Search

Introduction 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. Evidence acquisition 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. Evidence synthesis 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 ischemia, 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. Conclusions 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.

A 22-year-old man came to our institution with upper gastrointestinal bleeding and massive intra-abdominal hemorrhage. His history included an abdominal gunshot, with aortic and multiple intestinal perforations, 9 months before. At the time of the original injury, he was treated elsewhere by primary closure of the aortic laceration and multiple intestinal resections. An aortic pseudoaneurysm was revealed by means of an angiogram of the descending aorta. Conventional surgical procedures were deemed not feasible because of previous abdominal operations, so a balloon-expandable bifurcated endoprosthesis was constructed and inserted into the terminal aorta through the femoral approach, with resolution of the abdominal aortic pseudoaneurysm. (J Vasc Surg 1998;28:345-8.)