Association of revascularization strategy with wound healing following toe amputation in chronic limb-threatening ischemia.

Abstract

Chronic limb-threatening ischemia often requires toe amputation. However, the extent of tissue loss varies according to the procedure and is not fully captured by conventional wound-grading systems. This study compared wound healing after toe amputation following endovascular therapy (EVT) and bypass surgery, stratified by the number of toes amputated. This retrospective multicenter cohort study included consecutive patients with chronic limb-threatening ischemia who underwent infrainguinal revascularization with concomitant toe amputation between 2015 and 2023. Tissue loss was defined by the number of toes amputated at the initial procedure, and patients were subsequently classified into single- and multiple-toe amputation cohorts. Wound healing was evaluated using cumulative incidence functions, with death and major amputation treated as competing risks. Clinical outcomes between EVT and bypass surgery were compared using inverse probability of treatment weighting. Factors associated with wound healing were assessed using multivariate Fine-Gray regression models. In total, 412 patients were analyzed. In the single-toe cohort, bypass surgery was associated with faster wound healing compared with EVT, and this difference remained significant at 1 year (84.4% vs 72.7%, respectively). Conversely, limb salvage did not differ significantly between the two treatment modalities. In the multiple-toe cohort, early wound-healing trajectories were similar; however, the bypass surgery group demonstrated a trend toward better 1-year wound-healing rates (73.6% vs 53.4%) and improved limb salvage. Multivariate Fine-Gray analysis identified bypass surgery as an independent predictor of wound healing. Meanwhile, hemodialysis, higher inframalleolar disease, and greater tissue loss severity were associated with delayed healing. Bypass surgery was associated with improved wound healing following toe amputation. These findings highlight the importance of considering the number of toes amputated when evaluating wound-healing outcomes after different revascularization strategies.