An observational study of intermittent claudication (IC) practice patterns before and after publication of the Society for Vascular Surgery (SVS) appropriate use criteria (AUC) for IC management points to a series of areas where care has improved, alongside aspects still in need of attention, according to the authors.
The researchers noted improvements in optimal medical therapy (OMT), particularly in the postoperative setting, and patient selection, as well as a decrease in complex aortoiliac and infrapopliteal peripheral vascular interventions (PVIs). However, they reported no changes in medical optimization or bypass practices, and an increase in endovascular common femoral artery (CFA) and infrapopliteal disease interventions, “suggesting that there may be further improvement in this area.”
The data, drawn from the Vascular Quality Initiative (VQI), were presented during the 2024 Eastern Vascular Society annual meeting in Charleston, South Carolina (Sept. 19–22) by Andrea Alonso, MD, a general surgery resident at Boston Medical Center, on behalf of a research team led by Jeffrey Siracuse, MD, an attending vascular surgeon at Boston Medical Center and professor of surgery and radiology at Boston University.
The SVS AUC, published in the Journal of Vascular Surgery (JVS) in April 2022, came amid a significant increase in the number of interventions for claudication over the past couple of decades, despite medical therapy being the first-line treatment for the less advanced form of peripheral arterial disease (PAD).
The research team defined the pre- AUC period as January 2018–December 2019, with the period after the AUC’s publication in JVS set as May 2022– December 2023. The period in between was excluded for matters related to the COVID-19 pandemic.
All patients with claudication who underwent an intervention in the VQI PVI, and suprainguinal and infrainguinal bypass registries were included in the analysis. Alonso informed EVS 2024 that the investigators tried to adhere to as many of the SVS AUC principles as possible, pointing out the exception of exercise therapy, which is not available as part of the VQI. The team primarily looked at complex aortoiliac and femoropopliteal lesions, as well as isolated infrapopliteal lesions.
“When we looked at PVI demographics, we saw that, post-AUC, there was a significant increase in severe disease as an indication for interventions, and that there was a significant increase in optimal medical therapy [OMT] use following the AUC [publication] in the postoperative period,” Alonso told EVS 2024 attendees. “However, we noted that there was no significant change in current smoking or preoperative medical therapy.”
Among significant comorbidities in the patient population, Alonso pointed to an increased number of interventions in patients with coronary artery disease (CAD), but a significant decrease in those on dialysis.
Homing in on interventions in specific anatomic segments, Alonso and colleagues saw that there was a significant decrease in the number of endovascular interventions for complex aortoiliac and femoropopliteal disease, but a notable increase in endovascular treatment for disease in the CFA and isolated infrapopliteal disease.
“With suprainguinal bypass, we didn’t see any significant changes in the use of extra-anatomic revascularization, and, in the infrainguinal bypass registry, we did not see any changes in bypasses, specifically those using prosthetic conduit,” she said.
“An important limitation of this study is that, as it was observational, we were unable to conclude if the changes seen were due to the guidelines or other external factors, and we were unable to evaluate exercise therapy.”
The SVS AUC for IC was the work of a multidisciplinary team of experts who evaluated several unique scenarios for disease in the aortoiliac, CFA and femoropopliteal regions, Alonso pointed out. They looked at several variables, including exercise therapy, OMT use, smoking, medical risk, degree of lifestyle-limiting disease, walking distance, lesion location, endovascular interventions and the type of bypass used.
“The key principles of the AUC are that the first-line treatment [for patients with claudication] is a combination of exercise therapy, medical therapy and smoking cessation, and that interventions may have a benefit if a patient has undergone conservative management and has severe lifestyle-limiting disease, and more short distance walking,” Alonso observed.
As published in JVS, those key AUC principles for the management of IC—by anatomic segment—are as follows: “invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance; in the CFA, open common femoral endarterectomy will provide greater net benefit than endovascular intervention; in the infrapopliteal segment, invasive intervention is of unclear benefit and could be harmful.”
Additionally, Alonso noted from the AUC that, in the aortoiliac region, patients who may have a benefit from invasive interventions for claudication could undergo endovascular treatment primarily, but also inline bypasses in certain scenarios.
Discussion afterward raised the specter of payment and reimbursement. Rabih Chaer, MD, chief of vascular surgery at the University of Pittsburgh in Pittsburgh, Pennsylvania, suggested that guidelines themselves “are not going to change practice patterns, unless this perhaps impacts reimbursements and insurance providers.” He asked Alonso whether she thought this scenario would eventually play out. Alonso agreed that changes in practice would have to come through reimbursement channels, adding that, “to a point, AUCs do affect payment.” According to the AUC for IC paper published in JVS, the Centers for Medicare & Medicaid Services and other payors have taken notice of AUC, primarily for their role in reducing overuse.
