Invited commentary

Abstract

Patients with critical limb ischemia (CLI) are a clinically diverse group, and “all wounds are not created equal.” As the TNM classification system was developed to stratify and stage the burden of cancer, the Wound, Ischemia, and foot Infection (WIfI) classification system has been similarly developed to stratify the risk of amputation in the diverse group of patients presenting with limb-threatening CLI. Using WIfI, amputation risk is assessed by a clinical score generated by grading wound characteristics, degree of perfusion, and extent of infection. This grading process is fairly straightforward; however, WIfI can be cumbersome, raising the question as to its utility to accurately obtain clinically useful data at sequential time points in the course of complex cases involving multiple providers. However, WIfI has been clinically validated in select settings. Cull et al retrospectively graded patients using WIfI for comparison with actual outcomes as well as with outcomes predicted by a panel of experts.1Cull D.L. Manos G. Hartley M.C. Taylor S.M. Langan E.M. Eidt J.F. et al.An early validation of the Society for Vascular Surgery lower extremity threatened limb classification system.J Vasc Surg. 2014; 60: 1535-1542Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar The severity of the WIfI scores correlated with 1-year limb salvage and, interestingly, wound healing rates. Zhan et al provided clinical validation by correlating score severity with the outcomes of limb salvage and wound healing.2Zhan L.X. Branco B.C. Armstrong D.G. Mills J.L. 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: 939-944Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar This study also demonstrated the benefit of revascularization to wound healing in patients with a certain score. The current article adds an additional dimension to the WIfI grading process by examining the ability of rescoring during the patient's clinical course to predict outcomes. The authors found that restaging during the clinical course may be indicative of future amputation-free survival. WIfI wound and infection grades, both initially and postoperatively, correlated with limb preservation. Interestingly, the ischemia grade at initial presentation was least important in predicting ultimate outcome, although the postintervention ischemia score at the 1-month follow-up interval seemed helpful to guide the need for further reintervention. Potentially, this observation could have an impact on the need to develop an actual data point to guide the need for additional revascularization, as additional endovascular therapy, or the move to bypass surgery. WIfI was not meant to function as an independent clinical decision-making tool but to allow better stratification of patients for accurate comparisons in clinical trials and evaluation of new strategies for treating CLI. To truly guide clinical algorithms, assessment of patient comorbidity and a more useful scheme to incorporate arterial anatomy would be required. Although this may add an additional layer of complexity to the process, the combination would be a powerful clinical tool in the management of patients in danger of limb loss. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Importance of postprocedural Wound, Ischemia, and foot Infection (WIfI) restaging in predicting limb salvageJournal of Vascular SurgeryVol. 67Issue 2PreviewThe Wound, Ischemia, and foot Infection (WIfI) classification system was created to encompass demographic changes and expanding techniques of revascularization to perform meaningful analyses of outcomes in the treatment of the threatened limb. The WIfI index is intended to be analogous to the TNM staging system for cancer, with restaging to be done after control of infection and after revascularization. Our goal was to evaluate the effectiveness of WIfI restaging after therapy in the prediction of limb outcomes. Full-Text PDF Open Archive