Classification of lower extremity peripheral artery disease
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
When selecting treatment options for lower extremity revascularization the risks of a given intervention relative to the patient’s medical condition must be weighed against the expected improvement in the patient’s clinical condition (eg, pain relief, ulcer healing, maintenance of ambulatory and functional status) and the durability of the intervention in the context of the patient’s life-expectancy . Grading the symptoms of peripheral artery disease and the anatomic lesions responsible for these symptoms provides objective measures by which to follow patients clinically, and, importantly, provides consistency when comparing medical and interventional treatment strategies in clinical studies. For patients who suffer from symptoms related to peripheral artery disease (PAD), impairment and disability may need to be quantified for insurance purposes, or in order to qualify for a disability program.
Classification schemes that are useful in guiding management of peripheral artery disease are reviewed here. The clinical diagnosis and treatment of claudication and critical limb ischemia are discussed elsewhere. (See "Clinical features and diagnosis of lower extremity peripheral artery disease" and "Surgical management of claudication" and "Percutaneous interventional procedures in the patient with lower extremity claudication" and "Treatment of chronic lower extremity critical limb ischemia".)
LOWER EXTREMITY ANATOMY
Knowledge of lower extremity arterial anatomy is important for classifying lower extremity PAD.
The lower extremity is perfused by the common femoral artery (figure 1). The common femoral artery branches into the superficial and deep femoral vessels. The superficial femoral artery runs anteriorly down the thigh between the adductor and quadriceps muscles within the anterior compartment (figure 2). In the distal third of the femur, the superficial femoral artery is in close proximity to the femur. The superficial femoral artery passes through the adductor canal to become the popliteal artery (picture 1) which divides at the level of the tibial tuberosity into the anterior tibial artery and tibioperoneal trunk, which further divides into the posterior tibial and peroneal arteries (picture 2A-B). The anterior tibial artery accompanies the deep peroneal (fibular) nerve along the posterior margin of the tibia (figure 3). The peroneal artery passes adjacent the medial margin of the fibula throughout its course distally. The posterior tibial artery is accompanied by the tibial nerve within the deep posterior compartment.
The collateral circulation in the lower extremity is derived from the deep femoral artery (profunda femoris) (figure 2). Collaterals are poorly developed in younger patients who tend to develop severe acute ischemia with arterial disruption.
- Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5.
- Jaff MR, White CJ, Hiatt WR, et al. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: A supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II): The TASC steering committee. Catheter Cardiovasc Interv 2015; 86:611.
- Antoniou GA, Ibrahim R, Ahmad N, Torella F. Commentary: TASC II Anatomic Classification for Infrapopliteal Arterial Disease: A Framework for Clinical Practice and Future Research. J Endovasc Ther 2015; 22:678.
- Bollinger A, Breddin K, Hess H, et al. Semiquantitative assessment of lower limb atherosclerosis from routine angiographic images. Atherosclerosis 1981; 38:339.
- Bradbury AW, Adam DJ, Bell J, et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A description of the severity and extent of disease using the Bollinger angiogram scoring method and the TransAtlantic Inter-Society Consensus II classification. J Vasc Surg 2010; 51:32S.
- Graziani L, Silvestro A, Bertone V, et al. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg 2007; 33:453.
- Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes Care 2001; 24:1433.
- Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26:517.
- FONTAINE R, KIM M, KIENY R. [Surgical treatment of peripheral circulation disorders]. Helv Chir Acta 1954; 21:499.
- Zhan LX, Branco BC, Armstrong DG, Mills JL Sr. The Society for Vascular Surgery lower extremity threatened limb classification system based on Wound, Ischemia, and foot Infection (WIfI) correlates with risk of major amputation and time to wound healing. J Vasc Surg 2015; 61:939.
- Darling JD, McCallum JC, Soden PA, et al. Predictive ability of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system following infrapopliteal endovascular interventions for critical limb ischemia. J Vasc Surg 2016; 64:616.
- Beropoulis E, Stavroulakis K, Schwindt A, et al. 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; 64:95.
- Cull DL, Manos G, Hartley MC, et al. An early validation of the Society for Vascular Surgery lower extremity threatened limb classification system. J Vasc Surg 2014; 60:1535.
- Mills JL Sr, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 2014; 59:220.
- Armstrong DG, Mills JL. Juggling risk to reduce amputations: The three-ring circus of infection, ischemia and tissue loss-dominant conditions, Wound Medicine 2013; 1:13. http://www.sciencedirect.com/science/article/pii/S2213909513000037.
- Rutherford, RB. Acute limb ischemia: Clinical assessment and standards for reporting. Semin Vasc Surg 1992; 5:4.
- Katzen BT. Clinical diagnosis and prognosis of acute limb ischemia. Rev Cardiovasc Med 2002; 3 Suppl 2:S2.
- Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.
- Spieler EA, Barth PS, Burton JF Jr, et al. Recommendations to guide revision of the Guides to the Evaluation of Permanent Impairment. American Medical Association. JAMA 2000; 283:519.
- Rondinelli, R. Guides to the Evaluation of Permanent Impairment, Sixth Edition, American Medical Association, Chicago 2008.
- Cocchiarella L, Turk MA, Andersson G. Improving the evaluation of permanent impairment. JAMA 2000; 283:532.
- http://www.ssa.gov/disability/professionals/bluebook/4.00-Cardiovascular-Adult.htm (Accessed on October 04, 2011).
- http://www.ssa.gov/disability/professionals/bluebook/1.00-Musculoskeletal-Adult.htm (Accessed on October 04, 2011).
- LOWER EXTREMITY ANATOMY
- ANATOMIC LESION CLASSIFICATIONS
- TASC classification
- - Type A lesions
- - Type B lesions
- - Type C lesions
- - Type D lesions
- Bollinger scoring method
- Graziani morphologic classification
- SYMPTOM CLASSIFICATION
- Chronic extremity ischemia
- - Rutherford
- - Fontaine
- - WIfI (Wound, Ischemia, foot Infection)
- Acute extremity ischemia
- - Viable
- - Marginally-threatened
- - Immediately-threatened
- - Irreversible (nonviable)
- LOWER EXTREMITY IMPAIRMENT
- Class 0
- Class 1
- Class 2
- Class 3
- Class 4
- SUMMARY AND RECOMMENDATIONS