Interactive tool
Convert and interpret
Choose the clinical picture: the converter returns the correspondence between the two systems and the management approach.
How to use it
Instructions
Correspondence table — chronic arterial disease
| Fontaine | Rutherford: grade / category | Clinical picture |
|---|---|---|
| Stage I | Grade 0 · category 0 | Asymptomatic |
| Stage IIa | Grade I · category 1 | Mild claudication (walking distance > 200 m) |
| Stage IIb | Grade I · category 2 | Moderate claudication |
| Stage IIb | Grade I · category 3 | Severe claudication (walking distance < 200 m) |
| Stage III | Grade II · category 4 | Ischaemic rest pain |
| Stage IV | Grade III · category 5 | Minor tissue loss: non-healing ulcer, focal gangrene with diffuse pedal ischaemia |
| Stage IV | Grade III · category 6 | Major tissue loss: extending above the transmetatarsal level, functional foot no longer salvageable |
Rutherford's objective criteria
Rutherford's advantage over Fontaine is the addition of instrumental criteria that make the categories less dependent on the patient's account:
- Category 1: completes the standard treadmill test (2 mph, 12% gradient, 5 minutes); ankle pressure after exercise > 50 mmHg but at least 20 mmHg lower than the resting value.
- Category 2: between categories 1 and 3.
- Category 3: cannot complete the standard treadmill test; ankle pressure after exercise < 50 mmHg.
- Category 4: resting ankle pressure < 40 mmHg; flat or barely pulsatile ankle or metatarsal pulse volume recording (PVR); toe pressure < 30 mmHg.
- Categories 5 and 6: resting ankle pressure < 60 mmHg; flat or barely pulsatile ankle or metatarsal PVR; toe pressure < 40 mmHg.
Rutherford classification of acute limb ischaemia
This is a different classification, which shares only the author's name. It applies to acute arterial occlusion and determines the urgency and type of intervention.
| Category | Sensory loss | Muscle weakness | Arterial Doppler | Venous Doppler | Prognosis |
|---|---|---|---|---|---|
| I — viable | None | None | Audible | Audible | Not immediately threatened |
| IIa — marginally threatened | Minimal (toes) or none | None | Often inaudible | Audible | Salvageable if promptly treated |
| IIb — immediately threatened | More than toes, associated with rest pain | Mild to moderate | Inaudible | Audible | Salvageable with immediate revascularisation |
| III — irreversible | Profound, anaesthetic | Profound paralysis (rigor) | Inaudible | Inaudible | Major tissue loss or permanent nerve damage inevitable |
Category IIa allows preliminary imaging and revascularisation planned within the next few hours; IIb requires immediate revascularisation, without waiting for imaging if this would cause delay. Category III is not an indication for revascularisation: attempting it exposes the patient to reperfusion syndrome, with hyperkalaemia, rhabdomyolysis, acute kidney injury and risk of death. In that case primary amputation is the correct treatment.
Clinical references
Guidelines and interpretation
Management by stage — chronic arterial disease
| Clinical picture | Medical therapy | Revascularisation |
|---|---|---|
| Asymptomatic (Fontaine I, Rutherford 0) | Smoking cessation, high-intensity statin, antiplatelet therapy if PAD is documented, blood pressure and glucose control, physical activity | Not indicated |
| Claudication (Fontaine II, Rutherford 1–3) | Optimal medical therapy + supervised structured exercise programme for at least 3 months: it is first-line treatment and improves walking distance as much as, and sometimes more than, revascularisation | To be considered if disabling limitation persists after 3 months of optimal therapy and the lesion is anatomically favourable |
| Rest pain (Fontaine III, Rutherford 4) | Optimal medical therapy, pain control | Indicated: this is chronic limb-threatening ischaemia |
| Tissue loss (Fontaine IV, Rutherford 5–6) | Medical therapy, wound care, infection control, offloading | Indicated and urgent; stage with WIfI and define the anatomy (GLASS) |
Why WIfI is also used today
Fontaine and Rutherford grade the severity of symptoms, but they do not capture two elements that determine limb prognosis: the extent of the wound and the presence of infection. Two patients who are both “Fontaine IV” may have a superficial ulcer of the great toe and forefoot gangrene with sepsis: prognosis and strategy are not comparable.
For this reason the 2019 Global Vascular Guidelines replaced the notion of “critical limb ischaemia” with chronic limb-threatening ischaemia (CLTI) and adopted the WIfI classification as the staging tool. Fontaine and Rutherford remain useful as a short, widely shared common language, and are still required in most European medical records and registries.
Baseline medical therapy, valid at every stage
- Smoking cessation: the single intervention with the greatest impact on disease progression, patency after revascularisation and mortality.
- High-intensity statin with an LDL cholesterol target < 55 mg/dL (1.4 mmol/L) and a reduction of at least 50% from baseline, according to ESC guidelines.
- Antiplatelet therapy in symptomatic PAD; in patients at high ischaemic risk and low bleeding risk, the combination of rivaroxaban 2.5 mg twice daily with aspirin should be considered (COMPASS and VOYAGER PAD trials).
- Blood pressure and glucose control; in diabetic patients, consider drug classes with proven cardiovascular benefit.
- Structured exercise: in claudication it is a treatment in its own right, not generic advice.
- Foot care: daily inspection, appropriate footwear and early treatment of any lesion, especially in diabetic or neuropathic patients.
Five-year mortality in symptomatic peripheral arterial disease is 20–30%, largely from coronary and cerebrovascular events. Staging the limb should not obscure the fact that the greatest risk for that patient is not amputation but myocardial infarction or stroke.
References
Sources
- Rutherford RB. et al., J Vasc Surg 1997 — Recommended standards for reports dealing with lower extremity ischemia: revised version.
- Fontaine R. et al., Helv Chir Acta 1954 — Die chirurgische Behandlung der peripheren Durchblutungsstörungen.
- ESC 2024 — Guidelines for the management of peripheral arterial and aortic diseases (developed with EACTS).
- Björck M. et al., Eur J Vasc Endovasc Surg 2020 (ESVS) — Clinical practice guidelines on the management of acute limb ischaemia.
- Conte MS. et al., J Vasc Surg 2019 — Global Vascular Guidelines on the management of chronic limb-threatening ischemia.
Quick-reference tool for healthcare professionals. It does not replace the original guidelines, the summaries of product characteristics or the specialist's clinical judgement. All calculations run in the browser: no patient data is transmitted to or stored on any server.