The Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic/Ischemia/foot Infection (WIfI) to stratify the risk of limb amputation at 1 year. Although intuitive in nature, the new system has not been validated. The purpose of this study was to determine whether the WIfI system is predictive of limb loss/wound healing. Between 2008 and 2010, we prospectively scored 139 patients with foot wounds (158 revascularizations) at the time of the revascularization procedure using a novel wound classification grading system similar to WIfI. The ischemic component of the grading system was obtained immediately postprocedure. Adapting our data to the WIfI classification, the influence of grading system factors on time to wound healing was analyzed. Empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion. Seventy-nine percent (125 of 158) of the foot wounds healed. The median time to wound healing was 4 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). A comparison of observed vs theoretical outcomes is shown in the Table. The theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.Tabled 1Table. One-year outcomes (predicted and observed) of revascularized foot wounds by estimated Wound characteristic/Ischemia/foot Infection (WifI) classificationEstimated WIfI classificationNo.Predicted outcome, %Observed outcome, %Limb lossLimb lossNonhealing woundClass 0-very low risk40∼33 ± 38 ± 4Class 1-low risk63∼810 ± 4%19 ± 5Class 2-moderate risk46∼2523 ± 630 ± 7Class 3-high risk6∼5040 ± 2263 ± 21 Open table in a new tab

Objective: The Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic, Ischemia, and foot Infection (WIfI) to stratify the risk for limb amputation at 1 year. Although intuitive in nature, this new system has not been validated. The purpose of the following study was to determine whether the WIfI system is predictive of limb amputation and wound healing.Methods: Between 2007 and 2010, we prospectively obtained data related to wound characteristics, extent of infection, and degree of postrevascularization ischemia in 139 patients with foot wounds who presented for lower extremity revascularization (158 revascularization procedures). After adapting those data to the WIfI classifications, we analyzed the influence of wound characteristics, extent of infection, and degree of ischemia on time to wound healing; empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion.Results: Of the 158 foot wounds, 125 (79%) healed. The median time to wound healing was 2.7 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). The WIfI clinical stage was predictive of 1-year limb amputation (stage 1, 3%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and wound nonhealing (stage 1, 8%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and correlated with the theoretical outcome estimated by the SVS expert panel.Conclusions: The theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.

We present two cases of ascending aortic pseudoaneurysm exclusion with off-the-shelf aortic stent grafts. The right common carotid artery was used for access to facilitate graft delivery. Control of graft deployment was aided using a compliant right atrial occlusion balloon to lower cardiac output at the time of deployment. Transesophageal echocardiography facilitated the sizing and positioning of the right atrial balloon and was used to survey the heart and ascending aorta on successful exclusion of the pseudoaneurysm. These simple maneuvers made an uncommon procedure straight forward, predictable, and successful.

Traditionally, blunt thoracic aortic injuries (BTAIs) have been regarded as surgical emergencies due to the perceived imminent risk of rupture and death. Due to an observed aortic stability, our group has adopted a policy of planned observation and surveillance for patients with BTAI. The aim of this study was to evaluate the intermediate outcomes of this non-operative, observational strategy. A retrospective analysis of all patients with BTAI was performed at a single institution with a Level I trauma center. Aortic injuries identified by CT scan were classified as pseudoaneurysm (n=13, 76%), intimal injury (n=2, 12%), intra-mural hematoma (n=1, 6%), and localized dissection (n=1, 6%).Each patient was treated with medical anti-impulse therapy (systolic BP< 140mm; heart rate< 90bpm) in a monitored setting. CT scans were obtained at intervals during the in-hospital period and following discharge. Overall intervention-free survival and freedom from rupture was evaluated using Kaplan-Meier life table analysis. A total of 65 patients were identified with BTAI who survived their initial injury and were admitted to our institution. 17 patients were selected for surveillance of their BTAI with serial CT scans for a median follow-up of 22.6 months (range 1 - 128 months) and elective repair when indicated. Two patients (11%) in the observational group received open thoracic aortic repair. Otherwise, there was no significant increase in size of the injured aorta or other aortic associated morbidity during follow-up. The 5 year intervention-free survival and 5 year freedom from rupture was 78% and 100% respectively. Our intermediate outcomes indicate that BTAI in stable patients is not a surgical emergency. Indeed, many patients with BTAI can be spared surgical intervention, and when indicated, can safely undergo elective repair. These findings support a non-operative approach to BTAI and that medical therapy should be the initial management of choice.

Acquired arteriovenous fistulas are historically attributed to penetrating injuries, most commonly to the extremities. However, iatrogenic arteriovenous fistulas are becoming more prevalent. We discuss the case of a patient presenting with an acquired arteriovenous fistula and pseudoaneurysm after a plantar fascia release of the foot.