Invasive treatment of claudication: Time for better measures and better controls

Peripheral artery disease (PAD) is a common in our aging population, and intermittent claudication (IC) its most frequent symptom. The current evidence-based practice guidelines support the use of optimal medical therapy, including statins antiplatelet agents, risk factor management (eg, smoking cessation), exercise, as primary strategy.1Siracuse J.J. Woodson J. Ellis R.P. Farber A. Roddy S.P. Kalesan B. et al.Intermittent treatment patterns commercially insured non-Medicare population.J Vasc Surg. 2021; 74: 499-504Abstract Full Text PDF PubMed Scopus (2) Google Scholar, 2Conte M.S. Pomposelli F.B. Clair D.G. Geraghty P.J. McKinsey J.F. Mills J.L. al.Society for Vascular Surgery Lower Extremity Guidelines Writing GroupSociety Practice atherosclerotic occlusive lower extremities asymptomatic claudication. Introduction.J 2015; 61: 2S-41SPubMed (232) 3Gerhard-Herman M.D. Gornik H.L. Barrett C. Barsches N.R. Corriene M.A. Drachman D.E. al.2016 AHA/ACC guideline on patients with extremity peripheral disease: executive summary: report American College Cardiology/American Heart Association Task Force Clinical Guidelines.J Am Coll Cardiol. 2017; 69: 1465-1508Crossref (328) 4Aboyans V. Ricco J.B. Bartelink M.E.L. al.Editor's choice – 2017 ESC diagnosis arterial diseases, collaboration European Society (ESVS).Eur J Endovasc 2018; 55: 305-368Abstract (504) Scholar appropriate invasive procedures IC has remained controversial subject significant public health resource implications. Effective revascularization those severely disabling symptoms can greatly improve patients' function quality life. However, comparative effectiveness evidence this field shockingly limited. selective approach based estimations risk, benefit, durability. increase ambulatory centers office-based laboratories coincided increasing volumes endovascular interventions IC. lack standardized measures criteria provided large open turf everyday practice. Siracuse al5Siracuse Levin S.R. Osborne N.H. Srinivasan (7) reported an analysis evolution from MarketScan commercial payor database. They reviewed claims new 2007 to 2016. median age cohort was 58 years. Overall, they found that statin usage distressingly low (52%); 14% had undergone vascular interventions, whom 20% multiple interventions. time intervention declined 230 days 49 days. A notable occurred outpatient facility atherectomy during study period. Similar observations secular trends PAD have been by others.6Jones W.S. Mi X. Qualls L.G. Vemulapalli S. Peterson E.D. Patel M.R. al.Trends settings effect changes prospective payment system.J 65: 920-927Crossref (114) ready availability less therapies are reimbursed well be expected promote increased use. As dedicated specialists, we obligation educate nature disease, natural history, importance therapy management, role exercise. clinical mantra “stop smoking, start walking, come back 6 months” increasingly being replaced “let's do some imaging take look at anatomy” earlier point. many these unclear inadequately captured reinterventions alone. Large national registries such Quality Initiative provide opportunity objective performance noninvasive testing PAD. Counseling cessation providing options supervised or home-based exercise should also benchmarks. Payors recognized broader application guideline-based will cardiovascular reduce procedures, hospitalizations, costs. begun give closer attention and, one might expect, near future, exert greater control. Appropriate adherence societal become important. overdue largescale trials better comparing strategies incorporating patient-centered measures. opinions views expressed commentary authors not necessarily reflect recommendations Journal Surgery.