Clinical Decisionmaking

Vascular surgery works better than medication alone to improve functioning of patients with peripheral vascular disease

Lower extremity bypass grafting surgery and angioplasty have traditionally been reserved for patients with limb-threatening ischemia (poor circulation to the feet), usually signaled by leg pain at rest, gangrene, or skin ulcers. However, vascular surgeons are seeing increasing numbers of older patients who have difficulty walking due to mild or moderate lower extremity arterial occlusive disease. In these patients, pain and weakness often occur during walking but then subside after a period of rest. These peripheral vascular disease patients may also benefit from revascularization procedures, according to a new study supported by the Agency for Healthcare Research and Quality (HS07184).

The researchers found that on average patients who underwent these procedures reported significant improvement over 18 months of followup in physical functioning (14 to 17 percent), bodily pain (13 to 18 percent), and the distance they were able to walk (22 to 28 percent). They also reported fewer leg symptoms than similar patients who received medication only. These gains were much higher for the 60 percent of patients who had "technically successful" procedures and much more modest for the 40 percent of patients with little improvement in blood flow after the procedure. While most patients who received medication only declined on all outcome measures, the subgroup of patients who were most disabled at baseline improved 5 percent on the walking distance score.

Most of the functional improvement achieved by patients who underwent revascularization procedures appeared to be related to surgical or endovascular treatment of leg blood vessels, explains Joe Feinglass, Ph.D. He and colleagues at Northwestern University Medical School prospectively studied the outcomes of 526 patients seen at 16 Chicago-area vascular surgery clinics who had abnormal ankle-brachial blood pressure index (ABI, an indicator of the severity of lower extremity vascular disease) without signs of rest pain, ulcer, or gangrene and without prior lower extremity revascularization procedures. They compared the outcomes of patients undergoing revascularization with those of patients receiving medication only.

See "Functional status and walking ability after lower extremity bypass grafting or angioplasty for intermittent claudication: Results from a prospective outcomes study," by Dr. Feinglass, Walter J. McCarthy, M.D., Rael Slavensky, R.N., M.A., and others, in the January 2000 Journal of Vascular Surgery 31, pp. 93-103.

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