1. Systemic
review
of
treatment
of
intermi1ent
claudica5on
in
the
lower
extremi5es
RFS
Journal
Primer
2. BOTTOM
LINE
• Given
the
limited
research,
supervised
exercise
therapy,
endovascular
therapy,
and
open
surgery
are
superior
to
medical
management
in
terms
of
walking
distance,
pain,
and
claudication.
• Blood
Alow
parameters
(ABI)
improved
faster
and
better
with
both
forms
of
revascularization,
which
may
not
necessarily
correlated
with
clinical
improvement.
MAJOR
POINTS
• High
quality
evidence
from
2
Cochrane
systematic
trials
favoring
supervised
exercise
therapy
(SET)
for
improved
walking
performance
• High
quality
evidence
favoring
revascularization
as
compared
to
optimal
medical
therapy
(OMT)
for
improved
walking
performance
and
blood
Alow
parameters
• Low
quality
evidence
showing
better/faster
improvement
in
ABI
with
revascularization
(open
or
PTA)
as
compared
to
SET
• Moderate
evidence
showing
increase
in
30-‐day
morbidity
and
mortality,
longer
length
of
stay,
higher
complication
rate,
but
increase
in
durability
and
patency
in
open
surgery
compared
to
PTA
• Limited
studies
demonstrating
higher
mean
cost
of
PTA
compared
to
SET
CRITICISM
• Limited
number
of
trials
and
systematic
reviews
from
which
to
draw
conclusions
Quick
Summary
3. Meta-‐analysis
of
multiple
RCTs
and
systematic
reviews
• A
total
of
1548
patients
in
a
total
of
12
trials.
• A
total
of
8
systematic
reviews
were
evaluated
(3
Cochrane
reviews
on
exercise
therapy,
2
on
SET
with
endovascular
therapy,
and
3
of
nonrandomized
surgical
case
series)
• The
median
length
of
follow-‐up
was
15
months
INCLUSION
CRITERIA
• Randomized
trials
or
systematic
reviews
• Enrolled
patients
with
claudication
(ie,
symptomatic
patients
with
peripheral
vascular
disease
who
had
exertional
pain
with
walking)
• Evaluated
open
bypass,
endovascular
revascularization,
or
exercise
therapy
• Measured
the
outcomes
of
interest
EXCLUSION
CRITERIA
• Duplicates,
no
original
data,
or
ab
irrelevant
population
(ie:
patients
with
CLI)
Study
design
4. • To
evaluate
the
available
modalities
currently
in
practice
to
treat
patients
with
claudication
with
respect
to
their
efAicacy.
Purpose
5. • RCTs
and
systematic
reviews
comparing
medical
management,
supervised
exercise
therapy
(SET),
endovascular
treatment,
and
open
bypass
• Metrics
evaluated
were
• Mortality/morbidity
• Amputation
• QOL
• Walking
distance
• ABI
• Patency
• Cost
Interven7on
6. Outcome
• Exercise
therapy
• 2
systematic
reviews,
a
total
of
2818
patients
from
44
RCTs
• Outcomes
• Exercise
signiAicantly
improved
maximal
walking
distance
and
time
compared
with
usual
care
or
placebo
(including
pentoxifylline,
iloprost,
antiplatelet
agents
and
vitamin
E,
or
pneumatic
calf
compression).
Improvements
persisted
over
2
years.
• Supervised
therapy
translated
to
an
increase
in
walking
distance
of
180
meters
as
compared
to
non-‐supervised
therapy
• Comparing
endovascular
therapy
with
medical
management
• MIMIC
trial:
PTA
vs
no
PTA
in
patients
already
in
SET
programs,
follow
up
for
24
months
• PTA
group
had
higher
adjusted
walking
distance
and
ABI,
but
not
QOL
• Creasy
et
al,
1990:
PTA
vs
SET,
follow-‐up
9-‐10
months
• SET
lead
to
better
mean
claudicating
distance.
PTA
had
initial
improvement
for
3
months
without
subsequent
improvement.
SET
continued
to
improved
over
15
months.
• Nylaende
et
al,
2007:
PTA
+
medical
therapy
vs
medical
therapy.
2
year
follow
up
• Early
management
with
PTA
and
medical
therapy
better
than
medical
therapy
alone
with
regards
to
pain
free
walking
distance
,
pain,
and
QOL.
Greatest
difference
at
3
months.
No
difference
at
2
years.
7. Outcome
• Comparing
endovascular
therapy
with
medical
management
(cont)
• Hobbs
et
al,
2006:
PTA
superior
to
SET
and
best
medical
treatment
on
basis
of
ABI,
initial
claudication
distance,
and
absolute
claudication
distance
at
6
months
• Perkins
et
al,
1996.
Early
improvement
with
SET,
but
no
difference
at
long
term
follow
up.
PTA
increased
ABI.
• Spronk,
et
al,
2009.
No
difference
between
endovascular
therapy
and
SET
with
respect
to
pain-‐free
walking
distance
at
6
and
12
months,
and
7
year
follow-‐up.
Somewhat
faster
improvement
with
PTA.
• Whyman,
et
al,
1997.
Adding
PTA
to
medical
therapy
(aspirin,
smoking
cessation,
and
exercise)
did
not
result
in
signiAicant
difference
in
walking,
onset
of
claudication,
walking
distance,
or
ABI.
• CLEVER
trial.
Longer
peak
walking
time
at
6
months
in
the
SET
arm
compared
with
optimal
medical
therapy
(OMT)
and
stenting.
ABI
improved
in
the
stenting
group.
• After
6
months,
stent
revascularization
had
better
patient
reported
QOL
as
compared
with
SET
and
OMT
• ABI
improved
in
the
stenting
group
• ERASE
trial.
Endovascular
therapy
+
SET
resulted
in
signiAicant
greater
improvement
in
pain-‐free
and
maximum
walking
disease
and
health-‐related
QOL
compared
to
SET
alone
• 2
separate
systematic
reviews
(Frans
et
al
and
Ahimastos
et
al)
concluded
that
endovascular
therapy
and
SET
are
likely
equal
• Combination
of
both
is
likely
better
than
1
approach
alone
8. Outcome
• Comparing
endovascular
therapy
with
surgery
• Van
der
Zaag
et
al,
2004:
Bypass
had
higher
clinical
improvement
in
Rutherford
classiAication
than
PTA
• Bypass
had
higher
1
year
patency
and
less
incidence
of
reocclusion
• Wolf
et
al,
1993.
Both
had
improvement
in
functional
status
• A
systematic
review
(which
also
included
CLI
patients)
with
a
total
of
5358
patients
showed
that
bypass
was
associated
with
longer
hospital
stay,
higher
complication
rate,
and
30-‐day
mortality.
Bypass
had
higher
patency
and
durability.
2nd
review
showed
increased
30-‐day
morbidity,
but
no
difference
in
mortality.
• Comparing
any
revascularization
with
medical
management
or
exercise
• Gelin
et
al,
2001.
Invasive
vascularization
increases
walking
capacity
and
was
more
effective
than
supervised
training
in
alleviating
illness
speciAic
symptoms
compared
to
medical
management
or
exercise
• Nordanstig
et
al,
2014.
Invasive
vascularization
is
associated
with
improved
QOL
and
higher
initial
claudication
distance,
but
not
maximum
walking
distance
9. Outcome
• Cost
utilization
data.
Very
limited
data
due
to
most
RCTs
that
included
cost
analysis
also
included
CLI
• Spronk
et
al,
2008.
Higher
cumulative
cost
per
patient
for
endovascular
therapy
compared
to
a
hospital-‐based
exercise
program,
despite
similar
outcomes
at
12-‐months
• Bermingham
et
al,
2013.
SET
more
cost
effective
than
unsupervised
therapy
• Mazari
et
al,
2013.
SET
with
PTA
is
more
cost
effective
than
PTA
alone
11. Credits
SUMMARY
BY:
Alexander
Lam
M.D.,
R1
PGY2
Department
of
Radiological
Sciences
University
of
California,
Irvine
Medical
Center
Malgor
RD,
Alalahdab
F,
Elraiyah
TA,
et
al.
A
systematic
review
of
treatment
of
intermittent
claudication
in
the
lower
extremities.
Journal
of
vascular
surgery.
2015;61(3
Suppl):54S-‐73S.
12. Society
of
Interven7onal
Radiology
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Ridge
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