Predictors of wound recurrence after wound healing in patients with chronic limb-threatening ischemia

Introduction Patients with chronic limb-threatening ischemia (CLTI) who achieved wound healing after revascularization often suffer wound recurrence. Previous studies reported that the incidence of wound recurrence within three years ranges from 9 to 17%. Some risk factors have been associated with delayed wound healing in CLTI patients. However, there are limited reports investigating the risk factors of wound recurrence. Purpose The aim of this study was to assess the predictors of wound recurrence after wound healing in CLTI patients. Methods This is the sub-analysis from the SAtellite database of Patients with chronic LImb-threateniNG Ischemia (SAPLING registry), a multicenter retrospective observational study. Present study included 1106 limbs with tissue loss in 877 CLTI patients who underwent endovascular therapy (EVT) and achieved wound healing between April 2010 and March 2023. The primary endpoint was wound recurrence after complete wound healing. Cox proportional hazard model was used to analyze the relationship between patient characteristics and the incidence of primary endpoint. Result The prevalence of hypertension, diabetes mellitus and hemodialysis in the study patients were 69.2%, 64.0%, and 45.7%, respectively. The rate of limbs classified into Rutheford class 6 was 20.7%. The rate of freedom from wound recurrence at one and three years after wound healing was 81.9% and 65.6%, respectively. The median time to wound recurrence after initial wound healing was 498 days. Multivariate analysis revealed the time to wound recurrence was independently associated with hemodialysis (hazard ratio [HR]: 1.82; 95% confidence interval [CI]: 1.39-2.37; p<0.001), non-ambulatory status (HR: 1.41; 95% CI: 1.09-1.84; p=0.009), isolated below-the-knee (BTK) legion (HR: 1.50; 95% CI : 1.16-1.94; p=0.002), higher postoperative ankle-brachial index (ABI) (HR: 0.32; 95% CI : 0.09-0.62; p=0.004), and the Global Limb Anatomic Staging System (GLASS) infrapopliteal (IP) grade 4 (HR: 1.49; 95% CI: 1.01-2.20; p=0.006). Patients were categorized into three groups based on the number of these risk factors: low-risk group (0-1 risk factor), moderate-risk group (2-3 risk factors), and high-risk group (4-5 risk factors). The incidence of wound recurrence increased with a higher number of risk factors. Conclusion Hemodialysis, non-ambulatory status, isolated BTK legion, postoperative ABI <0.90, and GLASS IP grade 4 were identified as independent predictors of wound recurrence in CLTI patients. The risk stratification using these factors may contribute to predict wound recurrence.