Hg, toe pressure ≥ 30 mm Hg and a transcutaneous pressure 702169D STXXX10.1177/1932296817702169Journal of Diabetes Science and TechnologyChung…”