Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
Division of Vascular Surgery and Endovascular Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA.
J Vasc Surg. 2022 Jul;76(1):3-22.e1. doi: 10.1016/j.jvs.2022.04.012. Epub 2022 Apr 22.
The Society for Vascular Surgery appropriate use criteria (AUC) for the management of intermittent claudication were created using the RAND appropriateness method, a validated and standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process. These criteria serve as a framework on which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition of treatments rated as inappropriate (risk outweighs benefit). Clinical situations will occur in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC requires a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with the best available evidence should determine the treatment strategy. These scenarios require mechanisms to track the treatment decisions and outcomes. AUC should be revisited periodically to ensure that they remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral, and femoropopliteal segments in the round 2 rating. Of these, only nine (0.4%) showed a disagreement using the interpercentile range adjusted for symmetry formula, indicating an exceptionally high degree of consensus among the panelists. Post hoc, the term "inappropriate" was replaced with the phrase "risk outweighs benefit." The term "appropriate" was also replaced with "benefit outweighs risk." The key principles for the management of IC reflected within these AUC are as follows. First, exercise therapy is the preferred initial management strategy for all patients with IC. Second, for patients who have not completed exercise therapy, invasive therapy might provide net a benefit for selected patients with IC who are nonsmokers, are taking optimal medical therapy, are considered to have a low physiologic and technical risk, and who are experiencing severe lifestyle limitations and/or a short walking distance. Third, considering the long-term durability of the currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance. Fourth, in the common femoral segment, open common femoral endarterectomy will provide greater net benefit than endovascular intervention for the treatment of IC. Finally, in the infrapopliteal segment, invasive intervention for the treatment of IC is of unclear benefit and could be harmful.
血管外科学会（SVS）间歇性跛行管理的适宜性使用标准（AUC）是使用 RAND 适宜性方法制定的，这是一种经过验证和标准化的方法，它结合了来自医学文献的最佳可用证据和专家意见，并使用改良的 Delphi 流程。这些标准是个体化患者和临床医生共同决策的基础。这些标准不是绝对的。AUC 不应被解释为管理被评为适宜的治疗方法的要求（收益大于风险）。也不应将 AUC 解释为禁止使用被评为不适宜的治疗方法（风险大于收益）。在某些临床情况下，不包括在这些 AUC 中的调节因素会改变个体患者治疗方法的适宜性水平。正确实施 AUC 需要描述那些调节患者因素。对于不确定评级的情况，临床医生的判断结合最佳可用证据应确定治疗策略。这些情况需要有机制来跟踪治疗决策和结果。应定期审查 AUC，以确保其仍然适用。在第二轮评级中，专家组对 2280 个独特的间歇性跛行（IC）治疗方案进行了评估，涉及腹主动脉、股总动脉和股腘动脉段。其中，只有 9 个（0.4%）使用对称公式调整的百分位区间显示出不一致，这表明专家组之间存在极高的一致性。事后，术语“不适宜”被替换为“风险大于收益”。术语“适宜”也被替换为“收益大于风险”。这些 AUC 中反映的 IC 管理的关键原则如下。首先，运动疗法是所有 IC 患者的首选初始治疗策略。其次，对于未完成运动疗法的患者，对于那些不吸烟、正在接受最佳药物治疗、生理和技术风险较低、且生活方式严重受限和/或行走距离较短的特定 IC 患者，侵入性治疗可能会带来净收益。第三，考虑到目前可用技术的长期耐久性，对于股腘动脉疾病，侵入性干预应保留给生活方式严重受限且行走距离较短的患者。第四，在股总动脉段，开放性股总动脉内膜切除术治疗 IC 的净获益大于血管内介入治疗。最后，在腘动脉段，IC 的侵入性治疗的获益不明确，可能有害。
