Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia
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Updated: Aug 11, 2025
High-Resolution Three-Dimensional Imaging of the Footpad Vasculature in a Murine Hindlimb Gangrene Model
Published on: March 16, 2022
Justin Chin-Bong Choi1,2, Jorge Miranda1, Erin Greenleaf1,2
1Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.
Insights
Noninvasive tests show promise in detecting peripheral artery disease (PAD) for threatened limbs. Improved testing strategies are needed to accurately diagnose chronic limb-threatening ischemia (CLTI).
Area of Science:
- Vascular Surgery
- Diagnostic Imaging
- Peripheral Artery Disease
Background:
- The Society for Vascular Surgery Threatened Limb Classification System (WIfI) aids in predicting limb loss and identifying peripheral artery disease (PAD) in patients with foot ulcers or gangrene.
- Chronic limb-threatening ischemia (CLTI) requires accurate identification for timely intervention.
Purpose of the Study:
- To estimate the diagnostic sensitivity of various clinical and noninvasive arterial parameters for identifying CLTI.
- To evaluate the effectiveness of different noninvasive measures in conjunction with the Global Limb Anatomic Staging System (GLASS).
Main Methods:
- A single-center review of 100 patients undergoing angiography for foot ulcers or gangrene.
- Assessment of WIfI stages/grades, toe-brachial index (TBI), ankle-brachial index (ABI), and brachial pressure measurements.
- Quantification of medial artery calcification on foot radiographs and characterization of CLTI severity using GLASS stages and angiosomes.
Main Results:
- Toe-brachial index < 0.7 and ankle-brachial index < 0.9 demonstrated high sensitivity (97.8% and 91.5%) for identifying severe GLASS findings (II and III).
- Noninvasive measures achieved diagnostic accuracy rates of 74.7% for GLASS II/III and 89.3% for GLASS I+.
- Medial artery calcification significantly reduced the sensitivity of most noninvasive parameters.
Conclusions:
- Alternative noninvasive arterial testing parameters can enhance the sensitivity for detecting PAD.
- Abnormal noninvasive results warrant further investigation with diagnostic angiography to detail arterial anatomy.
- There is a need for improved noninvasive testing strategies with higher diagnostic accuracy for CLTI.
Introduction:
The Society for Vascular Surgery Threatened Limb Classification System ('WIfI') is used to predict risk of limb loss and identify peripheral artery disease in patients with foot ulcers or gangrene. We estimated the diagnostic sensitivity of multiple clinical and noninvasive arterial parameters to identify chronic limb-threatening ischemia (CLTI).
Methods:
We performed a single-center review of 100 consecutive patients who underwent angiography for foot gangrene or ulcers. WIfI stages and grades were determined for each patient. Toe, ankle, and brachial pressure measurements were performed by registered vascular technologists. CLTI severity was characterized using Global Limb Anatomic Staging System (GLASS stages) and angiosomes. Medial artery calcification in the foot was quantified on foot radiographs.
Results:
GLASS NA (not applicable), I, II, and III angiographic findings were seen in 21, 21, 23, and 35 patients, respectively. A toe-brachial index < 0.7 and minimum ipsilateral ankle-brachial index < 0.9 performed well in identifying GLASS II and III angiographic findings, with sensitivity rates 97.8% and 91.5%, respectively. The diagnostic accuracy rates of noninvasive measures peaked at 74.7% and 89.3% for identifying GLASS II/III and GLASS I+ angiographic findings, respectively. The presence of medial artery calcification significantly diminished the sensitivity of most noninvasive parameters.
Conclusions:
The use of alternative noninvasive arterial testing parameters improves sensitivity for detecting PAD. Abnormal noninvasive results should suggest the need for diagnostic angiography to further characterize arterial anatomy of the affected limb. Testing strategies with better accuracy are needed.
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