Classification Systems for Lower Extremity Occlusive Disease

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The management of lower extremity occlusive disease involves some of the most complex decision making in the field of vascular surgery. Patients with lower extremity occlusive disease often present with a wide spectrum of clinical manifestations ranging from mild intermittent claudication to severe ischemia with gangrene. Moreover, the prognosis and clinical management are dependent on the location and extent of the atherosclerotic disease burden, the presence of comorbid conditions that affect life expectancy and procedural patency, the revascularization options available, and the functional status of the patient. In an effort to bring order to this challenging disease, a number of lower extremity classification systems have been developed. This review discusses challenges of establishing a classification system, anatomic classification systems, classification systems based on presenting symptoms/clinical presentation, morbidity/mortality risk stratification systems, and disability classification systems. Tables outline the Society for Vascular Surgery runoff score, clinical categories of acute limb ischemia, Rutherford clinical categories of chronic limb ischemia, Fontaine clinical stages of chronic limb ischemia, LEGS (Lower Extremity Grading System) score used to recommend invasive treatment for patients with chronic lower extremity ischemia, WIfI (Wound Ischemia foot Infection) classification system grades, consensus estimate of 1 year amputation risk and likelihood of benefit of/requirement for revascularization based on WIfI spectrum score, predicted and observed 1-year outcomes (limb amputation, wound nonhealing) based on WIfI clinical stage classification, morbidity and mortality risk stratification methods, US social security administration disability criteria for patients with lower extremity occlusive disease and amputation, and criteria for rating impairment due to lower extremity peripheral vascular disease. Figures illustrate the TransAtlantic Inter-Society Consensus classification of aortoiliac and femoropopliteal lesions and Graziani System classes of progressive vascular disease severity and distribution in patients with diabetes mellitus presenting with foot wounds. This review contains 3 figures, 11 tables, and 35 references.