Rafael D Malgor1, Fares Alahdab2, Fares Alalahdab2, Tarig A Elraiyah2, Adnan Z Rizvi3, Melanie A Lane2, Larry J Prokop2, Olivia J Phung4, Wigdan Farah2, Victor M Montori5, Michael S Conte6, Mohammad Hassan Murad7. 1. Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, Minn; Division of Vascular Surgery, University of Oklahoma, Tulsa, Okla. 2. Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, Minn. 3. Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Vascular and Endovascular Surgery, Minneapolis, Minn. 4. College of Pharmacy, Western University of Health Sciences, Pomona, Calif. 5. Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, Minn; Division of Endocrinology, Mayo Clinic, Rochester, Minn. 6. Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif. 7. Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, Minn; Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minn. Electronic address: murad.mohammad@mayo.edu.
Abstract
BACKGROUND: Peripheral arterial disease is common and is associated with significant morbidity and mortality. METHODS: We conducted a systematic review to identify randomized trials and systematic reviews of patients with intermittent claudication to evaluate surgery, endovascular therapy, and exercise therapy. Outcomes of interest were death, amputation, walking distance, quality of life, measures of blood flow, and cost. RESULTS: We included eight systematic reviews and 12 trials enrolling 1548 patients. Data on mortality and amputation and on cost-effectiveness were sparse. Compared with medical management, each of the three treatments (surgery, endovascular therapy, and exercise therapy) was associated with improved walking distance, claudication symptoms, and quality of life (high-quality evidence). Evidence supporting superiority of one of the three approaches was limited. However, blood flow parameters improved faster and better with both forms of revascularization compared with exercise or medical management (low- to moderate-quality evidence). Compared with endovascular therapy, open surgery may be associated with longer length of hospital stay and higher complication rate but resulted in more durable patency (moderate-quality evidence). CONCLUSIONS: In patients with claudication, open surgery, endovascular therapy, and exercise therapy were superior to medical management in terms of walking distance and claudication. Choice of therapy should rely on patients' values and preferences, clinical context, and availability of operative expertise.
BACKGROUND: Peripheral arterial disease is common and is associated with significant morbidity and mortality. METHODS: We conducted a systematic review to identify randomized trials and systematic reviews of patients with intermittent claudication to evaluate surgery, endovascular therapy, and exercise therapy. Outcomes of interest were death, amputation, walking distance, quality of life, measures of blood flow, and cost. RESULTS: We included eight systematic reviews and 12 trials enrolling 1548 patients. Data on mortality and amputation and on cost-effectiveness were sparse. Compared with medical management, each of the three treatments (surgery, endovascular therapy, and exercise therapy) was associated with improved walking distance, claudication symptoms, and quality of life (high-quality evidence). Evidence supporting superiority of one of the three approaches was limited. However, blood flow parameters improved faster and better with both forms of revascularization compared with exercise or medical management (low- to moderate-quality evidence). Compared with endovascular therapy, open surgery may be associated with longer length of hospital stay and higher complication rate but resulted in more durable patency (moderate-quality evidence). CONCLUSIONS: In patients with claudication, open surgery, endovascular therapy, and exercise therapy were superior to medical management in terms of walking distance and claudication. Choice of therapy should rely on patients' values and preferences, clinical context, and availability of operative expertise.
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Authors: Marie D Gerhard-Herman; Heather L Gornik; Coletta Barrett; Neal R Barshes; Matthew A Corriere; Douglas E Drachman; Lee A Fleisher; Francis Gerry R Fowkes; Naomi M Hamburg; Scott Kinlay; Robert Lookstein; Sanjay Misra; Leila Mureebe; Jeffrey W Olin; Rajan A G Patel; Judith G Regensteiner; Andres Schanzer; Mehdi H Shishehbor; Kerry J Stewart; Diane Treat-Jacobson; M Eileen Walsh Journal: Circulation Date: 2016-11-13 Impact factor: 29.690