SS01 - Comparing Major Adverse Limb Events in Claudicants with Complete, Partial, and Non-Adherence to Pre-Operative Guideline-Directed Care

Objectives: The Society for Vascular Surgery recommends intervention be considered in claudicants with severe lifestyle limiting symptoms that have failed optimal medical therapy (OMT) and supervised exercise therapy – the sum of these known as guideline-directed care (GDC). However, most claudicants do not receive the full spectrum GDC prior to surgical intervention. We investigate the impact of complete versus partial versus non-adherence to pre-operative GDC in claudicants and assess its impact on major adverse limb events (MALE) at two years.

Methods: A retrospective analysis was performed on claudicants with endovascular or open intervention at a tertiary care institution between 2014-2023. GDC was measured prior to surgical intervention and is defined as: 1) severe lifestyle limitation documentation, 2) OMT adherence (composite of single antiplatelet agent, lipid-lowering therapy, smoking cessation), and 3) exercise therapy completion. Partial adherence was defined by OMT adherence only, and non-adherence was defined by a lack of OMT adherence. The primary outcome was two-year MALE, defined as a composite of major amputation or major open/endovascular reintervention of the target limb. Statistical analysis included independent sample t-tests, Pearson χ2 tests, Kaplan-Meier survival analysis, and univariable and multivariable Cox regression modeling.

Results: Of the 258 claudicants receiving surgical intervention, 43.0% demonstrated non-adherence to GDC, 44.2% demonstrated partial adherence (OMT only), and 12.8% demonstrated complete adherence. MALE was seen in 23.3% of claudicants at two years, primarily due to re-interventions. On Kaplan-Meier analysis, claudicants with non-adherence to GDC demonstrated a MALE-free survival of 72.1%, partial-adherence with 78.1%, and complete with 87.9% (p < 0.01) (Fig 1). On multivariable Cox regression modeling, negative predictors of MALE included complete guideline adherence (hazard ratio [HR]: 0.24 [0.09, 0.69]) and open intervention (HR: 0.51 [0.28, 0.93]) (Table I). Positive predictors of MALE were hyperlipidemia (HR: 2.35 [1.07, 5.16]) and TASC C and D lesions (HR: 2.15 [1.33, 3.50]).

Conclusions: Adherence to GDC is protective against MALE in claudicants undergoing intervention out to two years post-intervention. Optimal medical therapy alone may not be protective enough in preventing adverse limb outcomes. The presence of severe lifestyle limitation and exercise therapy completion prior to surgical intervention in claudicants is essential in ensuring long-term risk mitigation and preventing complications.