Intermittent claudication

IR intermittent claudication journal primer

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.$$
• Blood$Alow$parameters$(ABI)$improved$faster$and$better$with$both$forms$of$revascularization,$which$
may$not$necessarily$correlated$with$clinical$improvement.$$
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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$30Tday$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. Meta3analysis%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$of$followTup$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$CLI)$
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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.$$
• Supervised$therapy$translated$to$an$increase$in$walking$distance$of$180$meters$as$compared$to$
nonTsupervised$therapy$
• Comparing$endovascular$therapy$with$medical$management$
• MIMIC$trial:$PTA$vs$no$PTA$in$patients$already$in$SET$programs,$follow$up$for$24$
months$
• PTA$group$had$higher$adjusted$walking$distance$and$ABI,$but$not$QOL$
• Creasy$et$al,$1990:$PTA$vs$SET,$followTup$9T10$months$
• SET$lead$to$better$mean$claudicating$distance.$$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$painTfree$walking$distance$at$6$and$12$months,$and$7$year$followTup.$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$in$
painTfree$and$maximum$walking$disease$and$healthTrelated$QOL$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$30Tday$mortality.$Bypass$had$higher$patency$and$durability.$2
nd
$review$showed$
increased$30Tday$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$hospitalTbased$exercise$program,$despite$similar$outcomes$at$12Tmonths$
• Bermingham$et$al,$2013.$SET$more$cost$effective$than$unsupervised$therapy$
• Mazari$et$al,$2013.$SET$with$PTA$is$more$cost$effective$than$PTA$alone$
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10. Outcome !!
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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):54ST73S.$

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