Evaluation of revascularization benefit quartiles using the Wound, Ischemia, and Foot Infection classification system for diabetic patients with chronic limb-threatening ischemia.
Open accessAbstract
Objective The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system was developed to stratify the risk of 1-year major amputation. Recently, the WIfI scores were used to define the estimated revascularization benefit quartiles ranging from high benefit (Q1) to questionable benefit (Q4). The aim of our study was to evaluate the revascularization benefit quartiles in a cohort of diabetic patients presenting with chronic limb-threatening ischemia (CLTI).Methods All diabetic patients presenting to our multidisciplinary diabetic foot and wound clinic (June 2012 to May 2020) who underwent lower extremity revascularization for CLTI were included. The affected limbs were graded using the WIfI system and assigned to an estimated benefit of revascularization quartile as previously published. One-year major amputation, complete foot healing, secondary patency, and amputation-free survival were calculated among the quartiles using Kaplan-Meier curve analyses and compared using Cox proportional hazards models.Results Overall, 136 diabetic patients underwent revascularization of 187 limbs (mean age, 64.9 ± 11.2 years; 63.2% male; 58.8% black). The limbs were revascularized using an endovascular approach for 66.8% and open surgery for 33.2%. Of the 187 limbs, 27.3% had a high estimated benefit of revascularization (Q1), 31.6% had a moderate estimate benefit of revascularization (Q2), 20.3% had a low estimated benefit of revascularization (Q3), and 20.9% had a questionable benefit of revascularization (Q4). The estimated 1-year major amputation rates were 7.2% ± 4.1% for Q1, 3.8% ± 2.6% for Q2, 7.0% ± 4.8% for Q3, and 25.7% ± 7.5% for Q4 (P = .006). The estimated 1-year foot healing rates were 87.3% ± 5.7% for Q1, 84.8% ± 5.6% for Q2, 83.8% ± 7.4% for Q3, and 68.2% ± 9.1% for Q4 (P = .06). The overall secondary patency (P = .23) and amputation-free survival (P = .33) did not significantly differ among the groups. Using Cox proportional hazard modeling, the Q4 group had a significantly greater risk of major amputation compared with Q1 (hazard ratio, 4.26; 95% confidence interval, 1.15-15.70). Of the 14 limbs requiring major amputation, 9 (56.3%) had a patent revascularization at the time of amputation, including one of three limbs in Q1, two of two limbs in Q2, no limb in Q3, and six of nine limbs in Q4.Conclusions The questionable estimated revascularization benefit quartile using the WIfI classification system is significantly associated with 1-year major amputation in diabetic patients presenting with CLTI. Limbs with a questionable benefit of revascularization (Q4) will frequently require major amputation despite a patent revascularization, suggesting that the wound size and infection burden are the driving factors behind the elevated risk of major amputation in this group. Our findings support the previously described use of the WIfI classification system to predict revascularization benefit among diabetic patients with CLTI.
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Multiple well-designed randomized clinical trials support the use of negative pressure wound therapy to improve healing in both partial foot amputations and diabetic foot ulcers.
“Multiple well-designed randomized clinical trials support its use to improve healing in both partial foot amputations and diabetic foot ulcers.73,74”
From Diabetic Foot Ulcers (2023) · cites this paper as [73]
The Methods (Treatment paradigm; page unavailable) describe revascularization, debridement or minor amputation, and wound care, but do not mention negative pressure wound therapy. Searches for negative pressure wound therapy, randomized trials, and vacuum-assisted closure found no passage reporting trial evidence that it improves healing after partial foot amputation or in diabetic foot ulcers. (LLM, conf=0.74)
Experimental — accuracy not yet measuredIn a meta-analysis of 943 patients, negative pressure wound therapy improved healing compared with standard moisture-balancing dressings (odds ratio, 3.60; 95% CI, 2.38-5.45; P < .001).
“Negative pressure wound therapy Used in treatment of complicated and postoperative wounds in the diabetic foot Improved healing in a meta-analysis of 943 patients who received negative pressure wound therapy vs standard moisture-balancing dressings (odds ratio, 3.60; 95% CI, 2.38-5.45;P < .001).”
From Diabetic Foot Ulcers (2023) · cites this paper as [73]
The Methods (Treatment paradigm; page unavailable) describe revascularization and subsequent wound care, while the Results compare healing across revascularization-benefit quartiles. Searches for negative pressure wound therapy, moisture-balancing dressings, 943 patients, and the reported odds ratio found no passage addressing the claimed meta-analysis. (LLM, conf=0.75)
Experimental — accuracy not yet measuredNegative pressure wound therapy is effective in resolving wound depth.
“Effective in resolving wound depth.64,[73][74][75]”
From Diabetic Foot Ulcers (2023) · cites this paper as [73]
The Methods (Treatment paradigm; page unavailable) describe revascularization, debridement, and wound care, while the Discussion addresses wound healing after revascularization. Searches for negative-pressure wound therapy and wound depth found no passage assessing whether that therapy resolves wound depth. (LLM, conf=0.76)
Experimental — accuracy not yet measured
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- Authors
- Hicks, C. W., Canner, J. K., Sherman, R. L., Black, J. H., Lum, Y. W., & Abularrage, C. J.
- Affiliations
- Johns Hopkins University (US)
- Corresponding author
- Abularrage, Christopher J.
- Venue
- Journal of Vascular Surgery
- Publisher
- Elsevier BV
- Published
- 2021-10
- Volume
- 74
- Issue
- 4
- Pages
- 1232-1239.e3
- ISSN
- 0741-5214 (ISSN-L)
- PMC
- PMC9834912
- OpenAlex
- W3145301640
- Cited by
- 36
- References
- 23
- Citations by year
- 2026: 8 · 2025: 6 · 2024: 6 · 2023: 8 · 2022: 4 · 2021: 4
- FWCI
- 5.16
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Vascular Surgery (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Diabetes and Digestive and Kidney Diseases (K23DK12451)
- Topics
- Health Sciences › Medicine › Surgery › Peripheral Artery Disease Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetic Foot Ulcer Assessment and Management
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Vascular Procedures and Complications
- Keywords
- critical limb ischemia, diabetic foot, WIfI classification, major amputation, endovascular revascularization, open surgical revascularization, amputation-free survival, risk stratification, diabetic patients, lower extremity revascularization, wound healing outcomes, amputation risk prediction, endovascular versus surgical revascularization
- MeSH terms
- Clinical Decision-Making, Progression-Free Survival, Amputation, Surgical, Chronic Disease, Decision Support Techniques, Female, Humans, Ischemia, Male, Middle Aged, Predictive Value of Tests, Retrospective Studies, Risk Factors, Time Factors, Vascular Patency, Vascular Surgical Procedures, Wound Healing, Databases, Factual, Diabetic Foot, Risk Assessment, Limb Salvage, Endovascular Procedures
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