WIfI classification versus Angiosome concept: a change in the infrapopliteal angioplasties paradigm

Abstract Objective The objective of this study was to determine whether the angiosome concept and WIfI classification in patients undergoing endovascular treatment is associated with the limb salvage rate and wound healing rate in patients with critical limb ischemia (CLI). Methods This was a retrospective, consecutive cohort study of CLI patients who underwent infrapopliteal angioplasty at the Vascular and Endovascular Surgery Service of the Hospital do Servidor Publico Estadual, Sao Paulo, between January 2013 and January 2019. The primary outcome variable was the limb salvage rate and wound healing rate. The secondary outcome variables were patency, survival, time free from reintervention and operative mortality rate. Results Overall, 95 infrapopliteal endovascular procedures were performed in 95 patients. The initial technical success rate was 100%. The mean ± standard deviation outpatient follow-up time was 775 ± 107.5 days. The analyses were performed at 360 days for wound healing rate and 720 days for limb salvage rates, overall survival and time freedom from reintervention. According to angiosome concept, there were 54 patients (56.8%) classified in the direct group and 41 patients (43.2%) in the indirect group. Regarding the WIfI classification subanalysis, there were 22 patients WIfI 0-1 (23.2%) and 73 patients WIfI 2-3 (76.8%). Furthermore the indirect group had higher ulcer healing rate than the direct group, however it was not statistically significant (82.9%; 66.7%% respectively, p = 0.059). However the time to heal the ulcer was faster in WIfI 0-1 groups than WIfI 2-3 groups (164.82 days versus 251,48; p = 0.017). The limb salvage rates at 720 days were similar among indirect and direct Groups (92.6% and 85.4%, p = 0.79). Likewise, the freedom from reintervention rates at 720 days were also similar in Indirect and direct groups (74.6% and 64%,p= 0.23). The survival rates at 720 days were similar in both indirect and direct groups (86.8 and 85.6%, respectively; P = 0.82). The amputation free survival rate at 720 days by the Kaplan-Meier method was 91.3% in the indirect group and 85.9% in the direct group, but with no statistical significance between the groups (p = 0.37) Conclusion This study concluded that, in endovascular treatment, the angiosome concept is no longer important to limb salvage rates neither ulcer / wound healing rates. Moreover, the WIfI classification 0-1 is associated with faster and higher wound / ulcer healing rates than WIfI classification 2-3.