Clinical Assessment

History of claudication, rest pain, ulceration, or embolic events is essential. On examination:

* **Arterial:** pulse deficit, bruits, trophic skin changes. In patients with diabetes, a comprehensive foot examination is mandatory to identify neuropathy, deformity, and skin integrity issues [@acc2025].[@acc2026].
* **Venous:** varicosities, edema, skin pigmentation, ulceration.
* **Lymphatic:** swelling, non-pitting edema, skin thickening.

For peripheral artery disease (PAD), risk-stratify limb threat with Wound, Ischemia, and foot Infection (WIfI) staging and integrate with patient risk, limb threat, and anatomic pattern (PLAN) to guide revascularization strategy [@conte2019-gvg]. Angiographic scoring systems within the PLAN framework are increasingly utilized to predict clinical outcomes and technical success [@lyons2026].

### Perioperative Cardiac Risk Assessment

Vascular surgery patients have high rates of coronary artery disease. The Revised Cardiac Risk Index (RCRI) helps stratify perioperative major adverse cardiac events (MACE) risk before non-cardiac surgery [@lee1999]. Vascular procedures (especially aortic and lower extremity) are classified as high-risk surgery, contributing 1 point to the RCRI score. In patients with established atherosclerotic cardiovascular disease (ASCVD), the SMART2-HF model may be used to predict the risk of incident heart failure, further refining the clinical profile of the high-risk vascular patient [@reitsma2026].

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