A qualitative investigation of interventionalists’ views and experiences on clinical decision-making in claudication

<h2>Abstract</h2><h3>Background</h3> Claudication, pain with walking, is a common presentation of peripheral artery disease (PAD), which can significantly impact quality of life. Recent appropriate use criteria from the Society of Vascular Surgery provide a framework for management, particularly considerations for revascularization; however, consensus on the indications for revascularization remain elusive. This study seeks to understand the interventionalist perspective on decision making around intermittent claudication (IC). <h3>Methods</h3> Semi-structured interviews were conducted with 30 interventionalists including interventional cardiologists, interventional radiologists, and vascular surgeons. Transcripts were iteratively analyzed through steps informed by inductive thematic analysis. <h3>Results</h3> Three key thematic patterns were identified regarding interventionalists' perspectives on management, particularly procedural intervention, for patients with claudication: (1) periprocedural risk for complications and long-term durability of interventions for claudication was a persistent consideration in decision making; (2) despite the risks, there were opportunities to improve the patient's quality of life, in other words, there were "good reasons" to be risky; (3) interventionalists' expectations of the patient regarding adherence to medical management and indication influence providers' decisions to pursue intervention. <h3>Conclusions</h3> While there are recommendations to guide an interventionalists' decision making to pursue revascularization for a patient with claudication, in practice, there is heterogeneity in the factors that influence the decision to intervene. Interventionalists contend with not only the risks of a procedure but must interpret patients' treatment goals and subjectivity of symptoms when determining benefit of revascularization. Interventionalists' value judgements are frequently incorporated into the decision-making process, which may introduce bias. As such, there are opportunities to improve shared decision-making.