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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1376

for detecting significant restenosis.14,19 If issues with revascularization are identified early, prompt reintervention can improve outcomes (eg, patency). To date, limited data show clinical benefits of a duplex ultrasound surveillance program. However, Venermo et al13 created a consensus document from a systematic literature review toward the goal of providing standardized surveillance postrevascularization based on a combination of evidence and authors’ expertise. Multisocietal appropriate use criteria for vascular testing have been published that include criteria for surveillance after endovascular and surgical revascularization.17,20 In 2018, the Society for Vascular Surgery published practice guidelines for follow-up after vascular surgery arterial procedures based on observational studies, committee consensus, and indirect evidence.14 These guidelines address surveillance after endovascular and surgical revascularization and by arterial segment. Clinical evidence to support the use of duplex ultrasound for surveillance after revascularization is most robust for surveillance of infrainguinal autogenous vein bypass grafts, including randomized trials and a metaanalysis with mixed results.18,21,22 However, duplex ultrasound surveillance of prosthetic bypass grafts has not been shown to reliably predict graft failure as it does in vein graft surveillance.23,24 Low flow is often an indicator of an increased risk of graft failure, especially in prosthetic bypass grafts.23 Multiple observational studies have evaluated duplex ultrasound surveillance after endovascular revascularization by anatomic level (ie, aortoiliac, femoropopliteal, infrapopliteal vessels).14,19 The finding of a severe stenosis within a bypass graft or at the site of an endovascular procedure often requires additional intervention and revascularization, especially in the presence of new lower extremity signs or symptoms, but is beyond the scope of this document. 10.	 Telehealth (eg, virtual visits) is an alternative

mode of clinical evaluation and care for patients with PAD, but its usefulness in clinical practice depends on the patient’s clinical presentation and stability of symptoms. Use of telehealth can be appropriate for evaluation and follow-up of patients with subclinical or chronic symptomatic PAD. However, it is of limited use for the evaluation of patients with more severe symptoms, including those with suspected CLTI (including lower extremity wounds) or ALI, in which case an in-person visit is more appropriate. Early observational studies reporting experience with use of telehealth for patients with stable, symptomatic PAD have been published.25–27 A scientific statement on the use of telehealth for cardiovascular care has been published.28 13 EVIDENCE GAPS AND ADVOCACY

PRIORITIES FOR PAD 13.1. Evidence Gaps In performing its evidence review and in developing the present guidelines, the writing committee identified these critical evidence gaps in the field of PAD to which priority should be given for the development and funding of future studies: 1.	 Studies to determine the potential benefit of screening for PAD among asymptomatic, at-risk patients with subsequent implementation of therapies for cardiovascular risk reduction. 2.	 Clinical trials to determine the potential benefit of medical therapies to prevent MACE and MALE among patients with asymptomatic PAD. 3.	 Further clinical trials to determine the optimal antiplatelet and antithrombotic regimen (drug and dose, duration) for patients with PAD who have undergone revascularization procedures. 4.	 Studies of use of telehealth technology to improve access to SET for PAD compared with facilitybased supervised exercise. 5.	 Development of effective new medical therapies to improve functional status in patients with PAD. 6.	 Development of patient-reported metrics of functional status and walking performance for PAD and integration of these metrics in outcome measures of studies of revascularization. 7.	 RCT or registry data analyzing outcomes for patients with chronic symptomatic PAD (claudication and other ischemia-related exertional leg symptoms) treated by exercise therapy, endovascular management, and surgical management with hard outcomes, including MACE and MALE. Further analyses of such data to identify which patients are most likely to benefit from revascularization, to predict the degree of functional response, and to develop evidence-based algorithms for selection of patients for revascularization and determination of modality of revascularization. Such data could be incorporated into future decision aids and other tools for shared decision-making discussions with patients regarding revascularization. 8.	 Expanding the evidence base with comparative effectiveness studies of different endovascular devices (eg, balloon angioplasty, drug-coated balloon angioplasty, atherectomy) for revascularization of PAD. 9.	 Studies investigating the effect of shared decisionmaking strategies in the management of chronic symptomatic PAD and CLTI. 10.	 Studies comparing outcomes of different revas-

cularization strategies for CLTI for optimal wound healing and limb salvage (ie, in-line flow, angiosome, wound blush, etc.).

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