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Dr Gurewich raises the question of how to establish indications for new vascular interventions and suggests the formation of a new specialty of vascular medicine. In fact, the indications for intervention in peripheral vascular disease are well established and are based on an understanding of the natural history of the disease. Patients with ischemic rest pain, ulceration, or gangrene are at risk for limb loss and clearly are candidates for revascularization. In contrast, patients with intermittent claudication are at low risk for limb loss and most can be treated successfully with a program of no smoking and exercise. Only those patients who fail to improve with a conservative program and who have limiting or disabling symptoms should undergo angiography and vascular intervention. There is no evidence to suggest that treatment of asymptomatic stenoses or occlusions "before they get worse and cause symptoms" is of any benefit to the
Zarins CK. The Vascular War-Reply. JAMA. 1989;261(24):3551. doi:10.1001/jama.1989.03420240064021
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