Combination exercise therapy (ET) and lower extremity revascularization (LER) for the treatment of peripheral artery disease (PAD) improves walking performance better than either therapy alone, according to findings of a literature review published in the Journal of American College of Cardiology: Basic to Translational Science.

Researchers from the University of Colorado Anschutz Medical Campus searched publication databases through 2020 for publications on ET and LER in the treatment of PAD. A total of 47 articles were included in this analysis, inclusive of a median 100 participants aged 38 to 86 years (64% men).  Most of the studies had follow-ups ranging between 6 and 18 months, which is within this range commonly used for such therapies. Interventions included ET compared with control (n=27), LER compared with control (n=12), ET with LER (n=8), LER and ET compared with ET alone (n=6), and LER and ET compared with LER alone (n=6).

The review authors graded evidence using the A, B, C, D grading system. A grade of A indicated very strong evidence, in which 2 or more high-quality studies reported similar findings. A grade of B indicated similar findings from 1 or more high-quality and 1 or more low-quality studies. C indicated limited evidence (1 high-quality study and 1 or more low-quality studies), D weak evidence (1 low-quality study), and E inconclusive (conflicting findings).

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Compared with controls, ET improved walking performance with a grade of A in less than 6 months, 6-12 months, and 12-18 months. ET deferred claudication onset with a grade of B at less than 6-12 to18 months and a grade of A at 6-12 months. LER increased walking performance and deferred claudication onset with a grade of B at 6-12, 12-18, and >18 months.

When ET was compared with LER, the former was shown to be somewhat superior in terms of walking performance and deferred claudication, with evidence graded as A level for the time frame of 6-12 months in terms of walking performance and 12-18 months for walking performance and deferred claudication.

Combination therapy was superior to ET alone in improving walking performance at 6-12 (B Grade), 12-18 (B Grade), and >18 (C Grade) months and at deferring claudication onset at 6 -12 (C Grade) and 12-18 (B Grade) months. The combination therapy compared with LER alone was superior at improving walking speed at less than 6 (B) and 6 to 12 (C grade) months and was better at deferring claudication onset at less than 6 months (C grade).

This review was limited by the quality of the underlying studies, which, for the most part, were short-term.

These data indicate that combination ET and LER therapy can provide better clinical outcomes than either strategy alone in patients with PAD.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Biswas MP, Capell WH, McDermott MM, et al. Exercise Training and Revascularization in the Management of Symptomatic Peripheral Artery Disease. J Am Coll Cardiol Basic Trans Science. 2021;6(2):174-188. doi:10.1016/j.jacbts.2020.08.012