A recent study from North America suggests that a greater improvement in walking distance can be seen with exercise compared with invasive management strategies in peripheral artery disease (PAD).

The CLEVER (Claudication: Exercise versus Endoluminal Revascularization) study examined the relative benefit of supervised exercise, stenting, and optimal medical care in patients with aortoiliac PAD. Such proximal disease is usually thought of as ideal for stent revascularisation and these patients often have marked claudication and low ankle-brachial index readings.

The CLEVER trial randomised 111 patients with symptomatic aortoiliac PAD, from 22 sites in Canada and the United States, to one of three regimens: optimal medical care alone or optimal medical care with either a supervised exercise programme or stent revascularisation.

Optimal medical care included cilostazol 100mg twice daily with a home walking programme supported by a nurse co-ordinator who would call the patients to verify that they understood the need for walking.

The supervised exercise arm of the trial consisted of exercise according to a single study-wide protocol, for one hour, three times per week, for 26 weeks. Stent revascularisation aimed to treat all haemodynamically significant > 50% stenoses in the aorta and iliac arteries. The primary end point was the change in peak walking time on a graded treadmill test at six months compared with baseline.

At six months, supervised exercise had achieved the greatest change in peak walking time (mean change versus baseline 5.8 ± 4.6 min), compared with stent revascularisation (3.7 ± 4.9 min) and optimal medical care (1.2 ± 2.6 min). These changes were significant for supervised exercise versus both stent revascularisation (P= 0.04) and optimal medical care (P < 0.001). Furthermore, stent revascularisation was significantly better than optimal medical care (P= 0.02).

The secondary end point quality of life questionnaires favoured stent revascularisation over supervised exercise although both scored better than optimal medical care.

Supervised exercise resulted in better treadmill walking performance than stent revascularisation for those with aortoiliac PAD. The authors also note that both of these interventions were superior to standard medical care. This trial although small should inform efforts to develop and fund, either in part or full, supervised exercise programmes for patients with proximal PAD.

Dr Peter Savill