Adam Tanious, MD, MBA, is an associate professor within the Division of Vascular Surgery at the Medical University of South Carolina.

Adam Tanious, MD, MBA

Increasing Guideline-Directed Care Adherence in Peripheral Artery Disease

A recent study has indicated the suboptimal adherence to guideline-directed care (GDC) among patients with 

Presented at the 2026 Vascular Annual Meeting (VAM26) in Boston, Massachusetts, by Richard Shi, MD, a vascular surgery resident at the Medical University of South Carolina, and Adam Tanious, MD, MBA, associate professor within the Division of Vascular Surgery at the Medical University of South Carolina, these data highlight the larger issue of insufficient care among claudicants, potentially resulting in worse long-term outcomes following intervention.

“Real life in patient care always happens,” Tanious told 

 in an exclusive interview. “You’ve got 3 other patients waiting in clinic, and you get to your documentation at the end of the day. You were going to write the prescription for the pletal or for the aspirin, but it didn’t go through – real life always happens. We’re trying to obviate that by creating a pathway for it.”

The study itself was a retrospective analysis including claudicants with endovascular or open intervention between 2014 and 2023. GDC was defined as severe lifestyle limitation documentation, optimal medical therapy adherence, and exercise therapy completion. Partial adherence involved only medical therapy adherence, while non-adherence was a lack thereof. The primary endpoint was 2-year major adverse limb events (MALEs), which were a composite of major amputation or major open/endovascular reintervention of the target limb.

A total of 258 patients were included – of these, 43% demonstrated non-adherence. Another 44.2% demonstrated partial adherence, while 12.8% demonstrated complete GDC adherence. MALE was recorded in 23.3% of claudicants at 2 years, largely due to reintervention. Kaplan-Meier analysis indicated a higher MALE-free survival rate among patients with complete adherence (87.9%) versus partial adherence (78.1%) and nonadherence (72.1%).

Tanious and Shi highlighted the 12.8% of enrolled patients who had a record of completed GDC, leaving over ¾ of all patients with incomplete care prior to intervention. To combat this, the team is currently developing and testing a clinical pathway based on electronic health records to optimize claudicants’ access to GDC. An ongoing prospective study at the Medical University of South Carolina has enrolled >100 patients – Tanious and Shi plan to present these data at an as-yet-unspecified society meeting.

Tanious and Shi also discussed their hopes for the study’s impact on PAD care, particularly in terms of guiding as many patients as possible to receive and complete GDC prior to surgery. In addition to optimizing immediate treatment outcomes, the study reflects that GDC can prevent MALEs after intervention as well, mitigating long-term risk and avoiding complications.

“Our hope is that this paper encourages every vascular surgeon to think of the 3 boxes of guideline-directed care, and every time they see a claudicant, they should have a template in their notes for these patients so that they answer these 3 questions every time,” Tanious said. “How much is this disease affecting the way you live? Are you on all the optimal medical therapy we can offer? Have you tried doing some form of exercise therapy? And until all of these 3 are yes, you should try as hard as possible to refrain from intervening.”

Editors’ Note: Shi and Tanious report no relevant disclosures

Shi R, Tanious A, Bulatao N. Comparing Major Adverse Limb Events in Claudicants with Complete, Partial, and Non-Adherence to Pre-Operative Guideline-Directed Care. Presented at the 2026 Vascular Annual Meeting, Boston, MA. June 10-13, 2026.

Grassley B. Complete Adherence to Guideline-Directed Care Associated with Decreased Serious Limb Complications at Two Years. Society for Vascular Surgery. June 10, 2026. Accessed July 8, 2026. https://vascular.org/news-advocacy/articles-press-releases/complete-adherence-guideline-directed-care-associated

Videos

Richard Shi, MD, and Adam Tanious, MD, MBA, discuss the suboptimal number of patients at risk of long-term complications due to nonadherence.

Guideline-Directed Care Improves Limb Outcomes in Peripheral Artery Disease

Severe lifestyle limitation and completion of exercise therapy have been associated with reduced likelihood of major adverse limb events (MALEs) among patients with 

Presented by at the 2026 Vascular Annual Meeting (VAM26) in Boston, Massachusetts, by Richard Shi, MD, a vascular surgery resident at the Medical University of South Carolina, and Adam Tanious, MD, MBA, associate professor within the Division of Vascular Surgery at the Medical University of South Carolina, this study emphasizes the critical need for full guideline-directed care before surgical interventions in PAD to optimize patient outcomes.

“Each component of guideline-directed care has its own host of issues,” Shi told 

. “For exercise therapy, tons of studies have shown that if you have a job, you can’t do the 3 times recommended work with a physical therapist. With medications, it may be poor adherence, but they could also be unable to afford their medication. There’s a big socioeconomic and education gap.”

Defining Guideline-Directed Care and Major Adverse Limb Events

Shi and colleagues conducted a retrospective analysis of claudicants who received endovascular or open intervention between 2014-2023 at a tertiary care institution. Guideline-directed care was measured prior to intervention – Shi and colleagues defined it as documentation of severe lifestyle limitation, optimal medical therapy (OMT) adherence including single antiplatelet agents, lipid-lowering therapy, and smoking cessation, and exercise therapy completion. The team described partial adherence as OMT adherence only, while non-adherence was defined as a lack of OMT adherence.

The study’s primary outcome was 2-year MALE, which Shi and colleagues defined as a composite of major amputation or major open/endovascular reintervention of the target limb. Independent sample t-tests, Pearson X2 tests, Kaplan-Meier survival analyses, and univariable and multivariable Cox regression modeling were conducted during the study.

A total of 258 claudicants received surgical intervention and were included in the study. Among these patients, 43% demonstrated nonadherence to guideline-directed care, 44.2% demonstrated partial adherence, and 12.8% showed full adherence. The team recorded MALE in 23.3% of claudicants after 2 years, largely attributed to reinterventions.

According to the team, Kaplan-Meier analysis saw claudicants with nonadherence to guideline-directed care demonstrate MALE-free survival of 72.1%, partial adherence with 78.1%, and complete with 87.9% (

 <.01). Multivariable Cox regression modeling showed complete guideline adherence (HR, 0.24; 0.09-0.69) and open intervention (HR, 0.51; 0.28-0.93) as negative predictors of MALE. Positive predictors included hyperlipidemia (HR, 2.35; 1.07-5.16) and TASC C and D lesions (HR, 2.15; 1.33-3.5).

Ultimately, the team concluded that adherence to guideline-directed care is intrinsically protective against MALE in claudicants undergoing intervention out to 2 years following intervention. However, optimal medical therapy may not be protective enough on its own to prevent adverse limb outcomes, showcasing the importance of lifestyle interventions and exercise.

“These data should really push physicians to try and emphasize every aspect of guideline-directed care before they offer the intervention,” Tanious told 

. “It’s not telling physicians not to make the appropriate choice for the patient sitting in front of them – it’s saying that all avenues of guideline-directed care should be checked off, and when you go to offer the intervention, you can feel more secure that you’re doing what’s in the patient’s best interest.”

Editors’ Note: Shi and Tanious report no relevant disclosures.

Grassley B. Complete Adherence to Guideline-Directed Care Associated with Decreased Serious Limb Complications at Two Years. 

https://vascular.org/news-advocacy/articles-press-releases/complete-adherence-guideline-directed-care-associated

Richard Shi, MD, and Adam Tanious, MD, MBA, discuss the importance of exercise, medical interventions, and smoking cessation for PAD care.

Adam Tanious, MD, MBA

Articles