In Reply

Letters to the Editor Intermittent Claudication and Asymptomatic Peripheral Arterial Disease Conservative Treatment Versus Revascularization by Prof. Dr. med. Gerhard Rümenapf, Dr. med. Stephan Morbach, PD Dr. med. Andrej Schmidt, and Dr. med. Martin Sigl in issue 11/2020

We would like to thank all of our colleagues for their valuable contributions to our work (1). There is obviously a consensus that structured, supervised exercise training (SET) is a valuable treatment measure with high evidence for suitable PAD patients with intermittent claudication, but that there is a supply problem for SET in Germany. Unfortunately, SET is often only a virtual treatment option. In addition, in contrast to successful revascularization, SET does not immediately improve the pain-free walking distance but rather requires months, and this only occurs if it is practiced consistently and if the patient is at all suitable for SET (1). On the other hand, SET is a comparatively harmless treatment option.

Reining and colleagues object to the fact that the electrical spinal cord stimulation (SCS) method was not considered in the treatment of PAD patients with intermittent claudication. In our opinion, using SCS for intermittent claudication is without evidence, and there are no guidelines for this complex procedure for claudication. SCS can be used to treat pain in non-reconstructible (“no-option”) patients with critical limb ischemia (CLI) and legs at risk of amputation with poor evidence. SCS does not improve amputation rates or mortality of diabetics with CLI (2). A Cochrane analysis showed that SCS can reduce the amputation rate and pain for no-option patients with CLI within one year, but that it cannot improve wound healing (3). SCS is not recommended by any vascular medical guideline, not even for CLI (4). SCS is expensive and prone to complications (5).

Schlitt and colleagues state that SET is a standardized and established part of cardiovascular rehabilitation (6). In our work, we pointed out that the model of the CHD sports groups works in Germany, while that of the PAD sports groups does not (1). Sending patients with intermittent claudication to heart sports groups is not often considered. However, in our experience, PAD patients often do not fit into heart sports groups, due to their difficulties with walking, while the legs of heart patients allow them to walk longer distances painlessly. There can be no doubt that supervised walking in the context of rehabilitation for PAD patients is useful and successful. However, whether receiving an inpatient rehabilitation (which are usually approved for three weeks) will solve the problem of improving walking distances over the long term seems questionable. SET must be done regularly for three to six months to be successful. We are highly doubtful that an outpatient rehabilitation measure over such a long period will be financed by cost bearers.

Boehner points out that the risk of any revascularization procedure in patients with intermittent claudication should not be underestimated. This was discussed in detail in our work. Patients can gain an improved quality of life, and some are able to work, but this comes at a price. The endovascular interventions for intermittent claudication have become safer, so that the risk–benefit ratio is reasonable (1). It is important to thoroughly inform the patient about the possible complications of endovascular and vascular surgical procedures of revascularization and to avoid trivializing the matter. Unfortunately, our impression is that this is exactly what is happening in many places. However, no problem is solved if, as Dr. Böhner discusses, one would forego any form of revascularization in intermittent claudication as long as the conservative alternative SET is not available. Our pragmatic approach is therefore to offer revascularization procedures, so that at least something is improved for the patient, and to combine this with SET. We hope that the issue of the missing vascular sports groups is finally recognized by health policy and the cost bearers.

We thank Prof. Kiesewetter for his historically interesting contribution. There are vascular sports groups that function throughout Germany, as the example from Homburg shows. Such groups are kept alive by idealists who manage to motivate patients for SET over the long term. Unfortunately, the number of such groups is far too small to have a widespread effect on halting the increasing number of arterial revascularization procedures in the stage of intermittent claudication.

DOI: 10.3238/arztebl.2020.0677c

Prof. Dr. med. Gerhard Rümenapf

Gefäßzentrum Oberrhein Speyer-Mannheim, Klinik für Gefäßchirurgie, Diakonissen-Stiftungs-Krankenhaus, Speyer, Germany

Dr. med. Stephan Morbach

Abteilung für Diabetologie und Angiologie, Marienkrankenhaus, Soest, Germany

PD Dr. med. Andrej Schmidt

Klinik und Poliklinik für Angiologie, Universitätsklinikum Leipzig, Germany

Dr. med. Martin Sigl

Abteilung für Angiologie, 1. Medizinische Klinik, Universitätsklinikum Mannheim, Germany

Conflict of interest statement

PD Dr. Schmidt received consulting honoraria from Cook and Bard, meeting participation fees, travel expenses, and speaking honoraria from Cordis, Abbott, Cook, and Bard, and study support (third-party funding) from Abbott, Bard, Cook, Medtronic, and Intervascular.

The remaining authors declare that no conflict of interest exists.

References

1. Rümenapf G, Morbach S, Schmidt A, Sigl M: Intermittent claudication and asymptomatic peripheral arterial disease—conservative treatment versus revascularization. Dtsch Arztebl Int 2020; 117: 188–93

2. Klomp HM, Steyerberg EW, Habbema JD, van Urk H, ESES study group: What is the evidence on efficacy of spinal cord stimulation in (subgroups of) patients with critical limb ischemia? Ann Vasc Surg 2009; 23: 355–63

3. Ubbink DT, Vermeulen H: Spinal cord stimulation for non-reconstructible chronic critical leg ischemia. Cochrane Database Syst Rev 2013: CD004001

4. Lawall H, Huppert P, Espinola-Klein C, Rümenapf G: Clinical practice guideline: The diagnosis and treatment of peripheral arterial vascular disease. Dtsch Arztebl Int 2016; 113: 729–36

5. Simpson EL, Duenas A, Holmes MW, Papaioannou D, Chilcott J: Spinal cord stimulation for chronic pain of neuropathic or ischemic origin: systematic review and economic evaluation. Health Technol Assess 2009; 13: iii, ix–x, 154

6. AWMF: S3-Leitlinie Kardiologische Rehabilitation im deutschsprachigen Raum Europas (D-A-CH). Register-Nr. 133–01; https://www.awmf.org/leitlinien/detail/ll/133-001.html (last accessed on 5 July 2020).