Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 81-84

Role of wound, ischemia, and foot infection scores in predicting major limb loss despite appropriate revascularization


Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission21-Oct-2021
Date of Acceptance30-Nov-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Prabhu Premkumar
Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_107_21

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  Abstract 


Background: Wound, Ischemia, and foot Infection (WIfI) scores correlate well with amputation risk in patients with peripheral vascular disease. A certain subset will eventually require a major amputation despite revascularization. These patients may be offered the option of an upfront primary amputation and early rehabilitation. We sought to assess the WIfI staging and the novel WIfI composite scoring in identifying this subgroup. Patients and Methods: Patients with lower limb peripheral vascular disease with chronic lower limb extremity wounds who underwent revascularization procedures with the intent of limb salvage were included. Retrospective data of prospectively maintained preoperative WIfI scores, details of vascular intervention and occurrence of major amputation over 1 year from April 2018 to March 2019 was collected. Follow-up data were obtained for 1 year postoperatively. Results: Hundred thirty-seven patients were included. One hundred and one underwent an endovascular procedure, 17 underwent an aortobifemoral bypass, 16 underwent an open bypass procedure, and 3 were hybrid procedures. About 16.5% (23 patients) required a major amputation despite revascularization within 6 months of intervention. The mean total component score (out of 9) in these patients who required amputation was significantly higher (7.73 vs. 5.15, P < 0.05). Higher infection score preoperatively (2.17 vs. 0.88, P < 0.05) and higher wound score (2.7 vs. 1.63, P < 0.05) were significant. Mean ischemia scores were not significantly different between the two groups (2.87 vs. 2.65). The most common cause of amputation was infection (20 out of 23 events), and most of the amputations occurred in the first 1 month following. Three patients died within the 1-year follow-up period. Conclusion: Patients with higher total WIfI scores >7, higher wound, and infection components at presentation may have poor outcomes following revascularization.

Keywords: Amputation, revascularization, Wound Ischemia and foot Infection


How to cite this article:
Lazarus E, Premkumar P, Selvaraj D, Samuel V, Kota AA. Role of wound, ischemia, and foot infection scores in predicting major limb loss despite appropriate revascularization. Indian J Vasc Endovasc Surg 2022;9:81-4

How to cite this URL:
Lazarus E, Premkumar P, Selvaraj D, Samuel V, Kota AA. Role of wound, ischemia, and foot infection scores in predicting major limb loss despite appropriate revascularization. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:81-4. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/81/340493




  Introduction Top


Wound, Ischemia, and foot Infection (WIfI)[1] scores correlate well with amputation risk in patients with peripheral vascular disease with untreated lower extremity wounds. However, despite appropriate and successful revascularization with the intent of limb salvage, a certain subset of these patients, especially with higher WIfI stages, will require a major amputation.[2],[3],[4]

Limb salvage and revascularization efforts directed to that end are undoubtedly indicated for patients with critical limb ischemia. However, it may also be useful to identify those patients who may be at elevated risk for failure of limb salvage despite revascularization.

This subset of patients often require multiple complex procedures, have longer hospital stays, incur higher initial and recurring hospital costs, suffer wound complications, and have prolonged or nonhealing wounds.[5] It becomes important to reconsider if just a lesion-focused approach achieves revascularization but fails to salvage good functional outcomes. A select subset of patients may be offered the option of an upfront primary amputation and early rehabilitation rather than revascularization.[6] Unfortunately, it is not always apparent preoperatively which patients may not benefit from revascularization.

We sought to assess the WIfI staging and the novel WIfI component scoring described by Darling et al. in identifying this subgroup of patients.[2],[7] This is scored by adding the individual component scores of WIfI for a total score out of 9.


  Patients and Methods Top


Study design and setting

We conducted a retrospective study in the vascular surgical unit of a tertiary referral teaching institute in India, between April 2018 and March 2019, after approval from the institutional review board and institutional ethics committee.

Inclusion criteria

  • All patients with peripheral vascular disease with chronic limb-threatening ischemia of the lower limbs undergoing vascular intervention (open or endovascular or hybrid) with the intent of limb salvage.
  • Complete preoperative WIfI score data and details of intervention and postoperative outcome data available.


Exclusion criteria

  • Operative technical failure
  • Acute limb ischemia
  • Trauma-related injuries
  • Primary amputation for nonsalvageable limbs or WIfI Stage 5.


Sample size and data collection

In our department, WIfI scores were documented preoperatively at admission for all patients planned for revascularization. All patients fitting the eligibility criteria between April 2018 and March 2019 were included. Exclusion criteria were applied to this group and a total of 137 patients were eligible. [Figure 1] shows the algorithm of study flow.
Figure 1: Diagrammatic algorithm of study flow

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Follow-up

Patients were followed up for a period of 1 year from the date of surgery. Follow-up data were obtained either from outpatient department (OPD) follow-up visit entries in the hospital electronic medical record or from telephone calls if they had not been able to come for follow-up to the OPD.

Primary outcome measure

Primary outcome measures were as follows: first, the occurrence of major amputation following successful revascularization and second, the association of major amputation with the preoperative WIfI score.

Diagnostic criteria

All patients were stratified according to the WIfI score criteria into the corresponding WIfI stages. Individual score components were recorded separately. Major amputations were defined as above-knee amputations, below-knee amputations, and transtarsal amputations. All patients with infected wounds underwent either debridement or minor amputation with antibiotic therapy to achieve adequate source control before revascularization.

Statistical analysis

Descriptive statistics for demographic and clinical continuous variables were presented as mean and standard deviation. Frequencies and percentages were given for categorical factors. Chi-square tests were used to assess for correlation between categorical variables and logistic regression for correlation between continuous and categorical variables, and student's t-test was used for correlation between means.


  Results Top


A total of 156 patients with chronic lower extremity wounds underwent revascularization between April 2018 and March 2019, of these 19 were excluded. One hundred and thirty-seven patients were included in the study. The demographic details and baseline characteristics of this cohort are given in [Table 1] and the segment-wise distribution of procedures is given in [Table 2].
Table 1: Baseline clinical characteristics (n=137)

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Table 2: Segment-wise distribution of procedures (n=137)

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After revascularization, 23 out of 137 patients required a major amputation. Out of the nine patients with wet gangrene, seven patients required a major amputation after revascularization. All 23 patients who required amputation were WIfI Stage 4. The details of these patients are given in [Table 3].
Table 3: Details of patients requiring amputation post revascularization (n=23)

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Fourteen out of 23 amputations occurred in the first 1 month following the initial revascularization procedure, as shown in Kaplan–Meier graph in [Figure 2].
Figure 2: Kaplan–Meier graph – time to amputation event in different component score subgroups

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The wound and infection scores were significantly higher in the subgroup requiring amputation following revascularization; however, there was no difference in ischemia scores between those requiring amputation following revascularization and those who achieved limb salvage [Table 4].
Table 4: Bivariate analysis: Wound, Ischemia, and foot Infection components versus amputation

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There were three patients who died during the follow-up period [Table 5].
Table 5: Mortality details (n=3) out of 137 patients

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  Discussion Top


At our center, 67.1% of patients presented with the Society for Vascular Surgery (SVS) WIfI Stage 4, reflecting a referral bias. We were able to achieve limb salvage in 114 patients (83.3%).

However, despite appropriate revascularization, 23 patients (16.7%) required major amputation. All patients requiring amputations were SVS WIfI Stage 4. We found that a higher total component score >7 and higher infection and wound scores were associated with amputation risk despite revascularization, whereas ischemia component scores were not significant. Our findings corroborate the results obtained by Darling et al. and Zhan et al.[2],[8] Kobayaschi showed that the re-intervention rate was more for higher WIfI scores, with Stage 4 being 45.7% compared to 28.6% for Stage 2 and 34% for Stage 3 disease.[9] The work by Ramanan et al. underlines the difficult task of intervention for higher WIfI stages. Stage 4 limbs in particular are expensive to treat, often require multiple complex interventions, have prolonged wound healing, and are associated with longer hospital stay.[10]

Thus, while all patients with critical limbs should be offered an appropriate revascularization procedure with a view to achieve limb salvage, in patients with higher WIfI component scores >7, especially higher wound and infection scores, the option of an upfront amputation as an alternative treatment modality should be considered. The near near-universal availability of a wide range of cost-effective prostheses also helps achieve this goal.

When compared to countries where the government provides free health care, in India, the bulk of health-care expenses falls on the patient. Although there are government-subsidized health-care centers available, there is an unequal distribution of vascular services. Out-of-pocket health-care expenditure remains a major cause for poverty, leading to catastrophic expenditures in 17.9% of families, with expenditure on medicine alone responsible for an estimated 38 million persons to drop below the poverty lines in 2012.[10] The cost versus benefit of multiple revascularizations with persistent high risk of limb loss requires consideration. An early amputation and rehabilitation may serve as a viable alternative in such resource-limited settings for a select subset of patients.

Delayed presentation with advanced peripheral vascular disease burden leads to poor outcomes even in the best of centers. Therefore, the long-term focus should target prevention with risk factor modification and smoking cessation. Educating and increasing awareness of general practitioners, diabetologists, and surgeons on early identification and early referral to a vascular surgical center is key to achieving sustainable improvements in patient outcomes.

Limitations

There were more patients with Stage 4 disease, reflecting a referral bias. This was a retrospective study and was subject to biases inherent to this study design.


  Conclusion Top


Most patients achieve limb salvage with adequate revascularization. Patients with total WIfI scores >7, with higher wound and infection components at presentation appear to have adverse outcomes despite adequate revascularization. Though our goal is to revascularize effectively, in this select subset of patients, an early amputation and rehabilitation may hasten return to productivity, functional independence and mitigate the economic burden.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mills JL Sr., Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, et al. The society for vascular surgery lower extremity threatened limb classification system: Risk stratification based on Wound, Ischemia, and Foot Infection (WIfI). J Vasc Surg 2014;59:220- 34.e1.  Back to cited text no. 1
    
2.
Darling JD, McCallum JC, Soden PA, Meng Y, Wyers MC, Hamdan AD, et al. Predictive ability of the society for vascular surgery Wound, Ischemia, and Foot Infection (WIfI) classification system following infrapopliteal endovascular interventions for critical limb ischemia. J Vasc Surg 2016;64:616-22.  Back to cited text no. 2
    
3.
Cull DL, Manos G, Hartley MC, Taylor SM, Langan EM, Eidt JF, et al. An early validation of the society for vascular surgery lower extremity threatened limb classification system. J Vasc Surg 2014;60:1535-41.  Back to cited text no. 3
    
4.
Beropoulis E, Stavroulakis K, Schwindt A, Stachmann A, Torsello G, Bisdas T. Validation of the Wound, Ischemia, Foot Infection (WIfI) classification system in nondiabetic patients treated by endovascular means for critical limb ischemia. J Vasc Surg 2016;64:95-103.  Back to cited text no. 4
    
5.
Ramanan B, Ahmed A, Wu B, Causey MW, Gasper WJ, Vartanian SM, et al. Determinants of midterm functional outcomes, wound healing, and resources used in a hospital-based limb preservation program. J Vasc Surg 2017;66:1765-74.  Back to cited text no. 5
    
6.
Nehler MR, Hiatt WR, Taylor LM Jr. Is revascularization and limb salvage always the best treatment for critical limb ischemia? J Vasc Surg 2003;37:704-8.  Back to cited text no. 6
    
7.
Darling JD, McCallum JC, Soden PA, Guzman RJ, Wyers MC, Hamdan AD, et al. Predictive ability of the society for vascular surgery Wound, Ischemia, and Foot Infection (WIfI) classification system after first-time lower extremity revascularizations. J Vasc Surg 2017;65:695-704.  Back to cited text no. 7
    
8.
Zhan LX, Branco BC, Armstrong DG, Mills JL Sr. The society for vascular surgery lower extremity threatened limb classification system based on Wound, Ischemia, and Foot Infection (WIfI) correlates with risk of major amputation and time to wound healing. J Vasc Surg 2015;61:939-44.  Back to cited text no. 8
    
9.
Kobayashi N, Hirano K, Yamawaki M, Araki M, Sakai T, Sakamoto Y, et al. Characteristics and clinical outcomes of repeat endovascular therapy after infrapopliteal balloon angioplasty in patients with critical limb ischemia. Catheter Cardiovasc Interv 2018;91:505-14.  Back to cited text no. 9
    
10.
Selvaraj S, Farooqui HH, Karan A. Quantifying the financial burden of households' out-of-pocket payments on medicines in India: A repeated cross-sectional analysis of National Sample Survey data, 1994-2014. BMJ Open 2018;8:e018020.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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