Clinical Assessment

History of claudication, rest pain, ulceration, or embolic events is essential. In patients with diabetes mellitus, peripheral artery disease (PAD) often presents with atypical symptoms or may be entirely asymptomatic, necessitating a high index of clinical suspicion and regular, comprehensive foot examinations [@acc2025-b]. On examination:

* **Arterial:** pulse deficit, bruits, trophic skin changes.
* **Venous:** varicosities, edema, skin pigmentation, ulceration.
* **Lymphatic:** swelling, non-pitting edema, skin thickening.

For peripheral arterial disease (PAD),PAD, risk-stratify limb threat with Wound, Ischemia, and foot Infection (WIfI) staging (wound, ischemia, infection) and integrate with patient riskrisk, limb severity, and anatomyanatomic pattern (PLAN) to guide revascularization strategy [@conte2019-gvg]. While various angiographic scoring systems are utilized to characterize the anatomic pattern and predict clinical outcomes, their predictive performance and clinical utility remain variable [@lyons2026-clinical].

### 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 can further refine the prediction of incident heart failure (HF), which represents a significant component of long-term cardiovascular morbidity in this population [@reitsma2026-prediction].

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