The treatment of disabling intermittent claudication in patients with superficial femoral artery occlusive disease--decision analysis.
OBJECTIVE
To determine the preferred approach to superficial femoral artery (SFA) revascularization of Trans-Atlantic Inter-Societal Consensus (TASC) B and C lesions in claudicants requiring intervention based on a review of published data.


METHODS
Decision analysis, Markov state transition model.


METHODS
Hypothetical cohorts of claudicants with TASC B or TASC C superficial femoral artery lesions considered candidates for either angioplasty with selective stenting (PTA/S) or greater saphenous vein bypass (GSVB).


METHODS
Quality adjusted life years (QALYs).


RESULTS
For a 65-year-old man with disabling claudication, percutaneous transluminal angioplasty and selective stenting (PTA/S) was preferred over GSVB for a TASC B SFA lesion. In an otherwise identical patient with a TASC C lesion, bypass was the preferred therapy. Treating PTA/S failures with subsequent bypass increased the utility of PTA/S but bypass remained the preferred initial therapy for TASC C lesions. Sensitivity analysis showed that PTA/S surpasses bypass efficacy for TASC C lesions if PTA/S primary patency is >32% at 5 years, patient age is >80 years, or GSVB operative mortality is >6%.


CONCLUSIONS
PTA/S is the preferred initial therapy over GSVB for TASC B SFA lesions in patients with disabling intermittent claudication who require intervention. Given contemporary published outcomes for TASC C lesions, GSVB is the preferred therapy in operative candidates. In elderly patients or patients at high risk for bypass, PTA/S should be considered over GSVB. Improved technology that results in a 5-year primary patency of 32% would also justify PTA/S for TASC C SFA lesions.
Nolan
Brian
B
Center for Evaluative Clinical Sciences, Dartmouth Medical School, Division of Vascular Surgery Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA. Brian.Nolan@Hitchcock.org
Finlayson
Samuel
S
Tosteson
Anna
A
Powell
Richard
R
Cronenwett
Jack
J
D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000401:mortality; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D003198:Computer Simulation; D003661:Decision Support Techniques; D004185:Disability Evaluation; D005263:Femoral Artery / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D007383:Intermittent Claudication / Q000209:etiology* / Q000628:therapy; D008297:Male; D008390:Markov Chains; D009010:Monte Carlo Method; D018579:Patient Selection; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment; D012501:Saphenous Vein / Q000637:transplantation; D012720:Severity of Illness Index; D015607:Stents; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality