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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1356

treatment modalities with respect to walking performance and QOL.57 Symptom improvement after endovascular treatment for claudication is related to vessel patency, and long-term patency is greater in the aortoiliac than in the femoropopliteal segment.58 Furthermore, factors associated with lower vessel patency include longer lesion length, occlusion rather than stenosis, the presence of multiple and diffuse lesions, poor-quality runoff, diabetes, CKD, renal failure, and smoking.59–62 The CLEVER (Claudication: Exercise Versus Endoluminal Revascularization) trial, which enrolled patients with aortoiliac disease and compared endovascular therapy with SET and with medications alone, showed that endovascular therapy and supervised exercise had improved walking time compared with medication alone at 6 months.11,12 Other RCTs that included patients with aortoiliac disease have shown improvement in QOL, as assessed by questionnaires and time to onset of claudication, may be superior with endovascular treatment in combination with a medical and exercise treatment plan, compared with medical treatment alone.7,8,15 The ERASE (Endovascular Revascularization And Supervised Exercise) trial randomized patients with claudication and aortoiliac and femoropopliteal disease to endovascular revascularization plus supervised exercise or supervised exercise alone.9 After 1 year, patients in both groups had significant improvements in walking distances and health-related QOL, with greater improvements in the combined-therapy group.9 The long-term comparative effectiveness of (1) endovascular revascularization versus SET and (2) medical therapy versus SET and medical therapy without revascularization for aortoiliac disease is unknown. Multiple RCTs have shown short-term efficacy

of endovascular treatment of femoropopliteal disease for claudication versus SET or medical therapy, with benefit that diminishes by 1 year after the procedure.7,13–20,22,27 Two separate systematic reviews including RCTs that enrolled patients with femoropopliteal disease reported that endovascular treatment of claudication improved walking performance and QOL.8,10,29 When considering revascularization for a patient with functionally limiting claudication with aortoiliac disease, femoropopliteal disease, or both despite GDMT and structured exercise, data regarding risk of restenosis, durability, and repeat interventions, as well as outcomes, may inform discussions about endovascular revascularization. 5.	 Systematic reviews have concluded that surgical

revascularization procedures are an effective treatment for claudication involving both the aortoiliac and femoropopliteal segments and have a positive impact on QOL and walking parameters, but evidence data are sparse comparing surgery with other treatments.8,29–31,63 Selection of a revascularization approach is therefore individualized on the basis of the patient’s goals, anatomic findings, perioperative risk, and anticipated benefit. Surgical procedures for claudication are usually reserved for the following individuals: those who did not derive adequate benefit from nonsurgical therapy; those who have arterial anatomy favorable to obtaining a durable result with surgery; and those who have acceptable risk of perioperative adverse events. Acceptable risk is defined by the individual patient and provider based on symptom severity, comorbid conditions, and appropriate risk evaluation. Assessment of risk of perioperative MACE after surgical revascularization is an important consideration in determining revascularization strategy. Clinical practice guidelines for the evaluation and management of patients undergoing noncardiac surgery, including vascular surgical procedures, have been previously published.64

Revascularization for Claudication: Common Femoral Artery Disease

6 Although no randomized trials have compared

common femoral endarterectomy to medical therapy alone, endarterectomy has been performed in this anatomic location for many years with durable results.32,33 In a report of 713 patients observed for 7 years after common femoral endarterectomy, excellent patency rates were observed.32 However, common femoral endarterectomy is associated with potential for short-term morbidity.32,65 In an analysis of data from the National Surgical Quality Improvement Project database of 1513 patients who underwent common femoral endarterectomy, a minor or major complication occurred in 7.9% of patients.65 In their series of >700 patients, Wieker et al32 reported perioperative complications including wound infection (3.4%), lymphatic fistula (3.4%), and need for procedure-related local revision (8.6%). However, in this same series, primary patency was 78.5% at 7 years, suggesting that common femoral endarterectomy is a highly durable procedure.32 7.	 Meta-analytic data, including 2 RCTs of 197

patients, have demonstrated similar risk of 30-day mortality and early reintervention, less procedural morbidity, similar 1-year primary patency, and similar need for late reintervention when comparing common femoral endovascular interventions with surgical endarterectomy.33–35,38,66 Nevertheless, in observational studies, outcomes for endovascular

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