Validation of the Society for Vascular Surgery Appropriate Use Criteria for Management of Intermittent Claudication

OBJECTIVE To perform a multi-institutional retrospective validation of the Society for Vascular Surgery Appropriate Use Criteria (AUC) for management of intermittent claudication (IC). METHODS A retrospective review of patients treated for IC from 2005-2024 was performed across 7 institutions. Inclusion criteria followed AUC assumptions. All treated limbs were rated as appropriate (benefit outweighs risk, B>R), indeterminate (IND) or inappropriate (risk outweighs benefit, R>B) per the original AUC by 2 authors, who resolved discrepancies through discussion. Analysis was performed on the patient level. If one limb was rated as R>B, the patient was rated as R>B. For the purposes of comparison, B>R and IND were grouped together (B>R/IND). RESULTS A total of 372 patients were included. The median follow-up was 1190 days (interquartile range [IQR] 433-2115). Treatment was classified as B>R/IND in 245 patients (66%) and R>B in 127 (34%). More patients in R>B identified as Black (12.7% vs 6.7%) and Hispanic (19.8% vs 9.2%) (p=0.006). Fewer patients in R>B were on optimal medical therapy at the time of evaluation (58.3% vs 75.9%, p<0.01). More patients in R>B had mild or moderate lifestyle limitation (93.7% vs 68.6%, p<0.01) and fewer patients in R>B had exercise therapy prior to revascularization (22% vs 54%, p<0.01). The most affected segments were aortoiliac (30.9%) and femoropopliteal (49.7%). Revascularization was performed in 231 patients (104 B>R/IND and 127 R>B). Of patients who underwent revascularization, 149 underwent unilateral revascularization and 82 underwent bilateral revascularization. Interventions were most often performed in the femoropopliteal (48.1%) and aortoiliac (35.1%) segments. At 2 years from initial consultation with the vascular surgeon, 19% in the R>B group were free from revascularization compared to 57% in the B>R/IND group (p<0.01). Freedom from symptom recurrence at 2 years was lower in the R>B group but did not reach statistical significance (48.9% vs 60%, p=0.07). Freedom from reintervention at 2 years following revascularization was significantly lower in the R>B group (44% vs 72%, p=0.01). A total of 10 major amputations and 11 minor amputations occurred in 17 (4.6%) patients over the study period. Among patients who had mild/moderate lifestyle limitation and were classified as R>B, 15 (11.8%) underwent 9 minor amputations and 10 major amputations. Among patients who had mild or moderate lifestyle limitation and were classified as B>R/IND, no patients underwent any type of amputation. CONCLUSION In this retrospective multi-institutional cohort, patients with IC who were treated inappropriately (R>B) per SVS AUC experienced significantly worse outcomes compared to those who received appropriate/indeterminate (B>R/IND) treatment.