Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization

Abstract

OBJECTIVES: The natural history of limbs affected by ischemic ulceration is poorly understood. In this report, we describe the outcome of limbs with stable chronic leg ulcers and arterial insufficiency that were treated with wound-healing techniques in patients who were not candidates for revascularization. METHODS: A prospectively maintained database of limb ulcers treated at a comprehensive wound center was used to identify patients with arterial insufficiency, defined as an ankle-brachial index (ABI) 2.5 mg/dL), severity of ischemia measured by ABI or toe pressure, wound grade, wound size, and wound location. RESULTS: Between January 1999 and March 2005, 142 patients with 169 limbs having arterial insufficiency and full-thickness ulceration were treated without revascularization. Mean patient age was 70.8 +/- 4.5. Diabetes mellitus was present in 70.4% of limbs and chronic renal insufficiency in 27.8%. Toe amputations or other foot-sparing procedures were performed in 28% of limbs. Overall, limb loss occurred in 37 patients. By life-table analysis, 19% of limbs required amputation 0.5 (P = .01). The only risk factor associated with wound closure was initial wound size (P < .005). CONCLUSIONS: Limb salvage can be achieved in most patients with arterial insufficiency and uncomplicated chronic nonhealing limb ulcers using a program of wound management without revascularization. Healing proceeds slowly, however, requiring more than a year in many cases. Patients with an ABI <0.5 are more likely to require amputation. Interventions designed to improve outcomes in critical limb ischemia should stratify outcomes based on hemodynamic data and should include a comparative control group given the natural history of ischemic ulcers treated in a dedicated wound program