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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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          Most cited references 34

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

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            The dysvascular foot: a system for diagnosis and treatment.

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              Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

              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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                Author and article information

                Journal
                J Vasc Bras
                J Vasc Bras
                jvb
                Jornal Vascular Brasileiro
                Sociedade Brasileira de Angiologia e de Cirurgia Vascular (SBACV)
                1677-5449
                1677-7301
                08 May 2020
                2020
                : 19
                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.

                Article
                jvbAR20190070_PT 00311
                10.1590/1677-5449.190070
                8202158

                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.

                Page count
                Figures: 0, Tables: 14, Equations: 0, References: 30
                Categories
                Review Article

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