Recommendations for Surgical Revascularization for Claudication
COR	LOE	Recommendations
I	A	When surgical revascularization is performed, bypass to the popliteal artery with autogenous vein is recommended in preference to prosthetic graft material.263–271
See Online Data Supplements 37 and 38.		The superficial femoral and proximal popliteal arteries are the most common anatomic sites of stenosis or occlusion among individuals with claudication. Femoral-popliteal bypass is therefore one of the most common surgical procedures for claudication and may be performed under general or regional anesthesia. The type of conduit and site of popliteal artery anastomosis (above versus below knee) are major determinants of outcomes associated with femoral-popliteal bypass. Systematic reviews and meta-analyses have identified a clear and consistent primary patency benefit for autogenous vein versus to prosthetic grafts for popliteal artery bypass.270,271 Prosthetic grafts to the popliteal artery above the knee have reduced patency rates and increased rates of repeat intervention.263,266,269,272 Sparse evidence suggests a long-term patency advantage for Dacron over polytetrafluoroethylene (known as PTFE) graft for above-knee bypass,270 although this finding has not been consistently demonstrated in all RCTs.266,273,274
IIa	B-NR	Surgical procedures are reasonable as a revascularization option for patients with lifestyle-limiting claudication with inadequate response to GDMT, acceptable perioperative risk, and technical factors suggesting advantages over endovascular procedures.232,265,275–277
See Online Data Supplements 37 and 38.		Systematic reviews have concluded that surgical procedures are an effective treatment for claudication and have a positive impact on QoL and walking parameters but have identified sparse evidence supporting the effectiveness of surgery compared with other treatments.11,233,278,279 Although symptom and patency outcomes for surgical interventions may be superior versus less invasive endovascular treatments for specific patients, surgical interventions are also associated with greater risk of adverse perioperative events.280–286 Treatment selection should therefore be individualized on the basis of the patient's goals, perioperative risk, and anticipated benefit. Surgical procedures for claudication are usually reserved for individuals who a) do not derive adequate benefit from nonsurgical therapy, b) have arterial anatomy favorable to obtaining a durable result with surgery, and c) have acceptable risk of perioperative adverse events. Acceptable risk is defined by the individual patient and provider on the basis of symptom severity, comorbid conditions, and appropriate GDMT risk evaluation. Guidelines for the evaluation and management of patients undergoing noncardiac surgery, including vascular surgical procedures, have been previously published.21
III: Harm	B-R	Femoral-tibial artery bypasses with prosthetic graft material should not be used for the treatment of claudication.287–289
See Online Data Supplement 37.		Bypasses to the tibial arteries with prosthetic material for treatment of claudication should be avoided because of very high rates of graft failure and amputation.287–289
III: Harm	B-NR	Surgical procedures should not be performed in patients with PAD solely to prevent progression to CLI.234–237,262
See Online Data Supplements 37 and 38.		Claudication does not commonly progress to CLI. Reported rates of amputation or progression to CLI from prospective cohort studies of patients with claudication are <10% to 15% for 5 years or more, and increased mortality rate associated with claudication is usually the result of cardiovascular events rather than limb-related events.234–237,262 Surgical intervention should not be performed primarily to prevent disease progression, given the risk of adverse perioperative events without potential for significant benefit. Similarly, there are no data to support surgical revascularization in patients with asymptomatic PAD to prevent progression to CLI.