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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1354

9.1 Revascularization for Claudication

Recommendations for Revascularization for Claudication Referenced studies that support the recommendations are summarized in the Online Data Supplement.

COR LOE Recommendations Revascularization for Claudication: Initial Decision-Making

1 B-NR 1 In patients with functionally limiting claudication who

are being considered for revascularization, potential benefits with respect to QOL, walking performance, and overall functional status should be weighed against the risks and durability of intervention and possible need for repeated procedures.1–6

2a B-R 2 In patients with functionally limiting claudication

and an inadequate response to GDMT (including structured exercise), revascularization is a reasonable treatment option to improve walking function and QOL.7–14

3: No Benefit C-EO 3 In patients with claudication who have had an

adequate clinical response to GDMT (including structured exercise), revascularization is not recommended.

Revascularization for Claudication: Aortoiliac Disease and Femoropopliteal Disease (Excluding Common Femoral Artery Disease)

1 A 4 In patients with functionally limiting claudication

and hemodynamically significant aortoiliac or femoropopliteal disease with inadequate response to GDMT (including structured exercise), endovascular revascularization is effective to improve walking performance and QOL.7–28

2a B-NR 5 In patients with functionally limiting claudication

and hemodynamically significant aortoiliac or femoropopliteal disease with inadequate response to GDMT (including structured exercise), surgical revascularization is reasonable if perioperative risk is acceptable and technical factors suggest advantages over endovascular approaches.29–31

Revascularization for Claudication: Common Femoral Artery Disease

2a B-R 6 In patients with functionally limiting claudication

and hemodynamically significant common femoral artery disease with inadequate response to GDMT (including structured exercise), surgical endarterectomy is reasonable, especially if endovascular approaches adversely affect profunda femoris artery pathways.32,33

2b B-R 7 In patients with functionally limiting claudication

and hemodynamically significant common femoral artery disease with inadequate response to GDMT (including structured exercise), endovascular approaches may be considered in those at high risk for surgical revascularization and/or if anatomical factors are favorable (ie, no adverse effect on profunda femoris artery pathways).33–40

Revascularization for Claudication: Infrapopliteal Disease

2b C-LD 8 In patients with functionally limiting claudication and

isolated hemodynamically significant infrapopliteal disease with inadequate response to GDMT (including structured exercise), the effectiveness of endovascular revascularization is unknown.41

2b C-LD 9 In patients with functionally limiting claudication

and isolated hemodynamically significant infrapopliteal disease with inadequate response to GDMT (including structured exercise), the effectiveness of surgical revascularization is unknown.42 Synopsis

Ongoing reevaluation of patients with claudication is important to assess response to treatment (see Section 12, “Longitudinal Follow-Up of PAD”) (Figure 5). Patients with claudication who have had an adequate response to GDMT (see Section 5, “Medical Therapy and Preventive Foot Care for the Patient With PAD”), including structured exercise (see Section 6, “Exercise Therapy for PAD”), and who no longer have significant impairment of functional status, walking performance, and QOL should continue with prescribed therapies and should not undergo revascularization. For those patients with claudication who do not improve with GDMT, revascularization procedures are the next therapeutic option. When revascularization is contemplated, history and physical examination, physiological testing, and imaging studies (see Section 3, “Diagnostic Testing for PAD”) that include anatomic evaluation of disease help inform treatment decisions and planning of revascularization. Revascularization is performed on lesions that are deemed to be hemodynamically significant, and resting or provoked intravascular pressure measurements may be useful when lesion significance is in question.43,44 Revascularization decisions are based on many factors: clinical presentation, including severity of the patient’s symptoms and anticipated natural history; degree of functional limitation and QOL impairment; response to medical therapy, including structured exercise; and the likelihood of a beneficial short- and longer-term outcome, balanced against potential short-term (eg, bleeding, infection, MACE) and longer-term procedural risk.1–3,5,6,23,45 Patient-centered discussions are critical in making appropriate decisions regarding revascularization and for building a trusting longitudinal relationship. More than 70% of patients prefer to have an active role in determining their treatment plan for claudication.46–48 Such discussions should be undertaken when considering whether to undergo a revascularization procedure, its timing, and approach for revascularization (ie, endovascular or surgical), and should take into account the patient’s goals, treatment preferences, and perception of risk. Patient engagement is also essential to facilitate smoking cessation, medication adherence, and participation in structured exercise. Endovascular therapy typically involves the displacement or removal of stenotic or occlusive atherosclerotic disease using catheter-based techniques. Endovascular techniques for claudication include PTA (sometimes referred to as “plain-old balloon angioplasty”); drugcoated balloon angioplasty; bare-metal, drug-eluting, and covered stents; lithotripsy; and atherectomy. Endovascular tools are selected based upon lesion characteristics (eg, anatomic location, lesion length, degree of calcification), operator experience, and the range of available technologies. The appropriateness of particular endovascular therapies for the treatment of claudication is beyond the scope of this document but has been addressed in other multisocietal statements.49–51

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