Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Surgical management of claudication

David G Neschis, MD
Michael A Golden, MD
Section Editors
John F Eidt, MD
Joseph L Mills, Sr, MD
Denis L Clement, MD, PhD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Intermittent claudication is due to a deficiency in blood supply to exercising muscle and is generally a reliable indicator of occlusive arterial disease. Classic intermittent claudication is a reproducible discomfort of a defined group of muscles which is induced by exercise and relieved with rest [1,2]. However, atypical leg pain is more common [2]. Most patients with intermittent claudication remain stable with medical therapy. When revascularization is required, the options are percutaneous interventional procedures and surgery.

This topic will review the general indications for revascularization in patients with claudication, and the outcomes of lower extremity bypass surgery. The roles of medical therapy, percutaneous revascularization, and the management of limb-threatening ischemia are discussed separately. (See "Management of claudication" and "Percutaneous interventional procedures in the patient with lower extremity claudication" and "Treatment of chronic lower extremity critical limb ischemia".)


The location of lower extremity pain varies with the vessels that are involved. The severity of symptoms depends upon the degree of stenosis, the collateral circulation, and the vigor of exercise. Most patients with intermittent claudication remain stable with medical therapy. When revascularization is required, the options are percutaneous interventional procedures and surgery. (See "Clinical features and diagnosis of lower extremity peripheral artery disease", section on 'Claudication'.)

The usual relationship between the site of pain and site of arterial disease can be summarized as follows:

Buttock and hip: Aortoiliac disease

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: Apr 08, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26:517.
  2. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.
  3. Ouriel K. Peripheral arterial disease. Lancet 2001; 358:1257.
  4. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5.
  5. Pell JP. Impact of intermittent claudication on quality of life. The Scottish Vascular Audit Group. Eur J Vasc Endovasc Surg 1995; 9:469.
  6. Currie IC, Wilson YG, Baird RN, Lamont PM. Treatment of intermittent claudication: the impact on quality of life. Eur J Vasc Endovasc Surg 1995; 10:356.
  7. Zannetti S, L'Italien GJ, Cambria RP. Functional outcome after surgical treatment for intermittent claudication. J Vasc Surg 1996; 24:65.
  8. van Goor H, Boontje AH. Results of vascular reconstructions for atherosclerotic arterial occlusive disease of the lower limbs in young adults. Eur J Vasc Endovasc Surg 1995; 10:323.
  9. Karmody AM, Powers SR, Monaco VJ, Leather RP. "Blue toe" syndrome. An indication for limb salvage surgery. Arch Surg 1976; 111:1263.
  10. Donaldson MC, Mannick JA. Femoropopliteal bypass grafting for intermittent claudication: is pessimism warranted? Arch Surg 1980; 115:724.
  11. Dalman, RL, Taylor, LM Jr. Infrainguinal Revascularization Procedures. In: Basic Data Underlying Clinical Decision Making in Vascular Surgery, Porter, JM, Taylor, LM Jr (Eds), Quality Medical Publishing, Inc, St. Louis 1994. p.141.
  12. Conte MS, Belkin M, Donaldson MC, et al. Femorotibial bypass for claudication: do results justify an aggressive approach? J Vasc Surg 1995; 21:873.
  13. Goodreau JJ, Creasy JK, Flanigan P, et al. Rational approach to the differentiation of vascular and neurogenic claudication. Surgery 1978; 84:749.
  14. Lundell A, Lindblad B, Bergqvist D, Hansen F. Femoropopliteal-crural graft patency is improved by an intensive surveillance program: a prospective randomized study. J Vasc Surg 1995; 21:26.
  15. Davies AH, Hawdon AJ, Sydes MR, et al. Is duplex surveillance of value after leg vein bypass grafting? Principal results of the Vein Graft Surveillance Randomised Trial (VGST). Circulation 2005; 112:1985.
  16. Mills JL Sr. Is duplex surveillance of value after leg vein bypass grafting? Principal results of the Vein Graft Surveillance Randomised Trial (VGST). Perspect Vasc Surg Endovasc Ther 2006; 18:194.
  17. Wixon CL, Mills JL, Westerband A, et al. An economic appraisal of lower extremity bypass graft maintenance. J Vasc Surg 2000; 32:1.
  18. Mills JL, Bandyk DF, Gahtan V, Esses GE. The origin of infrainguinal vein graft stenosis: a prospective study based on duplex surveillance. J Vasc Surg 1995; 21:16.
  19. Mills JL, Fujitani RM, Taylor SM. The characteristics and anatomic distribution of lesions that cause reversed vein graft failure: a five-year prospective study. J Vasc Surg 1993; 17:195.
  20. Bandyk, DF. Surveillance of lower extremity bypass grafts. In: Current Therapy in Vascular Surgery, Ernst, CB, Stanley, JC (Eds), Mosby-Year Book, St. Louis 1995. p. 492.
  21. 2011 WRITING GROUP MEMBERS, 2005 WRITING COMMITTEE MEMBERS, ACCF/AHA TASK FORCE MEMBERS. 2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2011; 124:2020.
  22. DeBakey ME, Glaeser DH. Patterns of atherosclerosis: effect of risk factors on recurrence and survival-analysis of 11,890 cases with more than 25-year follow-up. Am J Cardiol 2000; 85:1045.
  23. Chew DK, Nguyen LL, Owens CD, et al. Comparative analysis of autogenous infrainguinal bypass grafts in African Americans and Caucasians: the association of race with graft function and limb salvage. J Vasc Surg 2005; 42:695.
  24. de Vries SO, Hunink MG. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-analysis. J Vasc Surg 1997; 26:558.
  25. Lindblad B, Wakefield TW, Stanley TJ, et al. Pharmacological prophylaxis against postoperative graft occlusion after peripheral vascular surgery: a world-wide survey. Eur J Vasc Endovasc Surg 1995; 9:267.
  26. Dörffler-Melly J, Koopman MM, Adam DJ, et al. Antiplatelet agents for preventing thrombosis after peripheral arterial bypass surgery. Cochrane Database Syst Rev 2003; :CD000535.
  27. Collins TC, Souchek J, Beyth RJ. Benefits of antithrombotic therapy after infrainguinal bypass grafting: a meta-analysis. Am J Med 2004; 117:93.
  28. Efficacy of oral anticoagulants compared with aspirin after infrainguinal bypass surgery (The Dutch Bypass Oral Anticoagulants or Aspirin Study): a randomised trial. Lancet 2000; 355:346.
  29. Belch JJ, Dormandy J, CASPAR Writing Committee, et al. Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease (CASPAR) trial. J Vasc Surg 2010; 52:825.
  30. Vorapaxar. Am J Cardiovasc Drugs 2010; 10:413.
  31. Morrow DA, Braunwald E, Bonaca MP, et al. Vorapaxar in the secondary prevention of atherothrombotic events. N Engl J Med 2012; 366:1404.
  32. Bonaca MP, Scirica BM, Creager MA, et al. Vorapaxar in patients with peripheral artery disease: results from TRA2{degrees}P-TIMI 50. Circulation 2013; 127:1522.
  33. Bonaca MP, Gutierrez JA, Creager MA, et al. Acute Limb Ischemia and Outcomes With Vorapaxar in Patients With Peripheral Artery Disease: Results From the Trial to Assess the Effects of Vorapaxar in Preventing Heart Attack and Stroke in Patients With Atherosclerosis-Thrombolysis in Myocardial Infarction 50 (TRA2°P-TIMI 50). Circulation 2016; 133:997.
  34. Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e669S.