Comparative Efficacy of Endovascular Revascularization Versus Supervised Exercise Training in Patients With Intermittent Claudication: Meta-Analysis of Randomized Controlled Trials

Ambarish Pandey, Subhash Banerjee, Christian Ngo, Purav Mody, Steven P. Marso, Emmanouil S. Brilakis, Ehrin J. Armstrong, Jay Giri, Marc P. Bonaca, Aruna Pradhan, Anthony A. Bavry, Dharam J. Kumbhani

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Abstract

Objectives The authors performed a meta-analysis of randomized controlled trials to compare the efficacy of initial endovascular treatment with or without supervised exercise training (SET) versus SET alone in patients with intermittent claudication. Background Current guidelines recommend SET as the initial treatment modality for patients with intermittent claudication, in addition to optimal medical therapy. The role of endovascular therapy as primary treatment for claudication has been controversial. Methods The primary outcome was treadmill-measured maximal walk distance at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance on follow-up. Risk of revascularization or amputations was also compared. Pooled estimates of the difference in outcomes between endovascular therapy with or without SET and SET-only groups were calculated using fixed and random effects models. Results A total of 987 patients from 7 trials were included. In pooled analysis, compared with SET only (reference group), patients that underwent combined endovascular therapy and SET had significantly higher maximum walk distance (standardized mean difference 0.79 [95% confidence interval (CI): 0.18 to 1.39]; weighted mean difference 98.9 [95% CI: 31.4 to 166.4 feet], and lower risk of revascularization or amputation (odds ratio 0.19 [95% CI: (0.09 to 0.40]; p < 0.0001, number needed to treat = 8) over a median follow-up of 12.4 months. By contrast, revascularization was not associated with significant improvement in exercise capacity or risk of future revascularization or amputation, compared with SET alone. Follow-up ABI was significantly higher among patients that underwent endovascular therapy with or without SET as compared with SET alone. Conclusions Compared with initial SET only, endovascular therapy in combination with SET is associated with significant improvement in total walking distance, ABI, and risk of future revascularization or amputation. By contrast, endovascular therapy-only was not associated with any improvement in functional capacity or clinical outcomes over an intermediate duration of follow-up.

Original languageEnglish (US)
Pages (from-to)712-724
Number of pages13
JournalJACC: Cardiovascular Interventions
Volume10
Issue number7
DOIs
StatePublished - Apr 10 2017

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Intermittent Claudication
Meta-Analysis
Randomized Controlled Trials
Exercise
Amputation
Ankle Brachial Index
Therapeutics
Confidence Intervals
Numbers Needed To Treat
Walking

Keywords

  • exercise capacity
  • intermittent claudication
  • peripheral arterial disease
  • revascularization
  • supervised exercise training

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Comparative Efficacy of Endovascular Revascularization Versus Supervised Exercise Training in Patients With Intermittent Claudication : Meta-Analysis of Randomized Controlled Trials. / Pandey, Ambarish; Banerjee, Subhash; Ngo, Christian; Mody, Purav; Marso, Steven P.; Brilakis, Emmanouil S.; Armstrong, Ehrin J.; Giri, Jay; Bonaca, Marc P.; Pradhan, Aruna; Bavry, Anthony A.; Kumbhani, Dharam J.

In: JACC: Cardiovascular Interventions, Vol. 10, No. 7, 10.04.2017, p. 712-724.

Research output: Contribution to journalArticle

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abstract = "Objectives The authors performed a meta-analysis of randomized controlled trials to compare the efficacy of initial endovascular treatment with or without supervised exercise training (SET) versus SET alone in patients with intermittent claudication. Background Current guidelines recommend SET as the initial treatment modality for patients with intermittent claudication, in addition to optimal medical therapy. The role of endovascular therapy as primary treatment for claudication has been controversial. Methods The primary outcome was treadmill-measured maximal walk distance at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance on follow-up. Risk of revascularization or amputations was also compared. Pooled estimates of the difference in outcomes between endovascular therapy with or without SET and SET-only groups were calculated using fixed and random effects models. Results A total of 987 patients from 7 trials were included. In pooled analysis, compared with SET only (reference group), patients that underwent combined endovascular therapy and SET had significantly higher maximum walk distance (standardized mean difference 0.79 [95{\%} confidence interval (CI): 0.18 to 1.39]; weighted mean difference 98.9 [95{\%} CI: 31.4 to 166.4 feet], and lower risk of revascularization or amputation (odds ratio 0.19 [95{\%} CI: (0.09 to 0.40]; p < 0.0001, number needed to treat = 8) over a median follow-up of 12.4 months. By contrast, revascularization was not associated with significant improvement in exercise capacity or risk of future revascularization or amputation, compared with SET alone. Follow-up ABI was significantly higher among patients that underwent endovascular therapy with or without SET as compared with SET alone. Conclusions Compared with initial SET only, endovascular therapy in combination with SET is associated with significant improvement in total walking distance, ABI, and risk of future revascularization or amputation. By contrast, endovascular therapy-only was not associated with any improvement in functional capacity or clinical outcomes over an intermediate duration of follow-up.",
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T2 - Meta-Analysis of Randomized Controlled Trials

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AU - Banerjee, Subhash

AU - Ngo, Christian

AU - Mody, Purav

AU - Marso, Steven P.

AU - Brilakis, Emmanouil S.

AU - Armstrong, Ehrin J.

AU - Giri, Jay

AU - Bonaca, Marc P.

AU - Pradhan, Aruna

AU - Bavry, Anthony A.

AU - Kumbhani, Dharam J.

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N2 - Objectives The authors performed a meta-analysis of randomized controlled trials to compare the efficacy of initial endovascular treatment with or without supervised exercise training (SET) versus SET alone in patients with intermittent claudication. Background Current guidelines recommend SET as the initial treatment modality for patients with intermittent claudication, in addition to optimal medical therapy. The role of endovascular therapy as primary treatment for claudication has been controversial. Methods The primary outcome was treadmill-measured maximal walk distance at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance on follow-up. Risk of revascularization or amputations was also compared. Pooled estimates of the difference in outcomes between endovascular therapy with or without SET and SET-only groups were calculated using fixed and random effects models. Results A total of 987 patients from 7 trials were included. In pooled analysis, compared with SET only (reference group), patients that underwent combined endovascular therapy and SET had significantly higher maximum walk distance (standardized mean difference 0.79 [95% confidence interval (CI): 0.18 to 1.39]; weighted mean difference 98.9 [95% CI: 31.4 to 166.4 feet], and lower risk of revascularization or amputation (odds ratio 0.19 [95% CI: (0.09 to 0.40]; p < 0.0001, number needed to treat = 8) over a median follow-up of 12.4 months. By contrast, revascularization was not associated with significant improvement in exercise capacity or risk of future revascularization or amputation, compared with SET alone. Follow-up ABI was significantly higher among patients that underwent endovascular therapy with or without SET as compared with SET alone. Conclusions Compared with initial SET only, endovascular therapy in combination with SET is associated with significant improvement in total walking distance, ABI, and risk of future revascularization or amputation. By contrast, endovascular therapy-only was not associated with any improvement in functional capacity or clinical outcomes over an intermediate duration of follow-up.

AB - Objectives The authors performed a meta-analysis of randomized controlled trials to compare the efficacy of initial endovascular treatment with or without supervised exercise training (SET) versus SET alone in patients with intermittent claudication. Background Current guidelines recommend SET as the initial treatment modality for patients with intermittent claudication, in addition to optimal medical therapy. The role of endovascular therapy as primary treatment for claudication has been controversial. Methods The primary outcome was treadmill-measured maximal walk distance at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance on follow-up. Risk of revascularization or amputations was also compared. Pooled estimates of the difference in outcomes between endovascular therapy with or without SET and SET-only groups were calculated using fixed and random effects models. Results A total of 987 patients from 7 trials were included. In pooled analysis, compared with SET only (reference group), patients that underwent combined endovascular therapy and SET had significantly higher maximum walk distance (standardized mean difference 0.79 [95% confidence interval (CI): 0.18 to 1.39]; weighted mean difference 98.9 [95% CI: 31.4 to 166.4 feet], and lower risk of revascularization or amputation (odds ratio 0.19 [95% CI: (0.09 to 0.40]; p < 0.0001, number needed to treat = 8) over a median follow-up of 12.4 months. By contrast, revascularization was not associated with significant improvement in exercise capacity or risk of future revascularization or amputation, compared with SET alone. Follow-up ABI was significantly higher among patients that underwent endovascular therapy with or without SET as compared with SET alone. Conclusions Compared with initial SET only, endovascular therapy in combination with SET is associated with significant improvement in total walking distance, ABI, and risk of future revascularization or amputation. By contrast, endovascular therapy-only was not associated with any improvement in functional capacity or clinical outcomes over an intermediate duration of follow-up.

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