The Society for Vascular Surgery (SVS) has issued a comprehensive update to its clinical practice guidelines for the management of intermittent claudication, urging clinicians to prioritize conservative treatment strategies and patient-centered care.
The new guidelines, published in April 2025, reflect the latest evidence on antithrombotic therapy, exercise interventions and revascularization procedures. They replace the SVS’s 2015 recommendations and aim to provide a more nuanced, evidence-based framework for treating patients with intermittent claudication.
“Intermittent claudication is a complex condition that affects millions of people worldwide,” said Michael S. Conte, MD, chair of the guideline writing group and professor of surgery at the University of California, San Francisco. “Our updated recommendations are designed to help clinicians tailor treatment to the individual patient, based on their symptoms, comorbidities, and personal goals.”
Conte will moderate a session at the 2025 Vascular Annual Meeting (VAM) in New Orleans on Friday, June 6 (2–3:30 p.m.) in the Morial Convention Center (Second Floor, Room 228–230) titled Translation of Clinical Guidelines to Practice: A Patient-Centered Approach to Management of Intermittent Claudication, which includes six talks, followed by discussion.
The guidelines reaffirm that first-line treatment for intermittent claudication should focus on education, smoking cessation, risk factor control, optimal medical therapy and structured exercise programs. Revascularization, whether surgical or endovascular, should be reserved for patients with lifestyle-limiting symptoms who do not respond to conservative therapy.
“Too often, patients are rushed into procedures without fully exploring non-invasive options,” said Bernadette Aulivola, MD, a vascular surgeon at Loyola University Chicago, and co-author of the guidelines. “We want to change that narrative.”
The updated guidelines include 12 formal recommendations and two best practice statements. Among them are:
- Dual pathway antithrombotic therapy—combining low-dose rivaroxaban (2.5 mg twice daily) with aspirin—is suggested for patients with intermittent claudication and high-risk comorbidities such as diabetes, heart failure or polyvascular disease, as well as for those who have undergone revascularization. This approach has been shown to reduce the risk of cardiovascular events, though it carries a modest increase in bleeding risk.
- Supervised exercise therapy (SET) is recommended as the gold standard for improving walking performance. Patients should walk at least three times per week for 12 weeks. For those unable or unwilling to participate in SET, structured home-based walking programs are recommended.
- Revascularization should only be considered after conservative measures have failed. Shared decision-making is essential and should include a discussion of potential risks-including mortality, major adverse cardiovascular events and limb complications-as well as expected benefits such as improved mobility and quality of life.
- Infrapopliteal interventions are discouraged in patients with IC due to a lack of evidence supporting their benefit and concerns about potential harm.
- For femoropopliteal lesions longer than 5cm, the use of drug-coated balloons, drug-eluting stents or bare metal stents is recommended over plain balloon angioplasty to reduce the risk of restenosis and reintervention.
The guideline development process included a panel of patient advisors, individuals with lived experience of PAD and claudication. Their input helped shape the recommendations and underscored the importance of clear communication, individualized treatment goals and transparency about the risks and benefits of various therapies.
Patient advisors also called for the development of a “patient-friendly” version of the guidelines and expressed interest in peer support networks where individuals considering treatment could speak with others who have undergone similar procedures.
Despite advances in pharmacotherapy and endovascular technology, the SVS identified several critical gaps in the evidence base. These include a lack of large-scale comparative effectiveness studies, limited data on long-term outcomes following revascularization and insufficient research on the optimal design of home-based exercise programs.
Ultimately, the updated guidelines aim to shift the focus from a one-size-fits-all approach to a more thoughtful, individualized model of care. Clinicians are encouraged to weigh the risks and benefits of each treatment option in the context of the patient’s overall health, preferences and life goals.
