Combination of endovascular revascularization and supervised exercise therapy for intermittent claudication

BACKGROUND: Peripheral arterial disease is a major health concern in the Western world, often treated with endovascular revascularization (EVR) or supervised exercise therapy (SET). In this systematic review and meta-Analysis, we assessed the outcomes after combination treatment of EVRand SET, compared with EVR or SET alone.
EVIDENCE ACQUISITION: We performed a systematic search of Embase, Medline, Web of Science, Cochrane Central and Google Scholar. Only randomized controlled trials comparing combination treatment with EVR or SET only, for patients with intermittent claudication due to femoropopliteal or aortoiliac peripheral artery disease, were included. Primary outcome was maximum walking distance (MWD) at 6 and 12 months' follow-up. Secondary outcomes included pain-free walking distance (PFWD), quality of life and adverse events. Pooled estimates of difference in walking distance between EVR plus SET, EVR only and SET only were calculated using random effects models.
EVIDENCE SYNTHESIS: Our search yielded 812 articles, of which 7 were finally included in the systematic review. Three studies reported the outcomes of combination treatment versus SET and three more reported the outcomes of combination versus EVR. Follow-up ranged between 6 and 24 months. Combination treatment was associated with a greater MWDat 6 months compared to EVRonly or SET only, with a standardized mean difference (SMD) of 0.86 (95% CI: 0.15, 1.57) and 0.41 (95% CI: 0.17, 0.66), respectively. At twelve months no significant difference in maximum walking distance was observed between combination treatment compared to EVR(SMD0.96 [95% CI: -0.44, 2.37]) or SET (SMD0.52 [95% CI: -0.17, 1.20]). Compared to EVRonly, the combination treatment was associated with a greater PFWDwalking distance at 12 months (SMD0.73 [95% CI0.01, 1.45]). Most studies reported only minor differences in quality of life in favor of the combination treatment, or no difference at all.
CONCLUSIONS: Combination treatment of endovascular revascularization followed by SET shows a greater improvement in maximum walking distance at 6 months' follow-up compared to EVRonly or SET only, while this difference was no longer present after 12 months. (Cite this article as: Klaphake S, Buettner S, Ultee KH, van Rijn MJ, Hoeks SE, Verhagen HJ. Combination of endovascular revascularization and supervised exercise therapy for intermittent claudication: A systematic review and meta-Analysis.