Medical Therapy in Peripheral Artery Disease

Jeffrey S. Berger and William R. Hiatt

Circulation. 2012;126:491-500
doi: 10.1161/CIRCULATIONAHA.111.033886
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 Peripheral Arterial Disease
Medical Therapy in Peripheral Artery Disease
Jeffrey S. Berger, MD, MS, FAHA; William R. Hiatt, MD, FAHA
T he epidemiology of peripheral artery disease (PAD) is
well described and related to age and, in particular, the
risk factors of diabetes mellitus and smoking. Recent data
from the National Health and Nutrition Examination Survey
found a 5.9% prevalence in subjects 40 years of age
resulting in an estimated prevalence of 7.2 million affected
individuals in the United States.1 These subjects have a
significant increased risk of all-cause mortality because of the
underlying atherosclerotic disease process and general under-
treatment of PAD risk factors.2
There is a wide spectrum of clinical manifestations for
PAD: (1) the completely asymptomatic patient found to have
PAD from a screening ankle-brachial index (ABI), (2) atyp-
ical leg symptoms associated with an exercise limitation, (3)
classic intermittent claudication, and (4) ischemic pain and
ulceration in the lower extremity from chronic limb ischemia.
However, despite the level and degree of limb symptoms,
even asymptomatic persons with PAD have a greatly reduced
functional capacity. This suggests that occlusive disease in
the lower extremity is associated with reduced exercise
capacity and functional status regardless of the symptomatic
state.
As noted above, symptomatic and asymptomatic PAD is
associated with an increased risk for morbidity and mortality,
and for impairment of quality of life, as well. A prospective
cohort in subjects 65 years of age found a similar high
ischemic risk in symptomatic and asymptomatic adults with
PAD.3 Pooled data from 11 studies in 6 countries found that
PAD, defined by a an ABI of 0.90 was associated with an
increased risk of subsequent all-cause mortality (relative risk
1.60), cardiovascular mortality (relative risk 1.96), coronary
heart disease (relative risk 1.45), and stroke (relative risk
1.35) after adjustment for age, sex, conventional cardiovas-
cular risk factors, and prevalent cardiovascular disease.4
The treatment of PAD has evolved over the past decade to
include a broad approach, focusing on the reduction of
adverse cardiovascular events, improving symptoms in clau-
dication, and preventing tissue loss in critical limb ischemia.5
Because quality of life is severely limited in these subjects,
great emphasis is placed on ameliorating symptoms and
reducing the risk of PAD progression.
From the Divisions of Cardiology and Vascular Surgery, New York University School of Medicine, New York, NY (J.S.B.); University of Colorado
School of Medicine, Division of Cardiology, and CPC Clinical Research, Aurora, CO (W.R.H.).
Correspondence to William R. Hiatt, MD, Professor of Medicine/Cardiology, University of Colorado School of Medicine, c/o CPC Clinical Research,
13199 E Montview Blvd, Suite 200, Aurora, CO 80045. E-mail Will.Hiatt@UCDenver.edu
(Circulation. 2012;126:491-500.)
2012 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
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491
Established Therapies for Management of the
Systemic Atherothrombosis in PAD
Several sets of guidelines provide physicians taking care of PAD
subjects with a list of recommendations regarding optimal
treatment recommendations.6 8 These include the American
College of Cardiology Foundation/American Heart Association
guidelines and the international Inter-Society Consensus
(TASC) II guidelines. Both are undergoing substantial revision
at this time. However, only 15% of the American College of
Cardiology Foundation/American Heart Association PAD
guidelines come from evidence that is level A.9 Thus, there is a
paucity of high-level data to guide decision making.
Many of the medical therapeutics used in PAD target athero-
thrombotic pathways. For example, statins, antiplatelets, and
angiotensin-converting enzyme inhibitors are used in PAD; yet,
much of the data supporting their use stem from data derived
from patients with coronary or cerebrovascular disease. For
example, the Heart Protection Study (HPS), which evaluated
simvastatin versus placebo, and the Clopidogrel versus As-
pirin in Patients at Risk of Ischemic Events (CAPRIE) trial
enrolled patients with atherosclerosis in several vascular
territories, including a large subgroup of patients with PAD.
Both studies found that in general PAD responds similarly to
non-PAD (except maybe somewhat better to clopidogrel than
to aspirin).10,11
Antiplatelet Therapy
Despite an abundance of data demonstrating the efficacy of
antiplatelet therapy in coronary artery disease and cerebro-
vascular disease, the data in PAD are less compelling. In the
Antithrombotic Trialists Collaborative meta-analysis, there
was a significant 23% lowering of cardiovascular events from
a combined analysis of all antiplatelet agents, but the bene-
ficial effects were driven by picotamide (an inhibitor of
thromboxane A2 synthase and thromboxane A2 receptors).12
Although antiplatelet therapy is effective at decreasing car-
diovascular events in patients with PAD, these drugs have no
effect on symptomatic improvement in subjects with inter-
mittent claudication.13
Aspirin, the most widely used antiplatelet agent in the world,
does not have compelling evidence supporting a reduction in
cardiovascular events in patients with PAD (despite a positive
DOI: 10.1161/CIRCULATIONAHA.111.033886
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492 Circulation July 24, 2012
Table 1. Effect of Medical Therapies in Subjects With
Peripheral Artery Disease
Symptomatic Reduced
Improvement Cardiovascular Risk
Exercise Not studied
Cilostazol Neutral
Statins / PAD.7,8 A landmark meta-analysis in 1995 demonstrated that
Antiplatelets supervised exercise improves claudication symptoms and in-
L-Carnitine and Not studied
propionyl-L-carnitine
Pentoxifylline Not studied
Naftidrofuryl Not studied
Gene therapy / Neutral
Cell therapy / Not studied
trend).14 In a recent meta-analysis of 18 prospective randomized
trials comprising 5269 subjects with PAD, aspirin resulted in a
12% reduction of the combined end point of nonfatal myocardial
infarction, nonfatal stroke, and cardiovascular death that failed to
reach statistical significance.14 Whether a larger sample would
provide more convincing benefit is unknown, but recent studies
of aspirin in subjects with asymptomatic PAD or PAD with
diabetes mellitus were entirely negative.15,16 However, the scar-
city of randomized data investigating aspirin in symptomatic
PAD compared with coronary artery disease or cerebrovascular
disease remains a major limitation in clinical decision making.
There is some evidence that clopidogrel monotherapy may
be particularly effective in PAD. In a subgroup analysis of
CAPRIE, clopidogrel (versus aspirin) had its greatest effect
on reducing cardiovascular events in subjects with PAD (P for
heterogeneity0.045).11 Subsequently, the Clopidogrel for High
Atherothrombotic Risk and Ischemic Stabilization, Management
and Avoidance (CHARISMA) trial evaluated the effect of
aspirin plus clopidogrel versus aspirin alone in patients with
established and at risk for cardiovascular disease. In a subgroup
analysis of PAD patients, no benefit was observed for dual-
antiplatelet therapy with aspirin plus clopidogrel.17
Current guidelines recommend antiplatelet therapy in patients
with PAD. Because the majority of patients with PAD have
concomitant symptomatic coronary artery disease or cerebrovas-
cular disease, aspirin is an acceptable antiplatelet agent in this
setting. In addition to aspirin, clopidogrel monotherapy is a
reasonable alternative strategy. Implicit in these recommenda-
tions is that a large prospective randomized trial investigating the
optimal antiplatelet strategy in patients with PAD is long
overdue.
Established Therapies for
Symptomatic Improvement
Over the past decade there has been a tremendous growth of
PAD limb-specific clinical studies suggesting that treatment
with metabolic agents, antimicrobials, cell therapy, and gene
therapy would result in improved lower-extremity function
and viability in subjects with PAD. Trials in humans have led
to inconsistent results. This review will provide the current
state of medical therapy in subjects with PAD (Table 1). This
will include the evidence for and against these new modalities
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with a focus on medical treatments including drugs and
biological agents. Revascularization trials are not within the
scope of this review.
Exercise Training
Exercise rehabilitation is a class I, level of evidence A, recom-
mendation for the treatment of claudication in patients with
creases pain-free walking distance on a treadmill by 100%.18
In 2008, a rigorous systematic review by the Cochrane group19
involving 1200 participants from 22 randomized trials with
stable claudication demonstrated a significant benefit in improv-
ing treadmill walking time and walking distance with a super-
vised exercise program. Although no benefit was seen in
reducing major adverse cardiovascular events or on improving
the ABI, subjects randomly assigned to exercise had improve-
ment in claudication symptoms out to 2 years.19
Although supervised exercise is very effective in PAD sub-
jects with claudication, several questions remain: (1) is exercise
effective in PAD subjects without claudication and (2) what is
the role of a nonsupervised exercise program? Two recent
randomized trials address these issues.21,22 The effect of
supervised treadmill exercise or lower-extremity resistance
training on functional performance and quality of life was
evaluated in a randomized trial of 156 PAD patients, of whom
20% had symptoms of classic claudication.20 Although any
exercise (treadmill or resistance training) improved func-
tional performance, the treadmill exercise group had greater
increases in the 6-minute walk distance and in the maximum
treadmill walking time in comparison with the resistance
group. Of note, the changes in the primary outcomes were
similar between subjects with and without claudication and
between asymptomatic and symptomatic participants. Despite
the efficacy of a supervised exercise program in PAD, lack of
reimbursement in the United States remains a major barrier to
utilization of this treatment.
Evaluating the role of home-based exercise, Gardner and
colleagues randomly assigned 119 subjects with claudication
to either home-based exercise, supervised exercise, or a usual
care control group.21 Both exercise programs increased clau-
dication onset time and peak treadmill walking time versus
the control group; however, the changes in average walking
cadence time were greater in the home-based exercise group.
Although this study was small, and nearly 25% of subjects
did not complete follow-up, it suggests that a quantified
home-based approach may be useful in this high-risk popu-
lation with impaired quality of life. However, a meta-analysis
of home-based exercise training in PAD was negative.22
Future exercise studies with improved home-training meth-
ods, larger populations, and clinically meaningful end points
are certainly warranted. In the meantime, subjects with PAD
(symptomatic or not) are likely to benefit from an aggressive
exercise regimen.
Cilostazol
Cilostazol is a phosphodiesterase type 3 inhibitor approved in
the United States in 1999 to treat intermittent claudication. Its
possible mechanism of action includes increasing intracellu-
 Berger and Hiatt
lar concentrations of cAMP, thereby causing vasodilation and
inhibiting platelet aggregation.23 Although other drugs with
vasodilating and platelet-inhibiting properties have not been
demonstrated to improve claudication symptoms, cilostazol is
effective in ameliorating symptoms. A meta-analysis of 8
randomized trials including 2702 PAD subjects with claudi-
cation found that cilostazol improved maximum and pain-free
treadmill walking distance and quality-of-life measures.24 Of
note, cilostazol decreased triglyceride concentration by 16%
and increased high-density lipoprotein levels by 13%, but
also increased the incidence of headache, bowel concerns,
and palpitations.
Cilostazol may have an additional benefit of reducing reste-
nosis and repeat revascularization following endovascular ther-
apy.25 Similar to patients with coronary artery disease,26 28
patients with PAD have lower rates of target vessel revascular-
ization following cilostazol therapy.29,30 However, these studies
have been small and open label in design, thus hypothesis
generating.
Milrinone, another phosphodiesterase type 3 inhibitor, was
noted to increase mortality in subjects with heart failure.31 In
response, the US Food and Drug Administration mandated a
long-term safety study of cilostazol. Hiatt and colleagues per-
formed a phase 4 (postmarketing) randomized, double-blind,
placebo-controlled trial of cilostazol in 1435 PAD subjects with
claudication.32 Although underpowered because of a lower
mortality than projected and poor study drug adherence, this is
the largest study to date that has evaluated serious adverse events
and mortality. No difference was observed for overall mortality
or serious bleeding events between the cilostazol and placebo
groups; however, the study could not exclude a modest increased
risk. In comparison with milrinone, cilostazol has fewer cardiac
inotropic effects but equivalent vasodilating and platelet-
inhibiting properties.33 Nonetheless, an advisory from the US
Food and Drug Administration stated that cilostazol should not
be used in subjects with congestive heart failure.
Statin Therapy
Subgroup analyses of PAD patients from large randomized
trial data in subjects with PAD found a reduction in cardiovas-
cular events from statin therapy. Exploratory analyses suggested
an improvement of claudication symptoms in subjects with
PAD.34 In a randomized trial of 354 PAD subjects with claudi-
cation, Mohler and colleagues35 demonstrated that atorvastatin
(10 or 80 mg daily) improved pain-free walking distance and
community-based physical activity. However, the functional
benefits of statins on claudication have not been proven.
Carnitine and Propionyl-L-Carnitine Therapy
L-Carnitine and propionyl-L-carnitine may improve muscle
metabolism and exercise performance in patients with PAD.
Initial studies evaluated L-carnitine given orally as 2 g twice
daily, and also given as a single 3-g dose intravenously.36
These early studies in PAD were indicative of clinical benefit
and therefore led to the development of propionyl-L-carnitine,
an acyl form of L-carnitine.
In 2 published phase 3 trials, propionyl-L-carnitine had a
significant improvement on claudication-limited treadmill
exercise performance. In Europe, a total of 501 subjects were
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Medical Therapy in Peripheral Artery Disease 493
randomly assigned to propionyl-L-carnitine 2 g/d for 12 months
(n248) or placebo (n253).37 The primary analysis was the
subgroup of 171 patients who had a maximum walking distance
between 50 and 250 m and baseline variability 25%. After
12 months of treatment, patients randomly assigned to pla-
cebo increase maximal walking distance 44% versus 61% on
drug. This difference had a probability value of 0.055 by the
primary analysis and 0.048 with a secondary analysis. The
quality-of-life questionnaire was also positive in favor of
drug (P0.002). In the second pivotal trial, a total of 161
subjects were randomly assigned to propionyl-L-carnitine, 2
g/d (n85), or placebo (n76).38 After 6 months of therapy,
treated patients increased peak walking time 78% with a 37%
increase in controls (P0.002). Patients randomly assigned
to propionyl-L-carnitine also had significant improvements in
the physical function scores of the SF-36 (P0.31), but not
with the Waling Impairment Questionnaire (P0.26). How-
ever, more recent studies in which propionyl-L-carnitine was
given on a background of exercise training, although showing
favorable trends, were not statistically significant on the
primary end point.39 Thus, the overall incremental benefit of
propionyl-L-carnitine in PAD remains to be determined.
Other Medical Therapies
Pentoxifylline
Pentoxifylline is a xanthine derivative used to treat patients
with intermittent claudication. Its mechanism of action is
thought to be a rheological modifier that includes improving
the deformability of red blood cells and white blood cells, and
decreasing fibrinogen concentration, platelet adhesiveness,
and whole-blood viscosity. A meta-analysis demonstrated a
modestly improved walking distance, substantially less effec-
tive than either cilostazol or a supervised exercise program.40
Naftidrofuryl
Naftidrofuryl is a serotonin 5-hydroxytryptamine 2 receptor
antagonist with vasoactive properties in addition to its effect
on oxidative metabolism and rheological properties on the red
blood cell and platelet.41 Although not approved in the United
States, it is currently used in Europe for the treatment of
claudication. In a patient-level meta-analysis, naftidrofuryl
improved symptomatic claudication without any serious ad-
verse events.42
Medical Treatment of the Patient
Undergoing Revascularization
Antiplatelet therapy has good evidence for the prevention of
graft occlusion after peripheral vascular surgical procedures.
In the Antithrombotic Trialists Collaboration meta-analysis,
3000 patients with peripheral artery procedures had a 16%
graft occlusion rate on antiplatelet therapy in comparison
with 25% in the control group (P0.00001).43 Aspirin with
or without other antiplatelet therapy was associated with a
significantly lower risk of graft occlusion.44 Ticlopidine has
also been shown to promote vein graft patency without any
difference in cardiovascular events.45 Dual-antiplatelet ther-
apy with aspirin plus clopidogrel versus aspirin alone was
tested in the clopidogrel and acetylsalicylic acid in bypass
surgery for peripheral arterial disease (CASPAR) trial.46
494 Circulation July 24, 2012
There was no significant difference in the primary end point
(graft occlusion, amputation, or death) between groups. In a
subgroup analysis, clopidogrel plus aspirin was better than
aspirin alone among patients who received prosthetic grafts.
As expected, bleeding was more common in the dual-antiplatelet
therapy group.47
Anticoagulation has also been recommended as an adju-
vant to maintain surgical graft patency.47 The use of heparin
anticoagulation in the immediate postoperative period, par-
ticularly low-molecular-weight heparin, may improve the
patency of infrainguinal bypass grafts (vein and prosthetic),
but has also been associated with increased bleeding.48,49 The
role of long-term oral anticoagulation is more controversial.
In one trial of patients undergoing infrainguinal bypass
surgery (including the use of vein, prosthetic material, and
endarterectomy), long-term warfarin was associated with an
increased bleeding risk but no benefit in patency or survival.50
In contrast, another study performed in a similar population
demonstrated that oral anticoagulation improved graft pa-
tency, limb salvage, and survival.51
Several trials have compared the benefits of anticoagula-
tion versus antiplatelet therapy. Among patients treated with
infrainguinal bypass procedures (predominantly using pros-
thetic material), randomization to low-molecular-weight hep-
arin versus aspirin and dipyridamole was associated with
better graft patency, especially in the patients treated for
critical limb ischemia.52 The Dutch Bypass Oral Anticoagu-
lants or Aspirin study evaluated 2690 patients undergoing
infrainguinal bypass.53 Half the patients were treated for
claudication and the other half were treated for critical limb
ischemia with a fairly even distribution of vein versus
prosthetic material. The aspirin dose was 80 mg/d, and, in
patients randomly assigned to anticoagulation, the interna-
tional normalized ratio was maintained at 3.0 to 4.5. The
primary end point of patency was equal between groups after
21 months follow-up. In subgroup analysis, anticoagulation
maintained vein graft patency better than aspirin but at a
higher risk of bleeding complications. In contrast, aspirin
maintained prosthetic graft patency better than anticoagula-
tion. Although these results suggest that patients receiving
vein grafts should be preferentially treated with warfarin and
those with prosthetic material with aspirin, adequately pow-
ered studies are needed to determine the optimal antithrom-
botic and antiplatelet strategy following vascular surgery.
In the context of promoting patency after a revasculariza-
tion procedure, antiplatelet and antithrombotic therapy have a
clear role, but the data are somewhat dated. In terms of
selection between type of therapy, aspirin may be favored for
prosthetic grafts and anticoagulation for vein grafts or for
higher-risk patients for occlusion.44 Future trials are needed.
Novel Therapies
Therapeutic angiogenesis is a promising investigational strat-
egy for the treatment of patients with claudication and
chronic leg ischemia (CLI). It is an application of biotech-
nology to stimulate new vessel formation via local adminis-
tration of proangiogenic growth factors delivered as recom-
binant protein or by gene therapy, or by implantation of
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endothelial or other progenitor cells that will synthesize
multiple angiogenic cytokines.
Gene Therapy
Gene therapy involves transfer of genetic material into cells
to modify their genetic expression to produce a clinically
useful effect on angiogenesis, capillary generation, and col-
lateral formation. Clinical trials have sought to establish the
role for therapeutic angiogenesis by use of gene transfer with
proangiogenic factors mediated by plasmids or viral vectors
in patients with PAD, although results have been inconsistent
(Table 2). These proangiogenic factors include vascular
endothelial growth factor (VEGF), fibroblast growth factor
(FGF), hypoxia-inducible factor (HIF)-1, and hepatocyte
growth factor (HGF).
In a meta-analysis evaluating the efficacy and safety of
different gene therapies, recombinant protein and cellular-
based treatment approaches in patients with PAD, therapeutic
angiogenesis was associated with a modest, albeit significant
clinical improvement in peak walking time, ulcer healing, rest
pain relief, and limb salvage versus placebo in subjects with
PAD (odds ratio 1.44, 95% CI 1.032.00).62 The improve-
ment was most impressive in subjects with CLI. There was
also a 30% increase in the odds of the adverse events of
edema, hypotension, and proteinuria. No significant differ-
ence was detected for the endpoints of mortality, malignancy,
or retinopathy.
Vascular Endothelial Growth Factor
Vascular endothelial growth factor is expressed under hy-
poxic conditions and is a potent regulator of endothelial cell
migration, proliferation, repair, and survival.63 In previous
studies involving animal studies, VEGF gene transfer induced
rapid production of nitric oxide and prostacyclin from endo-
thelium causing a vasculoprotective effect.64,65 In a hindlimb
ischemia animal model, VEGF was demonstrated to induce
angiogenesis and arteriogenesis.66,67 Initial uncontrolled clin-
ical trials have suggested promising therapeutic effects with
naked VEGF plasmid gene transfer.68,69 In a comparison of
intra-arterial infusion of adenoviral VEGF165, plasmid lipo-
some VEGF165, or Ringers lactate placebo, Makinen et al70
noted that both VEGF165 treatments appeared safe and were
associated with significant increases in vascularity.
In a phase I trial, Baumgartner and colleagues70 found that
intramuscular injection achieves overexpression of VEGF
sufficient to induce therapeutic angiogenesis in selected
patients with CLI.
In the Regional Angiogenesis with VEGF (RAVE) trial, a
single intramuscular adenoviral delivery of VEGF121 in
patients with unilateral exercise-limiting claudication failed
to achieve its primary end point of change in treadmill peak
walking time.54 There was no difference in any of the
secondary end points, and VEGF121 was associated with a
dose-dependent increase in peripheral edema. Reasons for the
lack of efficacy could be the population selected (patients
with bilateral PAD were excluded), the duration of expression
of the VEGF121 transgene by use of the adenoviral approach
may be insufficient to induce a phenotypic response, and the
single injection may be insufficient.71 It is possible that
 Berger and Hiatt Medical Therapy in Peripheral Artery Disease 495

Table 2. Phase II and Phase III Randomized, Controlled Trials of Gene Therapy and Cell Therapy in Subjects With Peripheral
Artery Disease
Primary End
Study Phase Population No. Treatment Follow-Up Point Findings
Gene therapy
RAVE54 II Claudication 105 VEGF121 12 wk Peak walking No benefit. Dose-dependent
time peripheral edema
Kusumanto II Diabetics 54 VEGF165 100 d Major No benefit in primary EP, but
et al55 with CLI amputation improvement in
hemodynamics and skin ulcer
healing
DELTA56 II Claudication 105 Del-1 90 d Peak walking No benefit and no major
time safety issues
TRAFFIC57 II Claudication 190 FGF-2 protein 90 d Peak walking Significant benefit in primary
time EP. No major safety concern
TALISMAN58 II CLI 125 NV1FGF 25 wk Ulcer healing No benefit in the primary EP.
Secondary of amputation and
death was reduced. No major
safety issues
TAMARIS59 III CLI 525 NV1FGF 1y Death or major No benefit and no major
amputation safety issues (malignancy,
retinopathy, or proteinuria)
Cell therapy
START60 II Claudication 40 GM-CSF 14 d Walking distance No benefit
Arai et al61 II CLI 39 G-CSF 1 mo Safety and No significant adverse events.
feasibility Improvement in ABI and
transcutaneous oxygen
pressure
CLI indicates critical leg ischemia; VEGF, vascular endothelial growth factor; Del-1, Developmentally Regulated Endothelial Locus; FGF, fibroblast growth factor;
GM-CSF, granulocyte-macrophage colony-stimulating factor; NV1FGF, nonviral 1 fibroblast growth factor; ABI, ankle-brachial index; and EP, end point.

locally expressed VEGF121 has a short tissue half-life and,
consequently, induces only the first step in angiogenesis,
whereas the longer tissue retention of VEGF165 may permit
execution of the full paradigm of angiogenesis.
In a small randomized trial, Kusumanto et al55 evaluated
the effect of 2 intramuscular injections of plasmid-encoded
VEGF165 versus placebo in 54 diabetic patients with PAD and
CLI. The authors claim the study was powered to detect a
25% absolute difference in major amputations. There were
numerically fewer major amputations (3 [11%] versus 6
[22%]), but this difference failed to reach statistical signifi-
cance. There was more skin ulcer healing and increased
hemodynamic improvement in the VEGF165 group.
Fibroblast Growth Factor
Fibroblast growth factor modulates and enhances new blood
vessel formation and activates migration, proliferation, and
differentiation of endothelial cells, resulting in angiogenesis.
FGF acts on endothelial cells, smooth muscle cells, and fibro-
blasts via an interaction with specific receptors on the cell
surface. There are 22 known FGF ligands that are involved in
angiogenesis.71 FGF-1 and FGF-2 have been studied in
human PAD gene therapy trials. FGF-1 and FGF-2 are
different from other FGF proteins in lacking a signal se-
quence for extracellular transport.72 In a phase I trial, intra-
muscular administration of nonviral 1 fibroblast growth
factor (NV1FGF) to limbs of patients with CLI was well
tolerated.73 In an open-label design, patients experienced
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improvements in wound healing, pain, transcutaneous partial
pressure of oxygen, and ABI. The Therapeutic Angiogenesis
with Intramuscular NV1FGF Improves Amputation-Free Sur-
vival in Patients with Critical Limb Ischemia (TALISMAN
201) trial was a phase II trial in patients with CLI.58 There
was no difference in the primary end point of ulcer healing
between the NV1FGF group and placebo group. However,
use of NV1FGF significantly reduced the secondary end
point of risk of all amputations by 50% with a nonsignifi-
cant trend toward a lower mortality. These results served as
the basis for a large phase 3 trial of NV1FGF on amputation-
free survival.
In a landmark trial, the Therapeutic Angiogenesis for the
Management of Arteriopathy in a Randomized International
Study (TAMARIS) study was designed to demonstrate the
clinical benefit of NV1FGF in delay of the time to major
amputation or death in patients with CLI.59 In this phase III
trial, 525 patients were enrolled from 171 sites in 30 countries
and were randomly assigned to NV1FGF or placebo in a 1:1
ratio. After follow-up of 1 year, there was no significant
difference in the primary efficacy end point (36% in the
NV1FGF group and 33% in the placebo group, hazard ratio
1.11, P0.48). There was no trend for a benefit for any of the
secondary end points or in any subgroup of patients. It is
likely that the different results observed in the phase II trial
may have occurred by chance, especially because the trial
was small (n125) and the primary outcome was null. The
disappointing results of the TAMARIS study highlight the
496 Circulation July 24, 2012
importance of performing large phase III trials in this new
area of gene therapeutics.
In the setting of claudication, Lederman and colleagues57
performed the Therapeutic Angiogenesis with FGF-2 for
Intermittent Claudication (TRAFFIC) phase II trial testing the
efficacy and safety of intra-arterial FGF-2 protein in 190
patients with moderate-to-severe intermittent claudication.
Intra-arterial FGF-2 protein resulted in a significant increase
in peak walking time at 90 days. No follow-up study has been
performed.
Hypoxia Inducible Factor-1
The transcription factor HIF-1 is important in vascular
hemostasis; HIF-1 regulates the expression of specific genes
involved in the response to hypoxia and wound healing.74
Because HIF-1 involves both physiological and pathologi-
cal angiogenesis, strategies that target this factor have been
tested in the setting of PAD. In a phase I dose escalation
study, HIF-1 delivered intramuscularly with an adenoviral
vector was safe out to 1-year.75 There were data to suggest
that certain subjects had amelioration of rest pain symptoms
and complete ulcer healing. In a larger study (WALK) to
assess the transcription factor HIF-1 , results demonstrated
no benefit in the primary end point.71
Hepatocyte Growth Factor
Hepatocyte growth factor stimulates the growth of endothe-
lial cells and promotes angiogenesis.76 HGF is able to induce
robust collateral formation in preliminary studies.77 Subse-
quently, a randomized trial was performed to assess the safety
and potential efficacy of intramuscular injections of HGF
plasmids in 104 patients with CLI.78 There was no safety
concern attributed to the HGF therapy. Seventy-three patients
were available for the efficacy component; the highest-dose
treated group had a significant increase in transcutaneous
partial pressure of oxygen at 6 months, which was signifi-
cantly greater than in the placebo group. There was no
difference between groups in the ABI, toe-brachial index,
pain relief, wound healing, or major amputation. In a recent
phase I/IIa study, Morishita and colleagues79 evaluated the
safety and potential efficacy of intramuscular injection of
plasmid HGF in patients with CLI. No serious adverse events
were noted. In a nonrandomized comparison, patients had an
improvement in ABI, toe-brachial index, rest pain, and ulcer
size at 6 months. There was no difference in transcutaneous
partial pressure of oxygen. Larger studies are needed to
determine the efficacy and safety profile of HGF.
Developmentally Regulated Endothelial Locus
Developmentally Regulated Endothelial Locus (Del-1) is an
extracellular matrix protein that accumulates around angio-
genic blood vessels and promotes angiogenesis even in the
absence of exogenous growth factors.80 The Del-1 for Ther-
apeutic Angiogenesis (DELTA) trial randomly assigned 105
PAD patients with claudication to intramuscular injections of
Del-1 plasmid with poloxamer 188 (to enhance transfection)
or poloxamer 188 alone.56 No significant safety issues were
associated with Del-1. Peak treadmill walking time improved
significantly in both groups without any incremental benefit
Downloaded from http://circ.ahajournals.org/ by guest on November 7, 2014
in the Del-1 group. Although ABI, claudication onset time,
and quality of life improved in both groups, no difference
emerged between Del-1 and the control group. The improve-
ment of outcomes in both groups observed in this study
underscores the substantial placebo effect and the importance
of having a placebo group.
Advancement of gene therapy from the safety-and-feasibility
stage to routine clinical use will require carefully designed,
adequately powered, large-scale, randomized, controlled phase
III trials that incorporate end points that address methodological
improvements, long-term safety, and clinically important end
points.
Cell Therapy
Another potential novel treatment modality for PAD patients
with claudication and chronic ischemia is the stimulation of
angiogenesis with cell therapy. Endothelial progenitor cells
are important mediators in postnatal neovascularization after
mobilization from the bone marrow.81,82 Numerous studies
have demonstrated that, in the setting of both hindlimb and
coronary ischemia models, endothelial progenitor cells can be
harvested, expanded ex vivo, and delivered to augment capillary
density, perfusion, and organ function.83 Bone marrow derived
mononuclear cell implantation stimulates the production of
endothelial progenitor cells and increases collateral vessel
formation in both ischemic limb models and patients with
limb ischemia.84,85 Implantation of bone marrow mononu-
clear cells (versus peripheral blood mononuclear cells) im-
proved the ABI, transcutaneous oxygen pressure, rest pain,
and pain-free treadmill walking time at 4 and 24 weeks after
injection.85 In a follow-up study, Higashi and colleagues86
demonstrated that bone marrow mononuclear cells improved
endothelium-dependent vasodilation in patients with limb
ischemia in addition to an effect on ischemic symptoms and
findings of angiography. Several international phase II trials
are underway to assess the benefit/safety profile of cell therapy
in patients with PAD.
In an animal model, intra-arterial infusion of granulocyte-
macrophage colony-stimulating factor (GM-CSF) stimulates
the development of arterial collateral blood vessels following
femoral artery occlusion.87 In a small study of 21 subjects
with extensive coronary artery disease not eligible for bypass
surgery, intracoronary injection of GM-CSF improved collat-
eral flow and led to a reduction in ST-segment changes and
episodes of angina.88 The STimulation of ARTeriogenesis
(START) study was the first placebo-controlled study in the
setting of moderate or severe claudication to investigate the
effect of GM-CSF on walking distance.60 Patients were
treated with placebo or subcutaneously applied GM-CSF (10
g/kg) for a period of 14 days. No major side effects were
observed; however, skin rash, muscle pain, and fever were
more common in the GM-CSF group. There was no differ-
ence in the primary end point (increase in maximum walking
distance) or secondary end point (ABI) either directly after
treatment or at 90 days of follow-up. Treatment with granu-
locyte colony-stimulating factor is another promising ap-
proach in this setting.61
 Berger and Hiatt
Antimicrobials
Observational data provided the groundwork suggesting that
an infectious agent may be an important link between chronic
inflammation and PAD. In a small study, 20 subjects sero-
positive to Chlamydia pneumonia who received roxitrhomy-
cin (400 mg daily) had better walking distance and fewer
invasive revascularization procedures than 31 subjects seropos-
itive for Chlamydia pneumonia who did not receive antibiotics.89
Several other small studies failed to demonstrate a benefit of
antimicrobial therapy in subjects with PAD.90,91 To better
understand the role of antimicrobials in PAD, Jaff and col-
leagues92 randomly assigned 283 PAD subjects with claudica-
tion to 25 mg rifalazil weekly for 8 weeks or matching placebo.
All subjects enrolled had Chlamydia pneumonia antibody titer
values 1:128. There was no benefit of rifalazil on the primary
or any secondary assessment measured.92 No difference in
cardiovascular events was noted, but the study was underpow-
ered to detect this difference. Combined with the plethora of
negative studies of antimicrobials in subjects with coronary
disease,93 there is little compelling reason to study this class of
compounds in subjects with atherosclerotic disease.
Future Directions
Medical management of PAD has gone through important
innovations over the past several decades with the widespread
use of exercise, antiplatelet therapy, and statin medications.
However, many of the recommendations for patients with
PAD were derived from subgroup analyses of trials per-
formed in populations with other atherosclerotic disease
manifestations. Even aspirin, a class I level of recommenda-
tion A therapy used in the treatment of PAD, has not been
demonstrated to decrease cardiovascular events in the setting
of PAD. There are considerable gaps in knowledge regarding
the optimal treatment of PAD patients with claudication and
CLI in comparison with patients with atherosclerotic disease
in other territories. Current need for improvement in PAD
patient outcomes include (1) PAD-focused systemic therapies
designed to reduce the risk of ischemic events in the target
population, and (2) continued development of limb-specific
therapies, particularly in CLI.
Conclusions
Despite the paucity of PAD-specific limb and systemic thera-
pies, PAD patients are at very high risk for cardiovascular
events and impaired quality of life and should therefore be
treated aggressively. Until additional prospective, random-
ized trials are performed in this population, patients should be
treated with strategies based on current recommendations for
other manifestations of atherosclerotic disease. Current phar-
macological options include cilostazol for claudication but
little else to recommend as other claudication therapies or
medical approaches to CLI.
Disclosures
Dr Hiatt has received grant support to his research institution (CPC
Clinical Research, a nonprofit affiliate of the University of Colorado)
from Sanofi-Aventis, AstraZeneca, Sigma Tau, and Aastrom. Dr
Berger has received grant support from AstraZeneca.
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Medical Therapy in Peripheral Artery Disease 497
References
1. Pande RL, Perlstein TS, Beckman JA, Creager MA. Secondary pre-
vention and mortality in peripheral artery disease: National Health and
Nutrition Examination Study, 1999 to 2004. Circulation. 2011;124:
1723.
2. Golomb BA, Dang TT, Criqui MH. Peripheral arterial disease: morbidity
and mortality implications. Circulation. 2006;114:688 699.
3. Diehm C, Allenberg JR, Pittrow D, Mahn M, Tepohl G, Haberl RL,
Darius H, Burghaus I, Trampisch HJ. Mortality and vascular morbidity in
older adults with asymptomatic versus symptomatic peripheral artery
disease. Circulation. 2009;120:20532061.
4. Fowkes FG, Murray GD, Butcher I, Heald CL, Lee RJ, Chambless LE,
Folsom AR, Hirsch AT, Dramaix M, deBacker G, Wautrecht JC, Kor-
nitzer M, Newman AB, Cushman M, Sutton-Tyrrell K, Lee AJ, Price JF,
dAgostino RB, Murabito JM, Norman PE, Jamrozik K, Curb JD, Masaki
KH, Rodriguez BL, Dekker JM, Bouter LM, Heine RJ, Nijpels G,
Stehouwer CD, Ferrucci L, McDermott MM, Stoffers HE, Hooi JD,
Knottnerus JA, Ogren M, Hedblad B, Witteman JC, Breteler MM, Hunink
MG, Hofman A, Criqui MH, Langer RD, Fronek A, Hiatt WR, Hamman
R, Resnick HE, Guralnik J. Ankle brachial index combined with Fra-
mingham Risk Score to predict cardiovascular events and mortality: a
meta-analysis. JAMA. 2008;300:197208.
5. Hiatt WR. Medical treatment of peripheral arterial disease and claudi-
cation. N Engl J Med. 2001;344:1608 1621.
6. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes
FG. Inter-Society Consensus for the Management of Peripheral Arterial
Disease (TASC II). J Vasc Surg. 2007;45(suppl S):S5S67.
7. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL,
Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks
D, Stanley JC, Taylor LM Jr, White CJ, White J, White RA, Antman EM,
Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ,
Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B.
ACC/AHA 2005 Practice Guidelines for the management of patients with
peripheral arterial disease (lower extremity, renal, mesenteric, and
abdominal aortic): a collaborative report from the American Association
for Vascular Surgery/Society for Vascular Surgery, Society for Cardio-
vascular Angiography and Interventions, Society for Vascular Medicine
and Biology, Society of Interventional Radiology, and the ACC/AHA
Task Force on Practice Guidelines (Writing Committee to Develop
Guidelines for the Management of Patients With Peripheral Arterial
Disease): endorsed by the American Association of Cardiovascular and
Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute;
Society for Vascular Nursing; TransAtlantic Inter-Society Consensus;
and Vascular Disease Foundation. Circulation. 2006;113:e463 e654.
8. Olin JW, Allie DE, Belkin M, Bonow RO, Casey DE Jr, Creager MA,
Gerber TC, Hirsch AT, Jaff MR, Kaufman JA, Lewis CA, Martin ET,
Martin LG, Sheehan P, Stewart KJ, Treat-Jacobson D, White CJ, Zheng
ZJ, Masoudi FA. ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010
performance measures for adults with peripheral artery disease: a report
of the American College of Cardiology Foundation/American Heart
Association Task Force on performance measures, the American College
of Radiology, the Society for Cardiac Angiography and Interventions, the
Society for Interventional Radiology, the Society for Vascular Medicine,
the Society for Vascular Nursing, and the Society for Vascular Surgery
(Writing Committee to Develop Clinical Performance Measures for Pe-
ripheral Artery Disease). Circulation. 2010;122:25832618.
9. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC Jr. Scientific
evidence underlying the ACC/AHA clinical practice guidelines. JAMA.
2009;301:831 841.
10. MRC/BHF Heart Protection Study of cholesterol lowering with simva-
statin in 20,536 high-risk individuals: a randomised placebo-controlled
trial. Lancet. 2002;360:722.
11. A randomised, blinded, trial of clopidogrel versus aspirin in patients at
risk of ischaemic events (CAPRIE). CAPRIE Steering Committee.
Lancet. 1996;348:1329 1339.
12. Collaborative meta-analysis of randomised trials of antiplatelet therapy
for prevention of death, myocardial infarction, and stroke in high risk
patients. BMJ. 2002;324:71 86.
13. Collaborative overview of randomised trials of antiplatelet therapyI:
Prevention of death, myocardial infarction, and stroke by prolonged
antiplatelet therapy in various categories of patients. Antiplatelet Tri-
alists Collaboration. BMJ. 1994;308:81106.
14. Berger JS, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention
of cardiovascular events in patients with peripheral artery disease: a
meta-analysis of randomized trials. JAMA. 2009;301:1909 1919.
498 Circulation July 24, 2012
15. Fowkes FG, Price JF, Stewart MC, Butcher I, Leng GC, Pell AC,
Sandercock PA, Fox KA, Lowe GD, Murray GD. Aspirin for prevention
of cardiovascular events in a general population screened for a low ankle
brachial index: a randomized controlled trial. JAMA. 303:841 848.
16. Belch J, MacCuish A, Campbell I, Cobbe S, Taylor R, Prescott R, Lee R,
Bancroft J, MacEwan S, Shepherd J, Macfarlane P, Morris A, Jung R,
Kelly C, Connacher A, Peden N, Jamieson A, Matthews D, Leese G,
McKnight J, OBrien I, Semple C, Petrie J, Gordon D, Pringle S, Mac-
Walter R. The prevention of progression of arterial disease and diabetes
(POPADAD) trial: factorial randomised placebo controlled trial of aspirin
and antioxidants in patients with diabetes and asymptomatic peripheral
arterial disease. BMJ. 2008;337:a1840.
17. Cacoub PP, Bhatt DL, Steg PG, Topol EJ, Creager MA. Patients with
peripheral arterial disease in the CHARISMA trial. Eur Heart J. 2009;
30:192201.
18. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the
treatment of claudication pain. A meta-analysis. JAMA. 1995;274:
975980.
19. Watson L, Ellis B, Leng GC. Exercise for intermittent claudication.
Cochrane Database Syst Rev. 2008:CD000990.
20. McDermott MM, Ades P, Guralnik JM, Dyer A, Ferrucci L, Liu K,
Nelson M, Lloyd-Jones D, Van Horn L, Garside D, Kibbe M, Domanchuk
K, Stein JH, Liao Y, Tao H, Green D, Pearce WH, Schneider JR,
McPherson D, Laing ST, McCarthy WJ, Shroff A, Criqui MH. Treadmill
exercise and resistance training in patients with peripheral arterial disease
with and without intermittent claudication: a randomized controlled trial.
JAMA. 2009;301:165174.
21. Gardner AW, Parker DE, Montgomery PS, Scott KJ, Blevins SM.
Efficacy of quantified home-based exercise and supervised exercise in
patients with intermittent claudication: a randomized controlled trial.
Circulation. 2011;123:491 498.
22. Bendermacher BL, Willigendael EM, Teijink JA, Prins MH. Supervised
exercise therapy versus non-supervised exercise therapy for intermittent
claudication. Cochrane Database Syst Rev. 2006:CD005263.
23. Reilly MP, Mohler ER III. Cilostazol. treatment of intermittent claudi-
cation. Ann Pharmacother. 2001;35:48 56.
24. Thompson PD, Zimet R, Forbes WP, Zhang P. Meta-analysis of results
from eight randomized, placebo-controlled trials on the effect of
cilostazol on patients with intermittent claudication. Am J Cardiol. 2002;
90:1314 1319.
25. Soga Y, Iida O, Hirano K, Suzuki K, Yokoi H, Nobuyoshi M. Restenosis
after stent implantation for superficial femoral artery disease in patients
treated with cilostazol. Catheter Cardiovasc Interv. 2012;79:541548.
26. Jennings DL, Kalus JS. Addition of cilostazol to aspirin and a thien-
opyridine for prevention of restenosis after coronary artery stenting: a
meta-analysis. J Clin Pharmacol. 2010;50:415 421.
27. Douglas JS Jr, Holmes DR Jr, Kereiakes DJ, Grines CL, Block E, Ghazzal
ZM, Morris DC, Liberman H, Parker K, Jurkovitz C, Murrah N, Foster J,
Hyde P, Mancini GB, Weintraub WS. Coronary stent restenosis in
patients treated with cilostazol. Circulation. 2005;112:2826 2832.
28. Lee SW, Park SW, Kim YH, Yun SC, Park DW, Lee CW, Kang SJ, Park
SJ, Lee JH, Choi SW, Seong IW, Lee NH, Cho YH, Shin WY, Lee SJ,
Hyon MS, Bang DW, Choi YJ, Kim HS, Lee BK, Lee K, Park HK, Park
CB, Lee SG, Kim MK, Park KH, Park WJ. A randomized, double-blind,
multicenter comparison study of triple antiplatelet therapy with dual
antiplatelet therapy to reduce restenosis after drug-eluting stent implan-
tation in long coronary lesions: results from the DECLARE-LONG II
(Drug-Eluting Stenting Followed by Cilostazol Treatment Reduces Late
Restenosis in Patients with Long Coronary Lesions) trial. J Am Coll
Cardiol. 2011;57:1264 1270.
29. Iida O, Nanto S, Uematsu M, Morozumi T, Kitakaze M, Nagata S.
Cilostazol reduces restenosis after endovascular therapy in patients with
femoropopliteal lesions. J Vasc Surg. 2008;48:144 149.
30. Soga Y, Yokoi H, Kawasaki T, Nakashima H, Tsurugida M, Hikichi Y,
Nobuyoshi M. Efficacy of cilostazol after endovascular therapy for fem-
oropopliteal artery disease in patients with intermittent claudication. J Am
Coll Cardiol. 2009;53:48 53.
31. Packer M, Carver JR, Rodeheffer RJ, Ivanhoe RJ, DiBianco R, Zeldis
SM, Hendrix GH, Bommer WJ, Elkayam U, Kukin ML, Mallis GI,
Sollano JA, Shannon J, Tandon PK, DeMets DL. Effect of oral milrinone
on mortality in severe chronic heart failure. The PROMISE Study
Research Group. N Engl J Med. 1991;325:1468 1475.
32. Hiatt WR, Money SR, Brass EP. Long-term safety of cilostazol in patients
with peripheral artery disease: the CASTLE study (Cilostazol: A Study in
Long-term Effects). J Vasc Surg. 2008;47:330 336.
Downloaded from http://circ.ahajournals.org/ by guest on November 7, 2014
33. Cone J, Wang S, Tandon N, Fong M, Sun B, Sakurai K, Yoshitake M,
Kambayashi J, Liu Y. Comparison of the effects of cilostazol and mil-
rinone on intracellular cAMP levels and cellular function in platelets and
cardiac cells. J Cardiovasc Pharmacol. 1999;34:497504.
34. Pedersen TR, Kjekshus J, Pyorala K, Olsson AG, Cook TJ, Musliner TA,
Tobert JA, Haghfelt T. Effect of simvastatin on ischemic signs and
symptoms in the Scandinavian simvastatin survival study (4S). Am J
Cardiol. 1998;81:333335.
35. Mohler ER III, Hiatt WR, Creager MA. Cholesterol reduction with
atorvastatin improves walking distance in patients with peripheral arterial
disease. Circulation. 2003;108:14811486.
36. Brevetti G, Chiariello M, Ferulano G, Policicchio A, Nevola E, Rossini
A, Attisano T, Ambrosio G, Siliprandi N, Angelini C. Increases in
walking distance in patients with peripheral vascular disease treated with
L-carnitine: a double-blind, cross-over study. Circulation. 1988;77:
767773.
37. Brevetti G, Diehm C, Lambert D. European multicenter study on
propionyl-L-carnitine in intermittent claudication. J Am Coll Cardiol.
1999;34:1618 1624.
38. Hiatt WR, Regensteiner JG, Creager MA, Hirsch AT, Cooke JP, Olin JW,
Gorbunov GN, Isner J, Lukjanov YV, Tsitsiashvili MS, Zabelskaya TF,
Amato A. Propionyl-L-carnitine improves exercise performance and
functional status in patients with claudication. Am J Med. 2001;110:
616 622.
30. Hiatt WR, Creager MA, Amato A, Brass EP. Effect of propionyl-L-
carnitine on a background of monitored exercise in patients with claudi-
cation secondary to peripheral artery disease. J Cardiopulm Rehabil Prev.
2011;31:125132.
40. Hood SC, Moher D, Barber GG. Management of intermittent claudication
with pentoxifylline: meta-analysis of randomized controlled trials. CMAJ.
1996;155:10531059.
41. Barradell LB, Brogden RN. Oral naftidrofuryl. A review of its pharma-
cology and therapeutic use in the management of peripheral occlusive
arterial disease. Drugs Aging. 1996;8:299 322.
42. De Backer T, Vander Stichele R, Lehert P, Van Bortel L. Naftidrofuryl
for intermittent claudication: meta-analysis based on individual patient
data. BMJ. 2009;338:b603.
43. Collaborative overview of randomised trials of antiplatelet therapyII:
Maintenance of vascular graft or arterial patency by antiplatelet therapy.
Antiplatelet Trialists Collaboration. BMJ. 1994;308:159 168.
44. Tangelder MJ, Lawson JA, Algra A, Eikelboom BC. Systematic review
of randomized controlled trials of aspirin and oral anticoagulants in the
prevention of graft occlusion and ischemic events after infrainguinal
bypass surgery. J Vasc Surg. 1999;30:701709.
45. Becquemin JP. Effect of ticlopidine on the long-term patency of
saphenous-vein bypass grafts in the legs. Etude de la Ticlopidine apres
Pontage Femoro-Poplite and the Association Universitaire de Recherche
en Chirurgie. N Engl J Med. 1997;337:1726 1731.
46. Belch JJ, Dormandy J, Biasi GM, Cairols M, Diehm C, Eikelboom B,
Golledge J, Jawien A, Lepantalo M, Norgren L, Hiatt WR, Becquemin JP,
Bergqvist D, Clement D, Baumgartner I, Minar E, Stonebridge P, Ver-
massen F, Matyas L, Leizorovicz A. Results of the randomized, placebo-
controlled clopidogrel and acetylsalicylic acid in bypass surgery for
peripheral arterial disease (CASPAR) trial. J Vasc Surg. 2010;52:
825 833, 833.e12.
47. Collins TC, Souchek J, Beyth RJ. Benefits of antithrombotic therapy after
infrainguinal bypass grafting: a meta-analysis. Am J Med. 2004;117:
9399.
48. Samama CM, Gigou F, Ill P. Low-molecular-weight heparin vs. unfrac-
tionated heparin in femorodistal reconstructive surgery: a multicenter
open randomized study. Enoxart Study Group. Ann Vasc Surg. 1995;
9(suppl):S45S53.
49. Sarac TP, Huber TS, Back MR, Ozaki CK, Carlton LM, Flynn TC, Seeger
JM. Warfarin improves the outcome of infrainguinal vein bypass grafting
at high risk for failure. J Vasc Surg. 1998;28:446 457.
50. Arfvidsson B, Lundgren F, Drott C, Schersten T, Lundholm K. Influence
of coumarin treatment on patency and limb salvage after peripheral
arterial reconstructive surgery. Am J Surg. 1990;159:556 560.
51. Kretschmer G, Herbst F, Prager M, Sautner T, Wenzl E, Berlakovich GA,
Zekert F, Marosi L, Schemper M. A decade of oral anticoagulant
treatment to maintain autologous vein grafts for femoropopliteal athero-
sclerosis. Arch Surg. 1992;127:11121115.
52. Edmondson RA, Cohen AT, Das SK, Wagner MB, Kakkar VV. Low-
molecular weight heparin versus aspirin and dipyridamole after femoro-
popliteal bypass grafting. Lancet. 1994;344:914 918.
 Berger and Hiatt
53. Efficacy of oral anticoagulants compared with aspirin after infrainguinal
bypass surgery (The Dutch Bypass Oral Anticoagulants or Aspirin
Study): a randomised trial. Lancet. 2000;355:346 351.
54. Rajagopalan S, Mohler ER III, Lederman RJ, Mendelsohn FO, Saucedo
JF, Goldman CK, Blebea J, Macko J, Kessler PD, Rasmussen HS, Annex
BH. Regional angiogenesis with vascular endothelial growth factor in
peripheral arterial disease: a phase II randomized, double-blind, con-
trolled study of adenoviral delivery of vascular endothelial growth factor
121 in patients with disabling intermittent claudication. Circulation.
2003;108:19331938.
55. Kusumanto YH, van Weel V, Mulder NH, Smit AJ, van den Dungen JJ,
Hooymans JM, Sluiter WJ, Tio RA, Quax PH, Gans RO, Dullaart RP,
Hospers GA. Treatment with intramuscular vascular endothelial growth
factor gene compared with placebo for patients with diabetes mellitus and
critical limb ischemia: a double-blind randomized trial. Hum Gene Ther.
2006;17:683 691.
56. Grossman PM, Mendelsohn F, Henry TD, Hermiller JB, Litt M, Saucedo
JF, Weiss RJ, Kandzari DE, Kleiman N, Anderson RD, Gottlieb D,
Karlsberg R, Snell J, Rocha-Singh K. Results from a phase II multicenter,
double-blind placebo-controlled study of Del-1 (VLTS-589) for inter-
mittent claudication in subjects with peripheral arterial disease. Am
Heart J. 2007;153:874 880.
57. Lederman RJ, Mendelsohn FO, Anderson RD, Saucedo JF, Tenaglia AN,
Hermiller JB, Hillegass WB, Rocha-Singh K, Moon TE, Whitehouse MJ,
Annex BH. Therapeutic angiogenesis with recombinant fibroblast growth
factor-2 for intermittent claudication (the TRAFFIC study): a randomised
trial. Lancet. 2002;359:20532058.
58. Nikol S, Baumgartner I, Van Belle E, Diehm C, Visona A, Capogrossi
MC, Ferreira-Maldent N, Gallino A, Wyatt MG, Wijesinghe LD, Fusari
M, Stephan D, Emmerich J, Pompilio G, Vermassen F, Pham E, Grek V,
Coleman M, Meyer F. Therapeutic angiogenesis with intramuscular
NV1FGF improves amputation-free survival in patients with critical limb
ischemia. Mol Ther. 2008;16:972978.
59. Belch J, Hiatt WR, Baumgartner I, Driver IV, Nikol S, Norgren L, Van
Belle E. Effect of fibroblast growth factor NV1FGF on amputation and
death: a randomised placebo-controlled trial of gene therapy in critical
limb ischaemia. Lancet. 2011;377:1929 1937.
60. van Royen N, Schirmer SH, Atasever B, Behrens CY, Ubbink D,
Buschmann EE, Voskuil M, Bot P, Hoefer I, Schlingemann RO, Biemond
BJ, Tijssen JG, Bode C, Schaper W, Oskam J, Legemate DA, Piek JJ,
Buschmann I. START Trial: a pilot study on STimulation of ARTerio-
genesis using subcutaneous application of granulocyte-macrophage
colony-stimulating factor as a new treatment for peripheral vascular
disease. Circulation. 2005;112:1040 1046.
61. Arai M, Misao Y, Nagai H, Kawasaki M, Nagashima K, Suzuki K,
Tsuchiya K, Otsuka S, Uno Y, Takemura G, Nishigaki K, Minatoguchi S,
Fujiwara H. Granulocyte colony-stimulating factor: a noninvasive regen-
eration therapy for treating atherosclerotic peripheral artery disease. Circ
J. 2006;70:10931098.
62. De Haro J, Acin F, Lopez-Quintana A, Florez A, Martinez-Aguilar E,
Varela C. Meta-analysis of randomized, controlled clinical trials in angio-
genesis: gene and cell therapy in peripheral arterial disease. Heart
Vessels. 2009;24:321328.
63. Dvorak HF, Brown LF, Detmar M, Dvorak AM. Vascular permeability
factor/vascular endothelial growth factor, microvascular hyperperme-
ability, and angiogenesis. Am J Pathol. 1995;146:1029 1039.
64. Yla-Herttuala S, Martin JF. Cardiovascular gene therapy. Lancet. 2000;
355:213222.
65. Laitinen M, Zachary I, Breier G, Pakkanen T, Hakkinen T, Luoma J,
Abedi H, Risau W, Soma M, Laakso M, Martin JF, Yla-Herttuala S.
VEGF gene transfer reduces intimal thickening via increased production
of nitric oxide in carotid arteries. Hum Gene Ther. 1997;8:17371744.
66. Gowdak LH, Poliakova L, Wang X, Kovesdi I, Fishbein KW, Zacheo A,
Palumbo R, Straino S, Emanueli C, Marrocco-Trischitta M, Lakatta EG,
Anversa P, Spencer RG, Talan M, Capogrossi MC. Adenovirus-mediated
VEGF(121) gene transfer stimulates angiogenesis in normoperfused
skeletal muscle and preserves tissue perfusion after induction of ischemia.
Circulation. 2000;102:565571.
67. Mack CA, Magovern CJ, Budenbender KT, Patel SR, Schwarz EA,
Zanzonico P, Ferris B, Sanborn T, Isom P, Isom OW, Crystal RG,
Rosengart TK. Salvage angiogenesis induced by adenovirus-mediated
gene transfer of vascular endothelial growth factor protects against ische-
mic vascular occlusion. J Vasc Surg. 1998;27:699 709.
68. Isner JM, Pieczek A, Schainfeld R, Blair R, Haley L, Asahara T,
Rosenfield K, Razvi S, Walsh K, Symes JF. Clinical evidence of angio-
Downloaded from http://circ.ahajournals.org/ by guest on November 7, 2014
Medical Therapy in Peripheral Artery Disease 499
genesis after arterial gene transfer of phVEGF165 in patient with
ischaemic limb. Lancet. 1996;348:370 374.
69. Baumgartner I, Pieczek A, Manor O, Blair R, Kearney M, Walsh K, Isner
JM. Constitutive expression of phVEGF165 after intramuscular gene
transfer promotes collateral vessel development in patients with critical
limb ischemia. Circulation. 1998;97:1114 1123.
70. Makinen K, Manninen H, Hedman M, Matsi P, Mussalo H, Alhava E,
Yla-Herttuala S. Increased vascularity detected by digital subtraction
angiography after VEGF gene transfer to human lower limb artery: a
randomized, placebo-controlled, double-blinded phase II study. Mol Ther.
2002;6:127133.
71. Creager MA, Olin JW, Belch JJ, Moneta GL, Henry TD, Rajagopalan S,
Annex BH, Hiatt WR. Effect of hypoxia-inducible factor-1alpha gene
therapy on walking performance in patients with intermittent claudi-
cation. Circulation. 2011;124:17651773.
72. Aviles RJ, Annex BH, Lederman RJ. Testing clinical therapeutic angio-
genesis using basic fibroblast growth factor (FGF-2). Br J Pharmacol.
2003;140:637 646.
73. Comerota AJ, Throm RC, Miller KA, Henry T, Chronos N, Laird J,
Sequeira R, Kent CK, Bacchetta M, Goldman C, Salenius JP, Schmieder
FA, Pilsudski R. Naked plasmid DNA encoding fibroblast growth factor
type 1 for the treatment of end-stage unreconstructible lower extremity
ischemia: preliminary results of a phase I trial. J Vasc Surg. 2002;35:
930 936.
74. Pugh CW, Ratcliffe PJ. Regulation of angiogenesis by hypoxia: role of
the HIF system. Nat Med. 2003;9:677 684.
75. Rajagopalan S, Olin J, Deitcher S, Pieczek A, Laird J, Grossman PM,
Goldman CK, McEllin K, Kelly R, Chronos N. Use of a constitutively
active hypoxia-inducible factor-1alpha transgene as a therapeutic strategy
in no-option critical limb ischemia patients: phase I dose-escalation expe-
rience. Circulation. 2007;115:1234 1243.
76. Bussolino F, Di Renzo MF, Ziche M, Bocchietto E, Olivero M, Naldini
L, Gaudino G, Tamagnone L, Coffer A, Comoglio PM. Hepatocyte
growth factor is a potent angiogenic factor which stimulates endothelial
cell motility and growth. J Cell Biol. 1992;119:629 641.
77. Morishita R, Nakamura S, Hayashi S, Taniyama Y, Moriguchi A, Nagano
T, Taiji M, Noguchi H, Takeshita S, Matsumoto K, Nakamura T, Higaki
J, Ogihara T. Therapeutic angiogenesis induced by human recombinant
hepatocyte growth factor in rabbit hind limb ischemia model as cytokine
supplement therapy. Hypertension. 1999;33:1379 1384.
78. Powell RJ, Simons M, Mendelsohn FO, Daniel G, Henry TD, Koga M,
Morishita R, Annex BH. Results of a double-blind, placebo-controlled
study to assess the safety of intramuscular injection of hepatocyte growth
factor plasmid to improve limb perfusion in patients with critical limb
ischemia. Circulation. 2008;118:58 65.
79. Morishita R, Makino H, Aoki M, Hashiya N, Yamasaki K, Azuma J,
Taniyama Y, Sawa Y, Kaneda Y, Ogihara T. Phase I/IIa clinical trial of
therapeutic angiogenesis using hepatocyte growth factor gene transfer to
treat critical limb ischemia. Arterioscler Thromb Vasc Biol. 2011;31:
713720.
80. Zhong J, Eliceiri B, Stupack D, Penta K, Sakamoto G, Quertermous T,
Coleman M, Boudreau N, Varner JA. Neovascularization of ischemic
tissues by gene delivery of the extracellular matrix protein Del-1. J Clin
Invest. 2003;112:30 41.
81. Asahara T, Murohara T, Sullivan A, Silver M, van der Zee R, Li T,
Witzenbichler B, Schatteman G, Isner JM. Isolation of putative progenitor
endothelial cells for angiogenesis. Science. 1997;275:964 967.
82. Asahara T, Masuda H, Takahashi T, Kalka C, Pastore C, Silver M,
Kearne M, Magner M, Isner JM. Bone marrow origin of endothelial
progenitor cells responsible for postnatal vasculogenesis in physiological
and pathological neovascularization. Circ Res. 1999;85:221228.
83. Leeper NJ, Hunter AL, Cooke JP. Stem cell therapy for vascular regen-
eration: adult, embryonic, and induced pluripotent stem cells. Circulation.
2010;122:517526.
84. Shintani S, Murohara T, Ikeda H, Ueno T, Sasaki K, Duan J, Imaizumi T.
Augmentation of postnatal neovascularization with autologous bone
marrow transplantation. Circulation. 2001;103:897903.
85. Tateishi-Yuyama E, Matsubara H, Murohara T, Ikeda U, Shintani S,
Masaki H, Amano K, Kishimoto Y, Yoshimoto K, Akashi H, Shimada K,
Iwasaka T, Imaizumi T. Therapeutic angiogenesis for patients with limb
ischaemia by autologous transplantation of bone-marrow cells: a pilot
study and a randomised controlled trial. Lancet. 2002;360:427 435.
86. Higashi Y, Kimura M, Hara K, Noma K, Jitsuiki D, Nakagawa K, Oshima
T, Chayama K, Sueda T, Goto C, Matsubara H, Murohara T, Yoshizumi
M. Autologous bone-marrow mononuclear cell implantation improves
500 Circulation July 24, 2012
endothelium-dependent vasodilation in patients with limb ischemia.
Circulation. 2004;109:12151218.
87. Buschmann IR, Hoefer IE, van Royen N, Katzer E, Braun-Dulleaus R,
Heil M, Kostin S, Bode C, Schaper W. GM-CSF: a strong arteriogenic
factor acting by amplification of monocyte function. Atherosclerosis.
2001;159:343356.
88. Seiler C, Pohl T, Wustmann K, Hutter D, Nicolet PA, Windecker S,
Eberli FR, Meier B. Promotion of collateral growth by granulocyte-mac-
rophage colony-stimulating factor in patients with coronary artery dis-
ease: a randomized, double-blind, placebo-controlled study. Circulation.
2001;104:20122017.
89. Krayenbuehl PA, Wiesli P, Maly FE, Vetter W, Schulthess G. Pro-
gression of peripheral arterial occlusive disease is associated with
Chlamydia pneumoniae seropositivity and can be inhibited by antibiotic
treatment. Atherosclerosis. 2005;179:103110.
90. Joensen JB, Juul S, Henneberg E, Thomsen G, Ostergaard L, Lindholt JS.
Can long-term antibiotic treatment prevent progression of peripheral
arterial occlusive disease? A large, randomized, double-blinded, placebo-
controlled trial. Atherosclerosis. 2008;196:937942.
Downloaded from http://circ.ahajournals.org/ by guest on November 7, 2014
91. Vainas T, Stassen FR, Schurink GW, Tordoir JH, Welten RJ, van den
Akker LH, Kurvers HA, Bruggeman CA, Kitslaar PJ. Secondary pre-
vention of atherosclerosis through chlamydia pneumoniae eradication
(SPACE Trial): a randomised clinical trial in patients with peripheral
arterial disease. Eur J Vasc Endovasc Surg. 2005;29:403 411.
92. Jaff MR, Dale RA, Creager MA, Lipicky RJ, Constant J, Campbell LA,
Hiatt WR. Anti-chlamydial antibiotic therapy for symptom improvement
in peripheral artery disease: prospective evaluation of rifalazil effect on
vascular symptoms of intermittent claudication and other endpoints in
Chlamydia pneumoniae seropositive patients (PROVIDENCE-1).
Circulation. 2009;119:452 458.
93. Andraws R, Berger JS, Brown DL. Effects of antibiotic therapy on
outcomes of patients with coronary artery disease: a meta-analysis of
randomized controlled trials. JAMA. 2005;293:26412647.
KEY WORDS: angiogenesis antiplatelet therapy arteries treatment
vascular disease