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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1319

Table 2.  Definitions of PAD Key Terms Term Definition ALI Acute (≤2 wk)32,33 hypoperfusion of the limb that may be characterized by: pain, pallor, pulselessness, poikilothermia, paresthesias, and/or paralysis.

ALI is further classified according to the Rutherford classification system (Table 4).34,35

Anatomic level36 Anatomic subsets to localize disease in the lower extremity. Patients with PAD can have multilevel arterial disease across multiple segments. Aortoiliac—Includes infrarenal abdominal aorta, common iliac, and external and internal iliac arteries.

Femoropopliteal—Includes common femoral, profunda femoris, superficial femoral, and popliteal arteries. Infrapopliteal—Includes tibial-peroneal trunk, anterior tibial artery, posterior tibial artery, peroneal artery, plantar pedal loop,

and pedal vessels (common plantar, medial plantar, and lateral plantar arteries).

Angiosome-based blood flow37 Uninterrupted arterial flow to the anatomic territory of a source artery in the skin and deep tissues. In the context of PAD, the angiosome refers to the skin region and underlying tissue, generally with a wound, supplied by a specific infrapopliteal artery.37 Claudication Fatigue, cramping, aching, pain, or other discomfort of vascular origin in the muscles of the lower extremities that is consistently induced by walking and consistently relieved by rest (usually within approximately 10 min). Claudication that limits functional status is known as functionally limiting claudication. Claudication is recognized as a manifestation of chronic symptomatic PAD (see Section 2.1, “Recognizing Clinical Subsets of PAD”). CLTI A condition characterized by chronic (>2 wk) ischemic rest pain, nonhealing wounds and ulcers, or gangrene attributable to objectively proven arterial occlusive disease.32 Current nomenclature has evolved from the previous commonly used term of CLI to reflect the chronic nature of this condition and its potentially limb-threatening nature with associated risk for amputation and to distinguish it from ALI. Endovascular revascularization Catheter-based revascularization procedures employing modalities such as percutaneous transluminal (balloon) angioplasty, drug-coated balloon angioplasty, stenting (bare-metal, drug-coated, or covered), and atherectomy. Functional status Patient’s ability to meet basic needs, fulfill usual roles, and maintain health and well-being (activities of daily living). Walking ability/performance and mobility are components of functional status. Hybrid revascularization Approach to revascularization that includes endovascular and surgical components either concomitantly or in a staged manner. In-line (pulsatile) blood flow Uninterrupted arterial flow via named infrapopliteal arteries to the foot. Inflow vs outflow Inflow refers to arteries proximal to the superficial femoral artery (aortoiliac, common femoral arteries). Outflow refers to arteries distal to the superficial femoral artery (popliteal and infrapopliteal arteries). MACE Variably defined but usually includes death (all-cause or cardiovascular), MI, acute coronary syndrome (acute MI, unstable angina), and stroke. May also include heart failure, rehospitalization for cardiovascular causes, and other cardiovascular endpoints. MALE Variably defined but usually includes major amputation and endovascular or surgical lower-extremity revascularization (initial or reintervention). May also include ALI.38,39 Multispecialty care team for PAD A team of professionals representing different specialties and disciplines to assist in the evaluation and management of the

patient with PAD and especially CLTI. For the care of patients with CLTI, the care team should include individuals who are skilled in endovascular revascularization,

surgical revascularization, wound-healing therapies and foot surgery, and medical evaluation and care. Table 15 includes the list of multispecialty care team members. Patients and family members collaborate with the multispecialty care team for management of CLTI.

Regions of the foot Forefoot—Extends from the tarsometatarsal joint and incorporates the phalanges, metatarsal, and sesamoid bones.

Midfoot—Begins at the transverse tarsal joint and extends to the tarsometatarsal joint, incorporating the navicular, cuboid,

and cuneiform bones. Hindfoot—Begins at the ankle joint and ends at the transverse tarsal joint, incorporating the calcaneus and talus bones.

Structured community-based exercise program A structured exercise program that takes place in the personal setting of the patient (eg, home, surrounding neighborhood, fitness facility). The program is self-directed with as-needed guidance of health care professionals who prescribe a structured exercise regimen similar to that performed in a supervised program setting. Community-based programs may incorporate behavioral change techniques, delivered by in-person or virtual health coaching or the use of activity monitors. Table 14 provides more detail regarding this form of structured exercise. Structured exercise program An exercise program planned by a qualified health care professional that provides recommendations for exercise training with a goal of improving functional status over time. The program provides individualized recommendations for frequency, intensity, time, and type of exercise. Supervised exercise therapy A supervised, structured exercise program that takes place in a hospital or outpatient facility that is directly supervised by a physician or advanced practice provider and most often implemented by a clinical exercise physiologist or nurse. Table 14 includes more detail regarding this form of structured exercise. Surgical revascularization Surgical procedures that may involve endarterectomy to remove plaque, thrombectomy, or bypass surgery to reconstruct arterial blood flow. Thrombolysis Administration of thrombolytic agents, generally through a catheter placed directly within an area of thrombus in an artery. Tissue loss Minor—Nonhealing ulcer, focal gangrene.

Major—Tissue loss extending above the transmetatarsal level; functional foot no longer salvageable.34

WIfI A clinical staging system for patients with CLTI that incorporates the wound extent, degree of ischemia, and severity of foot infection.15

WIfI class correlates with CLTI outcomes, including time to wound healing, amputation rate, and amputation-free survival.40–43

ALI indicates acute limb ischemia; CLTI, chronic limb-threatening ischemia; MACE, major adverse cardiovascular events; MALE, major adverse limb events; MI, myocardial infarction; PAD, peripheral artery disease; and WIfI, wound, ischemia, foot infection.

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