Evaluating the Added Value of Combined Revascularization and Supervised Exercise Therapy in Symptomatic Peripheral Artery Disease: A Systematic Review and Meta-Analysis with a Focus on Functional and Patient-Reported Outcomes.

BACKGROUND

Peripheral artery disease (PAD) affects over 236 million individuals globally and remains a major cause of functional limitation, disability, and limb loss. In symptomatic PAD, reduced lower limb perfusion leads to intermittent claudication and diminished quality of life. This systematic review and meta-analysis aimed to determine whether combining revascularization with supervised exercise therapy (SET) yields superior clinical outcomes compared to either treatment alone in patients with Fontaine stage II-III PAD.

METHODS

A comprehensive search of Medline, Embase, Cochrane Central, and Web of Science was performed on October 4, 2024. Randomized controlled trials comparing combined revascularization and SET versus revascularization or SET alone were included. Primary outcome was the maximum walking distance (MWD). Secondary outcomes were pain-free walking distance (PFWD), ankle-brachial index (ABI), health-related quality of life assessed by Short Form Health Survey (SF-36) physical and mental health scores, and vascular reintervention at 12 months. Meta-analyses used random-effects models. Risk of bias was assessed using the Cochrane RoB 2 tool, and the certainty of evidence was evaluated using the GRADE framework.

RESULTS

Seven trials met the inclusion criteria, enrolling 712 patients. Combined therapy significantly improved MWD (mean difference [MD] 106.35 m; 95% confidence interval [CI], 46.54-166.17), PFWD (MD 166.24 m; 95% CI, 16.29-316.18), and SF-36 mental health score (MD 4.11; 95% CI, 3.45-4.77). No significant differences were observed for ABI (MD 0.10; 95% CI, 0.00-0.19), SF-36 physical health score (MD 5.13; 95% CI, -6.88 to 17.14), or subsequent intervention rates (odds ratio 0.32; 95% CI, 0.08-1.39). Heterogeneity in exercise intervention and outcome definitions represented limitations.

CONCLUSION

In symptomatic PAD, the combination of revascularization with SET may yield additional improvements in walking performance and mental health compared to monotherapy. However, these findings are tempered by methodological limitations, including high risk of bias and heterogeneity, underscoring the need for further high-quality randomized trials.