Long-term outcomes following endovascular and surgical revascularization for peripheral artery disease: a propensity score-matched analysis.

AIMS: Peripheral artery disease (PAD) revascularization can be performed by either endovascular or open surgical approach. Despite increasing use of endovascular revascularization, it is still uncertain which strategy yields better long-term outcomes. METHODS AND RESULTS: This retrospective cohort study evaluated patients hospitalized with PAD in Australia and New Zealand who underwent either endovascular or surgical revascularization between 2008 and 2015, and compared procedures using a propensity score-matched analysis. Hybrid interventions were excluded. The primary endpoint was mortality or major adverse limb events (MALE), defined as a composite endpoint of acute limb ischaemia, urgent surgical or endovascular reintervention, or major amputation, up to 8 years post-hospitalization using time-to-event analyses 75 189 patients fulfilled eligibility (15 239 surgery and 59 950 endovascular), from whom 14 339 matched pairs (mean ± SD age 71 ± 12 years, 73% male) with good covariate balance were identified. Endovascular revascularization was associated with an increase in combined MALE or mortality [hazard ratio (HR) 1.13, 95% confidence interval (CI): 1.09-1.17, P < 0.001]. There was a similar risk of MALE (HR 1.04, 95% CI: 0.99-1.10, P = 0.15), and all-cause urgent rehospitalizations (HR 1.01, 95% CI: 0.98-1.04, P = 0.57), but higher mortality (HR 1.16, 95% CI: 1.11-1.21, P < 0.001) when endovascular repair was compared to surgery. In subgroup analysis, these findings were consistent for both claudication and chronic limb-threatening ischaemia presentations. CONCLUSION: Although the long-term risk of MALE was comparable for both approaches, enduring advantages of surgical revascularization included lower long-term mortality. This is at odds with some prior PAD studies and highlights contention in this space.

A systematic review and meta-analysis of gender differences in long-term mortality and cardiovascular events in peripheral artery disease.

OBJECTIVE: Individual studies of peripheral artery disease (PAD) have indicated that gender discrepancies exist in the symptoms, functional status, and treatment usage. It remains uncertain whether these discrepancies result in different long-term outcomes. We examined the potential gender differences in mortality and major adverse cardiovascular events (MACE) in patients with symptomatic PAD. METHODS: The PubMed and Embase databases were searched for studies from 2000 to January 2019. After a review of 13,582 citations, 14 articles were analyzed. The reported age-adjusted hazard ratios (HRs) for gender differences in mortality and MACE were included in the meta-analysis. The mortality outcomes were stratified according to the clinical presentation and study context. RESULTS: Male gender was associated with a greater risk of all-cause mortality (HR, 1.13; 95% confidence interval [CI], 1.10-1.16; P < .001) and MACE (HR, 1.10; 95% CI, 1.06-1.14; P < .001). In a stratified analysis, male gender was associated with a higher mortality risk for patients presenting with either critical limb ischemia (HR, 1.08; 95% CI, 1.05-1.10; P < .001) or mixed clinical presentations (HR, 1.16; 95% CI, 1.11-1.21; P < .001) but not for those with intermittent claudication (HR, 1.13; 95% CI, 0.98-1.30; P = .09). Elevated mortality risk was evident after revascularization (HR, 1.11; 95% CI, 1.04-1.19; P = .003), hospitalization (HR, 1.15; 95% CI, 1.08-1.22; P < .001), and amputation (HR, 1.09; 95% CI, 1.08-1.10; P < .001), although not in outpatient clinics (HR, 1.13; 95% CI, 0.97-1.32; P = .13), in men compared with women. CONCLUSIONS: Greater mortality and MACE rates in men with PAD occurred despite other accepted gender disparities. The mechanisms underlying these gender differences in the outcomes for PAD patients require further investigation.

Medical and lifestyle management of peripheral arterial disease.

OBJECTIVE: Peripheral arterial disease (PAD) is a global health issue associated with impaired functional capacity and elevated risk of major adverse cardiovascular events (MACEs). With changing risk factor profiles and an aging population, the burden of disease is expected to increase. This review considers evidence for the noninvasive management of PAD and makes clinical recommendations accordingly. METHODS: A comprehensive literature review was performed to examine the evidence for smoking cessation, exercise therapy, antiplatelet therapy, anticoagulant therapy, antihypertensive therapy, lipid-lowering therapy, and glycemic control in diabetes for patients with PAD. RESULTS: Nicotine replacement, bupropion, and varenicline are safe and more effective than placebo in achieving smoking abstinence. Wherever it is practical and available, supervised exercise therapy is ideal treatment for intermittent claudication. Alternatively, step-monitored exercise can increase walking performance and the participant's compliance with less staff supervision. Clopidogrel is preferable to aspirin alone for all patients. However, small studies support the use of dual antiplatelet therapy after revascularization to improve limb outcomes. More recently, the addition of low-dose rivaroxaban to aspirin alone was proven to be more effective in reducing MACEs without a significant increase in major bleeding. However, the exact role of direct oral anticoagulant therapy in the management of PAD is still being understood. Evidence is emerging for more intensive blood pressure and lipid-lowering therapy than traditional targets. Whereas research in PAD is limited, there is clinical scope for an individualized approach to these risk factors. The management of diabetes remains challenging as glycemic control has not been demonstrated to improve macrovascular outcomes. Any potential impact of glycemic control on microvascular disease needs to be weighed against the risks of hypoglycemia. Sodium-glucose cotransporter 2 inhibitors appear to reduce MACEs, although caution is advised, given the increased incidence of lower limb amputation in clinical trials of canagliflozin. CONCLUSIONS: Medical and lifestyle management of PAD should aim to improve functional outcomes and to reduce MACEs. Smoking cessation counseling or pharmacotherapy is recommended, although new strategies are needed. Whereas supervised exercise therapy is ideal, there can be barriers to clinical implementation. Other initiatives are being used as an alternative to walking-based supervised exercise therapy. More studies are required to investigate the role of intensive glycemic, blood pressure, and dyslipidemia control in patients with PAD. Overall, a multifactorial approach is recommended to alter the natural history of this condition.