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Trial of Nonsurgical Treatment of Intermittent Claudication Due to Femoro-popliteal Disease

Primary Purpose

Femoropopliteal Disease, Intermittent Claudication

Status
Completed
Phase
Not Applicable
Locations
United Kingdom
Study Type
Interventional
Intervention
Percutaneous Transluminal Angioplasty (PTA)
Supervised Exercise Programme (SEP)
Combined Treatment
Sponsored by
Hull University Teaching Hospitals NHS Trust
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Femoropopliteal Disease focused on measuring Claudication, Vascular claudication, Peripheral Vascular Disease, Peripheral arterial disease, Peripheral arterial occlusive disease, Angioplasty, Femoral angioplasty, Superficial femoral artery, Femoral arterial disease, Exercise, Supervised exercise, Exercise therapy, Exercise programme, Infrainuginal, Quality of life, SF36, Questionnaire, VascuQol, Randomised, Randomised trial, Combination therapy, Intermittent Claudication due to Femoropopliteal Disease

Eligibility Criteria

undefined - undefined (Child, Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Symptomatic unilateral Intermittent Claudication Femoro-popliteal lesion Angioplastiable lesion on duplex > 3 months on BMT

Exclusion Criteria:

  • Critical ischaemia Incapacitating systemic disease Inability to tolerate treadmill testing Ischaemic changes on ECG during treadmill testing Ipsilateral surgery / PTA in previous 6 months

Sites / Locations

  • Academic Vascular Surgery Unit, Vascular Laboratory, Alderson House, Hull Royal Infirmary

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm Type

Active Comparator

Active Comparator

Active Comparator

Arm Label

PTA

SEP

PTA+SEP

Arm Description

Outcomes

Primary Outcome Measures

Treadmill walking distances - Intermittent claudication distance(ICD),maximum walking distance(MWD)
Ankle brachial pressure indices(ABPI) measured at rest and post exercise

Secondary Outcome Measures

Patient Reported Walking Distances (PRWD)
Clinical outcomes(PTA patency,re-intervention rates, fatal&non-fatal events,amputation,mortality and ISCVS outcome)
Health economic analyses
Markers of ischaemia reperfusion
Heat-shock proteins

Full Information

First Posted
November 25, 2008
Last Updated
July 11, 2019
Sponsor
Hull University Teaching Hospitals NHS Trust
Collaborators
University of Hull
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1. Study Identification

Unique Protocol Identification Number
NCT00798850
Brief Title
Trial of Nonsurgical Treatment of Intermittent Claudication Due to Femoro-popliteal Disease
Official Title
Randomised Controlled Trial of Percutaneous Transluminal Angioplasty (PTA) Versus a Supervised Exercise Programme (SEP) in the Management of Intermittent Claudication (IC) Due to Femoro-popliteal Disease
Study Type
Interventional

2. Study Status

Record Verification Date
July 2019
Overall Recruitment Status
Completed
Study Start Date
August 2002 (undefined)
Primary Completion Date
November 2010 (Actual)
Study Completion Date
November 2010 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Hull University Teaching Hospitals NHS Trust
Collaborators
University of Hull

4. Oversight

Data Monitoring Committee
No

5. Study Description

Brief Summary
Intermittent Claudication (IC)is a common condition characterised by pain in the muscles of the legs on exertion caused by "hardening of the arteries" and a reduced blood supply. The investigators know that the vast majority of people suffering from this condition remain stable and do not deteriorate, and thus in general the viability of legs is not at risk. The main aim of treatment, therefore, is to try and improve walking thus reducing the impact this problem has on patients life style. There are many methods of management of intermittent claudication, but the investigators do not know which produces the best results. This study aims to compare the short and medium term outcomes of exercise programmes, percutaneous transluminal angioplasty and a combination of the two treatments for patients with intermittent claudication.
Detailed Description
Intermittent claudication (IC) is a common problem in the UK's elderly population with a prevalence of 5 -10%. Intermittent claudication infers significant quality of life limitations, however, it is a disease which generally runs a benign course with >80% of patients remaining stable. Yet the annual mortality rate in claudicants approaches 5%, three times that of age and sex matched population, due to the high prevalence of co-morbidity. IC is under-recognised as a risk factor for coronary and cerebrovascular events. Sixty percent of claudicants die from coronary heart disease and 10% of them die from stroke. Treating the patient with claudication, therefore, is likely to pay high dividends in terms of reducing deaths from myocardial infarction and stroke. The most appropriate management of IC, therefore remains a topic for debate but potentially beneficial therapies include: supervised exercise programmes (SEP); & percutaneous transluminal angioplasty (PTA). A recent Cochrane review of PTA versus non-surgical management for intermittent claudication highlighted only two appropriate studies. More recently the results of a randomized control trial from Sweden have been published. This emphasizes the dearth of reliable scientific data in this area. It is believed that aorta-iliac atherosclerosis is often a solitary disease as opposed to femoro-popliteal disease which is often a manifestation of more generalized atherosclerosis. Further, the 5-year PTA patency rates for aorta-iliac disease are much better than those for femoro-popliteal PTA. Therefore, PTA is a well-established treatment modality for aorta-iliac disease but its role in femoro-popliteal disease is debatable11. This trial aims to prove the most effective treatment modality for claudication due to femoro-popliteal disease. The two treatment modalities in question work by different mechanisms. PTA increases the blood flow to the limb. Whereas, exercise works by a combination of factors including optimized structural and metabolic performance of skeletal muscle, improvement in rheological parameters, development of collaterals, improved walking technique and marked psychological benefit. Still the efficacy of any treatment modality in claudication is judged by improvements in the standard measures of lower limb ischaemia as suggested by the International Society of Cardiovascular Surgery (ISCVS). These are essentially segmental pressure measurements and walking distances. The primary aim of any treatment for patients with peripheral vascular disease is to improve the quality of life (QoL) rather than prolong survival. Several studies have shown that the traditional measures of lower limb ischaemia bear little correlation to the patient's QoL and these therefore need to be assessed independently. Further, generic QoL measures on their own are not sensitive enough to detect minor changes in QoL and so disease-specific measures need to be included in the outcomes. Evidence is accumulating that each episode of exercise to the onset of claudication pain followed by rest may be considered as a low-grade ischaemia-reperfusion injury (IRI). Repeated episodes of IRI may have a cumulative effect leading to vascular endothelial damage and progression of atherosclerosis. This may explain the excess cardiovascular mortality seen in these patients16. Most experimental work measuring the biochemical markers of IRI is done following an episode of acute exercise. Few studies have shown the effect of an exercise -training programme on the biochemical markers of IRI. We intend to investigate this as a secondary component to the trial. Heat shock proteins (hsp) are ubiquitous proteins found in the cells of all organisms. They are mainly classified according to their molecular weight. In addition to being constitutively expressed heat shock proteins can be induced by a number of stressors including heat, ischaemia and oxidative stress. Members of the hsp70 family are the most extensively studied group of stress proteins and they have been implicated in the prevention of ischaemia-reperfusion induced apoptosis, necrosis and oxidative injury in a variety of cell types including the cardiac myocyte18. Studies have shown hsp and their antibodies in the serum of normal individuals. Anti-hsp70 antibody levels in serum have been shown to be higher in vascular patients (IC, critical ischaemia and aortic aneurysms). Heat shock proteins have been detected in atherosclerotic lesions in higher concentrations. It is postulated that hsp play a key role in the autoimmune pathogenesis of atherosclerosis. Levels of anti-hsp antibodies are elevated in patients with carotid and coronary atherosclerosis and this correlates with the degree of atherosclerosis. Measuring anti-hsp antibodies in patients with IC undergoing exercise over a period of time may provide further valuable evidence on the role of heat shock proteins in atherosclerosis. The secondary outcome measures of cost effectiveness analysis will interest health planners and clinicians as the health service has limited resources and 'value for money' has become increasingly important.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Femoropopliteal Disease, Intermittent Claudication
Keywords
Claudication, Vascular claudication, Peripheral Vascular Disease, Peripheral arterial disease, Peripheral arterial occlusive disease, Angioplasty, Femoral angioplasty, Superficial femoral artery, Femoral arterial disease, Exercise, Supervised exercise, Exercise therapy, Exercise programme, Infrainuginal, Quality of life, SF36, Questionnaire, VascuQol, Randomised, Randomised trial, Combination therapy, Intermittent Claudication due to Femoropopliteal Disease

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
178 (Actual)

8. Arms, Groups, and Interventions

Arm Title
PTA
Arm Type
Active Comparator
Arm Title
SEP
Arm Type
Active Comparator
Arm Title
PTA+SEP
Arm Type
Active Comparator
Intervention Type
Procedure
Intervention Name(s)
Percutaneous Transluminal Angioplasty (PTA)
Intervention Description
PTA will be performed by a consultant interventional radiologist with no deviation from the standard protocol at Hull & East Yorshire Yospitals NHS Trust.
Intervention Type
Procedure
Intervention Name(s)
Supervised Exercise Programme (SEP)
Intervention Description
SEP: Conducted 3 times per week for 12 weeks.The session will be supervised by a physiotherapist and conducted in the cardiac gym. Each session begins with gentle warming up exercises followed by an exercise circuit of 6 stations(2 minutes each). Station 1-Step-ups(20-cm high step,alternating leg after 10 step-ups) Station 2-Exercise bicycles Station 3-Knee extensions with weights(2kg beanbag) Station 4-Heel raises Station 5-Knee bends(Alternating legs after 10 bends) Station 6-Rest station(2Kg Biceps curls) Gentle walk for 2minutes in between the stations to recover.For first 6weeks patients complete one full circuit, followed by on extra station/week, thus by 12weeks patients will complete 2 full circuits.Finally patients perform a series of gentle stretching and cooling down exercises. This exercise programme was designed to comply with suggested guidelines based on a meta-analysis assessing the effectiveness of SEP for claudicants.
Intervention Type
Procedure
Intervention Name(s)
Combined Treatment
Intervention Description
PTA will be performed according to routine protocol followed by enrollment of patient in SEP. SEP will commence in the week following PTA.
Primary Outcome Measure Information:
Title
Treadmill walking distances - Intermittent claudication distance(ICD),maximum walking distance(MWD)
Time Frame
Pretreatment, 1, 3, 6, 12, 36, & 60 months post treatment
Title
Ankle brachial pressure indices(ABPI) measured at rest and post exercise
Time Frame
Pretreatment, 1, 3, 6, 12, 36, & 60 months post treatment
Secondary Outcome Measure Information:
Title
Patient Reported Walking Distances (PRWD)
Time Frame
Pre-treatment, 1, 3, 6, 12, 36, & 60 months post treatment
Title
Clinical outcomes(PTA patency,re-intervention rates, fatal&non-fatal events,amputation,mortality and ISCVS outcome)
Time Frame
Pre-treatment, 1, 3, 6, 12, 36, & 60 months post treatment
Title
Health economic analyses
Time Frame
Pre-treatment, 1, 3, 6, 12, 36, & 60 months post treatment
Title
Markers of ischaemia reperfusion
Time Frame
Pre-treatment, 1, 3, 6, 12, 36, & 60 months post treatment
Title
Heat-shock proteins
Time Frame
Pre-treatment, 1, 3, 6, 12, 36, & 60 months post treatment.

10. Eligibility

Sex
All
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Symptomatic unilateral Intermittent Claudication Femoro-popliteal lesion Angioplastiable lesion on duplex > 3 months on BMT Exclusion Criteria: Critical ischaemia Incapacitating systemic disease Inability to tolerate treadmill testing Ischaemic changes on ECG during treadmill testing Ipsilateral surgery / PTA in previous 6 months
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Peter T McCollum, FRCS
Organizational Affiliation
Academic Vascular Surgery Unit, University of Hull
Official's Role
Principal Investigator
Facility Information:
Facility Name
Academic Vascular Surgery Unit, Vascular Laboratory, Alderson House, Hull Royal Infirmary
City
Hull
State/Province
East Riding Of Yorkshire
ZIP/Postal Code
HU3 2JZ
Country
United Kingdom

12. IPD Sharing Statement

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Trial of Nonsurgical Treatment of Intermittent Claudication Due to Femoro-popliteal Disease

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