For Intermittent Claudication, Exercise is Key—But Intervention, Surgery Have Their Place

NEW YORK, NY—Treating real-world patients with intermittent claudication means weighing the risks and benefits of revascularization, exercise, and medical therapy for a range of clinical presentations, according to interventionalists and vascular surgeons attending the VEITH Symposium. The question is, what approach should come first?

“The thing about claudication is that for most patients it’s an inconvenience, no more than that,” said Jonathan Beard, ChM, MEd, of the University of Sheffield (Sheffield, England), during a discussion at last week’s meeting. “But it is a great opportunity to treat their systemic disease from which they are going to die. For that reason, I will not provide any intervention to any claudicant unless they are prepared to commit themselves to exercise therapy and smoking cessation, if required.”

When to Stent, When to Exercise

Providing the interventionalist’s viewpoint for how these patients should be addressed, William A. Gray, MD, of Columbia University Medical Center (New York, NY), said he doesn’t rule out an intervention-first approach. First of all, however, he looks at the “degree and pattern of limitation. This will help me assess how aggressive I’m going to be in terms of the ultimate therapy I’m going to recommend.”

If patients are “really quite severe and quite limited” in terms of their mobility, and medication is unlikely to help, “then I like to offer revascularization as a primary therapy,” Gray said. “These patients don’t die of their limbs. They die of their hearts and heads. If they cannot walk for 20 to 30 minutes after some aggressive management, I typically will say they have failed the attempt at the nonrevascularization approach, and I would recommend revascularization.

Established practice for general and cardiovascular health mandates 30 minutes of continuous exercise at least 3 times per week, Gray pointed out. He believes it’s important that patients be able to do this exercise and if they can’t, he offers them revascularization.

As for whether the patient should be treated with surgery or an endovascular approach, Gray said that “all ties go to the endovascular approach due to lower morbidity and quicker recovery.”

But because his patient population is more complex than in the past, Gray said he currently “refer[s] for surgical revascularization more than I probably ever have.” In general, he opts to send a patient for surgery in the presence of multi-level disease, hyper-calcification, or multiple endovascular failures.

A More Conservative Approach

Giving the vascular surgeon’s perspective, Frank Pomposelli, MD, of St. Elizabeth’s Medical Center (Brighton, MA), admitted to Gray, “It’s kind of hard to say this, but I don’t disagree with most of what you said.”

There is, however, value in a wait-and-see approach. “Intermittent claudication, we know, has a relatively benign natural history,” Pomposelli said. “Only about 5% of patients over a 5-year period will progress to limb-threatening ischemia, and I think that’s always an important thing to remember in your decision making.”

The patient’s physical function should be the “primary consideration” in determining treatment, he continued, adding that if patient symptoms are particularly severe “they are not going to exercise their way out of it.” Of patients with mild or moderate symptoms—who comprise the majority of Pomposelli’s current patients— “some may ultimately come to intervention, but I think many of these patients definitely should be treated conservatively at first,” he said.

For patients who only fear amputation, reassurance may be all that is required on the part of the physician, Pomposelli suggested.

With that said, intermittent claudication should not be minimized “even though it’s not life threatening,” according to Pomposelli. “The loss of productivity, social isolation, worse quality of life, depression, [and] anxiety all can happen in some patients.” Moreover, assessing the patient “on their perception of their disability, not on the basis of my own personal biases or perspectives” is also key, he added.

The Middle Line Between Home, Supervised Exercise

Taking a closer look at the specifics of exercise therapy, Beard pointed out that exercise programs are “more cost-effective than revascularization and exercise plus revascularization may improve clinical effectiveness.”

The problem is that simply giving patients the advice to do more exercise “doesn’t work,” he said, explaining that supervised programs have a compliance problem, especially in the long-term. Additionally, home-based exercise programs are less costly, but “may be less effective,” Beard noted.

“Both suffer from a lack of immediate benefit,” he said. “They don’t have that quick fix, which is what patients want. But if you give them a quick fix right away they won’t exercise. That’s why exercise needs to be done first.”

Beard reviewed the results of an augmented home exercise program his team designed based on walking with Nordic poles, as published in the British Journal of Surgery in 2014. Among 38 patients who participated in a structured walking program 3 times a week for 30 minutes at a time, walking distance more than doubled compared to those assigned standard exercise over 3 months with increased improvement over 1 year.

“If you provide good psychological support, [outcomes are] excellent for both groups but it was almost 100% for [the Nordic pole group],” he summarized. “You try getting those poles off the patient afterwards. They will not give them back.”

An informal audience poll following the session indicated that about half of attendees readily treat their patients with intermittent claudication with an endovascular-first approach, while almost no one raised their hand to admit that surgery would be their default.