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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1352

sessions have been used as the control arms of RCTs that have studied SET and various structured community-based exercise programs but have not shown any consistent benefit on outcomes.10–12,28 Thus, the usefulness of unstructured exercise for patients with chronic symptomatic PAD to improve walking performance, functional status, and QOL is uncertain, and providing access to structured exercise is a core component of care for these patients.

7 REVASCULARIZATION FOR

ASYMPTOMATIC PAD

The management of the patient with PAD without reported symptoms (asymptomatic PAD) focuses on GDMT (see Section 5, “Medical Therapy and Preventive Foot Care for the Patient With PAD”) (Figure 4). Occasionally, surgical or endovascular revascularization procedures are performed in asymptomatic patients to support other invasive clinically necessary procedures.

Recommendations for Revascularization for Asymptomatic PAD Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

2a B-NR 1 In patients with asymptomatic PAD, it is reasonable

to perform revascularization procedures (endovascular or surgical) to reconstruct diseased arteries if needed for the safety, feasibility, or effectiveness of other procedures (eg, transfemoral aortic valve replacement, mechanical circulatory support, endovascular aortic aneurysm repair).1–8

3: Harm B-NR 2.	 In patients with asymptomatic PAD,

revascularization procedures (endovascular or surgical) should not be performed solely to prevent progression of disease.9–16

Synopsis Patients with PAD may be asymptomatic despite having a significant burden of arterial lesions (stenoses, occlusions, or both). Here, we focus on patients with known arterial lesions who have no leg symptoms (asymptomatic PAD, see Section 2, “Clinical Assessment for PAD”). Although patients with asymptomatic PAD may have functional impairment compared with those without PAD, revascularization procedures are rarely indicated, particularly given the increased risk of MALE after revascularization, including the need for future procedures.

Recommendation-Specific Supportive Text

1 In patients with PAD, endovascular or surgical revas-

cularization procedures can be performed to reconstruct diseased arteries if needed to facilitate other clinically necessary procedures, including catheterbased cardiac or vascular procedures (eg, transfemoral aortic valve replacement, mechanical circulatory support, endovascular abdominal aortic aneurysm repair). This has been accomplished through conduit placement (eg, iliac artery conduit that is turned into an iliofemoral bypass at the end of the procedure), endovascular stenting to create an endoconduit,1 or other ancillary techniques that facilitate the safety of sheath insertion and removal.2,3 The Society for Cardiovascular Angiography and Interventions has published recommendations regarding specific clinical scenarios.4,5 There are also alternative access approaches for these procedures that can be used in patients with challenging anatomy due to obstructive PAD lesions,6,7 but alternative access can be associated with an increased risk of vascular complications.8

2 Some patients with asymptomatic PAD can progress

to symptomatic disease during longitudinal follow-up, emphasizing the need for longitudinal care of these patients (see Section 12, “Longitudinal Follow-Up of PAD”).17 However, no data suggest that invasive treatment while PAD is asymptomatic will alter its natural history. Data have shown that patients who have undergone a revascularization procedure are at increased risk of subsequent complications, particularly MALE, including the need for additional subsequent revascularization procedures.9–16 Consequently, the risk-benefit assessment of revascularization in a patient with asymptomatic PAD argues against revascularization in this setting. Therefore, no evidence supports a recommendation for early revascularization for asymptomatic individuals.

8 REVASCULARIZATION TECHNIQUES

AND REGISTRIES FOR CHRONIC SYMPTOMATIC PAD AND CLTI

Revascularization procedures have been studied extensively for patients with PAD and are generally offered to treat symptoms of claudication or the more severe PAD presentations of CLTI and ALI. In the sections that follow, we provide recommendations for the range of these revascularization procedures for chronic symptomatic PAD (claudication) and CLTI, along with therapies that are used adjunctively with revascularization in the setting of CLTI. Although recommendations addressing endovascular and surgical revascularization are provided, this document does not address specific technical aspects of revascularization, including choice of devices for endovascular treatment of specific lesions. Metaanalyses and appropriate use documents addressing specific technical scenarios have been published.1–3 Data registries, including the VQI (Vascular Quality Initiative), NCDR (National Cardiovascular Data Registry), PVI (Peripheral Vascular Intervention) Registry (now incorporated into the VQI), and the Society of Interventional Radiology VIRTEX Registry, have been developed

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