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      WIfI classification: the Society for Vascular Surgery lower extremity threatened limb classification system, a literature review

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          Abstract

          The Society for Vascular Surgery has proposed a new classification system for the threatened lower limb, based on the three main factors that have an impact on limb amputation risk: Wound (W), Ischemia (I) and foot Infection (“fI”) - the WIfI classification. The system also covers diabetic patients, previously excluded from the concept of critical limb ischemia because of their complex clinical condition. The classification’s purpose is to provide accurate and early risk stratification for patients with threatened lower limbs; assisting with clinical management, enabling comparison of alternative therapies; and predicting risk of amputation at 1 year and the need for limb revascularization. The objective of this study is to collect together the main points about the WIfI classification that have been discussed in the scientific literature. Most of the studies conducted for validation of this classification system prove its association with factors related to limb salvage, such as amputation rates, amputation-free survival, prediction of reintervention, amputation, and stenosis (RAS) events, and wound healing.

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          Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).

          L Norgren, W.R. Hiatt, J.A. Dormandy … (2007)
          Article 0 comments Cited 487 times – based on 0 reviews     Review now
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            Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

            Michael S. Conte, Andrew W Bradbury, Philippe Kolh … (2019)
            Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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              2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.

              B A Lipsky, A Berendt, P. B. Cornia … (2012)
              Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.
              Article 0 comments Cited 228 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Vasc Bras
                Journal ID (iso-abbrev): J Vasc Bras
                Journal ID (publisher-id): jvb
                Title: Jornal Vascular Brasileiro
                Publisher: Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV)
                ISSN (Print): 1677-5449
                ISSN (Electronic): 1677-7301
                Publication date (Electronic, pub): 08 May 2020
                Publication date (Electronic, collection): 2020
                Volume: 19
                Electronic Location Identifier: e20190070
                Affiliations
                [1 ] originalUniversidade Vila Velha – UVV, Cirurgia Vascular, Vila Velha, ES, Brasil.
                [2 ] originalCentro de Atuação Precoce em Úlceras Vasculares e Complicações do Pé Diabético – PROPÉ, Departamento de Cirurgia Vascular, Vila Velha, ES, Brasil.
                [3 ] originalHospital Estadual de Urgência e Emergência do Espírito Santo – HEUE, Departamento de Cirurgia Vascular, Vila Velha, ES, Brasil.
                [4 ] originalHospital Santa Mônica de Vila Velha, Serviço de Cirurgia Vascular e Endovascular, Vila Velha, ES, Brasil.
                [5 ] originalUniversidade Federal do Paraná – UFPR, Hospital de Clínicas, Serviço de Angiorradiologia e Cirurgia Endovascular, Curitiba, PR, Brasil.
                [6 ] originalHospital Angelina Caron, Departamento de Residência Médica em Cirurgia Vascular e Endovascular, Curitiba, PR, Brasil.
                [1 ] originalUniversidade Vila Velha – UVV, Cirurgia Vascular, Vila Velha, ES, Brasil.
                [2 ] originalCentro de Atuação Precoce em Úlceras Vasculares e Complicações do Pé Diabético – PROPÉ, Departamento de Cirurgia Vascular, Vila Velha, ES, Brasil.
                [3 ] originalHospital Estadual de Urgência e Emergência do Espírito Santo – HEUE, Departamento de Cirurgia Vascular, Vila Velha, ES, Brasil.
                [4 ] originalHospital Santa Mônica de Vila Velha, Serviço de Cirurgia Vascular e Endovascular, Vila Velha, ES, Brasil.
                [5 ] originalUniversidade Federal do Paraná – UFPR, Hospital de Clínicas, Serviço de Angiorradiologia e Cirurgia Endovascular, Curitiba, PR, Brasil.
                [6 ] originalHospital Angelina Caron, Departamento de Residência Médica em Cirurgia Vascular e Endovascular, Curitiba, PR, Brasil.
                Author notes

                Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

                Correspondence Lorena de Oliveira Cerqueira Universidade Vila Velha – UVV, Cirurgia Vascular Rua Arthur Czartoryski, 132/204 - Jardim da Penha CEP 29060-370 - Vitória (ES), Brasil Tel.: +55 (33) 98861-5146 E-mail: lorena.o.cerqueira@ 123456outlook.com

                Author information LOC - Physician graduated, Universidade Vila Velha (UVV); Intern, Serviço de Cirurgia Vascular e Endovascular, Hospital Santa Mônica and Centro de Atuação Precoce em Úlceras Vasculares e Complicações do Pé Diabético (PROPÉ). EGDJ - Vascular surgeon, Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV); Coordinator, PROPÉ; Vascular surgeon, Hospital Estadual de Urgência e Emergência do Espírito Santo (HEUE); Vascular surgeon, Hospital Santa Mônica de Vila Velha; Preceptor, UVV. ALSB - Vascular surgeon, PROPÉ - Centro de Atuação Precoce em Úlceras Vasculares e complicações do Pé Diabético; Preceptor, Universidade de Vila Velha (UVV). JRC - Vascular surgeon, SBACV; Attending coordinator, Serviço de Cirurgia Vascular e Endovascular, Hospital Santa Mônica. WJBA - MSc and PhD on Surgery, UFPR; Board-certified in Vascular Surgery, Vascular Doppler Ultrasound, Angioradiology and Endovascular Surgery from (SBACV)/Colégio Brasileiro de Radiologia (CBR)/Associação Médica Brasileira (AMB); Board-certified in Interventional Radiology and Angioradiology from Sociedade Brasileira de Radiologia Intervencionista e Cirurgia Endovascular (Sobrice)/CBR/AMB; Full member, SBACV and Sobrice; Primary physician, Serviço de Angiorradiologia e Cirurgia Endovascular, Hospital de Clínicas, Universidade Federal do Paraná (UFPR); Preceptor of Residência Médica em Cirurgia Vascular e Endovascular, Hospital de Clínicas, UFPR and Hospital Angelina Caron; Coordinator, Serviço de Ecografia Vascular; Owner partner of Instituto da Circulação.

                Author contributions: Conception and design: LOC, EGDJ Analysis and interpretation: LOC, EGDJ Data collection: LOC Writing the article: LOC Critical revision of the article: LOC, EGDJ, ALSB, JRC, WJBA Final approval of the article*: LOC, EGDJ, ALSB, JRC, WJBA Statistical analysis: N/A. Overall responsibility: LOC, EGDJ *All authors have read and approved of the final version of the article submitted to J Vasc Bras.

                Conflito de interesse: Os autores declararam não haver conflitos de interesse que precisam ser informados.

                Correspondência Lorena de Oliveira Cerqueira Universidade Vila Velha – UVV, Cirurgia Vascular Rua Arthur Czartoryski, 132/204 - Jardim da Penha CEP 29060-370 - Vitória (ES), Brasil Tel.: (33) 98861-5146 E-mail: lorena.o.cerqueira@ 123456outlook.com

                Informações sobre os autores LOC - Médica graduada, Universidade Vila Velha (UVV); Estagiária, Serviço de Cirurgia Vascular e Endovascular, Hospital Santa Mônica e do PROPÉ - Centro de Atuação Precoce em Úlceras Vasculares e Complicações do Pé Diabético. EGDJ - Cirurgião vascular, SBACV; Coordenador, PROPÉ - Centro de Atuação Precoce em Úlceras Vasculares e complicações do Pé Diabético; Cirurgião vascular, Hospital Estadual de Urgência e Emergência do Espírito Santo – HEUE; Cirurgião vascular, Hospital Santa Mônica de Vila Velha; Preceptor de ensino, Universidade de Vila Velha (UVV). ALSB - Cirurgião vascular, PROPÉ - Centro de Atuação Precoce em Úlceras Vasculares e complicações do Pé Diabético; Preceptor de ensino, Universidade de Vila Velha (UVV). JRC - Cirurgião vascular, SBACV; Coordenador responsável, Serviço de Cirurgia Vascular e Endovascular, Hospital Santa Mônica WJBA - Mestre e Doutor em Cirurgia, Universidade Federal do Paraná (UFPR); Título de especialista em Cirurgia Vascular, Ecografia Vascular com Doppler, Angiorradiologia e Cirurgia Endovascular, Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)/Colégio Brasileiro de Radiologia (CBR)/Associação Médica Brasileira (AMB); Título de especialista em Radiologia Intervencionista e Angiorradiologia, Sociedade Brasileira de Radiologia Intervencionista e Cirurgia Endovascular (Sobrice)/CBR/AMB; Sócio-titular, SBACV e Sobrice; Médico assistente, Serviço de Angiorradiologia e Cirurgia Endovascular, Hospital de Clínicas, UFPR; Preceptor da Residência Médica em Cirurgia Vascular e Endovascular, Hospital de Clinicas, UFPR e do Hospital Angelina Caron; Coordenador, Serviço de Ecografia Vascular; Sócio-proprietário, Instituto da Circulação.

                Contribuições dos autores Concepção e desenho do estudo: LOC, EGDJ Análise e interpretação dos dados: LOC, EGDJ Coleta de dados: LOC Redação do artigo: LOC Revisão crítica do texto: LOC, EGDJ, ALSB, JRC, WJBA Aprovação final do artigo*: LOC, EGDJ, ALSB, JRC, WJBA Análise estatística: N/A. Responsabilidade geral pelo estudo: LOC, EGDJ *Todos os autores leram e aprovaram a versão final submetida ao J Vasc Bras.

                Author information
                http://orcid.org/0000-0003-2806-0577
                http://orcid.org/0000-0003-1504-6303
                http://orcid.org/0000-0002-2808-7326
                http://orcid.org/0000-0002-9074-020X
                http://orcid.org/0000-0003-1537-0285
                Article
                Publisher ID: jvbAR20190070_PT Other ID: 00311
                DOI: 10.1590/1677-5449.190070
                PMC ID: 8202158
                PubMed ID: 34178056
                SO-VID: 575be14f-ffd5-4947-85f9-2a09708a518b
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 09 September 2019
                Date accepted : 19 December 2019
                Page count
                Figures: 0, Tables: 14, Equations: 0, References: 30
                Categories
                Subject: Review Article

                Keywords: diabetic foot,foot ulcer,ischemia,infection,amputation,mortality
                Data availability:
                Keywords: diabetic foot, foot ulcer, ischemia, infection, amputation, mortality

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