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Walking impairment questionnaires, assessment of functional and walking capacity Determining walking impairment, capacity, and functional status in all patients with PAD is mandatory (refer to Section 5.2). Assessment of amputation risk In patients with PAD and chronic lower-limb wounds (diabetic foot ulcer, non-healing lower-limb ulceration, or gangrene of ≥2 weeks of duration), even without haemodynamic parameters of critical limb perfusion, the additional presence of comorbidities such as diabetes and/or wound infection may contribute to an increased risk of amputation. The WIfI classification system takes the patients’ limb perfusion, wound size, and the extent of foot infection into account to determine the amputation risk (Table 8).417,444–446 8.1.1.1.2 Imaging methods. Duplex ultrasound is recommended as the first-line imaging method for PAD screening and diagnosis. CTA and/or MRA are recommended as adjuvant imaging. For details refer to Supplementary data online, Section 1.4. Suspicion of PAD Clinical assessment (personal history, physical examination), walking impairment assessment (questionnaire, treadmill), and functional assessment (6MWT, SPPB) Haemodynamic/vascular assessment (ABI, AP, TP, TcPO2, DUS), wound assessment (WIfl) PAD Y Typical symptoms Y N Ischaemic rest pain or gangrene or non-healing chronic wound and critical limb perfusion (AP <50 mmHg, TP <30 mmHg or TcPO2 <30 mmHg) N Masked PAD N Asymptomatic PAD with or without wound N Symptomatic PAD with or without wound Y Chronic limb-threatening ischaemia Other diagnosis Figure 9 Diagnostic algorithm for peripheral arterial disease. 6MWT, six-minute walk test; ABI, ankle–brachial index; AP, ankle pressure; DUS, duplex ultrasound; PAD, peripheral arterial disease; SPPB, short physical performance battery; TcPO2, transcutaneous oxygen pressure; TP, toe pressure; WIfI, Wound, Ischaemia, and foot Infection classification. Downloaded from academic.oup.com/eurheartj/article/45/36/3538/7738955 by guest on 07 October 2026