No disclosures Warren Gasper MD UCSF Vascular Surgery UCSF - - PowerPoint PPT Presentation

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WIfI Staging: Does It Predict Healing?

Warren Gasper MD UCSF Vascular Surgery

4/8/2017 UCSF Vascular Surgery Symposium 2017

No disclosures

2 4/8/2017 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017

Avoiding major amputation: a low bar?

Contemporary natural history studies of patients with CLI who do not undergo revascularization indicate the following:

• 1 year mortality rate: 22% (95% CI 12-33%)
• 1 year amputation rate: 22% (95% CI 2-42%)

However, the 1 year rate of wound worsening was 35% (95% CI 10-62%)

3 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2015;62:1642-51

But are we talking about the same types of wounds?

4 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017

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WIfI Classification System

Ambitious classification system designed to reflect the multi-factorial disease that threatens a limb

5 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2014;59:220-34

WIfI and Amputation

6 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017

WIfI Stage Predicted 1yr Amputation Rate 1 3% 2 8% 3 25% 4 50%

WIfI: amputation rate validation

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Study, year n Overall (%) Stage 1 Stage 2 Stage 3 Stage 4

Predicted Rates ~3% ~8% ~25% ~50% Cull, 2014 158 13% 3% 10% 23% 63% Zhan, 2015 201 21% 8% 64% Beropoulis, 2016 126 ? 2% 3% 12% Causey/UCSF, 2016 168 10% 8% 5% 20% Darling, 2016 551 15% 10% 11% 24% Darling, 2017 992 12% 4% 4% 21% Mathioudakis, 2017 279 6.5% 6% 5% 8% 6% Ward, 2017 98 27% 14% 21% 34%

WIfI and wound healing

Avoiding major amputation depends on healing of the index wound and/or the surgical debridement and minor amputation The WIfI system indirectly addresses wound healing by estimating the likely benefit of revascularization

8 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2014;59:220-34 | Ann Vasc Surg 2016; 36: 190–198 Amputation Amputation

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WIfI, ischemia and wound healing

9 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2015;61:939-44 | J Vasc Surg 2017; in press

WIfI Classification System: wound healing at 1 year

10 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2015;62:1642-51

Study, year n Overall Stage 1 Stage 2 Stage 3 Stage 4

Predicted Rates n/a n/a n/a n/a Cull, 2014 158 79% 92% 78% 65% 38% Darling, 2016 463 37% 100% 42% 39% 30% Zhan, 2015 201 ? ~97% ~97% ~92% ~85% Ramanan/UCSF, 2017 157 55%* 80% 75% 77% 81% Mathioudakis, 2017 279 85% 94% 93% 83% 70%

*complete index wound healing, includes ulcer recurrences

WIfI Classification System: wound healing at 1 year

11 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2015;62:1642-51

Study, year n Overall Stage 1 Stage 2 Stage 3 Stage 4

Cull, 2014 158 79% 92% 78% 65% 38% Darling, 2016 463 37% 100% 42% 39% 30% Zhan, 2015 201 ? ~97% ~97% ~92% ~85% Ramanan/UCSF, 2017 157 55%* 80% 75% 77% 81% Mathioudakis, 2017 279 85% 94% 93% 83% 70%

*complete index wound healing, includes ulcer recurrences

Retrospective +/- Revasc

WIfI Classification System: wound healing time

12 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2015;62:1642-51

Study, year n Overall Stage 1 Stage 2 Stage 3 Stage 4

Zhan, 2015 201 ? 94 days 115 days 163 days 264 days Ramanan/UCSF, 2017 157 116 days 31 days 49 days 130 days 111 days Mathioudakis, 2017 279 124 days 90 days 94 days 125 days 190 days

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WIfI Classification System: wound healing time

13 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2015;62:1642-51

Study, year n Stage 1 Stage 2 Stage 3 Stage 4 Time Revasc Time Revasc Time Revasc Time Revasc

Zhan, 2015 201 94 d ~2% 115 d ~2% 163 d 45% 264 d 37% Ramanan/UCSF, 2017 157 31 d 29% 49 d 75% 130 d 64% 111 d 90% Mathioudakis, 2017 279 90 d 6% 94 d 12% 125 d 17% 190 d 55%

WIfI and wound healing: is lesionology enough?

WIfI classification provides a systematic assessment of the threatened limb

• As expected, revascularization is associated with improved healing times

WIfI classification alone does not provide an assessment of the patient attached to the wound

• High prevalence of diabetes and end stage renal disease in this population

low albumin, elevated inflammatory biomarkers, extensive microvascular disease WIfI classification does not provide an assessment of the providers caring for the patient

• Multi-disciplinary teams reduce the amputation rate and improve care

14 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2015;62:1642-51

Summary

Data available so far indicate that there is a direct correlation between WIfI classification system stage and rate of amputation The correlation between WIfI score and wound healing is not simple

• Revascularization improves the rate of wound healing
• After revascularization, patient and healthcare system factors determine the

time to healing Restaging of WIfI after an intervention may help predict wound healing and recurrence rates

15 WIfI Staging to Predict Wound Healing | UCSF Vascular Symposium 2017 4/8/2017 J Vasc Surg 2015;62:1642-51