Validation of the Wound, Ischemia, foot Infection (WIfI) classification system in nondiabetic patients treated by endovascular means for critical limb ischemia

Beropoulis, Efthymios; Stavroulakis, Konstantinos; Schwindt, Arne; Stachmann, Arne; Torsello, Giovanni; Bisdas, Theodosios

doi:10.1016/j.jvs.2016.01.040

Cited by 67 publications

(51 citation statements)

References 11 publications

(33 reference statements)

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“…19 Our own statistical findings and the Beropoulis et al study illustrate the apparent overlap between clinical stages 2 and 3, prompting our implementation of the WIfI simplified stages, which also displayed tentative promise as another incorporation into the new classification system. Unfortunately, the small number of clinical stage 1 patients makes any statistical findings unreliable: Although this new stratification should be further evaluated, we do not believe that the cohort within this study is sufficient to make any substantial claims.…”

Section: Discussionmentioning

confidence: 60%

“…Although there have been several recent comprehensive evaluations of the SVS WIfI classification system, 17–19 none have assessed its impact on first time lower extremity revascularizations, nor its potential distinction between revascularization types. In this retrospective cohort study, we sought to evaluate the predictive ability of the SVS WIfI classification system, as well as our novel WIfI composite and WIfI mean scoring systems, following first time lower extremity revascularizations for CLTI.…”

Section: Introductionmentioning

confidence: 99%

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Predictive ability of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system after first-time lower extremity revascularizations

Darling

McCallum

Soden

et al. 2017

Journal of Vascular Surgery

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OBJECTIVES The SVS WIfI (wound, ischemia, foot infection) classification system was proposed to predict 1-year amputation risk and potential benefit from revascularization. Our goal was to evaluate the predictive ability of this scale in a “real world” selection of patients undergoing a first time lower extremity revascularization for chronic limb threatening ischemia (CLTI). METHODS From 2005 to 2014, 1,336 limbs underwent a first time lower extremity revascularization for CLTI, of which 992 had sufficient data to classify all three WIfI components (wound, ischemia, and foot infection). Limbs were stratified into the SVS WIfI clinical stages (from 1 to 4) for 1-year amputation risk estimation, as well as a novel WIfI composite score from 0 to 9 (that weighs all WIfI variables equally) and a novel WIfI mean score from 0 to 3 (that can incorporate limbs missing any of the three WIfI components). Outcomes included major amputation, RAS events (revascularization, major amputation, or stenosis [>3.5× step-up by duplex]), and mortality. Predictors were identified using Cox regression models and Kaplan-Meier survival estimates. RESULTS Of the 1,336 first-time procedures performed, 992 limbs were classified in all three WIfI components (524 endovascular, 468 bypass; 26% rest pain, 74% tissue loss). Cox regression demonstrated that a one-unit increase in the WIfI clinical stage increases the risk of major amputation and RAS events in all limbs (Hazard Ratio [HR] 2.4; 95% Confidence Interval [CI] 1.7–3.2 and 1.2 [1.1–1.3], respectively). Separate models of the entire cohort, a bypass only cohort, and an endovascular only cohort showed that a one-unit increase in the WIfI mean score is associated with an increase in the risk of major amputation (all three cohorts; 5.3 [3.6–6.8], 4.1 [2.4–6.9], and 6.6 [3.8–11.6], respectively) and RAS events (all three cohorts; 1.7 [1.4–2.0], 1.9 [1.4–2.6], and 1.4 [1.1–1.9], respectively). The novel WIfI composite and WIfI mean scores were the only consistent predictors of mortality among the three cohorts, with the WIfI mean score proving most strongly predictive in the entire cohort (1.4 [1.1–1.7]), the bypass only cohort (1.5 [1.1–1.9]) and the endovascular only cohort (1.4 [1.0–1.8]). Although the individual WIfI wound component was able to predict mortality among all patients (1.1 [1.0–1.2]) and bypass only patients (1.2 [1.1–1.3]), no other individual WIfI component, nor the WIfI clinical stage, were able to significantly predict mortality among any cohort. CONCLUSION This study supports the ability of the SVS WIfI classification system to predict major amputation; however, the novel WIfI mean and WIfI composite scores predict amputation, RAS events, and mortality more consistently than any other current WIfI scoring system. The WIfI mean score allows inclusion of all limbs, and both novel scoring systems are easier to conceptualize, give equal weight to each WIfI component, and may provide clinicians more effective comparisons in outcomes between patients.

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Section: Discussionmentioning

confidence: 60%

Section: Introductionmentioning

confidence: 99%

Predictive ability of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system after first-time lower extremity revascularizations

Darling

McCallum

Soden

et al. 2017

Journal of Vascular Surgery

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show abstract

“…The population of threatened limb patients has changed as the prevalence of diabetes mellitus has increased and wound etiology has broadened beyond solely ischemic disease. Whereas limb perfusion is a key factor in predicting amputation risk, 3,4,6,7 it is only one factor among a triad including the extent of a wound and infection that places a limb at risk for amputation.…”

Section: Discussionmentioning

confidence: 99%

Importance of postprocedural Wound, Ischemia, and foot Infection (WIfI) restaging in predicting limb salvage

Leithead

Novák

Spangler

et al. 2018

Journal of Vascular Surgery

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WIfI restaging is an important tool for predicting limb loss and assessing adequacy of intervention, more so than baseline WIfI alone. The 1- and 6-month postoperative ischemia grade correlated with AFS, whereas preoperative grade did not. The 1- and 6-month postoperative wound and foot infection grades additionally correlated with AFS. WIfI restaging at 1 month and 6 months postoperatively may help identify a cohort that remains at higher risk for limb loss and may merit more expeditious reintervention.

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“…22 The WIfI classification system was developed to predict patients' likelihood of undergoing major amputation within 1 y of initial assessment. 22 It has also been shown to correlate closely with wound healing time [23][24][25][26][27] and, most recently, may be useful in stratifying patients into those who would benefit from revascularization (i.e., WIfI stage 3/4) versus those in whom revascularization may not be necessary to achieve wound healing (i.e., WIfI stage 1/2). 28,29 Understanding the risks and benefits of lower extremity revascularization procedures, as well as an individual's prognosis for limb salvage, will allow physicians to engage in more patientcentered care.…”

Section: Discussionmentioning

confidence: 99%

Hemodialysis patients have worse outcomes after infrageniculate revascularization procedures

Hicks

Canner

Kirkland

et al. 2018

Journal of Surgical Research

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Validation of the Wound, Ischemia, foot Infection (WIfI) classification system in nondiabetic patients treated by endovascular means for critical limb ischemia

Abstract: The WIfI classification system predicted the amputation risk and survival in this highly selected group of nondiabetic CLI patients treated by endovascular means, with a statistically significant difference between very low-risk and high-risk patients already at 1 year.

Cited by 67 publications

References 11 publications

Predictive ability of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system after first-time lower extremity revascularizations

Predictive ability of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system after first-time lower extremity revascularizations

Importance of postprocedural Wound, Ischemia, and foot Infection (WIfI) restaging in predicting limb salvage

Hemodialysis patients have worse outcomes after infrageniculate revascularization procedures

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