Response to Letter Regarding Article, “Absence of Long-Term Benefit of Revascularization in Patients With Intermittent Claudication: Five-Year Results From the IRONIC Randomized Controlled Trial”

HomeCirculation: Cardiovascular InterventionsVol. 13, No. 6Response to Letter Regarding Article, "Absence of Long-Term Benefit of Revascularization in Patients With Intermittent Claudication: Five-Year Results From the IRONIC Randomized Controlled Trial" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Letter Regarding Article, "Absence of Long-Term Benefit of Revascularization in Patients With Intermittent Claudication: Five-Year Results From the IRONIC Randomized Controlled Trial" Henrik Djerf, MD, Johan Millinger, MD, Mårten Falkenberg, MD, Lennart Jivegård, MD, Mikael Svensson, PhD and Joakim Nordanstig, MD Henrik DjerfHenrik Djerf Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden. , Johan MillingerJohan Millinger Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden. , Mårten FalkenbergMårten Falkenberg Department of Radiology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sweden (M.F.). , Lennart JivegårdLennart Jivegård HTA Centrum (Health Technology Assessment Center) Västra Götaland (L.J.), Sahlgrenska University Hospital, Gothenburg, Sweden. , Mikael SvenssonMikael Svensson Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (M.S.). and Joakim NordanstigJoakim Nordanstig Department of Vascular Surgery (H.D., J.M., J.N.), Sahlgrenska University Hospital, Gothenburg, Sweden. Originally published10 Jun 2020https://doi.org/10.1161/CIRCINTERVENTIONS.120.009385Circulation: Cardiovascular Interventions. 2020;13:e009385In Response:We thank Ng and Choong for the letter and their interest in our research, especially because there has previously been a paucity in evidence on the long-term effects of lower limb revascularization procedures for intermittent claudication.1As pointed out, the IRONIC (Invasive Revascularization or Not in Intermittent Claudication) results favored an invasive revascularization strategy up to 2 years of follow-up.2,3 We find it unlikely that the main explanation of observable lack of benefit at 5 years would be the development of restenosis, a process that is known to develop mainly during the first postprocedural year, rather than beyond 2 years of follow-up.4A more plausible explanation in our opinion would be that progression of atherosclerosis mitigated the initially observed revascularization benefit. But since the IRONIC trial focused on patient-centered end points (walking performance and health-related quality of life) and did not assess target vessel patency or included any postrevascularization imaging of the vasculature, our own data cannot definitely answer this question. The associations between hemodynamic parameters and health-related quality of life are, however, generally poor.5The choice between an open or endovascular procedure in the trial was guided by concurrent international consensus guidelines and are, therefore, likely to reflect clinical practice in many countries. Although we agree with the authors that bypass surgery may translate to higher patency rates than endovascular interventions in the femoropopliteal segment, such open surgical procedures have other inherent drawbacks and associated risks that may not be appropriate for many intermittent claudication patients, given the relative benign natural course of the disease in terms of limb outcomes.6As vascular surgeons, we continuously strive to improve the health-related quality of life and walking ability for our patients with intermittent claudication. With advances in technology, we will eventually have more effective revascularization techniques for accomplishing this task. We should, however, not forget the importance of patient selection to enhance the benefit of revascularization procedures offered to patients with intermittent claudication. We also need to be aware that we are treating a patient with a generalized atherosclerotic disease that subsequently may limit the overall benefit of any invasive intervention provided. Future studies should aim at identifying intermittent claudication subgroups that benefit the most from invasive treatment and exercise respectively to enhance the overall patient benefit from available treatment options. The cost of these procedures and treatments must also be acceptable for the health care provider in the context of other important treatments available across the practice of medicine.DisclosuresDr Djerf has had occasional lecture compensation from Gore. The other authors report no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.References1. Djerf H, Millinger J, Falkenberg M, Jivegård L, Svensson M, Nordanstig J. Absence of long-term benefit of revascularization in patients with intermittent claudication: five-year results from the IRONIC randomized controlled trial.Circ Cardiovasc Interv. 2020; 13:e008450. doi: 10.1161/CIRCINTERVENTIONS.119.008450LinkGoogle Scholar2. Nordanstig J, Taft C, Hensäter M, Perlander A, Österberg K, Jivegård L. Two-year results from a randomized clinical trial of revascularization in patients with intermittent claudication.Br J Surg. 2016; 103:1290–1299. doi: 10.1002/bjs.10198CrossrefMedlineGoogle Scholar3. Djerf H, Falkenberg M, Jivegård L, Lindgren H, Svensson M, Nordanstig J. Cost-effectiveness of revascularization in patients with intermittent claudication.Br J Surg. 2018; 105:1742–1748. doi: 10.1002/bjs.10992CrossrefMedlineGoogle Scholar4. Orford JL, Selwyn AP, Ganz P, Popma JJ, Rogers C. The comparative pathobiology of atherosclerosis and restenosis.Am J Cardiol. 2000; 86:6H–11H. doi: 10.1016/s0002-9149(00)01094-8CrossrefMedlineGoogle Scholar5. Johnston AL, Vemulapalli S, Gosch KL, Aronow HD, Abbott JD, Patel MR, Smolderen KG, Shishebor M, Spertus JA, Jones WS. Ankle-brachial index in patients with intermittent claudication is a poor indicator of patient-centered and clinician-based evaluations of functional status.J Vasc Surg. 2019; 69:906–912. doi: 10.1016/j.jvs.2018.07.039CrossrefMedlineGoogle Scholar6. Kumakura H, Kanai H, Hojo Y, Iwasaki T, Ichikawa S. Long-term survival and fate of the leg in de novo intermittent claudication.Eur Heart J Qual Care Clin Outcomes. 2017; 3:208–215. doi: 10.1093/ehjqcco/qcw057CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails June 2020Vol 13, Issue 6 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.120.009385PMID: 32519878 Originally publishedJune 10, 2020 PDF download Advertisement SubjectsCost-EffectivenessPeripheral Vascular DiseaseQuality and Outcomes