Randomized clinical trial of percutaneous transluminal angioplasty, supervised exercise and combined treatment for intermittent claudication due to femoropopliteal arterial disease

  • Author: F. A. K. Mazari, J. A. Khan, D. Carradice, N. Samuel, M. N. A. Abdul Rahman, S. Gulati, H. L. D. Lee, T. A. Mehta, P. T. McCollum, I. C. Chetter

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Sir
We read with interest the randomized clinical trial of percutaneous transluminal angioplasty (PTA), supervised exercise (SET) and combined treatment for intermittent claudication due to femoropopliteal arterial disease by Mazari et al. We were pleased to read that SET was suggested as an alternative treatment for peripheral arterial disease. 
 
However its conclusions might be questioned considering several issues in the provided SET. In our opinion SET was not optimized according to recent literature. Nicolai et al. suggested that SET should consists of training sessions lasting over at least 30 minutes during the first 12 weeks which is later tailored to the patient's needs (1). Moreover, SET should focus on increasing maximum walking distance, aerobic endurance, increasing pain tolerance and inducing lifestyle changes – with specific attention to smoking cessation and medication compliance. Inducement of life style changes are an essential benefit of SET compared to PTA alone. It is likely we think that the provided exercise program (closed-circuit training, each lasting for 2 min) is relatively insufficient and negatively impacts the outcome results.
 
Furthermore, is it possible that the described lack of a significant difference at 12 months in ICD and MWD can be explained by a ceiling effect of the used treadmill protocol. We found that use of a graded treadmill protocol instead of a fixed one, leads to higher reliability (2).
Finally, only unilateral patients were selected, whereas treatment possibilities should be translated to a more diverse patient group.
H. Fokkenrood, MD, MSc; R. de Bie, PhD; J. Teijink, MD, PhD
Catharina Ziekenhuis Eindhoven
Michelangelolaan 2
Eindhoven 5623EJ
The Netherlands
References
1) Nicolaï SP, Viechtbauer W, Kruidenier LM, Candel MJ, Prins MH, Teijink JA. Reliability of treadmill testing in peripheral arterial disease: a meta-regression analysis. J Vasc Surg. 2009 Aug;50(2):322-9
 
2) Nicolaï SP, Hendriks EJ, Prins MH, Teijink JA, EXITPAD study group; Optimizing supervised exercise therapy for patients with intermittent claudication. J Vasc Surg. 2010 Nov;52(5):1226-33. Epub 2010 Aug 8.
  • Commentor: H Fokkenrood - Catharina Ziekenhuis eindhoven
  • Date: Jan 17, 2012