Algorithm for the management of claudication

CT: computed tomography; MR: magnetic resonance.
* Exclude other causes of vascular occlusive disease based upon demographics, risk factors and clinical signs such as embolism (eg, atrial fibrillation), thrombosed arterial aneurysm (eg, palpable popliteal mass), and extrinsic vascular compression (younger age).
¶ Noninvasive studies include ankle-brachial index, segmental pressures, pulse volume recordings, and exercise testing.
Δ Supervised exercise therapy is preferred but not always possible. Unsupervised exercise with monitoring is an acceptable alternative. For patients with predicted limited exercise capability, cilostazol can be initiated concurrently.
◊ We suggest a therapeutic trial of cilostazol for patients with moderate-to-severe claudication. Naftidrofuryl, which has fewer side effects, can be tried first where available. For patients with contraindications or who do not tolerate cilostazol, pentoxifylline is an alternative. These can be prescribed concurrently with initiation of an exercise program.
§ CT or MR angiography. For patients with proximal occlusive disease (weak femoral pulse), conventional catheter-based arteriography may be performed initially in anticipation of possible intervention.
¥ Tibial vessel disease alone is rarely a cause of lifestyle-limiting claudication. Tibial revascularization is rarely indicated for claudication.
‡ Good candidates for peripheral bypass surgery have favorable anatomy for bypass (target vessel; good runoff; and, ideally, vein conduit), are medically fit, and have an anticipated life expectancy that will allow the patient to benefit from the procedure.
† Following revascularization, antithrombotic therapy depends upon the nature of revascularization (ie, type of stent, type of bypass conduit); if initiated, cilostazol may be discontinued.