For patients with claudication, surgical revascularization is meant to restore quality of life. But a new retrospective study finds that most patients are arriving for that intervention without completing the pre-operative care that guidelines recommend and that the shortfall carries real consequences. The research shows that the gap between partial and complete adherence to guideline-directed care (GDC) translates into a meaningful difference in major adverse limb events (MALE) at two years.
Claudication, defined as exercise-induced leg pain caused by peripheral arterial disease, occupies a distinct clinical category from more urgent limb-threatening conditions. The Society for Vascular Surgery (SVS) recommends that revascularization be reserved for patients with severe, lifestyle-limiting symptoms that persist despite both optimal medical therapy (OMT) and supervised exercise therapy — the two components that together constitute GDC.
“Our aim was to quantify how many claudicants received pre-operative GDC and whether partial and/or complete adherence had any impact on surgical outcomes,” said Richard Shi, MD, who will present the findings during Plenary Session 1 (8:10-9:45 a.m.) at VAM 2026.
Among the 258 claudicants included in the analysis, only 33 patients demonstrated complete adherence to GDC prior to intervention. Another 114 patients met criteria for partial adherence, defined as completion of OMT alone. Supervised exercise therapy had the lowest individual adherence rate of any GDC component. At two years, 76.7% of the overall cohort remained free from MALE.
Kaplan-Meier analysis revealed a clear stratification in outcomes according to adherence level. Claudicants with complete GDC adherence achieved a MALE-free survival of 87.9% at two years, compared with 78.1% among those with partial adherence and 72.1% among non-adherent patients. On multivariable logistic regression, complete GDC adherence and open vascular intervention were both identified as negative predictors of MALE, meaning each was associated with reduced event rates. Partial adherence, however, did not confer a statistically significant protective benefit over non-adherence.
The practical weight of that last finding comes through clearly in the clinical interpretation. “We found that complete adherence to GDC is protective against MALE in claudicants undergoing intervention out to two years post-intervention and that partial adherence to GDC is insufficient in preventing MALE,” said Adam Tanious, MD, senior author on the study.
That distinction carries particular significance given that claudicants are, by definition, an elective surgical population. Shi said incomplete pre-operative preparation appears to offer patients little meaningful protection against post-operative limb-related complications, making the case that going through only part of the recommended process is not a reasonable middle ground.
“Surgical intervention in claudicants is not without risk and vascular surgeons must carefully consider which claudicants are likely to benefit from surgical intervention,” said Shi. “GDC should be a requirement prior to intervention on any claudicant, as this confers a protective benefit to MALE post-operatively.”
The data also expose a notable gap between established guidelines and real-world practice. Fewer than one in seven patients in the cohort fully completed the pre-operative pathway that guidelines recommend and Tanious said that rate of non-compliance warrants broader scrutiny and targeted corrective action. “Our findings call for research to understand national rates of adherence to GDC, as well as quality improvement initiatives aimed at improving patient adherence,” he said.
The study frames pre-operative GDC not as a formality but as a modifiable variable with measurable downstream consequences, one Tanious said clinicians should treat as a meaningful determinant of which patients are truly ready for surgical intervention. “Pre-operative adherence to guideline-directed care is low and must be improved, as it is a critical contributor to major adverse limb events in a patient population undergoing intervention to improve quality of life,” he said.
