Surgery-first approach for CLI offers faster wound healing rate than endovascular treatment

Jin Okazaki

A surgical-first strategy appears to be superior to endovascular treatment for critical limb ischaemia (CLI) revascularisation, exhibiting improved wound healing rate and overall healing time, according to data presented by Jin Okazaki (Kitakyushu, Japan) at the Vascular Annual Meeting (VAM; 30 May–3 June, San Diego, USA).

“The ideal goal of revascularisation for CLI patients with ischaemic wounds are the achievement of wound healing and the maintenance of a wound-free state,” Okazaki told the VAM audience. “However, the wound healing process and long-term outcome of ischaemic limbs has not been well studied. The question of what kinds of patients, limbs and wounds have a risk of delayed wound healing still needs to be answered. In addition, there is another question of how a wound-free state can be maintained after healing.”

Okazaki and colleagues designed a retrospective, single-centre study (2009 to 2013) to investigate the risk factors working against wound healing and maintenance of wound-free state, as well as to compare the effectiveness of surgical and endovascular approaches to revascularisation. Patients had peripheral artery disease with ischaemic tissue loss and underwent either surgical or endovascular revascularisation for infrainguinal vessels. The patients treated were followed out to three years.

In total, 394 limbs were treated with an average patient age of 72.6 years, 65% of whom were male. Diabetes was present in 69% of all limbs treated. Patient demographics were well-matched across the endovascular and surgical groups, although the proportion of non-ambulatory patients was higher in the endovascular group (51% vs. 21%, p<0.0001) as was the rate of heel wound (15% vs. 8%, p=0.03).

Of the 364 limbs involved, 194 were treated with an endovascular approach and 170 with a surgery-first approach. The three-year wound healing rate for all patients was 64.2%, for the endovascular group was 53.1%, and for the surgery-first group 77.1% (p<0.0001).

Notable differences in three-year wound healing rate were seen for: patients with (53.4%) and without (79.9%) dialysis-dependent end-stage renal disease (p=0.0002); patients with (41.7%) and without (69.5%) congestive heart failure as defined by left ventricle ejection fraction <40% (p=0.0001); ambulatory patients (76.9%) and non-ambulatory patients (43%) (p=0.0005); and patients with WIfI (wound, ischaemia and foot infection) grade I (82.2%) and grades 2/3 (56.8%) (p<0.0001).

Proportional hazards analysis identified endovascular-first treatment as a risk factor for wound healing time, with a relative risk multivariate value of 2.01 (p<0.0001). WIfI wound of grade 2 or higher was also shown to be a significant risk factor with a relative risk multivariate value of 1.4 (p=0.0163).

The overall mean wound-free period was 713 days, with a surgery-first approach resulting in an extended wound-free period (763.1 days) compared with endovascular treatment (648.7 days) (p=0.0082). The extent of the wound-free period also varied significantly for patients with a history of coronary artery disease (650.3 days) and those without (795.1 days) (p<0.0008); patients with (625.1 days) and without (798.7 days) dialysis-dependent end-stage renal disease (p=0.0001); and ambulatory patients (747.4 days) and non-ambulatory patients (609.5 days) (p=0.0054).

“The type of revascularisation (endovascular or surgery first) and the state of the wound treated (WIfI grade) were associated with delayed wound healing and, therefore, poor wound healing rate,” Okazaki explained. “Systemic factors—such as dialysis dependence, congestive heart failure, and ambulatory status) are not associated with delayed wound healing time, but their limited survival results in poor wound healing rate. Once healed, the maintenance of a wound-free state is influenced by the durability of blood supply and the probability of supply, but not by initial wound status.”

“Compared with initial endovascular treatment, a surgery-first strategy to CLI seems to produce superior results in wound healing rate and overall time,” Okazaki concluded.


  1. Whether intervention is successful depends entirely on the pattern of disease and run-off. If there are occluded arteries in the foot then an endovascular approach is the only possible option as open surgery is not possible. The problem with studying these groups is that there are so many different variables and each patient is quite different making conclusions like this nonsensical.


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