Print this pageThe Treatment Of Disabling Intermittent Claudication In Patients With Superficial Femoral Artery Occlusive Disease - Decision Analysis
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Brian Nolan*, Samuel Finlayson*, Richard Powell, Jack Cronenwett
Dartmouth Hitchcock Medical Center, Lebanon, NH
Introduction: While percutaneous translumenal angioplasty and stenting (PTA/S) of the superficial femoral artery (SFA) in patients with intermittent claudication (IC) is associated with low morbidity, its durability relative to femoropopliteal bypass is considered inferior. We have applied decision analysis modeling to integrate short and long term risks and benefits of PTA/S and bypass for TASC B and C SFA lesions. Methods: A multistate transition model (Markov process) was developed to simulate hypothetical patient cohorts considered candidates for either SFA PTA/S or bypass. Cohorts were followed to estimate the quality-adjusted life year (QALY) benefit from each therapy in the treatment of TASC B and C SFA lesions. The strategies modeled were femoropopliteal bypass with greater saphenous vein (GSVB) versus PTA with selective stenting. A third strategy, bypass following failed PTA/S, was also modeled. Input data on procedural success, risks, patency, health state specific survival and quality of life were derived from contemporary literature (2000 to 2006). Results: For 65-year old men with disabling claudication and TASC B SFA lesions, PTA/S was the preferred initial therapy. Referring failures for subsequent bypass increased the utility of PTA/S. In patients treated for TASC C lesions, bypass was the preferred initial therapy (Table). Sensitivity analysis showed that PTA/S would surpass bypass for TASC C lesions if primary patency were 32% at 5-yrs.
| Grade of Lesion | 5-year Primary Patency Assumptions | Claudication Management Strategy Results (in QALYs) | |||
| TASC | PTA/S | GSVB | PTA/S alone | PTA/S + GSVB | GSVB alone |
| B | 55% | 65% | 4.61 | 4.86 | 4.34 |
| C | 15% | 65% | 3.99 | 4.19 | 4.34 |
Conclusion: PTA/S is the preferred initial therapy for TASC B SFA lesions in patients with disabling IC. Given contemporary published outcomes for TASC C lesions, GSVB is the preferred initial therapy in appropriate candidates. Improved technology resulting in a 5-year primary patency rate of 32% would justify primary PTA/S for TASC C SFA lesions.
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