Editor’s note: The 14 ACS Advisory Councils, which serve as liaisons in the communication of information to and from surgical societies and the Regents, periodically submit articles on notable initiatives taking place in their respective specialties.
This week’s issue features a submission from the Advisory Council for Vascular Surgery.
The Society for Vascular Surgery recently released updated clinical guidelines for the management of intermittent claudication (IC), the most common symptom associated with peripheral artery disease (PAD). These guidelines are the first to include a formal patient panel during their development process.
The updated guidelines were published in the August 2025 issue of the Journal of Vascular Surgery, incorporating nearly a decade of new evidence.
PAD affects more than 10 million Americans, yet it remains widely underdiagnosed. Intermitted claudication—pain or cramping while walking that stops when you rest—is not just a nuisance of aging, but a significant warning sign of a serious vascular condition that can lead to amputation and even death.
By directly involving patients in the guideline development process, the recommendations reflect not only the latest evidence but also the values, preferences, and experiences of people living with PAD. The patient panel emphasized the importance of clear physician/patient communication, setting realistic treatment goals, and providing support resources beyond the clinic setting.
The updated guidelines highlight evidence-based approaches to treatment for intermittent claudication. The first step in management includes patient education and lifestyle changes including smoking cessation, controlling risk factors like blood pressure and cholesterol, taking recommended cardioprotective medications, and following a structured exercise program.
Other key recommendations include:
- Dual pathway antithrombotic therapy combining low-dose rivaroxaban (2.5 mg twice daily) with aspirin is suggested for patients with intermittent claudication and high-risk comorbidities such as diabetes, heart failure, or polyvascular disease, as well as for those who have undergone revascularization. This approach has been shown to reduce the risk of cardiovascular events, though it does carry a modest increase in bleeding risk.
- Supervised exercise therapy (SET) is recommended as the gold standard for improving walking performance. Patients should walk at least 3 times per week for 12 weeks. For those unable or unwilling to participate in SET, structured home-based walking programs are recommended. Exercise should be continued after intervention for those who undergo revascularization to maximize functional gain.
- Revascularization should only be considered after conservative measures have failed and symptoms are lifestyle-limiting. Shared decision-making is essential and should include a discussion of potential risks, which include mortality, major adverse cardiovascular events, and limb complications. Expected benefits should also be discussed, including improved mobility and quality of life.
- Infrapopliteal interventions are discouraged in patients with IC due to a lack of evidence supporting their benefit and concerns about potential harm.
- When performing endovascular intervention for femoropopliteal lesions longer than 5 cm, the use of drug-coated balloons, drug-eluting stents or bare metal stents is recommended over plain balloon angioplasty to reduce the risk of restenosis and reintervention.
The guidelines also identify gaps in current research, including the need for large-scale studies on treatment effectiveness and innovative home-based walking programs.
