Rutherford Becker Classification System

What is the Rutherford Becker classification system?

  • This is a classification system for chronic limb ischemia.
  • This Rutherford Becker classification system is based on the clinical and objective criteria
  • 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.

Clinical Categories of Chronic Limb Ischemia (Rutherford Becker Classification System)

00Asymptomatic, not hemodynamically significantNormal treadmill/stress test
I1Mild claudicationCompletes treadmill test, ankle pressure after exercise <25-50 mm Hg less than blood pressure
2Moderate claudicationBetween categories 1 and 3
3Severe claudicationCannot complete treadmill test, ankle pressure after exercise <50 mm Hg
II4Ischemic rest painResting ankle pressure <40 mm Hg, flat or barely pulsatile ankle or metatarsal pulse volume recording, toe pressure <30 mm Hg
5Minor tissue loss: nonhealing ulcer, focal gangrene with diffuse pedal edemaResting ankle pressure <60 mm Hg, flat or barely pulsatile ankle metatarsal pulse volume recording, toe pressure <40 mm Hg
III6Major tissue loss: extending above transmetatarsal level, functional foot no longer salvageableSame as category 5

What is Chronic or Critical limb ischemia?

  • Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease.
  • Critical limb ischemia (CLI) may be considered the most severe pattern of peripheral artery disease (PAD), being associated with a high risk of major amputation, cardiovascular events and death.
  • CLI has a high short-term risk of limb loss and cardiovascular events. Noninvasive or invasive angiography help determine the feasibility and approach to arterial revascularization.
  • A mortality rate of 20% within 6 months after the diagnosis and 50% at 5 years has been reported.
  • Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease.
  • It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels.
  • It is popular in the United States.
  • This excessive mortality may be related to the systemic cardiovascular diseases, including coronary artery disease and cerebrovascular arterial disease. Furthermore, CLI is associated with peripheral complications such as ulceration, gangrene, infection and a high risk of lower limb amputation estimated in 10%–40% of patients at 6 months, especially in non-treatable patients
  • The Rutherford-Becker Classification System helps clinicians determine the appropriate treatment options for peripheral arterial disease, ranging from lifestyle modifications and medical management for milder stages to more invasive interventions such as endovascular procedures or surgery for advanced stages.
  • The classification system provides a framework for assessing the severity of PAD and helps guide decisions regarding the optimal management approach for individual patients.
  • It’s important to note that the Rutherford-Becker Classification is one of several classification systems used in the evaluation and management of peripheral arterial disease.
  • Other classification systems, such as the Fontaine classification, may also be used in different clinical settings.
  • Healthcare professionals, including vascular specialists, will evaluate the patient’s symptoms, clinical presentation, and imaging findings to determine the appropriate classification and treatment plan for each individual.

Symptoms of Critical Limb Ischemia: The hallmark symptom of CLI is severe pain, usually in the feet or toes, even while at rest. This pain is known as “rest pain” and can be excruciating. The pain occurs because the affected tissues are not receiving enough oxygen and nutrients due to the lack of blood flow. Other symptoms may include:

  1. Non-healing Wounds: Ulcers or sores on the legs or feet that do not heal or take an extended time to heal.
  2. Gangrene: Tissue death (gangrene) that may appear as black or darkened areas on the toes, feet, or legs.
  3. Cool Skin: The skin on the affected limb may feel cool to the touch.
  4. Hair and Nail Changes: Decreased hair growth and slow nail growth on the affected limb.
  5. Weak or Absent Pulses: The pulses in the affected limb may be weak or absent.
  6. Pale Skin Color: The skin on the limb may appear pale or bluish.

It’s crucial to seek immediate medical attention if you experience symptoms of critical limb ischemia, as the condition can progress rapidly and lead to severe complications, including tissue loss and the risk of limb amputation. Early diagnosis and intervention are essential to prevent further damage and improve outcomes.

Treatment of Critical Limb Ischemia: The treatment of CLI aims to restore blood flow to the affected limb and alleviate symptoms. Depending on the severity and extent of the disease, treatment options may include:

  1. Medications: Medications may be prescribed to manage risk factors like high blood pressure, cholesterol, and diabetes, which can contribute to the progression of CLI.
  2. Angioplasty and Stenting: These procedures involve using a balloon-like device to open up narrowed or blocked arteries and placing a stent to keep the artery open.
  3. Bypass Surgery: In more severe cases, bypass surgery may be performed to redirect blood flow around the blocked artery.
  4. Endovascular Revascularization: This minimally invasive procedure uses various techniques and devices to improve blood flow.
  5. Amputation: In some cases where limb tissue is severely damaged or infected, amputation may be necessary to prevent life-threatening complications.

The choice of treatment depends on various factors, including the location and extent of arterial blockages, the overall health of the patient, and the presence of other medical conditions. Timely intervention and ongoing management are critical to improving outcomes and preserving limb function in individuals with critical limb ischemia.


  • The Rutherford-Becker Classification System, also known as the Rutherford Classification or the Rutherford System, is a classification system commonly used to assess the severity of peripheral arterial disease (PAD) in the lower extremities. It helps in determining the appropriate treatment approach based on the level of arterial occlusion and the resulting clinical presentation. The classification system takes into account both the anatomical and clinical aspects of PAD.
  • Here is an overview of the Rutherford-Becker Classification System:

Category 0: Asymptomatic

  • No symptoms of PAD are present.

Category 1: Mild claudication

  • Mild discomfort or pain in the leg(s) during physical activity, typically relieved by rest.

Category 2: Moderate claudication

  • Moderate pain or discomfort in the leg(s) during physical activity, limiting the individual’s ability to walk longer distances.

Category 3: Severe claudication

  • Severe pain or discomfort in the leg(s) even at rest, significantly limiting the individual’s ability to walk or engage in physical activity.

Category 4: Ischemic rest pain

  • Constant pain or discomfort in the leg(s) even at rest, indicating reduced blood flow and inadequate tissue perfusion.

Category 5: Minor tissue loss

  • Superficial ulcers or non-healing wounds on the toes or foot, usually associated with poor blood circulation.

Category 6: Major tissue loss

  • Deep ulcers, gangrene, or extensive tissue loss involving the toes, foot, or lower leg, often requiring amputation.

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