More than 230 million adults worldwide are estimated to have peripheral artery disease (PAD)1,2, including at least 8 to 12 million US adults1,3,4. Intermittent claudication (IC) is a phenotype of PAD characterized by reduced blood flow that meets baseline metabolic demands but not the higher metabolic demands of activity. The specific burden of IC is difficult to quantify based on existing epidemiological data, largely because IC is often not clearly or consistently differentiated from asymptomatic disease or more severe chronic limb-threatening ischemia (CLTI). Prospective cohort studies, primarily from the US and Europe, report an incidence of IC between 6 and 22 cases per 1000 person-years in adults aged 50 years and older5,6. Both the incidence and prevalence increase with age, and best available evidence suggests IC affects up to 8% of adults 50 years of age and older and as many as 18% to 20% of adults 75 years of age and older2,6–13. The presence of other well-established risk factors for IC, including tobacco use, diabetes mellitus, hypertension, and dyslipidemia, further increases the risk of PAD. A higher burden of these risk factors in non-White adults and those with low socioeconomic status are proposed to contribute to disproportionately high rates of PAD in minority racial/ethnic groups in the US6,14.

IC can be highly disabling, especially in patients for whom walking is central to work duties or activities of daily living. However, fewer than 5% to 10% of patients with incident IC will progress to CLTI—characterized by rest pain, tissue loss, and risk of amputation—within 5 years of diagnosis15,16. Given the low risk of limb threat in patients with IC, the primary goals of treatment are focused on addressing symptoms, preserving or improving functional status, and improving health-related quality of life16. First line treatment for IC comprises multimodal medical therapy, risk factor modification, and supervised exercise therapy to increase pain-free walking distance. Because therapy for IC is primarily symptom-driven and conservative management has been shown to be effective for improving quality of life long-term17,18, interventional therapies for IC have historically been reserved for patients with lifestyle-limiting claudication that is refractory to best medical management. However, advances in endovascular technologies, including percutaneous transluminal angioplasty (PTA), stenting, atherectomy and intravascular lithotripsy, have contributed to increased use of these peripheral vascular interventions (PVI) in the management of IC in the United States19.

Clinical practice guidelines aim to improve adherence to evidence-based care and reduce variation in practice patterns and patient outcomes across physicians, settings, and specialties. The Society for Vascular Surgery (SVS) (2015)4, American College of Cardiology/American Heart Association Task Force (AHA/ACC) (2016)20, and the European Society for Vascular Surgery (ESVS) (2024)21 have each published guidelines for the management of IC within the past decade. Appropriate use criteria (AUC) for PVI in the treatment of claudication based on RAND/UCLA methodology22 have been recently published by a multidisciplinary committee representing the American College of Cardiology Appropriate Use Criteria Task Force, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine (ACC/AHA/SCAI/SIR/SVM)23 and, separately, by the SVS24 to supplement these groups’ previously published clinical practice guidelines. There is wide agreement between these guidelines and AUC on the major tenets of IC management. However, there are also notable differences in their interpretation of existing evidence and in their recommendations for management, specifically regarding the benefit-risk balance of interventions for which high quality evidence in IC populations is lacking.

The current review will summarize current SVS, AHA/ACC, and ESVS clinical practice guidelines for both non-interventional and interventional management of intermittent claudication4,20,21, provide an overview of published AUC for PVI in the management of IC23,24, and highlight similarities and differences in treatment recommendations for intervention with a focus on the use of novel and/or high-cost PVI.