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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1355 Surgical revascularization for claudication most commonly involves the removal of plaque from diseased arteries (endarterectomy) or bypass around narrowed or occluded segments, sometimes performed in combination with endovascular treatments (“hybrid approaches”). Assessment of options for bypass conduit is performed as part of evaluation for surgical revascularization. Factors such as diabetes, poor functional status, frailty, ESKD, and obesity have all been shown to increase the risks of complications for patients undergoing surgical revascularization, and caution is warranted in offering surgical treatment to patients with several of these conditions.52 Recommendation-Specific Supportive Text Revascularization for Claudication: Initial Decision-Making 1 Treatment of claudication can improve health- related QOL as well as pain-free and total walking distance.7–14 Both parameters should be evaluated, when possible, before and after revascularization for claudication. However, given the benefits of the less invasive measures of GDMT and structured exercise, revascularization is a second-tier treatment for most patients with claudication. Patients and clinicians should collaboratively consider the evidence-based, anticipated interventional outcome compared with the existing patient QOL and functional impairment and the natural history of the untreated arterial lesions in a shared decision-making process.46,53 Revascularization strategies should be closely aligned with both short- and longer-term patient-centered goals of care. Revascularization procedures increase the risk of readmission and subsequent MALE, including restenosis and repeat intervention, and risk of ALI; thus, balancing risks and benefits is important.1–3,5,6,45 The following factors should be considered in the shared decision-making process: possibility of symptomatic recurrence; development of more advanced symptoms, including ALI or CLTI; and the finite durability of revascularization procedures with potential need for repeat intervention(s). A specific tool for shared decision-making related to claudication has been developed and published.54,55 2 Ongoing reevaluation and discussions between patients with PAD and clinicians are important to assess response to treatment. For patients who remain functionally limited despite implementation of GDMT and structured exercise, revascularization is the next therapeutic consideration. Revascularization (open and endovascular) has shown effectiveness in mitigation of pain with walking and improving walking distance as well as QOL,7–13 although tradeoffs in durability need to be considered. These improvements are most durable in the larger, inflow arteries of the aortoiliac segment but are also seen in the infrainguinal outflow arterial segments. The addition of SET after revascularization can further improve functional outcomes and walking performance (see Section 6, “Exercise Therapy for PAD”).9 For patients with functionally limiting claudication who have multilevel PAD (ie, aortoiliac and infrainguinal disease), a staged approach to care incorporating revascularization, GDMT (including structured exercise), and reassessment of clinical response during longitudinal follow-up is undertaken. 3. Patients with claudication who have had an adequate response to medical therapies, including structured exercise, and who no longer have significant impairment of functional status and walking performance and QOL, do not require revascularization. Although revascularization may improve symptoms of claudication, it may also be subject to restenosis, recurrence of symptoms, and risk of MALE, including need for additional procedures.1–3,5,45 Patients with claudication should be observed longitudinally for change in symptoms, including worsening functional status or development of signs or symptoms of CLTI, and to ensure maintenance of GDMT (see Section 12, “Longitudinal Follow-Up of PAD”). Revascularization for Claudication: Aortoiliac and Femoropopliteal Disease (Excluding Common Femoral Artery Disease) 4 Multiple RCTs have compared endovascular proce- dures with various combinations of medical treatment with or without supervised or unsupervised exercise programs for patients with aortoiliac and/ or femoropopliteal disease and claudication.7–28 Although these trials have used different endpoints and enrolled patients with anatomic disease distribution at different levels, overall, these studies have shown the effectiveness of revascularization to improve walking performance and QOL in patients with claudication.8,10,23,30 Combining revascularization with either supervised exercise or pharmacotherapy results in greater improvements in these endpoints than exercise or medical therapy alone.9,10,23,24,56 In a network meta-analysis of 37 trials (15 of which included endovascular therapy) that randomized 2983 patients over a mean weighted follow-up of 12 months to best medical therapy, SET, endovascular therapy (12 trials), or endovascular therapy plus SET (8 trials), the combination of endovascular therapy plus SET outperformed other Downloaded from http://ahajournals.org by on October 7, 2026