Long-Term Outcome of Patients with Peripheral Arterial Disease and Tissue Loss Stratified to a Nonrevascularization Approach.

ABSTRACT

BACKGROUND: To evaluate the long-term outcome of patients presenting with peripheral artery disease (PAD) and tissue loss that were stratified in our limb preservation program to receive aggressive wound care without revascularization. METHODS: Veterans presenting with PAD and nonhealing wounds were prospectively enrolled into our Prevention of Amputation in Veterans Everywhere (PAVE) program. Patients were stratified according to management strategies, which include revascularization, primary amputation, palliative limb care, and aggressive local wound care without revascularization (conservative group). This study focuses on the conservative cohort. Wound presentation, type of wound care provided, wound care-associated procedures, healing rates, revascularization, major amputation, wound recurrences, management of recurrent wounds, and patient survival were analyzed. RESULTS: Between January 2006 and November 2014, 601 patients were prospectively enrolled in our PAVE program. A total of 203 limbs in 183 patients with 231 wounds were allocated to the conservative group based on a validated pathway of care. Mean follow-up for this cohort was 33.6 months (range, 1.5-104). Complete wound healing was achieved in 148 limbs (73%). The mean time to healing was 4.1 months. Twenty-four limbs (11.8%) received "late revascularization" (beyond 6 months from enrollment). Overall limb preservation was 90% at 4 years, with 57% freedom from wound recurrence. In patients with recurrence over 80% were successfully managed without revascularization. Limb loss was attributed to infection in most cases. CONCLUSIONS: In this selected group, an initial approach with aggressive wound care without revascularization appears justified with good limb salvage. Long-term analysis demonstrated a notable incidence of wound recurrence (43%) albeit most recurrences can be successfully managed without the need for late revascularization and no increased incidence of limb loss.