title: Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication.
abstract: Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. There are limited Level I data available for many of the critical questions in the field, demonstrating the urgent need for comparative effectiveness research in PAD. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance. Screening for PAD appears of unproven benefit at present. Revascularization for IC is an appropriate therapy for selected patients with disabling symptoms, after a careful risk-benefit analysis. Treatment should be individualized based on comorbid conditions, degree of functional impairment, and anatomic factors. Invasive treatments for IC should provide predictable functional improvements with reasonable durability. A minimum threshold of a >50% likelihood of sustained efficacy for at least 2 years is suggested as a benchmark. Anatomic patency (freedom from restenosis) is considered a prerequisite for sustained efficacy of revascularization in IC. Endovascular approaches are favored for most candidates with aortoiliac disease and for selected patients with femoropopliteal disease in whom anatomic durability is expected to meet this minimum threshold. Conversely, caution is warranted in the use of interventions for IC in anatomic settings where durability is limited (extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff). Surgical bypass may be a preferred strategy in good-risk patients with these disease patterns or in those with prior endovascular failures. Common femoral artery disease should be treated surgically, and saphenous vein is the preferred conduit for infrainguinal bypass grafting. Patients who undergo invasive treatments for IC should be monitored regularly in a surveillance program to record subjective improvements, assess risk factors, optimize compliance with cardioprotective medications, and monitor hemodynamic and patency status.
authors: University of California, San Francisco, San Francisco, Calif. Electronic address: michael.conte@ucsfmedctr.org.
authors: Michael S
authors: MS
authors: Conte
authors: St. Elizabeth's Medical Center, Boston, Mass.
authors: Frank B
authors: FB
authors: Pomposelli
authors: Cleveland Clinic Foundation, Cleveland, Ohio.
authors: Daniel G
authors: DG
authors: Clair
authors: Washington University Medical School, St. Louis, Mo.
authors: Patrick J
authors: PJ
authors: Geraghty
authors: Mount Sinai School of Medicine, New York, NY.
authors: James F
authors: JF
authors: McKinsey
authors: University of Arizona Health Science Center, Tucson, Ariz.
authors: Joseph L
authors: JL
authors: Mills
authors: Oregon Health & Science University, Portland, Ore.
authors: Gregory L
authors: GL
authors: Moneta
authors: Mayo Clinic, Rochester, Minn.
authors: M Hassan
authors: MH
authors: Murad
authors: Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors: Richard J
authors: RJ
authors: Powell
authors: Penn State Hershey College of Medicine, Hershey, Pa.
authors: Amy B
authors: AB
authors: Reed
authors: University of Massachusetts Medical School, Worcester, Mass.
authors: Andres
authors: A
authors: Schanzer
authors: George Washington University, Washington, D.C.
authors: Anton N
authors: AN
authors: Sidawy
mesh_terms: D058070:Asymptomatic Diseases; D057510:Endovascular Procedures / Q000009:adverse effects / Q000592:standards*; D006801:Humans; D007383:Intermittent Claudication / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D035002:Lower Extremity / Q000098:blood supply*; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000592:standards*