RS17 - Wound Care-first Strategies Provide Superior Amputation Free Survival in Patients with Chronic Limb-Threatening Ischemia (CLTI) Wound, Ischemia, and Foot Infection (WIfI) Clinical Stages 1 and 2

Objectives: Accumulating evidence suggests equipoise between conservative-first versus early-revascularization strategies in patients with mild/moderate chronic limb-threatening ischemia (CLTI.) We aim to evaluate the impact on long-term outcomes of conservative first versus early-revascularization in mild/moderate CLTI.

Methods: A ten-year, retrospective two-center analysis of patients with CLTI and WIfI Stage 1 and 2 was conducted. At both centers, the practice is to revascularize anyone with toe pressure (TP) < 30mmHg, but offer those with less severe ischemia a trial of conservative management (wound care, offloading.) Patients were grouped into conservative management first (Group I) versus early revascularization ( < 30 days from presentation, Group II). Group I was subdivided into Group Ia (conservative care only) and Group Ib (>30 days delayed revascularization). Outcomes were wound healing, major limb amputation, amputation-free survival (AFS), and mortality.

Results: During the study period, 1404 patients were treated at two limb salvage centers, of whom 512 (36.5%) with WIfI stage 1 or 2 limbs were analyzed (573 limbs; median age 65 years, IQR 57–74; 60.7% male; median follow up 852 IQR 346, 1415 days), showing similar demographics and comorbidities except for TP (Group I: 32mmHg [IQR 0–50] vs. Group II: 22mmHg [IQR 0–40]; p < .01). Patients in Group II, more likely to have TP < 30mmHg, underwent significantly more endovascular procedures (1.85±1.84 vs. 0.93±1.3; p=.001) and bypasses (0.45 ± 0.59 vs. 0.31 ± 0.49; p < .001). AFS was longer in Group I (2603 vs. 1756 days, p < .001; Figure 1) with a significant difference between Group Ia and Group Ib (1513 vs. 3677 days, p < .001). Cox regression showed Group Ia (HR 0.32, 95% CI 0.21–0.51; p < .001) and Group Ib (HR 0.56, 95% CI 0.36–0.88; p = .012) were protective, while heart failure predicted worse outcomes (HR 2.0, 95% CI 1.4–2.9; p < .001). Among patients with baseline wounds (n=111; n=117 limbs), AFS (1960 vs. 1768 days, p=0.26) and wound healing rates (61.4% vs. 52.9%, p=0.26) were comparable.

Conclusions: This study demonstrates that in WIfI Clinical Stages 1 and 2, early revascularization does not improve AFS or wound healing compared to conservative management with/without delayed revascularization. Patients undergoing conservative care had a 66% reduced hazard for amputation/death compared to those managed with early revascularization. Our data can inform appropriate use decisions for revascularization, future clinical trials, and highlight the value of wound care in low/moderate-risk CLTI.