The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI)

J Vasc Surg. 2014 Jan;59(1):220-34.e1-2. doi: 10.1016/j.jvs.2013.08.003. Epub 2013 Oct 12.


Critical limb ischemia, first defined in 1982, was intended to delineate a subgroup of patients with a threatened lower extremity primarily because of chronic ischemia. It was the intent of the original authors that patients with diabetes be excluded or analyzed separately. The Fontaine and Rutherford Systems have been used to classify risk of amputation and likelihood of benefit from revascularization by subcategorizing patients into two groups: ischemic rest pain and tissue loss. Due to demographic shifts over the last 40 years, especially a dramatic rise in the incidence of diabetes mellitus and rapidly expanding techniques of revascularization, it has become increasingly difficult to perform meaningful outcomes analysis for patients with threatened limbs using these existing classification systems. Particularly in patients with diabetes, limb threat is part of a broad disease spectrum. Perfusion is only one determinant of outcome; wound extent and the presence and severity of infection also greatly impact the threat to a limb. Therefore, the Society for Vascular Surgery Lower Extremity Guidelines Committee undertook the task of creating a new classification of the threatened lower extremity that reflects these important considerations. We term this new framework, the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System. Risk stratification is based on three major factors that impact amputation risk and clinical management: Wound, Ischemia, and foot Infection (WIfI). The implementation of this classification system is intended to permit more meaningful analysis of outcomes for various forms of therapy in this challenging, but heterogeneous population.

Publication types

  • Practice Guideline

MeSH terms

  • Amputation, Surgical
  • Critical Illness
  • Decision Support Techniques*
  • Diabetic Foot / classification
  • Diabetic Foot / diagnosis
  • Diabetic Foot / etiology
  • Diabetic Foot / therapy
  • Foot Ulcer / classification*
  • Foot Ulcer / diagnosis
  • Foot Ulcer / etiology
  • Foot Ulcer / therapy
  • Humans
  • Ischemia / classification*
  • Ischemia / complications
  • Ischemia / diagnosis
  • Ischemia / therapy
  • Limb Salvage
  • Lower Extremity / blood supply*
  • Predictive Value of Tests
  • Prognosis
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Terminology as Topic*
  • Wound Infection / classification*
  • Wound Infection / diagnosis
  • Wound Infection / etiology
  • Wound Infection / therapy