Heart and Vessels

, Volume 34, Issue 1, pp 84–94 | Cite as

Impact of infection severity on clinical outcomes in critical limb ischemia with tissue loss after endovascular treatment

  • Kenji MakinoEmail author
  • Keisuke Hirano
  • Norihiro Kobayashi
  • Masahiro Yamawaki
  • Motoharu Araki
  • Yasunari Sakamoto
  • Mori Shinsuke
  • Yoshiaki Ito
Original Article


Critical limb ischemia with infected wounds is known to have a poor prognosis and evaluation of infection severity using the Wound, Ischemia, and foot Infection classification system has been recommended. However, little is known about how infection severity influences the clinical outcomes of critical limb ischemia in patients with tissue loss. We investigated the impact of infection severity on the clinical outcomes in critical limb ischemia with tissue loss after endovascular treatment. In April 2007–August 2014, we enrolled 263 patients (328 limbs) who received endovascular treatment for critical limb ischemia with tissue loss. In the limbs examined, 369 individual wounds existed. We evaluated wound infection using the Infectious Disease Society of America (IDSA) classification. We also investigated wound healing rates at 12 months and limb salvage and major amputation-free survival rates at 2 years after endovascular treatment. Wound healing rates at 12 months for class 0, 1, 2, and 3 were 89, 81, 58, and 33%, respectively (log rank P < 0.001). Limb salvage and major amputation-free survival rates at 2 years were lower in patients with lower vs. higher IDSA classes (classes 0–3: limb salvage rate: 97, 90, 61, and 0%, respectively; P < 0.001; major amputation-free survival: 67, 61, 38, and 0%, respectively; P < 0.001). In Rutherford category 5, only wound healing rates at 12 months and limb salvage and major amputation-free survival rates at 2 years were stratified according to wound infection severity (wound healing rates: 87% in classes 0 and 1 and 65% in classes 2 and 3; P < 0.001; limb salvage rates: 93% in classes 0 and 1 and 69% in classes 0 and 2; P < 0.0001; major amputation-free survival rates: 61% in classes 0 and 1 and 46% in classes 2 and 3; P < 0.001). Wound infection severity affects clinical outcomes of critical limb ischemia with tissue loss, especially in critical limb ischemia with systemic inflammatory response syndrome. In Rutherford category 5, only clinical outcomes of critical limb ischemia were well-stratified according to infection severity. Wound infection affects clinical outcomes of patients with critical limb ischemia with tissue loss.


Infected wounds Ischemia Wound healing Salvage Amputation Systemic inflammatory response syndrome 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no financial relationships or other conflicts of interest relevant to the contents of this paper.


  1. 1.
    Kawarada O, Fujihara M, Higashimori A, Yokoi Y, Honda Y, Fitzgerald PJ (2012) Predictors of adverse clinical outcomes after successful infrapopliteal intervention. Catheter Cardiovasc Interv 80:861–871CrossRefGoogle Scholar
  2. 2.
    Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, Jones DN (1997) Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 26:517–538CrossRefGoogle Scholar
  3. 3.
    Mills JL Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, Andros G, Society for Vascular Surgery Lower Extremity Guidelines Committee (2014) The Society for vascular surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 59:220–234CrossRefGoogle Scholar
  4. 4.
    Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, Deery HG, Embil JM, Joseph WS, Karchmer AW, Pinzur MS, Senneville E (2012) IDSA clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 54:132–173CrossRefGoogle Scholar
  5. 5.
    Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Haris KA, Fowkes FG (2007) Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 45:65–67CrossRefGoogle Scholar
  6. 6.
    Schultz GS, Barillo DJ, Mozingo DW, Chin GA, Wound Bed AdvisoryBoard M (2004) Wound bed preparation and a brief history of TIME. Int Wound J 1:19–32CrossRefGoogle Scholar
  7. 7.
    Soga Y, Iida O, Takahara M, Hirano K, Suzuki K, Kawasaki D, Miyashita Y, Tsuchiya T (2014) Two-year life expectancy in patients with critical limb ischemia. JACC Cardiovasc Interv 7:1444–1449CrossRefGoogle Scholar
  8. 8.
    Kobayashi N, Hirano K, Nakano M, Muramatsu T, Tsukahara R, Ito Y, Ishimori H, Yamasaki M, Araki M, Kato T (2015) Predictors of non-healing in patients with critical limb ischemia and tissue loss following successful endovascular therapy. Catherter Cardiovasc Interv 85:850–858CrossRefGoogle Scholar
  9. 9.
    Armstrong DG, Lavery LA, Harkles LB (1998) Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 21:855–859CrossRefGoogle Scholar
  10. 10.
    Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A, Bakker K, Edmonds M, Holstein P, Jirkovska A, Mauricio D, Ragnarson Tennvall G, Reike H, Spraul M, Uccioli L, Urbancic V, Van Acker K, van Baal J, van Merode F, Schaper N (2007) High prevalence of ischemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 50:18–25CrossRefGoogle Scholar
  11. 11.
    Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L, Urbancic V, Bakker K, Holstein P, Jirkovska A, Piaggesi A, Ragnarson-Tennvall G, Reike H, Spraul M, Van Acker K, Van Baal J, Van Merode F, Ferreira I, Huijberts M (2008) Prediction of outcome in individual with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia 51:747–755CrossRefGoogle Scholar
  12. 12.
    Iida O, Nakamura M, Yamauchi Y, Kawasaki D, Yokoi Y, Yokoi H, Soga Y, Zen K, Hirano K, Suematsu N, Inoue N, Suzuki K, Shintani Y, Miyashita Y, Urasawa K, Kitano I, Yamaoka T, Murakami T, Uesugi M, Tsuchiya T, Shinke T, Oba Y, Ohura N, Hamasaki T, Nanto S, OLIVE Investigators (2013) Endovascular treatment for infrainguinal vessels in patients with critical limb ischemia OLIVE registry, a prospective, multicenter study in Japan with 12-month follow up. Circ Cardiovasc Interv 6:68–76CrossRefGoogle Scholar
  13. 13.
    Iida O, Soga Y, Kawasaki D, Hirano K, Yamaoka T, Suzuki K, Miyashita Y, Yokoi H, Takahara M, Uematsu M (2012) Angiographic restenosis and its clinical impact after infrapopliteal angioplasty. Eur J Vasc Endovasc Surg 44:425–431CrossRefGoogle Scholar
  14. 14.
    Söderstrom M, Aho PS, Lepäntalo M, Albäck A (2009) The influence of the characteristics of ischemic tissue lesions on ulcer healing time after infrainguinal bypass for critical leg ischemia. J Vasc Surg 49:932–937CrossRefGoogle Scholar
  15. 15.
    Iida O, Takahara M, Soga Y, Yamauchi Y, Hirano K, Tazaki J, Yamaoka T, Suematsu N, Suzuki K, Shintani Y, Miyashita Y, Uematsu M (2014) Impact of angiosome-oriented revascularization on clinical outcomes in critical limb ischemia patients without concurrent wound infection and diabetes. J Endovasc Ther 21:607–615CrossRefGoogle Scholar
  16. 16.
    Azuma N, Uchida H, Kokubo T, Koya A, Akasaka N, Sasajima T (2012) Factors influencing wound healing of critical limb ischemia foot after bypass surgery: is the angiosome important in selecting bypass target artery? Eur J Vasc Endovasc Surg 43:322–328CrossRefGoogle Scholar
  17. 17.
    Pomposelli FB Jr, Jepsen SJ, Gibbons GW, Campbell DR, Freeman DV, Miller A (1990) Efficacy of the dorsal pedal bypass for limb salvage in diabetic patients: short-term observations. J Vasc Surg 11:745–751CrossRefGoogle Scholar
  18. 18.
    Fujii M, Armsrong DG, Terashi H (2013) Efficacy of magnetic resonance imaging in diagnosing diabetic foot osteomyelitis in the presence of ischemia. J Foot Ankle Surg 52:717–723CrossRefGoogle Scholar
  19. 19.
    Garcia LA, Rosenfield KR, Metzger CD, Zidar F, Pershad A, Popma JJ, Zaugg M, Jaff MR (2017) SUPERB final 3-year outcomes using interwoven nitinol biomimetic supera stent. Catheter Cardiovasc Interv 89:1259–1267CrossRefGoogle Scholar
  20. 20.
    Liistro F, Porto I, Angioli P, Grotti S, Ricci L, Ducci K, Falsini G, Ventoruzzo G, Turini F, Bellandi G, Bolognese L (2013) Drug-eluting balloon in peripheral intervention for below the knee angioplasty evaluation (DEBATE-BTK): a randomized trial in diabetic patients with critical limb ischemia. Circulation 128:615–621CrossRefGoogle Scholar
  21. 21.
    Roberts D, Niazi K, Miller W, Krishnan P, Gammon R, Schreiber T, Shammas NW, Clair D (2014) Effective endovascular treatment of calcified femoropopliteal disease with directional atherectomy and distal embolic protection: final results of the DEFINITIVE Ca ++ trial. Catheter Cardiovasc Interv 84:236–244CrossRefGoogle Scholar

Copyright information

© Springer Japan KK, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of CardiologySaiseikai Yokohama City Eastern HospitalKanagawaJapan

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