The Value of Restaging WIfI (Wound, Ischemia, Foot Infection) after Initial Vascular and Podiatric Intervention

Abstract

Objective: Wound, ischemia, and foot infection (WIfI) is an important staging system for diabetic patients presenting with chronic limb-threatening ischemia (CLTI) of the lower extremities (LE). This study examines the clinical implications of restaging WIfI after initial vascular and podiatric interventions.

Methods: A prospective database of patients undergoing vascular intervention treatment of the LE for tissue loss between 2018 and 2022 was queried. Cases were reviewed and staged preoperatively according to WIfI and then based on the WIfI restaging after primary vascular and podiatric interventions. Three groups were identified: Improvement of WIfI score (Improved), WIfI unchanged (No Change), and Deterioration of WIfI score (Worsened) groups. In cases of active infection, patients underwent infection control (drainage and/or amputation) followed by revascularization (endovascular or open intervention). In contrast, patients with no active infection underwent revascularization followed by podiatric intervention. Amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or significant re-intervention [new bypass graft, jump/interposition graft revision]) were evaluated.

Results: One thousand four hundred and four patients (61% male, age 64±12years, mean ± SD) presented with CLTI underwent initial vascular and podiatric LE interventions. On initial presentation, 37% of the patients presented with WIfI stage 3, and 63% presented with WIfI stage 4. The majority of the patients had GLASS III anatomic disease. Fifty-six percent of the patients had a primary infection control procedure, and 78% had a vascular intervention (71% endovascular intervention and 29% open bypass). After completing the primary podiatric and vascular procedures and restaging the WIfI score, 48% of the patients were Improved, 32% were Unchanged, and 20% were Worsened. The post operative change in WIfI classification impacted both 30-day rate of MALE (5% vs. 9% vs. 24% for the Improved, unchanged, and Worsened groups, respectively; p=0.01) and the 30-day rate of major Amputation (2% vs. 3% vs. 14% for the Improved, unchanged and upgraded groups respectively; p<0.02). At five years, freedom from MALE was progressively worse in the Improved, Unchanged, and Worsened groups (47±5% vs. 38±5% vs. 23±9%, respectively; mean ± SEM, p=0.001). The five-year AFS also deteriorated for the Improved, Unchanged and Worsened groups (49±5% vs. 33±5% vs. 19±6% respectively; mean ± SEM, p=0.001) CONCLUSIONS: Restaging WIfI after primary vascular and podiatric intervention results in significant downgrading of WIfI staging, allows for better differentiation of 30-day outcomes, and influences freedom from MALE and AFS outcomes.

Keywords: Limb-threatening critical Ischemia; Outcomes; Restaging; Vascular intervention; WIfI. Podiatric surgery.