Vicki Bishop

Delayed Revascularization After a Trial of Conservative Therapy Is Safe and Effective for Ischemic Wounds in a Multidisciplinary Setting

Objective: Our group has previously shown that a high percentage of ischemic wounds in patients with peripheral arterial disease heal with conservative therapy alone. However, some patients require delayed revascularization. Our goal was to evaluate wound healing and limb salvage among patients with ischemic wounds when revascularization was necessary after a failure of conservative therapy. Methods: Patients with peripheral arterial disease and tissue loss were prospectively enrolled into our Prevention of Amputation in Veterans Everywhere (PAVE) program. Limbs were stratified on the basis of perfusion evaluation and a validated pathway of care. Conservatively treated limbs that failed to demonstrate a positive wound trajectory underwent delayed revascularization. Rates of wound healing, recurrence, limb salvage, and survival were retrospectively compared of patients who underwent delayed vs immediate revascularization by univariate and multivariate analysis, controlling for Wound, Ischemia, and foot Infection (WIfI) classification. Results: Between January 2008 and December 2017, there were 855 patients who were prospectively enrolled in our PAVE program. Of 236 limbs stratified to a conservative approach, 185 (78%) healed and 33 (14%) underwent delayed (mean, 2.76 2.6 months) revascularization. During this same period, 203 limbs underwent immediate revascularization. Mean long-term follow-up was 41.4 6 29.0 months. Delayed compared with immediate revascularization demonstrated similar rates of wound healing (67% vs 58%; P 1⁄4 .33), wound recurrence (24% vs 19%; P 1⁄4 .50), limb salvage (82% vs 75%; P 1⁄4 .39), and survival (55% vs 51%; P 1⁄4 .69). After adjustment for WIfI classification, delayed revascularization remained noninferior to immediate revascularization for wound healing (odds ratio [OR], 1.4; 95% confidence interval [CI], 0.6-3.1), recurrence (OR, 0.8; 95% CI, 0.3-1.8), limb salvage (OR, 0.7; 95% CI, 0.3-1.9), and survival (OR, 0.2; 95% CI, 0.6-2.5). Conclusions: Patients who fail to respond to conservative therapy and undergo delayed revascularization achieve similar rates of wound healing and limb salvage as those undergoing immediate surgical intervention, independent of WIfI classification. A stratified approach to critical limb ischemia achieves acceptable clinical outcomes without introducing increased risk in patients in whom an initial attempt at conservative therapy fails.