Reviewed for medical accuracy by Dr Evelyne Jonniaux, Medical Advisor
Last updated 17 September 2026
Supervised walking gains 80 to 120 metres, at high certainty. Revascularisation adds a real gain at one year, which is no longer measurable at five. And neither has demonstrated an effect on survival or amputation. The only treatment that has is a drug.
The questions we get asked
What does supervised exercise actually do?
A Cochrane review of 32 trials and 1,835 participants gives 82 metres of gain in pain-free walking distance and 120 metres in maximum distance, at high certainty, and the benefit holds up to two years. It does not improve the ankle-brachial index, and its effect on mortality and amputation is not demonstrated.
Does revascularisation do better?
It depends what you measure, and this is the most interesting observation on the subject. In the American CLEVER trial, supervised exercise beats stenting on treadmill walking at six months. But on most quality of life scales, the stent does better. The two measures do not say the same thing.
The Dutch ERASE trial compared endovascular treatment plus exercise against exercise alone. At one year the combination gains 282 metres of maximum distance. At a median follow-up of 5.4 years the gap is 53 metres and is no longer significant.
In critical limb ischaemia, bypass or endovascular?
Two large trials reach opposite conclusions, and it is worth knowing why. The American BEST-CLI trial recruits patients with a good single-segment saphenous vein available and finds an advantage for bypass, including on major amputation, 10.3 against 14.9 percent. The British BASIL-2 trial specifically recruits patients requiring an infrapopliteal procedure and finds an advantage for endovascular treatment.
The decisive point is that the two trials do not diverge on the leg. BASIL-2 finds no difference in major amputation, 20 against 18 percent. Its entire gap is in overall mortality, whose dominant causes are cardiovascular and respiratory, and its investigators convened an international panel to try to understand it.
A defensible formulation: where a good vein exists and the lesion is not purely infrapopliteal, bypass preserves the leg better. Where the lesion requires work below the knee, endovascular first gives better overall results.
And medical treatment?
This is the underlying contrast of the subject. Exercise and revascularisation improve walking with no demonstrated effect on survival. Medical treatment does not make anyone walk further, but it is the only one that has reduced amputations and cardiovascular deaths in a randomised trial. The price is an increase in major bleeding, mainly gastrointestinal, without an increase in fatal bleeding.
What the figures say
| Finding | Figure | Source |
|---|---|---|
| Supervised exercise, pain-free distance | plus 82 metres, high certainty | Cochrane, 2017 |
| Supervised exercise, effect on mortality | not demonstrated | Cochrane, 2017 |
| Endovascular added to exercise, at 1 year | plus 282 metres | ERASE, JAMA, 2015 |
| Same comparison at 5.4 years | 53 metres, not significant | ERASE, Ann Surg, 2022 |
| Bypass against endovascular, major amputation | 10.3 against 14.9 percent | BEST-CLI, 2024 |
| Same outcome in infrapopliteal disease | 20 against 18 percent, not significant | BASIL-2, Lancet, 2023 |
Three widespread figures we could not source. “Exercise doubles walking distance”: Cochrane publishes absolute gains, never a ratio. “80 percent of claudicants stay stable, 5 percent are amputated at five years”: no primary source found. And “BASIL-2 shows endovascular saves more legs” is false: the advantage is in mortality, not amputation.
What Noria Health does, and does not do
We organise a vascular surgery consultation with a specialist team near Brussels, ankle-brachial index and arterial imaging according to the picture, and confirm feasibility within 24 to 48 hours. Follow-up is documented at D14, D30 and D90.
We do not set an indication for revascularisation remotely, we do not change any treatment under way, and we never advise stopping an anticoagulant or antiplatelet. Rest pain or a wound that will not heal needs prompt assessment, not remote organisation.
Who reviewed this page
Noria Health editorial team.
See also: all our articles on vascular surgery.
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