Treatment of Arterial Stenosis of Lower Extremities with Claudication

Initial Conservative Management

The American College of Cardiology recommends guideline-directed medical therapy combined with structured exercise therapy as the first-line treatment for claudication, with revascularization reserved for patients with lifestyle-limiting symptoms who fail to improve adequately with conservative management 1, 2
Only 10-15% of patients with claudication will progress to critical limb ischemia over 5 years, emphasizing the importance of comprehensive medical therapy before considering revascularization 3, 4, 5

Revascularization is reasonable for patients with lifestyle-limiting claudication who have an inadequate response to guideline-directed medical therapy, with a Class IIa, Level A recommendation 3, 4, 5, 1
The definition of lifestyle-limiting claudication includes patient-defined impairment affecting activities of daily living, work, or recreation, with persistent symptoms despite 3-6 months of optimal medical therapy and exercise 3, 4, 5, 1, 2

Endovascular therapy is the preferred initial approach for aortoiliac disease, with a Class I, Level A recommendation and superior long-term patency 3, 4, 6, 7
For femoropopliteal disease, endovascular procedures are reasonable but have reduced durability compared to aortoiliac interventions, with a Class IIa, Level B-R recommendation 6, 8, 7
Surgical revascularization is reasonable when there is an inadequate response to guideline-directed medical therapy, acceptable perioperative risk, and technical factors favoring surgery over an endovascular approach, with a Class IIa, Level B-NR recommendation 6, 8, 7

After successful revascularization, patients should continue all cardiovascular risk factor medications, antiplatelet therapy, supervised exercise program, and treatment of residual atherosclerotic lesions, although this recommendation is based on a lower-quality source 9

The American College of Cardiology/American Heart Association recommends endovascular revascularization for patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac occlusive disease, with Class I, Level A evidence supporting this approach 10
The European Society of Cardiology/European Society for Vascular Surgery guidelines also recommend an endovascular-first strategy for aortoiliac lesions, with >90% patency over 5 years for short stenosis/occlusion (<5 cm) of iliac arteries 11
Patients with iliac lesions may be considered for revascularization without undergoing extensive medical therapy, unlike those with infrainguinal disease alone, according to the American College of Radiology Appropriateness Criteria 12, 13

The American College of Cardiology/American Heart Association guidelines support primary stenting as effective primary therapy for common iliac artery stenosis and occlusions (TASC A and B lesions), with Class I, Level A evidence 10
The 2018 ACC/AHA/SCAI/SIR/SVM Appropriate Use Criteria note that iliac artery stenting provides similar durability to surgical revascularization but with much lower periprocedural risk 14

The recommendations are based on Class I, Level A evidence from the 2016 ACC/AHA guidelines for endovascular treatment of aortoiliac disease, as well as multiple RCTs including the CLEVER trial 10, 11, 15
Consensus from multiple societies, including ACC/AHA, ESC/ESVS, ACR, and SCAI/SIR, support an endovascular-first approach for iliac disease 10, 12, 13, 11, 15, 14

Lifelong antiplatelet therapy (aspirin or clopidogrel) is recommended following successful revascularization, according to the American College of Cardiology/American Heart Association guidelines 10
Statin therapy is recommended regardless of lipid levels, according to the American College of Cardiology/American Heart Association guidelines 10, 15