Wound care-first strategies provide superior amputation-free survival in patients with chronic limb-threatening ischemia Wound, Ischemia, and foot Infection clinical stages 1 and 2.

Abstract

The optimal timing of revascularization in patients with mild-to-moderate chronic limb-threatening ischemia (CLTI) remains unclear. We aimed to evaluate long-term outcomes associated with conservative-first vs early revascularization strategies in patients with Wound, Ischemia, and foot Infection (WIfI) stage 1-2 CLTI. A 10-year, retrospective two-center analysis of patients with WIfI stage 1-2 CLTI was conducted. At both centers, the standard practice is to revascularize patients with toe pressure <30 mm Hg, whereas those with less severe ischemia are typically offered an initial trial of conservative management (wound care and offloading). However, through shared decision-making, some patients with toe pressure >30 mm Hg may still opt for-and be offered-immediate revascularization. Patients were grouped into conservative care only, late revascularization, and early revascularization, defined as intervention <30 days from presentation. Outcomes were wound healing, major limb amputation, amputation-free survival (AFS), and mortality. During the study period, 1404 patients were treated at two limb preservation centers, of whom 512 (36.5%) with WIfI stage 1 or 2 limbs were analyzed (573 limbs; median age 65 years, interquartile range: 57-74 years; 60.7% male; median follow-up 852 days, interquartile range: 346-1415 days). AFS was longest in the late revascularization group (median 3677 days), followed by early revascularization (1756 days), and shortest in the conservative care only group (1513 days) (P < .001). Limb salvage was achieved in 88% of conservative, 89% of early, and 91% of late revascularization patients, with no significant differences (P = .83). Overall survival was 54.2% in the conservative group, 71.9% in the early revascularization group, and 76.4% in the late revascularization group (P = .048). On multivariable analysis, conservative care only (hazard ratio [HR]: 0.41, 95% confidence interval: 0.25-0.66) and WIfI stage 2 (HR: 0.69, 95% confidence interval: 0.48-0.99) were protective, whereas increasing age (HR: 1.02, P = .004), congestive heart failure (HR: 1.73, P < .001), and bypass occlusion (HR: 1.74, P = .025) predicted major amputation/death. In patients with ischemic wounds, survival and AFS remained highest in the late revascularization group, with no significant differences in wound healing or major amputation. In patients with WIfI clinical stages 1 and 2, early revascularization was not associated with improved AFS or wound healing compared with conservative management with or without delayed revascularization. These findings suggest that a selective, staged approach may be safe and effective in appropriately selected low- to moderate-risk CLTI patients.