title: Comparative Efficacy of Endovascular Revascularization Versus Supervised Exercise Training in Patients With Intermittent Claudication: Meta-Analysis of Randomized Controlled Trials.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Ambarish
authors.initials: A
authors.lastname: Pandey
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Subhash
authors.initials: S
authors.lastname: Banerjee
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Christian
authors.initials: C
authors.lastname: Ngo
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Purav
authors.initials: P
authors.lastname: Mody
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Steven P
authors.initials: SP
authors.lastname: Marso
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Emmanouil S
authors.initials: ES
authors.lastname: Brilakis
authors.affiliation: Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Denver, Colorado.
authors.forename: Ehrin J
authors.initials: EJ
authors.lastname: Armstrong
authors.affiliation: Cardiovascular Medicine Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Jay
authors.initials: J
authors.lastname: Giri
authors.affiliation: Divsion of Cardiovasular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Marc P
authors.initials: MP
authors.lastname: Bonaca
authors.affiliation: Divsion of Cardiovasular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Aruna
authors.initials: A
authors.lastname: Pradhan
authors.affiliation: Department of Medicine, University of Florida, Gainesville, Florida.
authors.forename: Anthony A
authors.initials: AA
authors.lastname: Bavry
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas. Electronic address: dharam@post.harvard.edu.
authors.forename: Dharam J
authors.initials: DJ
authors.lastname: Kumbhani
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D055109:Ankle Brachial Index; D003131:Combined Modality Therapy; D057510:Endovascular Procedures / Q000009:adverse effects; D019317:Evidence-Based Medicine; D005080:Exercise Test; D005081:Exercise Therapy / Q000009:adverse effects; D017079:Exercise Tolerance; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D020127:Recovery of Function; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D016138:Walking
keywords: exercise capacity; intermittent claudication; peripheral arterial disease; revascularization; supervised exercise training