Lower limb ischaemia – Related resources

Cochrane reviews

Drug therapy

• There is insufficient evidence on prostanoids for intermittent claudication .
• Prostanoids may have efficacy regarding rest-pain relief and ulcer healing in critical limb ischaemia, and iloprost may also have favourable results regarding major amputations .
• Buflomedil may improve pain free and maximum walking distance in intermittent claudication, but causes severe adverse effects at overdoses and has a narrow therapeutic range .
• Cilostazol compared with placebo appears to improve symptoms of peripheral arterial disease .
• Naftidrofuryl compared to placebo improves walking distance in intermittent claudication in the first six months after initiation of therapy .
• Anticoagulants (heparin, oral anticoagulants) are not beneficial in intermittent claudication .
• Reocclusion at 6 months following peripheral endovascular treatment may be reduced by use of antiplatelet drugs compared with placebo or control .
• Aspirin (ASA) or ASA/dipyridamole (DIP) improves infrainguinal bypass patency after peripheral artery bypass surgery .
• Vitamin K antagonists may improve venous but not artificial graft survival. Antiplatelet agents may improve artificial but not venous graft survival .
• Intra-arterial recombinant tissue plasminogen activator (rt-PA) might possibly be more effective than intra-arterial streptokinase or intravenous rt-PA in improving vessel patency in people with peripheral arterial occlusion although the evidence is insufficient .
• There is insufficient evidence to determine whether the choice of topical agent or dressing affects the healing of arterial leg ulcers .
• There is insufficient evidence on various anti-hypertensive drugs in people with peripheral arterial disease .
• Beta blockers may not cause significant worsening of symptoms or limb blood flow in patients with intermittent claudication.

Surgery

• Bypass surgery may be more effective than thrombolysis or thrombendarterectomy, and at least as effective as angioplasty in chronic lower limb ischaemia .
• There appears not to be difference in limb salvage or death at one year between initial surgery and initial thrombolysis for the management of acute limb ischaemia, but there is a higher incidence of major complications with thrombolysis, including stroke and major haemorrhage. The higher risk of complications must be balanced against individual risks in surgery .
• Lesions of the superficial femoral artery treated by percutaneous transluminal angioplasty (PTA) with stent insertion may have a small short term improvement in primary patency over lesions treated with PTA alone, but there seems not to be differences in quality of life .
• Cryoplasty might possibly not be more effective than conventional angioplasty in the treatment of peripheral vascular disease, but the evidence is insufficient .
• There is insufficient evidence on the benefits and harms of percutaneous transluminal angioplasty (PTA) and stenting compared to PTA alone in intermittent claudication .
• Peripheral artery brachytherapy as an adjunct to percutaneous transluminal angioplasty appears to be effective at improving the patency and preventing restenosis of femoropopliteal arteries in peripheral vascular disease .
• There is insufficient evidence on benefits of perioperative use of statins for noncardiac vascular surgery .

Others

• There is insufficient evidence of homocysteine lowering interventions on progression and outcomes for people with peripheral arterial disease (PAD) and hyperhomocysteinaemia .
• Garlic might possibly not be effective for peripheral arterial occlusive disease but the evidence is insufficient .
• Omega-3 fatty acids might possibly have no effect on clinical outcomes in people with intermittent claudication. They may have limited haematological benefits but also adverse effects such as nausea, diarrhoea and flatulence.
• Padma 28, a Tibetan herbal preparation, may improve short-term walking distance in patients with intermittent claudication. It may not have any effect on ankle brachial index .
• Spinal cord stimulation appears to be more effective than standard conservative treatment in non-reconstructable chronic leg ischaemia .

Other evidence summaries

• Iloprost appears to have a beneficial effect in patients with Fontaine stages III and IV peripheral occlusive arterial disease who have already failed attempt at arterial reconstitution and/or further reopening procedures are impossible. .
Defibrotide brings some advantage over placebo in walking distance in short-term studies in patients with intermittent claudication . Medical therapy, pentoxifylline in particular, can only modestly increase functional status in patients with moderate intermittent claudication .
• In patients with peripheral arterial disease, the combination of an oral anticoagulant and antiplatelet therapy is not more effective than antiplatelet therapy alone for preventing cardiovascular disease events and is associated with an increased risk for bleeding .
• Ginkgo biloba appears to have limited effect on symptoms of intermittent claudication .Angioplasty results in less patency compared with bypass surgery using saphenous vein, but in certain circumstances, equivalent patency compared with bypass surgery using polytetrafluoroethylene .
• Dupplex scanning is an accurate non-invasive test for the assessment of arterial occlusive disease of the lower extremities in patients with claudication or critical ischaemia .

Clinical guidelines

• European Stroke Organisation, Tendera M, Aboyans V et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011;32(22):2851-906.

Literature

Clinical practice reviews

• White C. Clinical practice. Intermittent claudication. N Engl J Med 2007 Mar 22;356(12):1241-50.

Other literature

• Perkins JM, Collin J, Creasy TS, Fletcher EW, Morris PJ. Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial. Eur J Vasc Endovasc Surg 1996 May;11(4):409-13.
• Norgren L, Hiatt WR, Dormandy JA et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg 2007;33 Suppl 1():S1-75.