, Amit S. Dayal2, 3, Rie Hirai4, Timothy E. Tanke5 and Robert S. Dieter6
Division of Cardiology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center/Loyola University Chicago, 2160 1st Ave., Maywood, IL 60153, USA
Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
Medicine, Edward Hines Jr. VA Hospital, Hines, IL, USA
Internal Medicine, Loyola University Medical Center, Maywood, IL, USA
Cardiology Department, Bellin Hospital, Green Bay, WI, USA
Medicine, Cardiology, Vascular and Endovascular Medicine, Loyola University Medical Center, Maywood, IL, USA
KeywordsPeripheral artery diseaseAcute and chronic limb ischemiaJENALI classificationAngiosomesRutherfordFontaineTASC II classificationPARC classification and ORC classification
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Joint Endovascular and Noninvasive Assessment of Limb Perfusion (JENALI ) Classification
JENALI scoring system divides each tibial vessel (anterior tibial artery, posterior tibial artery, and peroneal artery) into proximal, mid-, and distal segments . The segment is considered patent and assigned a score of 1 if contrast is visualized within the vessel. If the segment is occluded, it is assigned a score of 0. The segment will be considered patent, so long as there is constant contrast line regardless if it fills through direct antegrade flow or indirect retrograde flow. A maximum score of 9 signifies that all the tibial vessels are patent, and a minimum score of 0 signifies that none of the segment is angiographically patent. The strength of the scoring system lies in its simplicity .
In 1987, Dr. Taylor, the anatomist and plastic surgeon, introduced the angiosome concept, separating the body into distinct three-dimensional blocks of tissue fed by source arteries . Angiosomes of the foot are defined by different branches of the three main arteries (Fig. 3.1) [3, 4]. The anterior tibial artery supplies the anterior ankle which turns into the dorsalis pedis and subsequently supplies the dorsum of the foot. The posterior tibial artery supplies the heel through the calcaneal artery, instep through the medial plantar artery, while the lateral plantar artery supplies the lateral midfoot and forefoot. The peroneal artery breaks off into two segments which are the anterior perforating branch which supplies lateral anterior portion of the ankle and calcaneal branch which supplies the plantar portion of the heel .
Angiosome defined by arterial supply
TransAtlantic Inter-Society Consensus (TASC ) Document II Classification
The foundations for TASC were laid in 2000 in an attempt to discuss how to treat arterial disease . In an attempt to discuss key aspects of diagnosis and management, update the research, and provide more emphasis on management for the population with diabetes, the TASC group reconvened and updated the guideline in 2007 (TASC II system) . TASC II system has graphically presented and thus is more easily and uniformly applied. Classifications of aortoiliac lesions and femoral-popliteal lesions are summarized in Figs. 3.2 and 3.3, respectively.
TASC classification of aortoiliac lesions . CIA common iliac artery, EIA external iliac artery, CFA common femoral artery, AAA abdominal aortic aneurysm. From Norgren et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Journal of Vascular surgery 45:1 Supplement 2007. With permission from Elsevier Science and Technology Journals
TASC classification of femoral-popliteal lesions . CFA common femoral artery, SFA superficial femoral artery. From Norgren et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Journal of Vascular surgery 45:1 Supplement 2007. With permission from Elsevier Science and Technology Journals. For the tibial lesions, the unshaded region is the target stenosis/occlusion. The artery within the shaded rectangle is the associated, “background,” disease. Permission granted from Wiley
Endovascular therapy is the treatment of choice for type A lesions, and surgery is the treatment of choice for type D lesions. Endovascular treatment is the preferred treatment for type B lesions, and surgery is the preferred treatment for good-risk type C lesions. The patient’s comorbidities, the fully informed patient preference, and the local operators’ long-term success rates must be considered when making treatment recommendations for TASC B and C lesions .
Critical limb ischemia (CLI ) is a manifestation of peripheral artery disease that describes patients with typical chronic ischemic pain . The Rutherford and Fontaine symptom classification systems are the most widely used [7, 8]. The walking distance that defines mild, moderate, and severe claudication is not specified in the Rutherford classification but is part of the Fontaine classification.
Category 0: Asymptomatic
Category 1: Mild claudication
Category 2: Moderate Claudication
Category 3: Severe Claudication
Category 4: Rest pain
Category 5: Ischemic ulceration not exceeding ulcer of the digits of the foot
Category 6: Severe ischemic ulcers or frank gangrene
Stage 1: No symptoms
Stage 2: Intermittent claudication subdivided into:
Stage 2a: Claudication at a distance greater than 200 m
Stage 3b: Claudication at a distance less than 200 m
Stage 3: Nocturnal and/or rest pain
Stage 4: Tissue necrosis and/or gangrene in the limb
Wound, Ischemia, and Foot Infection (WIfI ) Classification
Rutherford and Fontaine classifications are based on symptom severity from perfusion. However, perfusion is only one determinant of outcome. Wound extent and the presence and severity of infection also greatly impact the threat to a limb. Therefore, a new classification was implemented by the Society for Vascular Surgery Lower Extremity Guidelines Committee . The estimated risk of amputation of each stage is summarized in Fig. 3.4.
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