Evaluating the management of intermittent claudication before and after publication of the Society of Vascular Surgery's Appropriate Use Criteria.

OBJECTIVE

In April 2022, the Society for Vascular Surgery (SVS) published the Appropriate Use Criteria (AUC) for the management of intermittent claudication (IC). Our goal was to compare practice patterns before and after publication of the AUC to identify changes.

METHODS

The Vascular Quality Initiative (VQI) peripheral vascular intervention (PVI) and suprainguinal and infrainguinal bypass registries were analyzed for interventions for IC. Relevant patient and intervention characteristics pre-AUC (2018-2019) and post-AUC (May 2022-December 2023) were compared. Key points of the AUC that are analyzable from the VQI include claudication severity, use of optimal medical therapy (OMT), smoking status, high-risk comorbid conditions (as indicators of operative risk), operative management of complex aortoiliac and femoropopliteal disease (TASC II C/D), common femoral artery (CFA) PVIs, and infrapopliteal procedures.

RESULTS

There were 15,892 PVI, 2352 suprainguinal bypass, and 3480 infrainguinal bypass procedures analyzed. Changes consistent with the appropriateness ratings for PVI included more interventions for severe symptoms (72% vs 66.6%; P < .001), improvement in postoperative OMT (83% vs 79.7%; P < .001), fewer patients on dialysis undergoing PVI (2% vs 2.7%; P < .002), and less interventions on complex (TASC II C/D) aortoiliac (6.3% vs 9.5%; P < .001) and femoropopliteal (4.5% vs 5.8%; P < .001) anatomy. No changes were seen in the rates of preoperative smoking and preoperative OMT use, interventions on octogenarians, or in the use of extra-anatomic suprainguinal bypass, infrapopliteal bypass, or prosthetic conduit. Inconsistent with appropriateness ratings were more patients with congestive heart failure (15.1% vs 12.8%; P < .001) undergoing PVIs, and more PVIs for CFA (5.2% vs 3.4%; P < .001) and isolated infrapopliteal disease (5.7% vs 3.5%; P < .001).

CONCLUSIONS

Since the publication of the AUC, there have been improvements with better OMT on discharge, fewer patients with end-stage renal disease undergoing interventions, and less endovascular treatment of complex disease. However, further work is needed to improve preoperative medical optimization in patients with IC undergoing an invasive intervention and decrease the use of endovascular interventions for CFA and infrapopliteal disease, extra-anatomic aortoiliac revascularizations, and prosthetic conduit use.