Intermittent Claudication and Asymptomatic Peripheral Arterial Disease

Abstract

eripheral arterial disease (PAD) is caused by atherosclerotic lesions in the pelvic and leg arteries. The incidence of atherogenic risk factors is rising worldwide (1), mainly due to the increasing age of the population. PAD is the third most common sequelae of arteriosclerosis after coronary heart disease and cerebrovascular diseases (1, 2). As a marker disease, it points to a high cardiovascular risk (3). It advances in stages (Table), initially causing a reduction in pain-free walking distance (intermittent claudication, IC), which impairs quality of life and ability to work. At the stage of critical limb ischemia (CLI), pain at rest occurs, followed ultimately by tissue necrosis and amputation. The majority of symptomatic PAD patients suffer from IC (4). Current guidelines (3-8) recommend lifestyle changes and risk factor management for all stages of PAD. In IC, vasoactive drugs and supervised exercise training (SET) are considered standard to achieve risk-free improvement in walking distance. Revascularization (percutaneous transluminal angioplasty [PTA]/stenting, vascular surgery) is not recommended at the asymptomatic stage, is recommended only in exceptional cases in IC (e.g., if conservative treatment fails), but is urgently recommended in CLI. Angioplasty for IC is not known to achieve better medium-and long-term outcomes compared to SET (3, 9). Unfortunately, in Germany as well as other countries (9), SET remains a largely theoretical option that is unachievable in a practical sense. Therefore, SET cannot be used as a yardstick for the results of arterial revascularization. Moreover, although revascularized patients are relieved of their symptoms in the immediate and longer term, most clinical studies have compared only the medium-and long-term benefit to SET. The primary objective of this review article is to investigate whether guideline-compliant conservative treatment for IC can be recommended as an evidencebased approach in view of its limited efficacy, availability, practicability, and acceptance among patients. In light of the treatment reality in Germany, the benefit of arterial revascularization in IC is evaluated, particularly in combination with SET. Methods In 2014, the German Society for Angiology (Deutsche Gesellschaft für Angiologie) performed an extensive Summary Background: The conservative treatment of peripheral arterial disease (PAD), as recommended in current guidelines, encompasses measures such as lifestyle modification and risk-factor management. In addition, in patients with vasogenic intermittent claudication (IC), it is recommended that patients first be given drugs to improve perfusion and undergo supervised gait training. Revascularization is not recommended for asymptomatic persons, but it is considered mandatory for patients with critical ischemia. In this article on conservative and revascularizing treatment strategies for IC, we address the following questions: whether all treatment options are available, how effective they are, and whether the reality of treatment for ...

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