This study by the Loma Linda group1Gabel J. Bianchi C. Possagnoli I. Mehta R. Abou-Zamzam Jr., A.M. Teruya T. et al.Multidisciplinary approach achieves limb salvage without revascularization in patients with mild to moderate ischemia and tissue loss.J Vasc Surg. 2020; 71: 2073-2080Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar suggests that wound healing and avoidance of amputation without revascularization can be achieved in carefully selected patients with mild to moderate ischemia when they are treated as part of a multidisciplinary limb care team. In this highly selected cohort of patients, Wound, Ischemia, and foot Infection (WIfI) stage did not correlate with amputation risk. Does this study contradict the general consensus that WIfI clinical stages correlate with wound healing and amputation risk? No, not at all. The original Society for Vascular Surgery WIfI clinical stages were derived by Delphi consensus based on predicted 1-year amputation rates among patients with 64 theoretically possible combinations of wound, ischemia, and foot infection grades.2Mills J.L. Conte M.S. Armstrong D.G. Pomposelli F. Schanzer A. Sidawy A.N. et al.The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on Wound, Ischemia and foot Infection (WIfI).J Vasc Surg. 2014; 59: 220-234Abstract Full Text Full Text PDF PubMed Scopus (738) Google Scholar Many publications have subsequently validated the correlation of WIfI clinical stages with wound healing time and 1-year amputation risk, including a recent meta-analysis.3van Reijen N.S. Ponchant K. Ubbink D.T. Koelemay M.J. The prognostic value of the WIfI classification in patients with chronic limb threatening ischemia: a systematic review and meta-analysis.Eur J Vasc Endovasc Surg. 2019; 58: 362-371Abstract Full Text Full Text PDF Scopus (14) Google Scholar Additional publications,4Marston W.A. Davies S.W. Armstrong B. Farber M.A. Mendes R.C. Fulton J.J. et al.Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization.J Vasc Surg. 2006; 44: 108-114Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar,5Elgzyri T. Larsson J. Thörne J. Eriksson K.F. Apelqvist J. Outcome of ischemic foot ulcer in diabetic patients who had no invasive vascular intervention.Eur J Vasc Endovasc Surg. 2013; 46: 110-117Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar which are referenced in both this article and the original WIfI article, previously documented that many patients with chronic limb-threatening ischemia (CLTI) can be healed and amputation avoided by a combination of good wound care, offloading, and meticulous follow-up care. Such data support an underlying premise of WIfI that CLTI is a spectrum and a range of patients may not require revascularization to heal, depending on the combination of wound, ischemia, and foot infection. It is important to note which patients were included in this study. All patients had low-grade ischemia (mean ankle-brachial index >0.61 and transcutaneous oxygen pressure >30 mm Hg [mean, 48.2 mm Hg]); low-grade, well-controlled infection or absence of severe infection; no gangrene; and no rest pain. Thus excluded were grade 3 ischemia (severe) patients and grade 3 foot infection patients; the majority of the wounds were grade 1 and grade 2. The report analyzes a subgroup of patients with mild to moderate, grade 1 and grade 2 ischemia and suggests that immediate revascularization may not be needed to achieve healing in such carefully selected individuals. As part of the Prevention of Amputation in Veterans Everywhere (PAVE) program, 233 of 961 limbs (24.2%) were initially stratified to conservative therapy without initial revascularization. It is important to note that the WIfI classification was intended to be applied to all comers across the spectrum of CLTI, not highly selected subgroups, and this analysis and the conclusions drawn are likely to be skewed by the study design, which excludes 76% of at-risk CLTI patients. One of the implications of WIfI is that ischemia should be graded and that if it is not the dominant factor (which may be true for patients with only mild or even moderate ischemia with small ulcers, absent gangrene, and severe infection), focusing on other aspects of care such as wound management and offloading may be all that is needed to achieve healing. This principle is reflected by examining Table IV, a and b, of the original WIfI article.2Mills J.L. Conte M.S. Armstrong D.G. Pomposelli F. Schanzer A. Sidawy A.N. et al.The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on Wound, Ischemia and foot Infection (WIfI).J Vasc Surg. 2014; 59: 220-234Abstract Full Text Full Text PDF PubMed Scopus (738) Google Scholar Table IV, a represents the consensus-estimated risks of amputation (four clinical stages) and Table IV, b estimates the likelihood of benefit or need for revascularization. The tables do not correlate 1:1. In the mild ischemia group (Ischemia – 1), for example, only 3 of 16 possible limb scenarios are thought to be highly likely to require revascularization, and these are driven by large wounds or gangrene combined with infection. I would thus summarize the findings of this paper as supportive of a trial of excellent wound care in a multidisciplinary setting for CLTI patients without severe ischemia, advanced gangrene, or severe infection requiring open débridement before considering revascularization. There is no question that going forward, WIfI may need some modification as the clinical stages for each of the 64 possible scenarios were assigned by Delphi consensus and as such require ongoing validation. However, single-center studies of selected patients will probably not help us much in revising and improving WIfI. A more promising approach that could be applied to patients receiving medical therapy and wound care only, open revascularization, and endovascular therapy is the use of cluster analysis with statistical power being achieved by analyzing large data sets from multiple centers using WIfI.6Mayor J. Chung J. Zhang Q. Montero-Baker M. Schanzer A. Conte M.S. et al.Using the Society for Vascular Surgery (SVS) Wound, Ischemia and foot Infection (WIfI) classification to identify patients most likely to benefit from revascularization.J Vasc Surg. 2019; 70: 776-785Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The widespread adoption of WIfI should aid such endeavors if further collaborative registries and data sets can be shared and exploited. 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. Multidisciplinary approach achieves limb salvage without revascularization in patients with mild to moderate ischemia and tissue lossJournal of Vascular SurgeryVol. 71Issue 6PreviewThe Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system has been validated to predict wound healing and limb salvage of patients with peripheral artery disease (PAD). Our goal was to evaluate the association between WIfI stage and wound healing, limb salvage, and survival in a select cohort of patients with PAD and tissue loss undergoing an attempt of wound healing without immediate revascularization (conservative approach) in a multidisciplinary wound program. Full-Text PDF Open Archive