Comparing major adverse limb events in claudicants with complete, partial, and nonadherence to preoperative...

The Society for Vascular Surgery recommends surgery be reserved for claudicants with severe lifestyle-limiting symptoms despite optimal medical therapy and supervised exercise therapy-the sum of these known as guideline-directed care (GDC). However, most claudicants do not receive the full spectrum of GDC prior to open surgery or endovascular intervention. We investigate the impact of complete vs partial vs nonadherence to preoperative GDC in claudicants and assess its impact on 2-year major adverse limb events (MALEs).

A retrospective analysis was performed on claudicants with open surgery or endovascular intervention at a tertiary care institution between 2016 and 2023. GDC was measured prior to surgery and defined as (1) severe lifestyle limitation documentation, (2) optimal medical therapy adherence (composite of single antiplatelet agent, lipid-lowering therapy, smoking cessation), and (3) exercise therapy completion. Partial adherence was defined by meeting one or two of these components, and nonadherence was defined by meeting none of the components. The primary outcome was 2-year MALE, defined as a composite of major amputation or major open/endovascular reintervention of the target limb. Statistical analysis included one-way analysis of variance, Pearson χ² tests, Kaplan-Meier, and univariable and multivariable Cox regression modeling.

Of the 258 claudicants receiving open surgery or endovascular intervention, 13.9% demonstrated nonadherence to GDC, 73.3% demonstrated partial adherence, and 12.8% demonstrated complete adherence. MALE was seen in 23.3% of claudicants at 2 years, primarily because of reinterventions. On Kaplan-Meier analysis, claudicants with nonadherence to GDC demonstrated a 2-year MALE-free survival of 66.6%, partial adherence with 76.7%, and complete adherence with 87.9% (P < .01). On multivariable Cox regression modeling, patients with complete guideline adherence demonstrated a decreased risk of MALE (hazard ratio, 0.24 [0.09, 0.69]) when compared with nonadherence, whereas partial adherence did not (hazard ratio, 0.99 [0.56, 1.74]).

Complete adherence to preoperative GDC is protective against MALE in claudicants undergoing intervention out to 2 years postintervention, whereas partial adherence may not offer a similar benefit. Future studies must prioritize improving adherence rates prior to surgery in claudicants to ensure long-term risk mitigation and prevent complications.