Richard Shi, MD, is a vascular surgery resident at the Medical University of South Carolina.

Richard Shi, MD

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.

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. 

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

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

Richard Shi, MD

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