Prognostic value of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification in patients with no-option chronic limb-threatening ischemia

• Published in: Journal of vascular surgery 2018-10, Vol.68 (4), p.1104-1113.e1
• Main Authors: van Haelst, Steven T.W., Teraa, Martin, Moll, Frans L., de Borst, Gert J., Verhaar, Marianne C., Conte, Michael S.
• Format: Article
• Language: English
• Subjects: Aged; Amputation; Chronic Disease; Chronic limb threatening ischemia; Decision Support Techniques; Diabetes; Endothelial Progenitor Cells - transplantation; Female; Humans; Ischemia - classification; Ischemia - diagnosis; Ischemia - surgery; Kaplan-Meier Estimate; Limb Salvage; Linear Models; Male; Middle Aged; Multivariate Analysis; Peripheral Arterial Disease - classification; Peripheral Arterial Disease - diagnosis; Peripheral Arterial Disease - pathology; Peripheral Arterial Disease - surgery; Peripheral artery disease; Predictive Value of Tests; Proportional Hazards Models; Randomized Controlled Trials as Topic; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome; Wound Healing
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2018.02.028

The Wound, Ischemia, and foot Infection (WIfI) classification was developed to assess amputation risk and hence to aid in clinical decision-making in patients with chronic limb-threatening ischemia (CLTI). WIfI has been validated in multiple CLTI cohorts worldwide. In this study, we examined the relationship between WIfI stage and clinical outcomes in a well-defined subpopulation of CLTI patients considered not eligible for conventional revascularization. The aim of this study was to assess the prognostic value of the WIfI classification for clinical outcomes in a “no-option” CLTI population. The Rejuvenating Endothelial Progenitor Cells via Transcutaneous Intra-arterial Supplementation (JUVENTAS) trial was a single-center, double-blinded, randomized placebo-controlled trial studying the effects of autologous bone marrow mononuclear cells in no-option CLTI patients (N = 160). We conducted a retrospective analysis incorporating baseline and follow-up data from the JUVENTAS trial. All wounds were photographed and described at the start and end of the trial to allow WIfI staging. Two independent researchers retrospectively classified all limbs according to the WIfI scheme, which was then related to prospectively collected trial data. Outcomes including wound healing, clinical improvement, minor and major amputation rate, amputation-free survival, and mortality were assessed using Kaplan-Meier analyses. Of the 160 patients, 150 could be included in this study. Most patients had been classified as Rutherford stage 4 (34%) and stage 5 (61%), with corresponding WIfI stage 2 (33%), stage 3 (21%), or stage 4 (35%). Diabetes, impaired renal function, and ankle-brachial index were independently associated with WIfI stage. On univariate analysis, WIfI stage was strongly associated with wound healing (P = .001), improvement of Rutherford stage (P = .009), amputation rate (P