Unfortunately, survival in these patients is poor, particularly in the patients with the lowest toe pressures less than 10 mm Hg, in whom only 8% of patients achieved amputation-free survival at 3 years. 33 If the toe pressure was 20 to 50 mm Hg, 85% of patients were able to achieve limb salvage with wound management using standard multispecialty wound protocols, compared with only 60% in those with a toe pressure less than 20 mm Hg. In another study of non-revascularized patients with CLI and wounds, limbs were separated into groups based on the toe pressure in the affected limb. Risk factor analyses revealed that the ankle-brachial index (ABI) and wound grade were associated with amputation at 1 year. 32 At 1-year follow-up, 52% of limb ulcers were healed, and 23% required amputation ( Fig. The natural history of chronic wounds with AI that do not receive revascularization was reported in a study of 169 limbs. The WIfI classification system (see the section on Wound Classification later) was designed to capture the severity of wound tissue damage, arterial insufficiency, and infection as an aid to prediction of healing potential. 115.2) may not require the same level of perfusion as a deep, complicated leg ulcer involving tendon or bone ( Fig. It appears clear that the severity of the wound itself is important, such that a superficial partial-thickness wound ( Fig. 29,30 However, the hemodynamic criteria for CLI are broad and further evaluation of the specific level of perfusion to the wound bed is needed to predict which patients have a good chance of healing without revascularization. Data from several clinical trials studying CLI have identified a risk of major amputation in 25% to 40% of patients at 1 year if revascularization is not performed. The treatment of patients with chronic nonhealing leg ulcers associated with arterial insufficiency involves a critical assessment of the patient's suitability for invasive procedures and the potential risk of limb loss based on ulcer characteristics.
Sidawy MD, MPH, in Rutherford's Vascular Surgery and Endovascular Therapy, 2019 Limb Ulcers Associated With Arterial Insufficiency