Claudication metres, the infrapopliteal strategy split, and the post-revascularisation prescription

Model answer

(A) The claudicant — exercise first with metre honesty (3 marks). Prescribe supervised exercise as first line: Cochrane pooling of 32 trials with 1835 participants shows pain-free distance up 82.11 m and maximum distance up 120.36 m, both high-quality evidence, with no ABI, mortality or amputation signal.^[16] Quote CLEVER for durability: 111 aortoiliac patients, 18-month peak walking gains of 5.0 minutes with exercise and 3.2 with stenting against 0.2 with medical care alone, exercise versus stenting not significantly different.^[14] Quote the ERASE long view: the 1-year combination advantage fades to a nonsignificant 53 m at 5.4 years, exercise-only carries 2.50-fold hazard of later revascularisation yet lifetime totals of 65 versus 149 procedures favour exercise-only.^[15] Offer cilostazol only with its modesty stated: initial distance up 26.49 m, absolute up 39.57 m, headache odds 2.83, no verdict on hard outcomes.^[17]

(B) The infrapopliteal woman without vein — stage thrice, then endo-first (4 marks). Stage the limb by WIfI (wound, ischaemia, infection together — perfusion alone misleads), the arteries by GLASS (target artery path to limb-based patency, three stages), and the decision by PLAN (patient risk, limb severity, anatomic complexity as independent axes).^[5][4] Her profile — mandatory infrapopliteal disease, no single-segment vein — maps to BASIL-2, not BEST-CLI cohort 1: vein-first versus best-endo-first gave amputation-or-death of 63 versus 53% (adjusted HR 1.35), driven by deaths, so run an endo-first strategy.^[7] State why BEST-CLI does not rescue bypass here: its surgery win (HR 0.68, 42.6 versus 57.4%) belongs to adequate-vein cohort 1, while alternative-conduit cohort 2 ties at HR 0.79 — she lives in cohort 2's world.^[8] Refer urgently per GVG and book long-term limb surveillance after revascularisation.^[4]

(C) The prosthetic bypass — clopidogrel-flavoured dual therapy plus vascular-dose rivaroxaban reasoning (3 marks). Base single therapy with a clopidogrel flavour: CAPRIE gives RRR 8.7% over aspirin, and EUCLID shows ticagrelor adds nothing over clopidogrel (HR 1.02, tied bleeds).^[12][11] Upgrade his prosthetic below-knee graft to dual therapy by CASPAR: prosthetic grafts gain (HR 0.65) while venous grafts do not (HR 1.25), interaction p=0.008, against an overall tied HR of 0.98.^[18] Add vascular-dose rivaroxaban reasoning per VOYAGER for the revascularised leg: 2.5 mg twice daily plus aspirin gives 17.3 versus 19.9% at 3 years (HR 0.85) with TIMI major bleeding tied but ISTH major bleeding higher (5.94 versus 4.06%) — select and counsel, never a free lunch.^[9]