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A Journal on Angiology

Official Journal of the International Union of Angiology, the International Union of Phlebology and the Central European Vascular Forum
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International Angiology 2016 Jul 07

language: English

Prioritisation of treatments for lower extremity peripheral artery disease in low- and middle-income countries

Francis G. FOWKES 1, Rachel FORSTER 2, Carol E. LEVIN 3, Nadraj G. NAIDOO 4, Ambuj ROY 5, Chang SHU 6, John SPERTUS 7, Kun FANG 8, Luis BECHARA-ZAMUDIO 9, Mariella CATALANO 10, Adriana VISONA 11, Sigrid NIKOL 12, John P. FLETCHER 13, Michael R. JAFF 14, William R. HIATT 15, Lars NORGREN 16, on behalf of the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC)

1 Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; 2 Cochrane Collaboration Review Group on Peripheral Vascular Diseases, University of Edinburgh, Edinburgh, UK; 3 Disease Control Priorities Network, School of Public Health, University of Washington, Seattle, USA; 4 Head of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; 5 Cardiothoracic Department, All India Institute of Medical Sciences, New Delhi, India; 6 Department of Vascular Surgery, The Second Xiangya Hospital, Central Southern University, Hunan, China; 7 St Luke’s Mid America Heart Institute, Kansas City, USA; 8 Department of Vascular Surgery, The Second Xiangya Hospital, Central Southern University, Hunan, China; 9 Vascular Surgery, University of Buenos Aires, Buenos Aires, Argentina; 10 Research Centre on Vascular Diseases and Angiology Unit, L. Sacco Hospital, Milan, Italy; 11 Angiology Unit, San Giacomo Hospital, Castelfranco Veneto, Treviso, Italy; 12 Asklepios Clinic St.Georg, Department of Clinical and Interventional Angiology, Hamburg, Germany; 13 Westmead Research Centre for Evaluation of Surgical Outcomes, University of Sydney, Department of Surgery, Westmead Hospital, Sydney, Australia; 14 Harvard Medical School, Paul and Phyllis Fireman Endowed Chair in Vascular Medicine, Massachusetts General Hospital, Boston, USA; 15 University of Colorado School of Medicine, Department of Medicine, Division of Cardiology, and President, CPC Clinical Research; 16 Department of Surgery, Faculty of Medicine and Health, Ӧrebro University, Sweden


Lower extremity peripheral artery disease (PAD) is increasing in prevalence in low- and middle-income countries creating a large health care burden. Clinical management may require substantial resources but little consideration has been given to which treatments are appropriate for less advantaged countries. The aim of this review was to systematically appraise published data on the costs and effectiveness of PAD treatments used commonly in high-income countries, and for an international consensus panel to review that information and propose a hierarchy of treatments relevant to low- and middle-income countries. Pharmacotherapy for intermittent claudication was found to be expensive and improve walking distance by a modest amount. Exercise and endovascular therapies were more effective and exercise the most cost-effective. For critical limb ischaemia, bypass surgery and endovascular therapy, which are both resource intensive, resulted in similar rates of amputation-free survival. Substantial reductions in cardiovascular events occurred with use of low cost drugs (statins, ACE inhibitors, anti-platelets) and smoking cessation. The panel concluded that, in low- and middle-income countries, cardiovascular prevention is a top priority, whereas a lower priority should be given to pharmacotherapy for leg symptoms and revascularisation, except in countries with established vascular units.

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