Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication. 2023

Takuro Shirasu, and Hisato Takagi, and Jun Yasuhara, and Toshiki Kuno, and K Craig Kent, and Behzad S Farivar, and Margaret C Tracci, and W Darrin Clouse
Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA.

The aim was to analyze the risk of progression to chronic limb-threatening ischemia (CLTI), amputation and subsequent interventions after revascularization versus noninvasive therapy in patients with intermittent claudication (IC). Conflicting evidence exists regarding adverse limb outcomes after each treatment strategy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. MEDLINE, Web of Science, and Google Scholar were searched aided by a health sciences librarian through August 16, 2022. Randomized control trials (RCTs) comparing invasive (endovascular or surgical revascularization) and noninvasive treatment (exercise and/or medical treatment) were included. PROSPERO registration was completed (CRD42022352831). A total of 9 RCTs comprising 1477 patients (invasive, 765 patients; noninvasive, 712 patients) were eligible. During a mean of 3.6-year follow-up, progression to CLTI after invasive [5 (2-8) per 1000 person-years] and noninvasive treatment [6 (3-10) per 1000 person-years] were not statistically different [rate ratio (RR): 0.77; 95% CI, 0.35-1.69; P =0.51, I2 =0%]. Incidence of amputation (RR: 1.69; 95% CI, 0.54-5.26; P =0.36, I2 =0%) and all-cause mortality (hazard ratio: 1.26; 95% CI, 0.91-1.74; P =0.16, I2 =0%) also did not differ between the groups. However, the invasive treatment group underwent significantly more revascularizations (RR: 4.15; 95% CI, 2.80-6.16; P <0.00001, I2 =83%). The results were not changed by fixed effect or random-effects models, nor by sensitivity analysis. Although there is equivalent risk of progression to CLTI, major amputation and all-cause mortality compared with noninvasive treatment, invasive treatment for patients with IC led to significantly more revascularization procedures and should be used selectively in patients with major lifestyle limitation. Guideline recommendation of noninvasive treatment for first-line IC therapy is supported.

UI MeSH Term Description Entries
D007383 Intermittent Claudication A symptom complex characterized by pain and weakness in SKELETAL MUSCLE group associated with exercise, such as leg pain and weakness brought on by walking. Such muscle limpness disappears after a brief rest and is often relates to arterial STENOSIS; muscle ISCHEMIA; and accumulation of LACTATE. Claudication, Intermittent
D007511 Ischemia A hypoperfusion of the BLOOD through an organ or tissue caused by a PATHOLOGIC CONSTRICTION or obstruction of its BLOOD VESSELS, or an absence of BLOOD CIRCULATION. Ischemias
D005081 Exercise Therapy A regimen or plan of physical activities designed and prescribed for specific therapeutic goals. Its purpose is to restore normal musculoskeletal function or to reduce pain caused by diseases or injuries. Rehabilitation Exercise,Remedial Exercise,Therapy, Exercise,Exercise Therapies,Exercise, Rehabilitation,Exercise, Remedial,Exercises, Rehabilitation,Exercises, Remedial,Rehabilitation Exercises,Remedial Exercises,Therapies, Exercise
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D012307 Risk Factors An aspect of personal behavior or lifestyle, environmental exposure, inborn or inherited characteristic, which, based on epidemiological evidence, is known to be associated with a health-related condition considered important to prevent. Health Correlates,Risk Factor Scores,Risk Scores,Social Risk Factors,Population at Risk,Populations at Risk,Correlates, Health,Factor, Risk,Factor, Social Risk,Factors, Social Risk,Risk Factor,Risk Factor Score,Risk Factor, Social,Risk Factors, Social,Risk Score,Score, Risk,Score, Risk Factor,Social Risk Factor
D014656 Vascular Surgical Procedures Operative procedures for the treatment of vascular disorders. Vascular Surgery,Procedure, Vascular Surgical,Procedures, Vascular Surgical,Surgical Procedure, Vascular,Surgical Procedures, Vascular,Vascular Surgical Procedure,Surgeries, Vascular,Surgery, Vascular,Vascular Surgeries
D016032 Randomized Controlled Trials as Topic Works about clinical trials that involve at least one test treatment and one control treatment, concurrent enrollment and follow-up of the test- and control-treated groups, and in which the treatments to be administered are selected by a random process, such as the use of a random-numbers table. Clinical Trials, Randomized,Controlled Clinical Trials, Randomized,Trials, Randomized Clinical
D016896 Treatment Outcome Evaluation undertaken to assess the results or consequences of management and procedures used in combating disease in order to determine the efficacy, effectiveness, safety, and practicability of these interventions in individual cases or series. Rehabilitation Outcome,Treatment Effectiveness,Clinical Effectiveness,Clinical Efficacy,Patient-Relevant Outcome,Treatment Efficacy,Effectiveness, Clinical,Effectiveness, Treatment,Efficacy, Clinical,Efficacy, Treatment,Outcome, Patient-Relevant,Outcome, Rehabilitation,Outcome, Treatment,Outcomes, Patient-Relevant,Patient Relevant Outcome,Patient-Relevant Outcomes
D057510 Endovascular Procedures Minimally invasive procedures, diagnostic or therapeutic, performed within the BLOOD VESSELS. They may be perfomed via ANGIOSCOPY; INTERVENTIONAL MAGNETIC RESONANCE IMAGING; INTERVENTIONAL RADIOGRAPHY; or INTERVENTIONAL ULTRASONOGRAPHY. Endovascular Techniques,Intravascular Procedures,Intravascular Techniques,Endovascular Procedure,Endovascular Technique,Intravascular Procedure,Intravascular Technique,Procedure, Endovascular,Procedure, Intravascular,Procedures, Endovascular,Procedures, Intravascular,Technique, Endovascular,Technique, Intravascular,Techniques, Endovascular,Techniques, Intravascular
D058729 Peripheral Arterial Disease Lack of perfusion in the EXTREMITIES resulting from atherosclerosis. It is characterized by INTERMITTENT CLAUDICATION, and an ANKLE BRACHIAL INDEX of 0.9 or less. Peripheral Arterial Diseases,Peripheral Artery Disease,Arterial Disease, Peripheral,Arterial Diseases, Peripheral,Artery Disease, Peripheral,Artery Diseases, Peripheral,Disease, Peripheral Arterial,Disease, Peripheral Artery,Diseases, Peripheral Arterial,Diseases, Peripheral Artery,Peripheral Artery Diseases

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