Supervised exercise as good as surgery for intermittent claudication due to iliac artery obstruction

International guidelines recommend supervised exercise therapy (SET) as primary treatment for all patients with intermittent claudication (IC), yet primary endovascular revascularisation (ER) might be more effective in patients with iliac artery obstruction.

This was a multicentre RCT including patients with intermittent claudication (IC) caused by iliac artery stenosis or occlusion (NCT01385774). Patients were allocated randomly to supervised exercise therapy (SET) or endovascular revascularisation (ER) stratified for maximum walking distance (MWD) and concomitant SFA disease. Primary endpoints were maximum walking distance (MWD) on a treadmill (3.2 km/h, 10% incline) and disease specific quality of life (VascuQol) after one year. Additional interventions during a mean follow up of 5.5 years were recorded.

The results of the study are:

• Between November 2010 and May 2015, 114 patients were allocated to supervised exercise therapy (SET), and 126 to endovascular revascularisation (ER). The trial was terminated prematurely after 240 patients were included.
• Compliance with supervised exercise therapy (SET) was 57/114 (50%) after six months.
• Ten patients allocated to endovascular revascularisation (ER) (8%) did not receive this intervention. One year follow up was complete for 90/114 (79%) supervised exercise therapy (SET) patients and for 104/126 (83%) endovascular revascularisation (ER) patients.
• The mean maximum walking distance (MWD) improved from 187 to 561 m in SET patients and from 196 to 574 m in endovascular revascularisation (ER) patients (p = .69). VascuQol sumscore improved from 4.24 to 5.58 in SET patients, and from 4.28 to 5.88 in ER patients (p = .048). Some 33/114 (29%) supervised exercise therapy (SET) patients had an endovascular revascularisation (ER) within one year, and 2/114 (2%) surgical revascularisation (SR). Some 10/126 (8%) ER patients had additional endovascular revascularisation (ER) within one year and 10/126 (8%) surgical revascularisation (SR).
• After a mean of 5.5 years, 49% of supervised exercise therapy (SET) patients and 27% of endovascular revascularisation (ER) patients underwent an additional intervention for intermittent claudication (IC).

Thus, taking into account the many limitations of the SUPER study, both a strategy of primary supervised exercise therapy (SET) and primary endovascular revascularisation (ER) improve maximum walking distance (MWD) on a treadmill and disease specific Qol of patients with intermittent claudication (IC)caused by an iliac artery obstruction. It seems reasonable to start with supervised exercise therapy (SET) in these patients and accept a 30% failure rate, which, of course, must be discussed with the patient. Patients continue to have interventions beyond one year.

Reference:

Editor's Choice – Randomised Clinical Trial of Supervised Exercise Therapy vs. Endovascular Revascularisation for Intermittent Claudication Caused by Iliac Artery Obstruction: The SUPER study by Mark J.W. Koelemay et al. published in the European Journal of Vascular and Endovascular Surgery.

DOI: https://doi.org/10.1016/j.ejvs.2021.09.042