SLR - April 2020 - Brandon A. Rogers
A Conservative Approach to Select Patients with Ischemic Wounds is Safe and Effective in the Setting of Deferred Revascularization
Reference: Gabel JA, Bianchi C, Possagnoli I, Oyoyo UE, Teruya TH, Kiang SC, Abou-Zamzam AM, Bishop V, Eastridge D. A Conservative Approach to Select Patients with Ischemic Wounds is Safe and Effective in the Setting of Deferred Revascularization. J Vasc Surg 2019 In Press https://doi.org/10.1016/j.jvs.2019.06.199
Scientific Literature Review
Reviewed By: Brandon A. Rogers
Residency Program: Long Island Jewish Forest Hills at Northwell Health – Queens, NY
Podiatric Relevance: Restoring blood flow is considered the most important predictor of limb salvage and survival for people with ischemic wounds. With the increasing prevalence of diabetes, end-stage renal disease and advanced age leading to peripheral arterial disease (PAD) and tissue loss, it is important to understand a timeline for when to refer our patients to a vascular surgeon. The authors’ main goal was to evaluate wound healing, limb salvage and survival among patients with ischemic wounds undergoing revascularization when surgical intervention was preceded by a trial of conservative wound therapy.
Methods: All patients with PAD and tissue loss were prospectively enrolled and stratified into four treatment groups based on potential for limb salvage: immediate revascularization, conservative management, primary amputation and palliative limb care. Primary amputation or palliative limb care groups consisted of poor physiologic reserve, excessive tissue loss, or lack of target vessels. Limbs with tissue loss, absent pedal pulses, ankle brachial index (ABI) <0.9 or suprasystolic ABI in the setting of diabetes were stratified into limb salvage. Immediate revascularization consisted of limbs deemed salvageable with a local transcutaneous oxygen pressure of less than 30mmHg. With TCPO2 30-50mmHg and expected weekly/biweekly follow-up were stratified into a conservative approach. Primary outcomes were wound healing, major amputation and survival. Data was retrospectively analyzed by treatment cohort and summarized.
Results: Eight hundred fifty-five limbs were prospectively enrolled in the program. Of the total, 203 underwent immediate revascularization. Two hundred thirty-six were grouped into conservative approach, where 185 (78.4 percent) healed and 33 (14.0 percent) underwent deferred vascularization (mean 2.7 +/- 2.6 months). Limbs undergoing deferred compared with immediate revascularization had decreased severity of WIfI states (WIfI stages 3 and 4, 63.7 percent vs 84.7 percent). Deferred versus immediate revascularization demonstrated wound healing 66.7 percent vs 57.6 percent, freedom from major amputation 81.8 percent vs 74.9 percent and survival 54.5 percent vs 50.7 percent. Median time to wound healing was 4.7 months for the deferred cohort vs 5.3 months for the immediate revascularization cohort. The mean estimated freedom from major amputation was 60.9 months for the deferred cohort and 65.6 months for the immediate revascularization cohort. On multivariate analysis, deferred revascularization remained similar to immediate revascularization for wound healing, freedom from major amputation, survival, wound recurrence, and number of wound recurrence events.
Conclusions: The mean time from treatment stratification to revascularization was 11 weeks in this study. There were no significant differences in overall wound healing or time to wound healing compared to those in the immediate revascularization cohort. For most patients with mild to moderate ischemia and tissue loss, immediate revascularization may not be necessary as long as proper follow up is accessible. The previous belief that patients must undergo immediate revascularization may not for long be the case with the advanced wound care treatments available today. At our institution, vascular intervention is not always immediately accessible on mildly to moderately ischemic patients. Understanding longer term outcomes helps us continue cross departmental discussions with our colleagues in other specialties.