Evaluating the Management of Intermittent Claudication Before and After Publication of the Society of Vascular Surgery’s Appropriate Use Criteria

In April 2022, the Society for Vascular Surgery published the appropriate use criteria (AUC) for the management of intermittent claudication (IC). Our goal was to assess variations in practice patterns after publication of the AUC guidelines to identify changes in clinical practices resulting from these recommendations. The Vascular Quality Initiative (VQI) peripheral vascular intervention (PVI), and suprainguinal, and infrainguinal bypass registries were analyzed for interventions for IC. Relevant patient and intervention characteristics pre-AUC (2018-2019) and post-AUC (May 2022-December 2023) were compared. Key points of the AUC that are analyzable from the VQI include patient medical risk (based off prior published risk calculators), claudication severity, use of optimal medical therapy (OMT), smoking status, and conservative management of complex disease (TASC II C/D), such as avoidance of extra-anatomic suprainguinal bypasses, common femoral artery (CFA) PVI, and infrapopliteal procedures. There were 15,892 PVI, 2352 suprainguinal, and 3480 infrainguinal interventions analyzed (Table). Changes consistent with the recommendations for PVI included more interventions for severe disease (72% vs 66.6%; P < .001), increase in postoperative OMT (83% vs 79.7%; P < .001), fewer patients on dialysis undergoing PVI (2% vs 2.7%; P < .002), and less interventions on complex (TASC II C/D) aortoiliac (6.3% vs 9.5%; P < .001) and femoropopliteal disease (4.5% vs 5.8%; P < .001). No changes were seen in the number of interventions in octogenarians, preoperative current smoking and OMT, or extra-anatomic suprainguinal or infrapopliteal bypass. Inconsistent with AUC guidelines were more patients undergoing PVI with congestive heart failure (15.1% vs 12.8%; P < .001) and more endovascular interventions for CFA (5.2% vs 3.4%; P < .001) and isolated infrapopliteal disease (5.7% vs 3.5%; P < .001). Since the publication of the AUC guidelines for IC, there have been improvements in care including better discharge OMT, fewer patients on dialysis undergoing PVI, and less frequent endovascular treatment of complex disease. However, there is still improvement needed in preoperative medical optimization and smoking cessation, as well as use of endovascular CFA and endovascular and open infrapopliteal revascularization.TablePrimary patient characteristics and interventions for intermittent claudication (IC) pre- and post-appropriate use criteria (AUC)CharacteristicsPre-AUCPost-AUCChange, %P-valuePVI, n ()n = 7969n = 7923Age >80 years1099 (12.0)868 (12.9)7.5.08Severe claudication6108 (66.6)4835 (72.0)8.1< .001Impaired ambulation978 (10.7)5963 (11.2)4.7.28Current smoking3816 (41.6)2732 (40.7)−2.2.26OMT preoperative6359 (69.3)4641 (69.1)−0.3.82OMT postoperative7311 (79.7)5571 (83.0)4.1< .001Endovascular interventions Aortoiliac TASC C/D872 (9.5)424 (6.3)−33.7< .001 CFA313 (3.4)350 (5.2)52.9< .001 Femoropopliteal TASC C/D528 (5.8)302 (4.5)−22.4< .001 Isolated infrapopliteal319 (3.5)381 (5.7)62.9< .001Medical history CHF1171 (12.8)1016 (15.1)18.0< .001 CAD3018 (32.9)2254 (33.6)2.1.38 COPD2597 (28.3)1845 (27.5)−2.8.26 Diabetes3687 (40.2)2648 (39.4)−2.0.35 Obesity3072 (33.5)2177 (32.4)−3.3.17 Dialysis/transplant250 (2.7)131 (2.0)−25.9.002 Creatinine >1.8 mg/dL354 (4.0)277 (4.1)2.5.41Suprainguinal bypassn = 1846n = 506 Impaired ambulation292 (15.8)99 (19.6)24.1.05 Open extra-anatomic681 (36.9)176 (34.8)−5.7.4 Axillary origin178 (9.6)35 (6.9)−28.1.07 Femoral origin503 (27.3)141 (27.9)2.2.78Infrainguinal bypassn = 2699n = 781 Infrapopliteal bypass1906 (70.6)560 (71.7)1.6.6 Non-SSGSV1472 (54.5)458 (58.6)7.5.05CAD, Coronary artery disease; CFA, common femoral artery; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; OMT, optimal medical therapy corresponding to being on an antiplatelet with a statin; PVI, peripheral vascular intervention; SSGSV, single-segment great saphenous vein; TASC C/D, Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease grade C and grade D lesions.Boldface P values indicate statistical significance.Data are presented as number (%).Pre-AUC corresponds to time January 2018 to December 2019, and post-AUC to May 2022 to December 2023. Open table in a new tab