Predictors of delayed wound healing after endovascular therapy of isolated infrapopliteal lesions underlying critical limb ischemia in patients with high prevalence of diabetes mellitus and hemodialysis.
OBJECTIVE
Acceptable limb salvage rates underlie the widespread use of endovascular therapy (EVT) for patients with critical limb ischemia (CLI) secondary to isolated infrapopliteal lesions; however, post-EVT delayed wound healing remains a challenge. Predictors of delayed wound healing and their use in risk stratification of EVT in patients with CLI due to isolated infrapopliteal lesions are explored.


METHODS
This was a retrospective multicenter study. 871 consecutive critically ischemic limbs were studied. There was tissue loss in 734 patients (age: 71 ± 10 years old; 71% male) who had undergone EVT between April 2004 and December 2012. The wound healing rate after EVT was estimated by the Kaplan-Meier method. The association between baseline characteristics and delayed wound healing was assessed by the Cox proportional hazard model.


RESULTS
Diabetes mellitus and regular dialysis were present in 75% (553/734) and 64% (476/734) of patients, respectively; 67% of limbs (585/871) had Rutherford class 5 CLI; 8% (67/871) of wounds were located in the heel only; 25% (219/871) of limbs had Rutherford 6 (involving not only the heel); and 42% (354/871) of wounds were complicated by infection. The rate of freedom from major amputation at 1 year reached 88%, whereas the wound healing rate was 67%. Median time to wound healing was 146 days. By multivariate analysis, non-ambulatory status (hazard ratio [HR], 1.58; 95% confidence interval [CI] 1.31-1.91) serum albumin <3 g/dL (HR 1.42; 95% CI 1.08-1.86), Rutherford 6 (not only heel) (HR 1.68; 95% CI 1.33-2.14), wound infection (HR 1.24; 95% CI 1.03-1.50), EVT not based on angiosome concept (HR 1.28; 95% CI 1.06-1.55), and below the ankle (BTA) 0 vessel runoff after EVT (HR 1.45; 95% CI 1.14-1.86) were independent predictors of delayed wound healing.


CONCLUSIONS
Non-ambulatory status, low albumin level, Rutherford 6 (not only heel), wound infection, indirect intervention, and poor BTA runoff were independent predictors for delayed wound healing after EVT in patients with CLI secondary to infrapopliteal lesions, and their use in risk stratification allows estimation of the wound healing rate.
Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan. Electronic address: shiraki.tatsuya@gail.com.
T
T
Shiraki
Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan.
O
O
Iida
Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
M
M
Takahara
Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan.
Y
Y
Soga
Department of Cardiology, Kikuna Memorial Hospital, Yokohama, Japan.
Y
Y
Yamauchi
Department of Cardiology, Yokohama-city Eastern Hospital, Yokohama, Japan.
K
K
Hirano
Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan.
D
D
Kawasaki
Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada, Japan.
M
M
Fujihara
Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan.
M
M
Utsunomiya
Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
J
J
Tazaki
Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan.
T
T
Yamaoka
Department of Cardiology, Shin-Koga Hospital, Kurume, Japan.
Y
Y
Shintani
Department of Cardiology, Fukuoka Red Cross Hospital, Fukuoka, Japan.
N
N
Suematsu
Department of Cardiology, Sendai Kosei Hospital, Sendai, Japan.
K
K
Suzuki
Department of Advanced PAD Therapeutics, Shinshu University, Matsumoto, Japan.
Y
Y
Miyashita
Division of Trans-catheter Cardiovascular Therapeutics, Kanazawa Medical University Hospital, Ishikawa, Japan.
T
T
Tsuchiya
Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan.
M
M
Uematsu
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003920:Diabetes Mellitus / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000453:epidemiology* / Q000601:surgery; D023821:Limb Salvage / Q000379:methods; D035002:Lower Extremity / Q000098:blood supply / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
Angiosome concept; Critical limb ischemia; Endovascular therapy; Risk factor stratification; Wound healing