WIfI Classification: the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System, a Literature Review

Overview

Journal J Vasc Bras

Specialty Cardiology & Vascular Diseases

Date 2021 Jun 28

PMID 34178056

Citations 17

Authors

Lorena de Oliveira Cerqueira

Eliud Garcia Duarte

Andre Luis de Souza Barros

Jose Roberto Cerqueira

Walter Junior Boim de Araujo

Affiliations

Soon will be listed here.

Abstract

The Society for Vascular Surgery has proposed a new classification system for the threatened lower limb, based on the three main factors that have an impact on limb amputation risk: Wound (W), Ischemia (I) and foot Infection ("fI") - the WIfI classification. The system also covers diabetic patients, previously excluded from the concept of critical limb ischemia because of their complex clinical condition. The classification's purpose is to provide accurate and early risk stratification for patients with threatened lower limbs; assisting with clinical management, enabling comparison of alternative therapies; and predicting risk of amputation at 1 year and the need for limb revascularization. The objective of this study is to collect together the main points about the WIfI classification that have been discussed in the scientific literature. Most of the studies conducted for validation of this classification system prove its association with factors related to limb salvage, such as amputation rates, amputation-free survival, prediction of reintervention, amputation, and stenosis (RAS) events, and wound healing.

Citing Articles

Predictive Factors of Wound Healing and Limb Salvage After Successful Below-the-Knee Endovascular Angioplasty in Patients with Diabetic Foot Ulcer: A Retrospective Study.

Shin C, Yoo K Medicina (Kaunas). 2025; 61(2).

PMID: 40005394 PMC: 11857322. DOI: 10.3390/medicina61020277.

Evaluation of wound temperature monitoring at various anatomical sites in the management of patients with diabetic foot undergoing microcirculation reconstruction.

Liu H, Yan X, Li G, Wang B, Wang D, Zhang Y J Orthop Surg Res. 2024; 19(1):776.

PMID: 39568046 PMC: 11577819. DOI: 10.1186/s13018-024-05278-7.

What is the agreement between principles and practice of antibiotic stewardship in the management of diabetic foot infection: an in-hospital quality control study.

Reinert N, Wetzel K, Franzeck F, Morgenstern M, Aschwanden M, Wolff T J Bone Jt Infect. 2024; 9(3):183-190.

PMID: 39040989 PMC: 11262018. DOI: 10.5194/jbji-9-183-2024.

Association between tissue loss type and amputation risk among Medicare patients with concomitant diabetes and peripheral arterial disease.

Ponukumati A, Krafcik B, Newton L, Baribeau V, Mao J, Zhou W J Vasc Surg. 2024; 80(5):1543-1552.e12.

PMID: 38880181 PMC: 11493498. DOI: 10.1016/j.jvs.2024.06.019.

Retrospective Evaluation of the Effect of Lumbar Sympathetic Blockade on Pain Scores, Fontaine Classification, and Collateral Perfusion Status in Patients with Lower Extremity Peripheral Arterial Disease.

Keser-Pehlivan C, Kucukbingoz C, Pehlivan U, Balli H, Unlugenc H, Ozbek H Medicina (Kaunas). 2024; 60(5).

PMID: 38792864 PMC: 11123493. DOI: 10.3390/medicina60050682.

References

Conte M, Bradbury A, Kolh P, White J, Dick F, Fitridge R . Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019; 69(6S):3S-125S.e40. PMC: 8365864. DOI: 10.1016/j.jvs.2019.02.016. View

Mills Sr J, Conte M, Armstrong D, Pomposelli F, Schanzer A, Sidawy A . The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2013; 59(1):220-34.e1-2. DOI: 10.1016/j.jvs.2013.08.003. View

Ward R, Dunn J, Clavijo L, Shavelle D, Rowe V, Woo K . Outcomes of Critical Limb Ischemia in an Urban, Safety Net Hospital Population with High WIfI Amputation Scores. Ann Vasc Surg. 2016; 38:84-89. PMC: 5521961. DOI: 10.1016/j.avsg.2016.08.005. View

van Haelst S, Teraa M, Moll F, de Borst G, Verhaar M, Conte M . Prognostic value of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification in patients with no-option chronic limb-threatening ischemia. J Vasc Surg. 2018; 68(4):1104-1113.e1. DOI: 10.1016/j.jvs.2018.02.028. View

Rutherford R, Baker J, Ernst C, Johnston K, Porter J, Ahn S . Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997; 26(3):517-38. DOI: 10.1016/s0741-5214(97)70045-4. View

Rogers L, Andros G, Caporusso J, Harkless L, Mills Sr J, Armstrong D . Toe and flow: essential components and structure of the amputation prevention team. J Vasc Surg. 2010; 52(3 Suppl):23S-27S. DOI: 10.1016/j.jvs.2010.06.004. View

Armstrong D, Cohen K, Courric S, Bharara M, Marston W . Diabetic foot ulcers and vascular insufficiency: our population has changed, but our methods have not. J Diabetes Sci Technol. 2012; 5(6):1591-5. PMC: 3262731. DOI: 10.1177/193229681100500636. View

Hicks C, Canner J, Karagozlu H, Mathioudakis N, Sherman R, Black 3rd J . The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system correlates with cost of care for diabetic foot ulcers treated in a multidisciplinary setting. J Vasc Surg. 2017; 67(5):1455-1462. DOI: 10.1016/j.jvs.2017.08.090. View

Hicks C, Canner J, Mathioudakis N, Sherman R, Malas M, Black 3rd J . The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification independently predicts wound healing in diabetic foot ulcers. J Vasc Surg. 2018; 68(4):1096-1103. DOI: 10.1016/j.jvs.2017.12.079. View

10.

Mathioudakis N, Hicks C, Canner J, Sherman R, Hines K, Lum Y . The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system predicts wound healing but not major amputation in patients with diabetic foot ulcers treated in a multidisciplinary setting. J Vasc Surg. 2017; 65(6):1698-1705.e1. DOI: 10.1016/j.jvs.2016.12.123. View

11.

Mills Sr J . BEST-CLI trial on the homestretch. J Vasc Surg. 2019; 69(2):313-314. DOI: 10.1016/j.jvs.2018.08.156. View

12.

Robinson W, Loretz L, Hanesian C, Flahive J, Bostrom J, Lunig N . Society for Vascular Surgery Wound, Ischemia, foot Infection (WIfI) score correlates with the intensity of multimodal limb treatment and patient-centered outcomes in patients with threatened limbs managed in a limb preservation center. J Vasc Surg. 2017; 66(2):488-498.e2. DOI: 10.1016/j.jvs.2017.01.063. View

13.

Cull D, Manos G, Hartley M, Taylor S, Langan E, Eidt J . An early validation of the Society for Vascular Surgery lower extremity threatened limb classification system. J Vasc Surg. 2014; 60(6):1535-41. DOI: 10.1016/j.jvs.2014.08.107. View

14.

Lipsky B, Berendt A, Cornia P, Pile J, Peters E, Armstrong D . 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012; 54(12):e132-73. DOI: 10.1093/cid/cis346. View

15.

Mills Sr J . The application of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification to stratify amputation risk. J Vasc Surg. 2017; 65(3):591-593. DOI: 10.1016/j.jvs.2016.12.090. View

16.

Mills Sr J . Update and validation of the Society for Vascular Surgery wound, ischemia, and foot infection threatened limb classification system. Semin Vasc Surg. 2015; 27(1):16-22. DOI: 10.1053/j.semvascsurg.2014.12.002. View

17.

Fontaine R, Kim M, KIENY R . [Surgical treatment of peripheral circulation disorders]. Helv Chir Acta. 1954; 21(5-6):499-533. View

18.

Beropoulis E, Stavroulakis K, Schwindt A, Stachmann A, Torsello G, Bisdas T . Validation of the Wound, Ischemia, foot Infection (WIfI) classification system in nondiabetic patients treated by endovascular means for critical limb ischemia. J Vasc Surg. 2016; 64(1):95-103. DOI: 10.1016/j.jvs.2016.01.040. View

19.

Causey M, Ahmed A, Wu B, Gasper W, Reyzelman A, Vartanian S . Society for Vascular Surgery limb stage and patient risk correlate with outcomes in an amputation prevention program. J Vasc Surg. 2016; 63(6):1563-1573.e2. DOI: 10.1016/j.jvs.2016.01.011. View

20.

Wagner Jr F . The dysvascular foot: a system for diagnosis and treatment. Foot Ankle. 1981; 2(2):64-122. DOI: 10.1177/107110078100200202. View