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.
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- 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