Endovascular Treatment for Intermittent Claudication in Patients with Peripheral Arterial Disease: A Systematic Review Jiawei Liu,1 Yidan Wu,1 Zilun Li,1 Wen Li,2 and Shenming Wang,1 Guangzhou, China
Background: We performed a systematic review and meta-analysis to examine whether patients with intermittent claudication can benefit from endovascular treatment (EVT). Methods: A prespecified search strategy was used to identify relevant studies in the MEDLINE, Embase, and Cochrane databases. A total of 10 different randomized, controlled trials were reviewed. Random effects meta-analysis was performed between the EVT plus conservative treatment (CT) group and the CT group alone. Also, random effects meta-analysis was performed between the EVT group and the supervised exercise therapy (SET) group. Results: The independent effect of EVT could directly improve the ankleebrachial index (ABI) and walking performance over the short term, but not over the long term. Moreover, compared to SET, EVT had the superiority in improving the ABI, while SET could improve walking performance more efficiently. Conclusions: Patients with intermittent claudication may benefit from endovascular treatment over the short term (within 12 months), with improvements in ABI, intermittent claudication distance, and maximum walking distance. However, considering improvements on walking performance (especially over the long term), SET is recommended.
INTRODUCTION Peripheral arterial disease (PAD) occurs mostly in the lower extremities and is caused by aortoiliac and/or femoropopliteal lesions. PAD of lower extremities most frequently presents with pain during ambulation, known as intermittent claudication (IC). IC is an early symptom of PAD that significantly impairs quality of life and should be taken seriously. Treatments of IC in PAD mainly include conservative treatment (CT) and endovascular
1 Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China. 2 Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
Correspondence to: Shenming Wang, MD, Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou 510080, China; E-mail: [email protected] Ann Vasc Surg 2014; 28: 977–982 http://dx.doi.org/10.1016/j.avsg.2013.05.022 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 4, 2013; manuscript accepted: May 13, 2013; published online: December 16, 2013.
treatment (EVT). Optimal medical treatment (OMT) refers to the best conservative medication (except supervised exercise therapy [SET]) given to patients according to individual condition. SET includes programmed exercise plans that are performed under supervision.1 EVT directly improves the narrowing of arteries and has been proven to bring about lasting regression of the ischemic conditions in a significant number of patients.2 However, whether EVT can bring functional benefit to patients, especially compared to SET, is still controversial. In 2011, Ahimastos et al.3 conducted a meta-analysis of randomized trials assessing the efficacy of EVT compared to noninvasive therapies for the treatment of IC. They concluded that patients with IC may benefit from EVT during early and intermediate follow-up, with improvements in anklee brachial index (ABI) and treadmill walking, but there is no evidence that EVT alone provides improved outcomes over SET alone. However, this meta-analysis missed a trial conducted by Husmann et al.4 Also, 2 relatively recent randomized controlled trials (RCTs) with large sample sizes 977
978 Liu et al.
have been published.5,6 Therefore, an objective, comprehensive, up-to-date review to assess the value of EVT in the treatment for IC in patients with PAD is needed. The primary aim of this systematic review and meta-analysis is to assess the value of EVT objectively and comprehensively in the treatment for IC in patients with PAD.
METHODS
Annals of Vascular Surgery
short-term (20% of participants were missing from an outcome, sensitivity analysis was performed. Both RevMan (version 5.1; The Cochrane Collaboration, London, United Kingdom) and Stata/SE (version 12.0; StataCorp, LP, College Station, TX) software programs were used to carry out statistical analysis. Fixed effect meta-analyses were first used for combining data. While substantial statistical heterogeneity was detected, random effects analysis was used to produce an overall summary. The results were presented as the average treatment effect and its 95% confidence interval (CI). The T2 (tausquared), I2, and chi-squared statistics were used to assess statistical heterogeneity. Heterogeneity was considered if I2 was >50% or there was a low P value (
Background: We performed a systematic review and meta-analysis to examine whether patients with intermittent claudication can benefit from endovascular treatment (EVT). Methods: A prespecified search strategy was used to identify relevant studies in the MEDLINE, Embase, and Cochrane databases. A total of 10 different randomized, controlled trials were reviewed. Random effects meta-analysis was performed between the EVT plus conservative treatment (CT) group and the CT group alone. Also, random effects meta-analysis was performed between the EVT group and the supervised exercise therapy (SET) group. Results: The independent effect of EVT could directly improve the ankleebrachial index (ABI) and walking performance over the short term, but not over the long term. Moreover, compared to SET, EVT had the superiority in improving the ABI, while SET could improve walking performance more efficiently. Conclusions: Patients with intermittent claudication may benefit from endovascular treatment over the short term (within 12 months), with improvements in ABI, intermittent claudication distance, and maximum walking distance. However, considering improvements on walking performance (especially over the long term), SET is recommended.
INTRODUCTION Peripheral arterial disease (PAD) occurs mostly in the lower extremities and is caused by aortoiliac and/or femoropopliteal lesions. PAD of lower extremities most frequently presents with pain during ambulation, known as intermittent claudication (IC). IC is an early symptom of PAD that significantly impairs quality of life and should be taken seriously. Treatments of IC in PAD mainly include conservative treatment (CT) and endovascular
1 Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China. 2 Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
Correspondence to: Shenming Wang, MD, Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou 510080, China; E-mail: [email protected] Ann Vasc Surg 2014; 28: 977–982 http://dx.doi.org/10.1016/j.avsg.2013.05.022 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 4, 2013; manuscript accepted: May 13, 2013; published online: December 16, 2013.
treatment (EVT). Optimal medical treatment (OMT) refers to the best conservative medication (except supervised exercise therapy [SET]) given to patients according to individual condition. SET includes programmed exercise plans that are performed under supervision.1 EVT directly improves the narrowing of arteries and has been proven to bring about lasting regression of the ischemic conditions in a significant number of patients.2 However, whether EVT can bring functional benefit to patients, especially compared to SET, is still controversial. In 2011, Ahimastos et al.3 conducted a meta-analysis of randomized trials assessing the efficacy of EVT compared to noninvasive therapies for the treatment of IC. They concluded that patients with IC may benefit from EVT during early and intermediate follow-up, with improvements in anklee brachial index (ABI) and treadmill walking, but there is no evidence that EVT alone provides improved outcomes over SET alone. However, this meta-analysis missed a trial conducted by Husmann et al.4 Also, 2 relatively recent randomized controlled trials (RCTs) with large sample sizes 977
978 Liu et al.
have been published.5,6 Therefore, an objective, comprehensive, up-to-date review to assess the value of EVT in the treatment for IC in patients with PAD is needed. The primary aim of this systematic review and meta-analysis is to assess the value of EVT objectively and comprehensively in the treatment for IC in patients with PAD.
METHODS
Annals of Vascular Surgery
short-term (20% of participants were missing from an outcome, sensitivity analysis was performed. Both RevMan (version 5.1; The Cochrane Collaboration, London, United Kingdom) and Stata/SE (version 12.0; StataCorp, LP, College Station, TX) software programs were used to carry out statistical analysis. Fixed effect meta-analyses were first used for combining data. While substantial statistical heterogeneity was detected, random effects analysis was used to produce an overall summary. The results were presented as the average treatment effect and its 95% confidence interval (CI). The T2 (tausquared), I2, and chi-squared statistics were used to assess statistical heterogeneity. Heterogeneity was considered if I2 was >50% or there was a low P value (
