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UrduPAD occurs when the arteries that carry blood away from the heart to the head, arms, legs and feet become narrow due to a build-up of fatty plaque. According to the American Heart Association, PAD affects more than 200 million people worldwide and causes pain, cramping or weakness in the legs and feet when walking. In 11% of people with PAD, the lack of blood flow can lead to chronic limb-threatening ischemia (CLTI) where people experience pain even when resting. Left untreated, tissue damage in the leg may result in amputation. PAD has a significant impact on a person’s health status and quality of life, such as limiting their ability to walk without pain and engage in leisure or social activities. A recent American Heart Association scientific statement on PAD quality of care reports that the negative impact of PAD on a person’s daily life “cannot be overstated.”
This is the first-ever randomized controlled trial of this scale, and it is a landmark effort in its breadth and depth,” said lead study author Matthew Menard, M.D., an associate professor of surgery at Harvard Medical School, and co-director of endovascular surgery at the Brigham and Women’s Hospital, both in Boston. “The large body of high-quality evidence that guides treatment of heart disease and stroke does not exist for PAD, and until now, there has been almost no data to inform the care of CLTI patients. Our hope is that this study may serve as a benchmark for future efforts in treating this particularly vulnerable patient population.”
A common treatment for people with high amputation risk due to PAD is leg bypass surgery, during which a passage around the blocked arteries is created using a patient’s leg vein or an artificial blood vessel. Alternatively, a less invasive approach is angioplasty with or without stenting during which a thin balloon-tipped catheter is inserted into the blockage to widen it, and a stent is placed to keep the artery open. Balloon angioplasty and stenting are also known as “endovascular” procedures.
The Best Endovascular versus Best Surgical Therapy for Patients with Chronic Limb Threatening Ischemia (BEST-CLI) Trial enrolled 1,830 people with severe PAD at 150 centers in the U.S., Canada, Italy, Finland and New Zealand. The first part of the trial compared safety, the need for repeat procedures and amputations between people who had an endovascular procedure and those who had bypass surgery. That part of the study found that people who have bypass surgery with their own leg vein as the bypass vessel had better results compared to those who had an endovascular procedure.
In this segment of the trial, BEST-CLI Trial: Quality of Life Analyses, researchers assessed the health-related quality of life for those who underwent either treatment.
To measure the health-related quality of life, researchers surveyed participants at the beginning of the study and at six follow-up visits over the four years after their surgery or procedure. The surveys asked about pain, activities of daily living, disease symptoms and severity, physical activity level and mental health (anxiety and depression). The questionnaires included in the survey were the VascuQOL for detecting changes in PAD severity; the European Quality of Life 5D to assess general quality of life, including mobility, self-care and usual activities; the Short Form 12 to assess daily living; and a numerical scale (1 – 10) to rate pain severity.
The study participants were adults aged 67 years on average, 28% were female and 72% were white. Participants included 36% who smoked cigarettes; 69% with diabetes (with and without insulin dependence); and 11% with end-stage kidney disease. About 22% reported leg pain at rest as a primary symptom.
The researchers found that quality-of-life scores were low at the beginning of the study, reflecting the notably poor health status and well-being of patients with CLTI, and pain levels were high. After surgery or an endovascular procedure, pain scores decreased substantially, and quality-of-life scores increased for all participants across all measures used for assessment.
“We anticipated low levels of quality of life at the beginning of the study due to the pain and other life-altering symptoms associated with chronic limb-threatening ischemia,” said Menard. “Improvement in health-related quality-of-life measures regardless of the type of procedure is very encouraging and highlights the importance of timely restoration of blood flow to the leg and foot.“
Menard noted there were a few differences in scores initially between the two study groups favoring endovascular repair, possibly reflecting the longer recovery time from surgical bypass, however, the differences were minor and leveled out over time.
“The quality-of-life data are a nice complement to the clinical results and suggest that both revascularization strategies may effectively improve a patient’s quality of life. So, while there is still much work to be done, and quality-of-life measures have not always been the focus in past PAD research, this is an important step forward.”
The study had some limitations including that there was little existing data to build upon. Additionally, the quality-of-life questionnaires were not all specific for vascular patients, and there were fewer female participants than expected according to the study goals, so conclusions cannot be drawn about sex differences.
Co-authors are Alik Farber, M.D., M.B.A.; Kenneth Rosenfield, M.D., FAHA; Taye Hamza, Ph.D.; Mark J. Cziraky, Pharm.D., FAHA; and Niteesh Choudhry, M.D., Ph.D. Authors’ disclosures are listed in the abstract.
The study was funded initially by the National Heart, Lung, and Blood Institute, a division of the National Institutes of Health. Funding during the follow-up period (2019-2021) was provided by Vascular InterVentional Advances (VIVA), the Society for Vascular Surgery, the New England Society for Vascular Surgery, the Western Vascular Society, the Eastern Vascular Society, the Midwest Vascular Surgery Society, the Southern Association of Vascular Surgeons, the Canadian Society for Vascular Surgery, the Society for Clinical Vascular Surgery, the Society of Interventional Radiology, the Vascular and Endovascular Surgery Society, the Society for Vascular Medicine, Janssen, Gore; Becton Dickinson and Company, Medtronic, Cook, Boston Scientific, Abbott, Cordis, and Cardiovascular Systems, Inc.
Statements and conclusions of studies that are presented at the American Heart Association’s scientific meetings are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. Abstracts presented at the Association’s scientific meetings are not peer-reviewed, rather, they are curated by independent review panels and are considered based on the potential to add to the diversity of scientific issues and views discussed at the meeting. The findings are considered preliminary until published as a full manuscript in a peer-reviewed scientific journal.
The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.
Additional Resources:
- Multimedia is available on the right column of the release link https://newsroom.heart.org/news/restored-blood-flow-meant-less-pain-better-quality-of-life-for-those-with-leg-artery-disease?preview=e24182a4fbe8db80a1301aaf29a19e8d
- Link to abstract; and AHA Scientific Sessions 2022 Online Program Planner
- AHA Guideline: 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary
- AHA health information: Why PAD Matters
- The PAD National Action Plan, developed by the AHA and 25 other organizations, is a guide to assist in preventing PAD complications and improving the quality of life for people living with PAD.
- For more news at AHA Scientific Sessions 2022, follow us on Twitter @HeartNews #AHA22
The American Heart Association’s Scientific Sessions 2022 is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science. The 3-day meeting will feature more than 500 sessions focused on breakthrough cardiovascular basic, clinical and population science updates occurring Saturday through Monday, November 5-7, 2022. Thousands of leading physicians, scientists, cardiologists, advanced practice nurses and allied health care professionals from around the world will convene virtually to participate in basic, clinical and population science presentations, discussions and curricula that can shape the future of cardiovascular science and medicine, including prevention and quality improvement. During the three-day meeting, attendees receive exclusive access to more than 4,000 original research presentations and can earn Continuing Medical Education (CME), Continuing Education (CE) or Maintenance of Certification (MOC) credits for educational sessions. Engage in Scientific Sessions 2022 on social media via #AHA22.
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