What is the management approach for peripheral arterial disease based on the Rutherford classification (formerly known as Glass classification)?

Management Approach for Peripheral Arterial Disease Based on Rutherford Classification

For patients with peripheral arterial disease (PAD), treatment should be tailored according to the Rutherford classification, with interventions ranging from risk factor modification for milder disease to urgent revascularization for limb-threatening ischemia.

Understanding the Rutherford Classification

The Rutherford classification (formerly known as Glass classification) is a clinical staging system that helps guide management of PAD based on symptom severity:

• Category 0: Asymptomatic
• Category 1: Mild claudication
• Category 2: Moderate claudication
• Category 3: Severe claudication
• Category 4: Ischemic rest pain
• Category 5: Minor tissue loss (ulceration, focal gangrene)
• Category 6: Major tissue loss (extending above transmetatarsal level, functional foot no longer salvageable)

Management Algorithm by Rutherford Category

Asymptomatic PAD (Category 0)

• Risk factor modification including smoking cessation, blood pressure control, and lipid management 1
• Antiplatelet therapy with aspirin or clopidogrel 1
• Regular follow-up with vascular specialist 1
• Surgical or endovascular intervention is NOT indicated in patients with severe decrements in limb perfusion (ABI <0.4) in the absence of clinical symptoms 1

Claudication (Categories 1-3)

• All measures for Category 0 plus:
• Supervised exercise therapy (SET) for at least 3 sessions per week, 30-60 minutes per session, for at least 12 weeks 1
• If SET is unavailable, structured home-based exercise training should be prescribed 1
• Pharmacotherapy with cilostazol (100 mg twice daily) to improve symptoms and increase walking distance 1
• Consider pentoxifylline (400 mg three times daily) as second-line alternative if cilostazol is contraindicated 1

Revascularization for Claudication

Consider revascularization only when ALL the following criteria are met:

• Inadequate response to exercise and pharmacotherapy 1
• Significant disability affecting work or important activities 1
• Favorable risk-benefit ratio 1
• Suitable vascular anatomy 1

For revascularization approach:

• Endovascular intervention is recommended as first-line for TASC type A iliac and femoropopliteal lesions 1
• For combined inflow and outflow disease, address inflow lesions first 1

Critical Limb Ischemia (Categories 4-6)

• Expedited evaluation and treatment 1
• Aggressive risk factor modification 1
• Systemic antibiotics for patients with skin ulcerations and evidence of infection 1
• Referral to specialized wound care for patients with skin breakdown 1

Revascularization for CLI

• For patients with limb-threatening ischemia with life expectancy >2 years and available autogenous vein conduit, bypass surgery is reasonable as initial treatment 1
• For patients with life expectancy ≤2 years without available autogenous vein conduit, balloon angioplasty is reasonable as initial procedure 1
• For acute limb ischemia (Rutherford categories I and IIa) of <14 days duration, catheter-based thrombolysis is indicated 1
• For acute limb ischemia (Rutherford category IIb) of >14 days duration, catheter-based thrombolysis or thrombectomy may be considered 1

Surgical Considerations for CLI

• For infrainguinal disease:
  • Bypasses to popliteal artery should use autogenous saphenous vein when possible 1
  • The most distal artery with continuous flow should be used as origin point for distal bypass 1
  • Tibial or pedal artery providing continuous outflow to foot should be used for distal anastomosis 1

Primary Amputation Considerations

Evaluate for primary amputation if patient has:

• Significant necrosis of weight-bearing portions of foot
• Uncorrectable flexion contracture
• Paresis of extremity
• Refractory ischemic rest pain
• Sepsis
• Very limited life expectancy due to comorbidities 1

Post-Revascularization Care

• All patients should receive antiplatelet therapy indefinitely unless contraindicated 1
• Regular follow-up with vascular specialist at least twice annually 1
• Periodic evaluations to assess for return of symptoms, presence of pulses, and ABI measurements 1

Common Pitfalls and Caveats

• PAD is frequently diagnosed after permanent damage has occurred, resulting in high rates of morbidity and amputation 2
• Fewer than half of individuals with PAD are aware of their condition, while physicians are unaware of PAD in 70% of affected patients 3
• Patients with PAD die mostly from cardiac and cerebrovascular events rather than from lower extremity obstructive disease 4
• Do not delay revascularization for patients with limb-threatening ischemia, as early intervention is essential for optimal outcomes 2
• Avoid endovascular intervention when there is no significant pressure gradient across a stenosis despite flow augmentation with vasodilators 1