Why patients know more about cars than peripheral artery disease.

A mericans who are interested in purchasing a motor vehicle often investigate automobile manufacturers, car models, and even competitive pricing using the World Wide Web. When one uses an Internet search engine to investigate Toyota, the largest automobile manufacturer in the world, there are >93 000 000 results. Virtually every possible question one would have about a Toyota vehicle is discoverable before ever visiting a local Toyota dealership. One would anticipate that physicians have a similar luxury. A patient presents with exertional discomfort in the calf that promptly resolves with rest. The patient struggles with her diet, is 30 pounds overweight, is on several medications for her high cholesterol and high blood pressure, and has been told that she has " prediabetes. " With the continued comparisons between Toyota LEAN (a practice which adds value to any process by limiting waste) mechanics and healthcare, patients likely anticipate that a physician would enter this history in a search engine and uncover the diagnosis. In fact, it is anticipated that many healthcare systems will use this type of E-diagnostic strategy for many disorders in the not too distant future. Unfortunately, despite IBM Watson's 1 correct diagnosis of intermittent claudication attributable to peripheral artery disease (PAD), the information highway stops here. Our ability to make data-driven decisions on the optimal management of intermittent claudication attributable to PAD is woefully inadequate. Despite an improvement in the quality of data on treatment strategies for femoropopliteal PAD, the best data we have comparing outcomes of uncoated percutaneous transluminal angioplasty, 2 bare nitinol stents, 3 atherectomy, 4 drug-eluting stents, 5 and drug-coated balloons 6 are embarrassingly weak. In this issue of Circulation, Subherwal and a team of renowned clinical scientists representing some of the brightest vascular trialists in the world highlight this painful reality in crystal-clear detail. 7 Using the clinicaltrials.gov database, the extent of trials in the peripheral vascular realm represents a paltry 1.7% of all investigations. Admittedly, this may underestimate early-stage trials and also excludes, for reasons unclear to me, trials of dialysis access salvage interventions, a critically important and much needed area of research. Nonetheless, this underscores the fact that trials are often initiated by the interests of commercial manufacturers who opt for market approval of products rather than pursuing the challenging areas in which patient need is greatest. The limited number of trials assessing the safety and efficacy of intervention for acute venous …