Danish Trends in Major Amputation After Vascular Reconstruction in Patients With Peripheral Arterial Disease 2002–2014

Trends in Lower Extremity Artery Disease Repair Incidence, Comorbidity, and Mortality: A Danish Nationwide Cohort Study, 1996-2018

Background

The prevalence of occlusive lower extremity artery disease (LEAD) is rising worldwide while European epidemiology data are scarce. We report incidence and mortality of LEAD repair in Denmark from 1996 through 2018, stratified on open aorto-iliac, open peripheral, and endovascular repair.

Methods

A nationwide cohort study of prospective data from population-based Danish registers covering 1996 to 2018. Comorbidity was assessed by Charlson's Comorbidity Index (CCI). Incidence rate (IR) ratios and mortality rate ratios (MRR) were estimated by multivariable Poisson and Cox regression, respectively.

Results

We identified 41,438 unique patients undergoing 46,236 incident first-time LEAD repairs by either aorto-iliac- (n=5213), peripheral surgery (n=18,665) or percutaneous transluminal angioplasty (PTA, n=22,358). From 1996 to 2018, the age- and sex-standardized IR for primary revascularization declined from 71.8 to 50.2 per 100,000 person-years (IRR, 0.70; 95% CI, 0.66-0.75). Following a 2.5-fold IR increase of PTA from 1996 to 2010, all three repair techniques showed a declining trend after 2010. The declining IR was driven by decreasing LEAD repair due to claudication, and by persons aged below 80 years, while the IR increased in persons aged above 80 years (p interaction<0.001). LEAD repair was more frequent in men (IRRfemale vs male, 0.78; 95% CI, 0.77-0.80), which was consistent over calendar time (p interaction=0.41). Crude mortality decreased following open/surgical repair, and increased following PTA, but all three techniques trended towards lower adjusted mortality comparing the start and the end of the study period (MRRaorto-iliac, 0.71; 95% CI, 0.54-0.93 vs MRRperipheral, 0.76; 95% CI, 0.69-0.83 vs MRRPTA, 0.96; 95% CI, 0.86-1.07). Increasing age and CCI, male sex, smoking, and care dependency associated with increased mortality.

Conclusion

The incidence rate of LEAD repair decreased in Denmark from 1996 to 2018, especially in persons younger than 80 years, and primarily due to reduced revascularization for claudication. Adjusted mortality rates decreased following open surgery, but seemed unaltered following PTA.

Lower Extremity Amputation and Peripheral Revascularisation Rates in Romania and Their Relationship with Comorbidities and Vascular Care

(1) Background: This retrospective Romanian study aimed to calculate the rate of, and comparison between, amputation and revascularisation for patients with either cardiovascular or diabetic comorbidities. (2) Materials: In our hospital-based database, we analysed patient-level data from a series of 61 hospitals for 2019, which covers 44.9% of the amputation patients for that year. The national database is compiled by the national houses of insurance and was used to follow amputations and revascularisations between 2016 and 2021. (3) Results: During the six-year period, the mean number of amputations and revascularisations was 72.4 per 100,000 inhabitants per year for both groups. In this period, a decline in open-surgical revascularisation was observed from 58.3% to 47.5% in all interventions but was not statistically significant (r = -0.20, p = 0.70). The mean age of patients with amputation (hospital-based database) was 67 years. Of these patients, only 5.1% underwent revascularisation in the same hospital prior to amputation. The most common comorbidities in those undergoing amputations were peripheral arterial disease (76.8%), diabetes (60.8%), and arterial hypertension (53.5%). Most amputations were undertaken by general surgeons (73.0%) and only a small number of patients were treated by vascular surgeons (17.4%). (4) Conclusions: The signal from our data indicates that Romanian patients probably have a high risk of amputation > 5 years earlier than Western European countries, such as Denmark, Finland, and Germany. The prevalence of revascularisations in Romania is 64% lower than in the Western European countries.

The influence of diabetes on temporal trends in lower extremity revascularisation and amputation for peripheral artery disease: A population-based repeated cross-sectional analysis

AIM/HYPOTHESIS

To describe the influence of diabetes on temporal changes in rates of lower extremity revascularisation and amputation for peripheral artery disease (PAD) in Ontario, Canada.

METHODS

In this population-based repeated cross-sectional study, we calculated annual rates of lower extremity revascularisation (open or endovascular) and amputation (toe, foot or leg) related to PAD among Ontario residents aged ≥40 years between 2002 and 2019. Annual rate ratios (relative to 2002) adjusted for changes in diabetes prevalence alone, as well as fully adjusted for changes in demographics, diabetes and other comorbidities, were estimated using generalized estimating equation models to model population-level effects while accounting for correlation within units of observation.

RESULTS

Compared with 2002, the Ontario population in 2019 exhibited a significantly higher prevalence of diabetes (18% vs. 10%). Between 2002 and 2019, the crude rate of revascularisation increased from 75.1 to 90.7/100,000 person-years (unadjusted RR = 1.10, 95% CI = 1.07-1.13). However, after adjustment, there was no longer an increase in the rate of revascularisation (diabetes-adjusted RR = 0.98, 95% CI = 0.96-1.01, fully-adjusted RR = 0.94, 95% CI = 0.91-0.96). The crude rate of amputation decreased from 2002 to 2019 from 49.5 to 45.4/100,000 person-years (unadjusted RR = 0.78, 95% CI = 0.75-0.81), but was more pronounced after adjustment (diabetes-adjusted RR = 0.62, 95% CI = 0.60-0.64; fully-adjusted RR = 0.58, 95% CI = 0.56-0.60).

CONCLUSIONS/INTERPRETATION

Diabetes prevalence rates strongly influenced rates of revascularisation and amputation related to PAD. A decrease in amputations related to PAD over time was attenuated by rising diabetes prevalence rates.

Major Lower Limb Amputations and Amputees in an Aging Population in Southwest Finland 2007-2017

Purpose

The aim of the present study was to describe and analyze changes in the incidences of lower extremity amputations (LEAs), patient characteristics, vascular history of amputees and survival in Southwest Finland.

Patients and Methods

This is a retrospective patient study in the Hospital District of Southwest Finland. All consecutive patients with atherosclerosis and diabetes-caused LEA, between 1st January 2007 and 31st December 2017, were included. The annual incidences of major LEA patients were statistically standardized. Patients' diagnoses, functional status, previous revascularizations and minor amputations were recorded, and survival was analyzed.

Results

During the 11-year-period major LEAs were performed on 891 patients, 118 (13.2%) were urgent operations. The overall incidence of major LEA was 17.2/100 000 and was age-dependent (3.1 for ≤64 years, 34.3 for 65-74 years, 81.5 for 75-84 years, 216 for ≥85 years). A decrease in incidence was detected in the <65 year-age-group (incidence 4.98 in 2007 and 1.88 in 2017; p = 0.0018). Among older age groups, there was no significant change. Half (50.6%) of all amputees were diabetics. Altogether, 472 patients (53.0%) had a history of revascularization before LEA. 80.1% of index amputations were transfemoral and 19.9% transtibial. Re-surgery was performed on 94 (10.5%) patients. The 1-, 3- and 5-year overall survival were 56%, 30%, and 18%, respectively.

Conclusion

Our results suggest that in an aging population, despite good availability of vascular services, a significant number of patients are not fit for active revascularization, and LEA is the only feasible treatment for critical limb ischemia.

Geographical Variation in the Management of Peripheral Arterial Occlusive Disease: A Nationwide Danish Cohort Study

OBJECTIVE

Equal access for equal needs is a key goal for many healthcare systems but geographical variation research has shown that this is often not the case in areas other than vascular surgery. This study assessed the variation across specialised vascular centres of an entire healthcare system in the costs and outcomes for patients having first time revascularisation for peripheral arterial occlusive disease.

METHODS

This was a national study of all first time revascularisations performed in the Danish healthcare system between 2009 and 2014. Episodes were identified in the Danish Vascular Registry (n = 10 300) and data on one year follow up in terms of the costs of specialised healthcare (€) and amputation status were acquired from national registers. Generalised gamma and logit regressions were used to predict margins between centres while adjusting for population heterogeneity (age, sex, education, smoking, hypertension, diabetes, use of prophylactic pharmacological therapy, indication and type of revascularisation). Cost effectiveness frontiers were used to identify efficient providers and to illustrate the cost of reducing the system level risk of amputation.

RESULTS

For each of the indications of chronic limb threatening and acute limb ischaemia, the one year amputation risks varied from 11% to 16% across centres (p = .003, p = .006) whereas for intermittent claudication there was no significant difference across centres. The corresponding costs of care varied across centres for all indications (p = .027, p = .028, p = .030). Linking costs and outcomes, three of seven centres were observed to provide poorer quality at higher costs. Exponentially increasing costs to obtain the maximum reduction of the amputation risk were observed.

CONCLUSION

The results suggest that there is substantial variation in the clinical management of peripheral arterial occlusive disease across the Danish healthcare system and that this results in very different levels of efficiency - on top of potentially unequal treatment for equal needs. Further research is warranted.

The Global Limb Anatomic Staging System (GLASS) for CLTI: Improving Inter-Observer Agreement

Objective: The 2020 Global Vascular Guidelines aim at improving decision making in Chronic Limb-Threatening Ischemia (CLTI) by providing a framework for evidence-based revascularization. Herein, the Global Limb Anatomic Staging System (GLASS) serves to estimate the chance of success and patency of arterial pathway revascularization based on the extent and distribution of the atherosclerotic lesions. We report the preliminary feasibility results and observer variability of the GLASS. GLASS is a part of the new global guideline and posed as a promising additional tool for EBR strategies to predict the success of lower extremity arterial revascularization. This study reports on the consistency of GLASS scoring to maximize inter-observer agreement and facilitate its application. Methods: GLASS separately scores the femoropopliteal (FP) and infrapopliteal (IP) segment based on stenosis severity, lesion length and the extent of calcification within the target artery pathway (TAP). In our stepwise approach, we used two angiographic datasets. Each following step was based on the lessons learned from the previous step. The primary outcome was inter-observer agreement measured as Cohen’s Kappa, scored by two (step 1 + 2) and four (step 3) blinded and experienced observers, respectively. Steps 1 (n = 139) and 2 (n = 50) were executed within a dataset of a Dutch interventional RCT in CLTI. Step 3 (n = 100) was performed in randomly selected all-comer CLTI patients from two vascular centers in the United States. Results: In step 1, kappa values were 0.346 (FP) and 0.180 (IP). In step 2, applied in the same dataset, the use of other experienced observers and a provided TAP, resulted in similar low kappa values 0.406 (FP) and 0.089 (IP). Subsequently, in step 3, the formation of an altered stepwise approach using component scoring, such as separate scoring of calcification and adding a ruler to the images resulted in kappa values increasing to 0.796 (FP) and 0.730 (IP). Conclusion: This retrospective GLASS validation study revealed low inter-observer agreement for unconditioned scoring. A stepwise component scoring provides acceptable agreement and a solid base for further prospective validation studies to investigate how GLASS relates to treatment outcomes.

Peripheral artery disease leading to major amputation: Trends in revascularization and mortality over 18 years

BACKGROUND

Patients with peripheral artery disease (PAD) are at risk for amputation. The aim of this study was to assess the type of revascularization prior to and the 30-day mortality rate after major amputation due to PAD.

METHODS

Retrospective analysis of consecutive patients undergoing major amputation for PAD between 01/2000 and 12/2017 at a tertiary referral center. The number and target level of ipsilateral revascularizations prior to amputation were analyzed per patient and over the years. There were 3 types of revascularization (open, endovascular and combined treatment) at 3 levels: aortoiliac, femoropopliteal and infrapopliteal. Univariate and multivariate logistic regression models were used to assess the association of level of amputation and patient characteristics with 30-day mortality.

RESULTS

A total of 312 patients (65.7% male) with a mean age of 73.3 ± 11 years underwent 338 major amputations: 70 (21%) above/through knee and 268 (79%) below knee. A median of 2 (interquartile range, IQR 1-4) revascularizations were performed prior to amputation, with a slight decrease of 1.4% per year from 2000-2017 (incidence rate ratio of 0.986 0.974-0.998; Poisson regression analysis, P = 0.021). 16% (53/338) of patients underwent primary amputation without revascularization; this number remained relatively stable throughout the study period. The proportion of exclusively open treatment before amputation decreased substantially from 35% in 2006 to none in 2016, while exclusively endovascular revascularizations were performed increasingly from 17% in 2002 to 64% in 2016. Amputation occurred after a median of 9.5 months (IQR 0.9-67.6 months) if the first revascularization was aortoiliac or femoropopliteal and after 2.1 months (IQR 0.5-13.8 months) if the first intervention was infrapopliteal (P < 0.001) with no significant change over the years (normal linear regression, P= 0.887). Thirty-day mortality was 8.9% (22/247) after below knee and 27.7% (18/65) after above/through knee amputation (adjusted OR 3.84, 95% CI 1.74-8.54, P= 0.001) with a slight increase of mortality over the study period (adjusted OR 1.09, 95% CI 1.018-1.159, Poisson regression analysis, P= 0.021). The uni- and multivariate analysis of patient characteristics did not show an association with mortality, except higher ASA classification (adjusted OR 2.65, 95% CI 1.23-5.72, P= 0.012).

CONCLUSIONS

Mortality, especially after above/through knee amputation, remains high over the past 2 decades. There is a clear shift towards endovascular treatment of patients with PAD prior to major amputation. In patients needing infrapopliteal revascularizations, amputation was performed much sooner than in those with aortoiliac or femoropopliteal interventions, with no improvement over the years. Strategies to extend limb salvage in these patients should be the focus of further research.

Risk factors associated with amputation-free survival for patients with peripheral arterial disease: a systematic review

AIMS

Peripheral arterial disease (PAD) is associated with morbidity and mortality, comprising a significant percentage of amputations. As it affects the quality of life of patients with PAD, it is an important health issue. Therefore, the risk factors affecting the outcomes of limb salvage after revascularization should be well investigated. The aim of this review is to summarize risk factors of amputation-free survival (AFS) after interventions targeting patients with PAD to develop evidence-based intervention for improving patient outcomes.

METHODS AND RESULTS

A systematic review following PRISMA guidelines was conducted, and the protocol was registered on PROSPERO (CRD42020183076). PubMed, CINAHL, EMBASE, Cochrane Library, and Web of Science were searched for observational studies published between 2008 and 2019. Search terms included 'peripheral arterial disease', 'risk factors', and 'amputation-free survival'. The quality of the studies was evaluated using the Joanna Briggs Institute's Critical Appraisal Tools. Seventeen cohort studies were included in our study, and 16 risk factors were identified. Risk factors exemplifying a significant influence on decreased AFS were divided into three categories: sociodemographic (e.g. older age, male gender, African-American race, low body mass index, high nutritional risk, frailty), disease-related characteristics (e.g. severity of the disease, intervention site), and comorbidities (e.g. cardiovascular disease, kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, dementia, wide pulse pressure).

CONCLUSION

We found that managing modifiable risk factors, as well as addressing high-risk populations, has the potential to improve outcomes of PAD interventions. More high-quality cohort studies are needed to confirm these findings.

Long-term outcomes following endovascular and surgical revascularization for peripheral artery disease: a propensity score-matched analysis

AIMS

Peripheral artery disease (PAD) revascularization can be performed by either endovascular or open surgical approach. Despite increasing use of endovascular revascularization, it is still uncertain which strategy yields better long-term outcomes.

METHODS AND RESULTS

This retrospective cohort study evaluated patients hospitalized with PAD in Australia and New Zealand who underwent either endovascular or surgical revascularization between 2008 and 2015, and compared procedures using a propensity score-matched analysis. Hybrid interventions were excluded. The primary endpoint was mortality or major adverse limb events (MALE), defined as a composite endpoint of acute limb ischaemia, urgent surgical or endovascular reintervention, or major amputation, up to 8 years post-hospitalization using time-to-event analyses 75 189 patients fulfilled eligibility (15 239 surgery and 59 950 endovascular), from whom 14 339 matched pairs (mean ± SD age 71 ± 12 years, 73% male) with good covariate balance were identified. Endovascular revascularization was associated with an increase in combined MALE or mortality [hazard ratio (HR) 1.13, 95% confidence interval (CI): 1.09-1.17, P < 0.001]. There was a similar risk of MALE (HR 1.04, 95% CI: 0.99-1.10, P = 0.15), and all-cause urgent rehospitalizations (HR 1.01, 95% CI: 0.98-1.04, P = 0.57), but higher mortality (HR 1.16, 95% CI: 1.11-1.21, P < 0.001) when endovascular repair was compared to surgery. In subgroup analysis, these findings were consistent for both claudication and chronic limb-threatening ischaemia presentations.

CONCLUSION

Although the long-term risk of MALE was comparable for both approaches, enduring advantages of surgical revascularization included lower long-term mortality. This is at odds with some prior PAD studies and highlights contention in this space.

The impact of diabetes mellitus on major amputation among patients with chronic limb threatening ischemia undergoing elective endovascular therapy- a nationwide propensity score adjusted analysis

AIM

To investigate the risk of major amputation after elective endovascular therapy in patients with chronic limb threatening ischemia (CLTI) comparing patients with and without diabetes mellitus (DM).

METHODS

In this nationwide cohort study, all patients registered in the Swedish Vascular Register after elective endovascular therapy for CLTI caused by infra-inguinal arterial disease from 2010 to 2014 were included. Among 4578 individuals, 2251 had DM and were registered in the National Diabetes Register between 2009 and 2014. A propensity score adjusted Cox regression analysis was conducted to compare outcomes between groups. Median follow-up was 4.0 and 3.6 years for patients with DM and without DM, respectively.

RESULTS

The incidence rates of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23-1.67) and 37% (95% CI 1.13-1.67) higher, respectively, among patients with DM compared to patients without DM. There was no difference in mortality (HR 1.04, 95% CI 0.95-1.14).

CONCLUSIONS

Patients with DM had a higher risk of major amputation and AMI compared to those without DM after elective endovascular therapy for CLTI. Prevention of DM with CLTI is of utmost importance to reduce the risk of adverse limb and cardiovascular outcomes.

Temporal Changes in Secondary Prevention and Cardiovascular Outcomes After Revascularization for Peripheral Arterial Disease in Denmark: A Nationwide Cohort Study

BACKGROUND

Patients with peripheral arterial disease (PAD) are at increased risk of cardiovascular morbidity and mortality. Medical prevention with antithrombotic and statin therapies is a mainstay of treatment to prevent adverse outcomes; nevertheless, patients with PAD are often undertreated. This study describes the temporal changes in medical prevention and adverse outcomes in a national cohort of patients with symptomatic PAD after revascularization.

METHODS

We identified all patients with a first open surgical or endovascular revascularization procedure in the lower extremities or abdomen in Denmark, from 2000 to 2016. We examined temporal changes in the use of aspirin, clopidogrel, and statins and 1-year cause-specific hazard ratios for adverse clinical outcomes, after adjusting for procedure type, treatment indication, age, sex, and cardiovascular risk factors. The analyses were performed overall and within strata of index procedure (endovascular versus surgical), treatment indication, age, sex, and high-risk comorbidities.

RESULTS

Between 2000 and 2016, we identified 32 911 patients who underwent revascularization for symptomatic PAD. The mean age was 69 years and increased over time, as did the burden of comorbidity. The cumulative incidence of medication use increased between 2000 to 2004 and 2013 to 2016, respectively, from 57.3% to 64.3% for aspirin, 3.6% to 24.8% for clopidogrel, and 36.2% to 77.1% for statins. Concurrently, the 1-year outcome rates declined. Compared with 2000 to 2004, the adjusted hazard ratios in 2013 to 2016 were 0.73 (95% CI, 0.62-0.84) for major adverse cardiovascular events, 0.92 (95% CI, 0.85-1.00) for major adverse limb events, 0.60 (95% CI, 0.48-0.74) for myocardial infarction, 0.94 (95% CI, 0.75-1.18) for ischemic stroke, 0.92 (95% CI, 0.75-1.12) for major bleeding, 0.54 (95% CI, 0.39-0.76) for cardiovascular death, and 0.80 (95% CI, 0.72-0.88) for all-cause death. These improvements in prognosis were most prominent from 2000 to 2004 to 2005 to 2008 and occurred in all strata of index procedure, treatment indication, sex, age, and comorbidity. In contrast, the adjusted hazard ratio for major amputations was 1.00 (95% CI, 0.90-1.11) when comparing 2013 to 2016 to 2000 to 2004.

CONCLUSIONS

Medical prevention of adverse events has increased considerably over time in patients who underwent revascularization for symptomatic PAD. This increase was accompanied by reductions in all adverse outcomes, except major amputations.

Changes in rates of vascular procedure types and lower extremity amputations in Finland for 2007-2017 inclusive, a population cohort study of 69,523 revascularizations

INTRODUCTION

Since 2000 the numbers of both open and endovascular revascularization procedures have increased. Despite these increases, the number of major lower extremity amputations (LEAs) has remained relatively constant. The aim of the present study was to assess the number of vascular procedures in relation to the frequency of major LEAs in Finland.

METHODS

The Finnish National Institute for Health and Welfare (THL) administers a national registry of all procedures conducted by official healthcare providers in Finland. Data regarding all revascularization procedures and major LEAs between 2007 and 2017 inclusive, were collected from the THL registry. The rates of both open and endovascular procedures were analyzed.

RESULTS

A total of 69,523 revascularization procedures were registered over the 11-year period. Of all revascularizations, 22.6% were endovascular in 2007, which rose to 60.5% in 2017. The annual rates of vascular procedures per 100,000 inhabitants increased from 66 in 2007 to 172 in 2017 (increase 10 procedures per year, 95% CI 8.6-12.3, P < 0.01) There was a significant increase (by 141 per year, 95% CI 110-174, P < 0.01) for open revascularizations (2705 operations in 2007, 3992 operations in 2017) and (by 491 per year, 95% CI 433-550, P < 0.01) for endovascular revascularizations (791 in 2007-5514 in 2017). Open aorto-iliac segment revascularization decreased, whereas the numbers of procedures increased for all other arterial segments. The overall frequency of amputations was 18-20 per 100,000. The frequency of amputations in the subpopulation over 65 years old decreased from 93 in 2007 to 72 in 2017 (P < 0.01).

CONCLUSION

The present study demonstrated increases in vascular surgery procedures over the 11-year study-period. The increase was greatest for endovascular procedures. During the same period, there was a significant decrease in the frequency of major LEAs in the >65-year-old subpopulation.

Potentials, challenges, and limitations of the analysis of administrative data on vascular limb amputations in health care

Although more and more data on lower limb amputations are becoming available by leveraging the widening access to health care administrative databases, the applicability of these data for public health decisions is still limited. Problems can be traced back to methodological issues, how data are generated and to conceptual issues, namely, how data are interpreted in a multidimensional environment. The present review summarised all of the steps from converting the claims data of administrative databases into the analytical data and reviewed the wide array of sources of potential biases in the analysis of such data. The origins of uncertainty of administrative data analysis include uncontrolled confounding due to a lack of clinical data, the left- and right-censored nature of data collection, the non-standardized diagnosis/procedure-based data extraction methods (i.e., numerator/denominator problems) and additional methodological problems associated with temporal and spatial analyses. The existence of these methodological challenges in the administrative data-based analysis should not deter the analysts from using these data as a powerful tool in the armamentarium of clinical research. However, it must be done with caution and a thorough understanding and respect of the methodological limitations. In addition to this requirement, there is a profound need for pursuing further research on methodology and widening the search for other indicators (structural, process or outcome) that allow a deeper insight how the quality of vascular care may be assessed. Effective research using administrative data is based on strong collaboration in three domains, namely expertise in claims data handling and processing, the clinical field, and statistical analysis. The final interpretations of results and the countermeasures on the level of vascular care ought to be grounded on the integrity of research, open discussions and institutionalized mechanisms of science arbitration and honest brokering.

Healthy diet and fiber intake are associated with decreased risk of incident symptomatic peripheral artery disease – A prospective cohort study

Peripheral artery disease (PAD) is caused by atherosclerosis and associated with an increased risk of leg amputation, cardiovascular disease, and death. A healthy diet has been shown to reduce the risk of cardiovascular events, but relationships between diet, fiber intake, and incidence of PAD are virtually unknown. The aim was to investigate the long-term impact of diet on the development of PAD among 26,010 middle-aged individuals in the prospective Malmö Diet and Cancer study (MDCS). Data on dietary intake were collected through a 7-day food diary combined with a food questionnaire and a 1-hour interview. Adherence to a recommended intake of six dietary components – saturated fat, polyunsaturated fat, fish and shellfish, fiber, fruit and vegetables, and sucrose – was scored (sum 0–6 points) to assess a diet quality index, adjusting for potential confounders. Cox regression analysis was used to estimate associations between diet variables and PAD incidence expressed in hazard ratios (HR) with 95% CI. During a median follow-up of 21.7 years, 1122 participants developed PAD. Diet score was associated with a reduced risk of PAD in multivariable analysis ( p = 0.03). When mutually adjusting for all dietary variables, only adherence to recommended levels of fiber intake was associated with a reduced risk of incident PAD (HR 0.84; 95% CI 0.72–0.99). In this prospective, population-based study including 26,010 participants with over 20 years of follow-up, a healthy diet, especially a high intake of fiber, was associated with a reduced risk of PAD. Primary prevention programs directed against PAD should therefore include a fiber recommendation.