Revascularization for Intermittent Claudication—Which Bridge to Cross

In this Vascular Quality Initiative (VQI) study of patients with claudication undergoing infrainguinal revascularization, Bellomo et al 1 reported that endovascular therapy was associated with a lower risk of major amputation at 1 year compared with surgical bypass.Multiple prior studies have shown that in the short term, peripheral vascular intervention (PVI) with endovascular therapy in patients with claudication is associated with reduced rates of major cardiovascular events, shorter hospital stays, and an earlier return to baseline function. 2For instance, a systematic review 3 reported that endovascular therapy plus supervised exercise therapy was found to be superior to supervised exercise therapy alone, and results like these, coupled with improving technical success rates and an attenuated procedural risk profile, underscore the current trend toward an endovascular-first treatment approach in patients with claudication.In the Medicare population, early PVI after diagnosis of claudication was associated with higher later PVI rates compared with early nonoperative management (ie, early intervention begets more future interventions), with concerns raised that intervention for claudication may actually hasten disease progression to chronic limbthreatening ischemia (CLTI). 4Paired with the finding that physicians with high use of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high-reimbursement settings, in 2022, the Society for Vascular Surgery launched a committee to generate appropriate use criteria for the management of intermittent claudication.One goal was to provide a solid evidence base for Centers for Medicare & Medicaid Services to realign reimbursement incentives and encourage guideline-concordant care. 5To this end, the Society for Vascular Surgery VQI database will be instrumental in evaluating whether guideline-concordant care truly promotes symptom alleviation while warding off disease progression in patients with claudication.Commonly taught in basic vascular surgery training are the principles of inflow, outflow, and conduit.Basic bypass training has also included in the syllabus that synthetic graft is the conduit of choice in femoral to above-knee popliteal bypasses.This dogma was countered in another contemporary VQI study evaluating conduit use in femoral to popliteal bypasses, in which two-thirds of above-knee popliteal bypasses and one-third of below-knee popliteal bypasses used polytetrafluoroethylene as conduit.While use of great saphenous vein (GSV) was associated with higher rates of wound infection and reoperation, polytetrafluoroethylene was associated with inferior 1-year outcomes independent of target artery level, suggesting that GSV should be used for femoral to above-and below-knee popliteal artery bypasses. 6Bellomo et al 1 similarly focused on the third principle to highlight that among patients undergoing open bypass, conduit choice remains important: reversed GSV demonstrated the most favorable outcomes with lower risk for amputation at 1 year, while prosthetic grafts, particularly Dacron, were associated with higher amputation risk despite similar primary patency rates between autologous and synthetic conduits.Although the BASIL and BEST-CLI trials focused on patients with CLTI, the study by Bellomo et al 1 adds insight into a different population.In BASIL-2, endovascular-first therapy was associated with improved amputation-free survival compared with bypass, a result that aligns with the findings of Bellomo et al 1 and underscores that patient selection and disease stage are critical determinants of outcomes. 7A study by Bodewes et al 8 found comparable mortality at 3 years in patients following endovascular or open treatment for CLTI and/or claudication in spite of a heavier comorbidity burden in the endovascular group.However, in this study, although lifestyle of patients with claudication may have temporarily improved, it may come at the price of their life, as Bodewes et al 8 also reported higher long-term mortality in patients undergoing an endovascular procedure for claudication.