Your doctor is right. For most patients with claudication, we recommend an initial medical treatment regimen that includes risk reduction, exercise therapy (for those who can participate), and possibly pharmacologic therapy, rather than initial vascular intervention. Symptoms of claudication are associated with a low risk of progression to limb-threatening lower extremity ischemia, and a major concern with intervention is that some patients may suffer complications that worsen their symptoms. A subset of patients with severe claudication and inflow disease may benefit from early vascular intervention.
For patients who can participate in exercise therapy, we suggest supervised rather than unsupervised exercise therapy, where available. The value of an unsupervised exercise program is less well studied, but can still generally be recommended for patients who cannot participate in a supervised exercise program. Exercise therapy should be performed for a minimum of 30 to 45 minutes at least three times per week for a minimum of 12 weeks prior to reevaluation. During each session, an exercise level that is of sufficient intensity to elicit claudication should be achieved.
For most patients with lifestyle-limiting claudication who do not have an improvement in symptoms with risk modification and exercise therapy, we suggest a therapeutic trial of naftidrofuryl or cilostazol (100 mg twice daily) depending upon availability. Naftidrofuryl has fewer side effects, and where both are available, naftidrofuryl can be tried first. If the effect is not sufficient, then changing to cilostazol is appropriate.
We schedule follow-up after three months to assess the effectiveness of the initial medical therapy regimen for reducing symptoms. Patients who show improvement and who are satisfied with their progress can be scheduled for annual vascular examination. For patients who have been compliant with risk reduction strategies, yet six months to a year of exercise therapy and adjunctive pharmacotherapy have failed to provide satisfactory improvement, referral for possible revascularization is appropriate.
Options for revascularization include percutaneous intervention, surgical bypass, or a combination of these, and the choice depends upon the level of obstruction (aortoiliac, femoropopliteal) and severity of disease, and the patient’s risk for the intervention. We agree with major cardiovascular society guidelines that recommend an initial attempt at percutaneous revascularization, reserving surgery for when arterial anatomy is not favorable for a percutaneous approach, provided the patient has an acceptable risk for surgery.