Wound healing, wound-free period and amputation-free survival in patients with Wound, Ischemia, and foot Infection (WIfI) stage 3 and 4 disease.

Abstract

Recent publications in low-risk Wound, Ischemia, and foot Infection (WIfI) stage 1 to 2 chronic limb-threatening ischemia (CLTI) suggest wound care-first strategies are safe. Although revascularization is widely accepted as beneficial in high-risk WIfI stage 3 to 4 patients, its impact on wound-centered outcomes such as wound healing time (WHT) and wound-free period (WFP) has not been well-characterized. A two-center, retrospective analysis was performed. Baseline data included demographics, comorbidities, perfusion indices, WIfI, and treatment modality (endovascular, open, hybrid, wound care only). Outcomes were WHT, WFP, and amputation-free survival. WHT was defined as the interval from initial presentation to complete epithelialization, regardless of interim reinterventions; major amputation or death prior to healing were classified as unhealed episodes. WFP was defined as the healed interval until recurrence or censoring. Over 9 years, 1483 patients were managed with CLTI, of whom 920 (1091 limbs) were WIfI stage 3 and 4 disease. These contributed 1158 wounds episodes (median follow-up, 29.0 months; interquartile range [IQR], 10.0-45.0 months). Most limbs underwent revascularization (n = 945; 81.6%), including endovascular (n = 713; 62%), open (n = 196; 17%), and hybrid (n = 36; 3%) approaches, whereas 18.4% were managed with wound care only. Overall, 550 wound episodes (47.6%) healed, with a median WHT of 248 days (IQR, 120-441 days). The median WHT did not differ meaningfully by revascularization strategy. Successful revascularization was independently associated with a higher likelihood of healing (adjusted odds ratio, 2.45; 95% confidence interval [CI], 1.71-3.50). Independent predictors of healing included successful revascularization (hazard ratio [HR], 2.45; 95% CI, 1.71-3.50; P < .001), obesity (HR, 1.52; P = .003), and hyperlipidemia (HR, 1.55; P = .044), whereas WIfI stage 4 predicted decreased healing (HR, 0.61; P < .001). Among 550 healed episodes, 79 (14.4%) developed recurrence or underwent major amputation at a median of 502 days (IQR, 163-1084 days). The median WFP was 502 days (95% CI, 350-654 days) and did not differ by treatment strategy on Kaplan-Meier analysis (P = .41). At last follow-up, 720 patients (62.2%) experienced major amputation/death. One-year limb salvage, survival, and amputation-free survival were consistently lower in the wound care-only group, whereas revascularized patients demonstrated more favorable early outcomes. In high-risk CLTI (WIfI 3-4), wound healing is prolonged (>6 months), and fewer than one-half of wound episodes heal. Revascularization was strongly associated with wound healing. Once healing occurred, durability (WFP) was similar across strategies. These findings highlight the value of wound-centered metrics (WHT and WFP) to complement traditional survival-based endpoints in this population.