Clinical Outcomes Associated with Lower Limb Angiographic Scoring Systems: A Systematic Review

Chronic limb-threatening ischemia is associated with high rates of mortality and limb loss. International guidelines recommend assessing anatomic severity using angiographic scoring systems (Global Limb Anatomic Staging System [GLASS], Trans-Atlantic Inter-Society Consensus [TASC], Bollinger, etc.) before intervention; however, there is a paucity of evidence for their use, and few studies have examined their ability to predict clinical outcomes such as survival and limb salvage (LS).

We performed a systematic review searching Ovid MEDLINE, Embase, and Cochrane Library from 1977 to February 28, 2025. We included all publications on adult infrainguinal angiography evaluated using GLASS, TASC, or Bollinger reporting clinical outcomes. Given the heterogeneity of endpoints and effect measures, we conducted a narrative synthesis.

Eight studies were included: 5 evaluated GLASS, 2 TASC, and one Bollinger. Three GLASS studies in endovascular cohorts suggested worse overall survival (OS), amputation-free survival (AFS), or LS with a higher GLASS stage, while 2 studies found no association. Across bypass cohorts, GLASS stage did not correlate with OS, AFS, or LS. TASC classification showed no consistent association with OS, AFS, or LS. A higher below-knee Bollinger score was associated with reduced OS in a single study.

The evidence suggesting that angiographic scoring systems (GLASS, TASC, and Bollinger) predict clinical outcomes is sparse and of poor quality; the GLASS score may be related to clinical outcomes for those who undergo endovascular intervention, but its utility for bypass remains unclear. Future studies should incorporate inframalleolar disease and collateral circulation and prospectively validate the prognostic performance.