New research shows that patients with peripheral arterial disease (PAD) who adhere to preoperative guideline-directed care, including documentation of severe lifestyle limitation, exercise therapy, and optimal medical therapy, are more likely to remain free from major adverse limb events (MALE) for up to two years after intervention.
Researchers from the Medical University of South Carolina (MUSC; Charleston, USA) presented novel evidence demonstrating the impact of guideline-directed care for patients with claudication at the Society for Vascular Surgery’s (SVS) Vascular Annual Meeting (VAM26; 10–13 June, Boston, USA).
Patients with PAD are at increased risk for MALE, which may result in amputation or the need for repeat limb procedures. Although current treatment guidelines recommend lifestyle modification, exercise therapy, smoking cessation, and medical therapy before surgical intervention, many patients do not receive the full spectrum of recommended care.
“Our study was designed to establish the evidence of a comprehensive multidisciplinary approach before considering surgical intervention,” said Richard Shi, vascular surgery resident at MUSC. “Too often, surgery is viewed in isolation rather than as one part of a broader continuum of care. By highlighting the role of preoperative guideline-directed care over immediate intervention or intervention in isolation, we hope to encourage more coordinated care pathways and improved patient outcomes.”
Researchers evaluated whether adherence to guideline-directed care before surgical intervention is associated with improved long-term limb outcomes. Adherence was evaluated across three components: 1) documentation of severe lifestyle-limiting symptoms, 2) adherence to optimal medical therapy (OMT), including single antiplatelet therapy, lipid-lowering therapy, and smoking cessation, and 3) completion of exercise therapy. Exercise therapy was defined as participation in either a supervised exercise programme or a structured home walking programme prescribed by a vascular surgeon or physical therapist, completed for at least three months before intervention. The primary outcome was freedom from MALE over two years following treatment.
The study enrolled 258 patients, all of whom underwent surgery. The researchers compared post-procedural outcomes based on the degree of adherence to guideline-directed care. Among the study population, 12.8% demonstrated non-adherence to guideline-directed care, 73.3% demonstrated partial adherence (OMT only), and 12.8% demonstrated complete adherence. At two years, MALE occurred in 23.3% of patients primarily due to reinterventions. Kaplan-Meier analysis demonstrated that patients with non-adherence had a MALE-free survival rate of 66.6%, compared with 76.7% among partially adherent patients and 87.9% (p<0.01) among patients with complete adherence to guideline-directed care.
“This study highlights the important role vascular surgeons and interventionalists have in ensuring that patients meet the full continuum of preoperative guideline-directed care before offering surgery,” said senior author Adam Tanious, associate professor within the Division of Vascular Surgery at MUSC. “These findings reinforce the importance of surgical appropriateness in claudicants and emphasise the need for established guidelines and pathways to direct care for this patient population.”
To combat non-adherence, the authors have developed an electronic health record-based clinical pathway to help claudicants receive guideline-directed care prior to surgery. They are currently running a prospective study at MUSC with over 100 patients enrolled and aim to present this data at future society meetings.
