Supervised Exercise Therapy and Revascularization for Intermittent Claudication: Network Meta-Analysis of Randomized Controlled Trials

Abstract Objectives The aim of this study was to perform a comprehensive meta-analysis comparing all therapeutic modalities for intermittent claudication (IC), including best medical therapy (BMT) alone, percutaneous angioplasty (PTA), supervised exercise therapy (SET), and PTA combined with SET, to establish the optimal first-line treatment for IC. Background IC is a common health problem that limits physical activity, results in decreased quality of life (QoL) and is associated with poor cardiovascular outcomes. Previous meta-analyses have attempted to combine data from randomized trials; however, none have combined data from all possible treatment combinations or synthesized QoL outcomes. Methods Following a systematic review of the published research (conducted in December 2018) that identified 37 published randomized trials, a network meta-analysis was performed combining all possible IC treatment strategies. Results Overall, 2,983 patients with IC were included (mean weighted age 68 years, 54.5% men). Comparisons were performed between BMT (688 patients, 28 arms) versus SET (1,189 patients, 35 arms) versus PTA (511 patients, 12 arms) versus PTA plus SET (395 patients, 8 arms). Mean weighted follow-up was 12 months (95% confidence interval: 9 to 23 months). Compared with BMT alone, PTA plus SET outperformed other treatment strategies, with a maximum walking distance gain of 290 m (95% credible interval: 180 to 390 m; p  Conclusions In addition to BMT, PTA combined with SET seems to be the optimal first-line treatment strategy for IC in terms of maximum walking distance and QoL improvement.