Fontaine and Rutherford Classification system

  • Two key classification systems for Peripheral Artery Disease (PAD) are Fontaine’s and Rutherford’s classifications:

    1. Fontaine Classification (1954):

      • Grades patients into four stages based solely on clinical symptoms.
      • Primarily used for research, not routine patient care.
      • Doesn’t incorporate diagnostic tests.
      • Table 1 below summarizes the stages.

    2. Rutherford Classification (1986, revised 1997):

      • Classifies PAD into acute and chronic limb ischemia, considering different treatment approaches for each.
      • Includes objective findings like Doppler, arterial brachial indices (ABI), and pulse volume recordings.
      • While it distinguishes between acute and chronic presentations, it doesn’t impose strict temporal criteria.
      • This classification is widely used in clinical practice for patient management and research.

    3. Assessment in Chronic Limb Pain:

      • Evaluation of chronic limb pain should involve assessing symptoms as per Rutherford’s classification.
      • It’s essential to determine the character and onset of the pain.
      • Claudication onset can be verified through walking/treadmill tests in a noninvasive vascular diagnostic laboratory.
      • Treadmill exercise testing with and without preexercise and postexercise ABIs helps distinguish claudication from pseudoclaudication in patients with exertional leg symptoms.
      • Treadmill exercise testing can also document the extent of symptom limitation in claudication patients.
      • For patients unable to perform treadmill testing, similar stress tests can be done using methods like plantar flexion or thigh blood pressure cuff compression to induce reactive hyperemia
FontineRutherford
StageSymptomsGradeCategoryClinical descriptionObjective Criteria
IAsymptomatic, incomplete blood vessel obstruction00AsymptomaticNormal treadmill or reactive hyperemia test
IIaMild Claudication (Claudication at a distance > 200 m)I1Mild ClaudicationCompletes treadmill exercise; AP (Ankle Pressure) after exercise > 50 mm Hg but at least 20 mm Hg lower than resting value
IIbModerate Severe Claudication (Claudication at a distance < 200 m)2Moderate ClaudicationBetween categories 1 and 3
3Severe ClaudicationCannot complete standard treadmill exercise, and AP after exercise < 50 mm Hg
IIIIschemic Rest Pain (mostly in feet)II4Ischemic Rest PainResting AP < 40 mm Hg, flat or barely pulsatile ankle or metatarsal PVR; (Toe Pressure) TP < 30 mm Hg
III5Minor Tissue Loss (nonhealing ulcer, focal gangrene with diffuse pedal ischemia)Resting AP < 60 mm Hg, ankle or metatarsal PVR flat or barely pulsatile; TP < 40 mm Hg
IVUlceration and Gangrene6Major Tissue Loss (extending above TM level, functional foot no longer salvageable)Same as category 5

Rutherford Classification for Acute Limb Ischemia:

CategoryDescriptionSensory LossMuscle LossArterial Doppler SignalVenous Doppler Signal
ViableNot immediately threatened--++
Marginally threatenedSalvageable with prompt treatmentMinimal (toes) or none--+
Immediately threatenedNeeds immediate treatment to establish revascularizationAssociated rest painMild to moderate-+
IrreversibleMajor tissue loss or permanent
nerve damage inevitable		ProfoundSevere--
  1. Fontaine R, Kim M, Kieny R. Surgical treatment of peripheral circulation disorders [in German] Helv Chir Acta. 1954;21(5–6):499–533. 
  2. Rutherford R B, Flanigan D P, Gupta S K. et al. Suggested standards for reports dealing with lower extremity ischemia. J Vasc Surg. 1986;4(1):80–94.
  3. Hardman, Rulon L et al. “Overview of classification systems in peripheral artery disease.” Seminars in interventional radiology vol. 31,4 (2014): 378-88. doi:10.1055/s-0034-1393976
  4. Aboyans, Victor et al. “2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS).” European heart journal vol. 39,9 (2018): 763-816. doi:10.1093/eurheartj/ehx0951996;348:1329–133
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