Long-term follow-up of patients with early atherosclerosis

Anticoagulation in Patients with Premature Peripheral Artery Disease Undergoing Lower Extremity Revascularization

BACKGROUND

Premature peripheral artery disease (PAD), defined by lower extremity revascularization (LER) at age ≤ 50 years, is associated with poor major adverse limb events. The early onset of disease is thought to be influenced by genetic factors that regulate homeostasis of the vascular wall and coagulation. The aim of this study is to investigate the effect of anticoagulation as an adjunct to antiplatelet therapy on the outcomes of LER in patients with premature PAD.

METHODS

There were 8,804 patients with premature PAD on preoperative and postoperative antiplatelet therapy only and 1,236 patients on preoperative and postoperative anticoagulation plus antiplatelet therapy in the Vascular Quality Initiative peripheral vascular intervention, infrainguinal, and suprainguinal files. Propensity score matching (2:1) was performed between patients with premature PAD who were on antiplatelet therapy and those on anticoagulation plus antiplatelet therapy. Perioperative and 1-year outcomes were analyzed including reintervention, major amputation, and mortality.

RESULTS

Patients on anticoagulation were more likely to have coronary artery disease (48.7% vs. 41.2%, P < 0.001), congestive heart failure (20.2% vs. 13.1%, P < 0.001), and have undergone prior LER (73.9% vs. 49.2%, P < 0.001) compared to patients on antiplatelet therapy only. They were also less likely to be independently ambulatory (74.2% vs. 81.8%, P < 0.001) and be on a statin medication (66.8% vs. 74.3%, P < 0.001) compared to patients on antiplatelet therapy only. Patients on anticoagulation were also less likely to be treated for claudication (38.1% vs. 48.6%, P < 0.001), and less likely to be treated with an endovascular procedure (64.8% vs. 73.8%, P < 0.001). After matching for baseline characteristics, there were 1,256 patients on antiplatelet therapy only and 628 patients on anticoagulation. Patients on anticoagulation were more likely to require a return to the operating room (3.7% vs. 1.6%, P < 0.001) and had higher perioperative mortality (1.1% vs. 0.3%, P = 0.032), but major amputation was not significantly different (1.8% vs. 1.6%, P = 0.798) compared to patients on antiplatelet therapy alone. At 1 year, amputation-free survival was higher in patients on antiplatelets only compared to patients on anticoagulation and antiplatelet medications (87.5% vs. 80.9%, log-rank P = 0.001).

CONCLUSIONS

Anticoagulation in addition to antiplatelet therapy in patients with premature PAD undergoing LER is associated with increased reintervention and mortality at 1 year.

Major adverse limb events among patients with premature peripheral artery disease compared with those at the common age undergoing revascularization in the Vascular Quality Initiative

OBJECTIVES

Premature peripheral artery disease (PAD), defined as ≤ 50 years of age, is associated with poor outcomes following lower extremity revascularization (LER). However, the specific characteristics and outcomes of this group of patients compared to those at the common age undergoing revascularization have not been examined. The aim of this study is to compare patients with early versus late onset premature PAD undergoing LER focusing on major adverse limb events (MALEs).

METHODS

All LER procedures (open and endovascular) in the Vascular Quality Initiative (VQI) were reviewed. A histogram of patient age at the time of initial LER (no prior LER) was used to define the common age, which included all patients within one standard deviation of the mean. Characteristics and outcomes of patients with premature PAD were compared to patients treated at the common age of presentation undergoing LER.

RESULTS

A histogram of all patients undergoing LER was used to define 60 to 80 years as the common age. Patients with premature PAD were more likely to be female, African American, and Hispanic compared to patients at the common age. Patients with premature PAD were also more likely to have insulin-dependent diabetes, be current smokers, on dialysis, and be treated for claudication. Patients with premature PAD were less likely to have Transatlantic Intersociety Consensus (TASC II) C or D disease and were less likely to be on antiplatelets and statins. These differences were more pronounced in patients with chronic limb-threatening ischemia (CLTI). Cox proportional hazards regression demonstrated that premature PAD was independently associated with major adverse limb events (MALEs) at one-year for patients with claudication (HR:1.7, 95% CI:1.4-2.0) and CLTI (HR:1.3, 95% CI:1.2-1.5) compared to patients 60 to 80 years of age.

CONCLUSION

Patients with premature PAD have significant differences in characteristics compared to patients treated at the common age. Vascular providers should emphasize medical therapy prior to LER given the lower rates of medical optimization and worse one-year MALEs in patients with premature PAD.

Outcomes of bypass and endovascular interventions for advanced femoropopliteal disease in patients with premature peripheral artery disease

OBJECTIVE

Patients with premature peripheral artery disease (PAD), defined as age ≤50 years at presentation, have had poor outcomes with open and endovascular lower extremity revascularization. It is unclear whether either strategy is associated with better outcomes because comparative studies have been limited to case series in this patient population. The aim of the present study was to compare the outcomes of patients with premature PAD who had undergone bypass or endovascular revascularization for advanced femoropopliteal disease. Our hypothesis was that open bypass would provide superior long-term outcomes compared with endovascular intervention for patients with premature advanced femoropopliteal PAD.

METHODS

All the patients with premature PAD who had undergone isolated femoropopliteal lower extremity revascularization and included in the Vascular Quality Initiative infrainguinal bypass and peripheral vascular intervention files were reviewed from 2003 through 2019. Propensity score matching (1:1) was performed between patients who had undergone femoropopliteal bypass and endovascular interventions for isolated femoropopliteal Trans-Atlantic Classification System C or D lesions. The 1-year outcomes, including reintervention, patency, major amputation, and mortality, were analyzed.

RESULTS

Of the 2538 included patients, 902 had undergone isolated femoropopliteal endovascular intervention and 1636 had undergone femoropopliteal bypass. The endovascular intervention group were more likely to have diabetes (68.9% vs 54.0%; P < .001), coronary artery disease (31.0% vs 23.0%; P < .001), renal failure requiring dialysis (14.2% vs 7.2%; P < .001), and claudication (45.1% vs 36.6%; P < .001) compared with the bypass group. After propensity score matching, 466 patients were in each group with no significant differences in the baseline characteristics. Perioperative morbidity was higher with femoropopliteal bypass compared with endovascular intervention (12.0% vs 7.9%; P = .038); however, the rates of major amputation and mortality were not different. At 1 year, patients who had undergone femoropopliteal bypass were less likely to require reintervention (17.0% vs 25.2%; P = .012). However, no differences were found in major amputation (7.7% vs 7.9%; P = .928) or mortality (5.2% vs 5.2%; P = 1.00). Propensity score matching was also performed between femoropopliteal bypass with the great saphenous vein and isolated femoropopliteal endovascular interventions, and the outcomes were similar.

CONCLUSIONS

For patients with premature PAD and advanced femoropopliteal disease, bypass surgery decreased the reintervention rate at 1 year but was associated with increased perioperative morbidity and hospital length of stay compared with endovascular therapy. No differences were found in major amputation or mortality between the two strategies.

Lower Extremity Revascularization for Chronic Limb-Threatening Ischemia among Patients at the Extremes of Age

BACKGROUND

Patients with chronic limb-threatening ischemia (CLTI) at the extremes of age are thought to have distinct risk factor profiles and poor outcomes after lower extremity revascularization (LER). The aim of this study is to examine the relationships among age, risk factor profiles, and outcomes of LER in patients with CLTI in a large database focusing on the extreme age groups.

METHODS

Patients undergoing LER for CLTI in the Vascular Quality Initiative suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention files were reviewed through 2019. Patients were stratified into 3 groups: premature peripheral artery disease (PAD) (≤50 years old), 51-84 years old, and elderly (≥85 years old). Trends in major amputation and mortality by age group were analyzed.

RESULTS

There were 156,513 patients who underwent LER for CLTI. Of these, 9,063 (5.79%) patients had premature PAD, 131,694 (84.14%) patients were 51-84 years old, and 15,756 (10.07%) were elderly. Patients with premature PAD were more likely to have insulin-dependent diabetes, be dialysis-dependent, and be active smokers compared to patients 51-84 years old and the elderly. Elderly patients were more likely to undergo an endovascular procedure for tissue loss compared to younger groups. Perioperative and 1-year major amputation rates were highest among patients with premature PAD and decreased with increasing age (P < 0.001), while perioperative and 1-year mortality increased with age (P < 0.001). On multivariable analysis, premature PAD was associated with an increased risk of major amputation (odds ratio, OR = 1.41 [1.22-1.62]), while elderly age was associated with decreased odds of major amputation compared to patients 51-84 years old (OR = 0.61 [0.51-0.73]).

CONCLUSIONS

Patients at the extremes of age have significantly different outcomes after LER for CLTI. Although mortality increases with age, the risk of major amputation decreases. Patients with premature PAD constitute a group of patients with a high risk of perioperative and 1-year major amputation.

Antithrombotic therapy in peripheral artery disease: A review of the EUCLID trial results and current ongoing trials

In addition to risk-factor modification, antithrombotic therapy is the hallmark of management to reduce cardiovascular ischemic events in patients with peripheral artery disease (PAD). Currently, the guidelines recommend long-term antiplatelet therapy with aspirin or clopidogrel in this patient population to reduce myocardial infarction, stroke, and vascular death. Past outcomes studies have shown some benefit of ticagrelor, another antiplatelet agent, as compared with clopidogrel in patients with coronary disease and concomitant PAD. However, most recently, the Examining Use of Ticagrelor in Peripheral Artery Disease (EUCLID) trial has shown no additional benefit of ticagrelor over clopidogrel. In this trial, a minority of patients had concomitant coronary artery disease, making it unique to previous studies. The EUCLID trial's evidence of neutrality between clopidogrel and ticagrelor sheds light into the complexity of studying the PAD population and the continued need to meticulously design trials to investigate the optimal therapies. The topics that will be discussed in this review include the role of antiplatelet therapy in the management of patients with PAD, a review of the EUCLID trial results and the important factors to be considered in interpreting the surprising results, and promising recent ongoing clinical trials assessing therapies in the treatment of patients with PAD.

Outcomes of infrainguinal bypass determined by age in the Vascular Study Group of New England

BACKGROUND

Many believe extremes of age correlate with poorer outcomes in treatment for lower extremity peripheral arterial disease (PAD). We hypothesized that the youngest patients would have significantly poorer outcomes compared with older cohorts due to the precocious nature of their PAD.

METHODS

We studied all patients in the Vascular Study Group of New England database undergoing infrainguinal bypass for PAD between 2003 and 2013. Age was grouped by <50 years, 50 to 79 years, and ≥80 years. Our primary outcomes were 1-year freedom from a major adverse limb event (MALE), defined as ipsilateral amputation or need for secondary intervention, and amputation-free survival. A second analysis was performed to analyze the subgroup of patients aged <50 years with critical limb ischemia (CLI), which included a Cox regression model to determine risk factors for MALE or death at 1 year.

RESULTS

Of 5265 patients who were treated with infrainguinal bypass for PAD, 324 (6.2%) were aged <50 years. The mean age was 44.6 years, and 66.4% were male. The proportion of African Americans was significantly higher in the youngest age group (<50 years: 6.8% vs 50-79 years: 3.5%, P = .002; vs ≥80 years: 3.5%, P = .013). More bypasses were done for claudication than acute limb ischemia in patients aged <50 years (33.3% vs 11.4%). More vein grafts were used vs prosthetic (<50 years: 72.1% vs 50-79 years: 65.9%, P = .024; vs ≥80 years: 62.6%, P = .002). Fewer concomitant proximal procedures were performed compared with the older groups (<50 years: 37.7% vs 50-79 years: 51.1%, P < .001; vs ≥80 years: 39.5%, P = .045). More young patients returned to the operating room within their initial hospitalization for early graft thrombosis (<50 years: 5.6% vs 50-79 years: 2.9%, P = .001; vs ≥80 years: 2.4%, P = .009) and revision (<50 years: 4.7% vs 50-79 years: 2.2%, P = .012; vs ≥80 years: 1.4%, P = .002) compared with the older patients. Overall, MALE-free survival was similar across age groups (P = .323), as were patency and amputation rates. When considering only patients with CLI, MALE-free survival in the youngest patients was again similar (P = .171) but with significantly more major amputations at 1 year (P = .022).

CONCLUSIONS

For patients aged <50 undergoing infrainguinal bypass surgery, this large series demonstrates similar overall medium-term graft-related outcomes compared with older cohorts. Further, although the youngest patients with CLI have similar MALEs, their amputation rates are higher than in older cohorts.

Clinical profile of aortoiliac occlusive disease and outcomes of aortobifemoral bypass in India

OBJECTIVE

Aortoiliac arterial occlusive (AIOD) disease is common in India. The clinical presentation and etiology are different than in the West. Intervention is frequently required for advanced lower extremity ischemia, but the results have not been systemically evaluated. We studied the clinical profile and midterm results of patients undergoing aortobifemoral bypass for AIOD at a tertiary care center in south India.

METHODS

Clinical data of patients undergoing aortobifemoral bypass for AIOD over a 6-year period from January 1, 2005 to December 31, 2010 were retrospectively analyzed. Clinical presentation and factors affecting outcome were evaluated. Graft patency and mortality were included as study end points.

RESULTS

Ninety-nine patients (mean age, 52 years) with AIOD who underwent aortobifemoral bypass were included. Etiology included atherosclerosis in 79 patients, thromboangiitis obliterans in 15, Takayasu's arteritis in two, and hematological conditions in 3. Smoking (82%), hypertension (40%), and diabetes (30%) were the most common risk factors; ischemic heart disease (4%), obesity (2%), and dyslipidemia (3%) were rare. Eighty-one percent of patients presented with critical limb ischemia. Mean duration of symptoms was 22 months (range, 4 months to 9 years). Concomitant infrainguinal arterial occlusive disease was identified in 81%, but intervened upon in only 2%. In-hospital mortality was 3%. Causes of death included myocardial infarction in two and colon ischemia in one. Major morbidity included nonfatal myocardial infarction (3%), pneumonia/atelectasis (5%), and renal dysfunction (2%). Groin wound complications occurred in 20%, seroma/lymph leak in 13%, infection in 7%, and anastomotic hemorrhage in 2%. Multidrug-resistant and polymicrobial infections were common. Early graft thrombosis (30 days) occurred in 15 patients; 8 of 11 reintervened grafts were salvaged. Four more grafts thrombosed during a mean follow-up of 2 years (range, 0-5 years) and two became infected. Overall study major limb loss rate was 10% (primary, 2%; secondary, 8%). Delayed presentation and smoking were more common in patients developing complications. There was no significant difference in overall complication rates between patients with thromboangiitis obliterans and atherosclerosis (P = .66).

CONCLUSIONS

Despite earlier age at presentation, atherosclerosis remains the predominant etiology of aortoiliac arterial occlusive disease in Indian patients. Results of open revascularization are comparable to those in the Western literature. Thromboangiitis obliterans is the underlying pathology in a minority of patients with no significant difference in operative outcome. Patients frequently present late with critical limb ischemia, but this does not affect outcome.

Distribution of risk factors in patients with premature coronary, supra-aortic branches and peripheral atherosclerotic disease

OBJECTIVE

The aim of this study was to determine the distribution of major risk factors among patients with atherosclerotic disease aged ≤50 years.

SUBJECTS AND METHODS

The study population comprised 944 patients aged ≤50 years with clinically significant manifestations of atherosclerotic disease compared with 350 consecutive (control) older patients (age >50 years).

RESULTS

The most significant risk factors for atherosclerotic disease of the supra-aortic branches were: smoking (87.5%, p < 0.001), family history of atherosclerosis (52.3%, p < 0.001), diabetes mellitus (28.5%) and being male (56.9%) (p < 0.05 for both). In patients with coronary artery disease, there was considerable disparity in the prevalence of smoking (85.4%), hyperlipoproteinemia (67.4%), and family history of atherosclerosis (68%) (p < 0.001). For peripheral artery disease, the most significant risk factors were smoking (97%, p < 0.001), hyperlipidemia (p < 0.01), and family history of atherosclerotic disease (p < 0.01). When compared to controls, patients with premature atherosclerosis smoked more frequently, had hyperlipidemia, had a family history of atherosclerosis, and were more frequently of male sex.

CONCLUSION

Premature atherosclerosis was most frequently associated with smoking, hyperlipidemia, family history of atherosclerotic disease, and male sex.

Risk factors for lower-extremity vein graft failure

Lower-extremity vein graft failure causes significant morbidity, increases health care costs, and negatively impacts patient quality of life. Identification of risk factors is essential for patient selection, risk factor modification, and identifying individuals who would benefit from more stringent surveillance protocols. Risk factors can be considered as either patient-related or technical. Here we discuss the patient-related risk factors for vein graft failure. Nontechnical factors related to the indication for operation include operation after a previously failed graft, or redo bypass, critical limb ischemia, and infection. Risk factors for vein graft failure are distinct from the risk factors for cardiovascular events. Young age and African American and Hispanic race are risk factors for lower-extremity vein graft failure. Hypercoaguable and inflammatory states also increase risk for vein graft failure. Therapy with statins is indicated in patients with peripheral atherosclerosis and may have beneficial effects on vein graft function, although further studies are needed in this area.

Resultados da cirurgia do aneurisma da aorta abdominal em pacientes jovens

CONTEXTO: A presença de aneurisma da aorta abdominal (AAA) é rara em pacientes jovens. OBJETIVO: Avaliar os resultados da cirurgia do AAA em pacientes com idade < 50 anos. MÉTODOS: De junho de 1979 a janeiro de 2008, 946 pacientes foram operados eletivamente do AAA infrarrenal pelo primeiro autor. Desses, 13 pacientes (1,4%) tinham idade < 50 anos no momento da cirurgia. Foram analisadas as características demográficas e cirúrgicas bem como os resultados precoces e tardios da cirurgia nesses pacientes. RESULTADOS: A média de idade foi 46±3,4 anos (variando de 43 a 50 anos), sendo a maioria homens (76,9%), hipertensos (76,9%) e tabagistas (61,5%). Não ocorreu nenhum óbito perioperatório, e a morbidade cirúrgica atingiu dois pacientes (15,4%) (um paciente com infecção respiratória e outro com angina instável). O seguimento mediano foi de 85,5 meses, ocorrendo dois óbitos devido a cardiopatia isquêmica em um paciente e acidente vascular cerebral em outro, durante o seguimento. CONCLUSÃO: A cirurgia do AAA é um procedimento seguro com bons resultados a longo prazo, pois, em nosso estudo, apresentou mortalidade perioperatória nula e boa sobrevida a longo prazo.

Tibial artery calcification as a marker of amputation risk in patients with peripheral arterial disease

OBJECTIVES

The purpose of this study was to evaluate the relationship between calcification in tibial arteries, the degree of limb ischemia, and the near-term risk of amputation.

BACKGROUND

Determining the amputation risk in patients with peripheral arterial disease (PAD) remains difficult. Developing new measures to identify patients who are at high risk for amputation would allow for targeted interventions and focused trials aimed at limb preservation.

METHODS

Two hundred twenty-nine patients underwent evaluation by history, arterial Doppler, and multislice computed tomography of the lower extremities. We then explored the relationship between a tibial artery calcification (TAC), traditional risk factors for PAD, limb status at presentation, and near-term amputation risk.

RESULTS

Increased age and traditional atherosclerosis risk factors were associated with higher TAC scores. Patients with critical limb ischemia had the highest TAC scores, and increasing TAC scores were associated with worsening levels of limb ischemia in ordinal regression analysis. Receiver-operator characteristic analysis suggested that the TAC score predicted amputation better than the ankle-brachial index (ABI). Symptomatic patients with a TAC score greater than 400 had a significantly increased risk of amputation. In Cox regression analysis, there was a strong association between the TAC score and the risk of major amputation that remained after adjustment for traditional risk factors and the ABI.

CONCLUSIONS

In patients presenting with PAD, the TAC score is associated with the stage of disease and it identifies those who are at high risk for amputation better than traditional risk factors and an abnormal ABI.

Risk factors for premature peripheral vascular disease: results for the National Health and Nutritional Survey, 1999-2002

PURPOSE

Premature peripheral vascular disease (PVD), occurring <60 years of age, is associated with significant cardiovascular morbidity, limb loss, and death. We hypothesized that different risk factors predict the development of PVD in patients <60 years than in patients > or =60 years.

METHODS

To address this question, we conducted a population-based observational study using the National Health and Nutritional Survey (NHANES) data set, which represents the noninstitutionalized civilian population in the United States. From 1999 to 2002, 5083 participants were analyzed as part of the NHANES survey. PVD status was defined by an ankle-brachial index (ABI) of <0.9. Putative risk factors for the development of PVD were collected by physical examination, interview, and laboratory testing. Univariate and multivariate logistic regression analyses were used to evaluate interactions between age strata and the development of PVD.

RESULTS

Premature PVD was found in 2.1% +/- 0.2% of the population <60 years, and PVD was found in 12.0% +/- 0.8% of the population > or =60 years. This corresponds to approximately 1.44 million people with premature PVD. Multivariate analysis determined coronary artery disease (odds ratio [OR] 2.90 vs 1.26, P = .083) and elevated serum fibrinogen (OR 1.07 vs 1.03, P = .034) were stronger predictors of PVD in subjects <60 years than in older subjects. Chronic renal insufficiency (OR 1.02 vs 1.16, P = .006) was more highly predictive of PVD in subjects >60 years. Other significant predictors, irrespective of age, in the multivariate model included hypertension (OR 1.99, P < .001), smoking (OR 2.22, P < .001), and serum homocysteine (OR 1.27, P = .067).

CONCLUSIONS

Clinicians should be aware of the high risk of developing premature PVD in patients <60 years with coexisting coronary artery disease or elevated plasma fibrinogen. Routine screening by ABI measurements in high-risk patients would enhance the detection of subclinical premature PVD and allow for secondary intervention.

Family history is a major determinant of subclinical peripheral arterial disease in young adults

BACKGROUND

Cardiovascular disease is prevalent in first-degree relatives of young adults with premature-onset peripheral arterial occlusive disease (premature PAD), but it is not known whether the genetic influence is independent of other risk factors, the most prevalent of which is smoking. This study was performed to determine the relative contributions of family history and smoking to the development of occult PAD in siblings of patients with premature PAD.

METHODS

The prevalence of occult PAD was determined with carotid, abdominal, and lower extremity duplex ultrasound scanning in 50 asymptomatic siblings (25 men, 25 women) of patients with premature PAD (onset <or=49 years). Thirty of the siblings (60%) were active smokers, and 20 had never smoked. Age-matched and sex-matched reference groups included 50 asymptomatic heavy smokers (>20 cigarettes/day) and 50 nonsmokers.

RESULTS

Duplex ultrasound scans demonstrated raised arterial lesions in 20 asymptomatic siblings (40%), 20 heavy smokers (40%), and 2 nonsmoking control subjects (4%), resulting in 42 affected and 108 unaffected subjects. As expected, smokers were far more likely to have arterial lesions than were nonsmokers (odds ratio [OR], 11.19; 95% confidence interval [CI], 4.1-30.7; P <.0001). Individuals with a family history of premature PAD were almost three times more likely to have arterial lesions than those with no family history of cardiovascular disease (OR, 2.76; 95% CI, 1.3-5.8; P =.006). Stratified and multivariable logistic regression indicated no interaction between smoking and family history, indicating simple additive effects on PAD.

CONCLUSIONS

Family history is a major determinant of occult PAD in young adults, and is at least as important as standard atherosclerotic risk factors. A high proportion of heavy smokers have clearly detectable lesions even though asymptomatic. Smoking and family history act additively to increase the risk for premature PAD.

Outcome of lower-extremity revascularization in patients younger than 40 years in a predominately diabetic population

OBJECTIVE

Incidence of perioperative complications is increased and outcome is poor in young patients undergoing vascular surgery. We extensively reviewed results of lower-extremity procedures in this group of patients to further define the extent of short-term and long-term morbidity.

METHODS

Results from our vascular registry were retrospectively reviewed for 76 lower-extremity revascularization procedures performed between January 1990 and May 2000 in 51 patients younger than 40 years. This represents 1.88% of 4052 lower-extremity bypass procedures performed during this period. Perioperative cardiac complications, long-term survival, graft patency, and limb salvage were evaluated. Kaplan-Meier curves were generated, and their significance was determined with the Cox-Mantel test.

RESULTS

Forty-nine percent of patients were male, and 51% were female; mean age at presentation was 35.9 years (range, 27.5-39.8 years). Preoperative morbidity included diabetes mellitus (96.1%), smoking (70.6%), hypertension (78.4%), coronary artery disease (37.3%), hyperlipidemia (33.3%), and renal dysfunction (52.9%). Overall rate for 30-day postoperative mortality was 0.0%, for myocardial infarction was 0.0%, and for congestive heart failure was 1.32%. Thirty-day graft failure was 11.1% (n = 9). At 1 year, primary patency was 71.0%, secondary patency was 82.5%, and limb salvage was 87.1%; and at 5 years these rates were 51.9%, 63.4%, and 77.2%, respectively. After the initial surgery 11.8% (n = 6) of patients required at least one additional ipsilateral revascularization procedure, 31.3% (n = 16) required a bypass graft in the contralateral limb, and 23.5% (n = 12) ultimately required amputation. In patients who required additional ipsilateral procedures, 1-year primary patency rate was 66.7%, secondary patency rate was 62.5%, and limb salvage rate was 77.8%, compared with 5-year rates of 44.4%, 41.7%, and 64.8%, respectively, representing a decrease in patency compared with primary revascularization procedures. Overall survival at 1 year was 88.2%, compared with 73.3% at 5 years. Patients with preexisting renal disease had significantly decreased survival at 5 years compared with those without renal dysfunction (64.5% vs 82.6%; P =.019).

CONCLUSIONS

Our data suggest that age younger than 40 years is not associated with increased perioperative morbidity and mortality. However, these patients have a significant rate of early graft failure and dismal long-term survival, especially in patients with preexisting renal dysfunction. In addition, ipsilateral repeat operations have a marginal success rate.

Results of iliac artery stent placement in patients younger than 50 years of age

PURPOSE

To determine long-term outcome in patients 50 years of age or younger treated with iliac artery stent placement.

MATERIALS AND METHODS

The records of 412 patients who underwent iliac artery stent placement during a 62-month study period were reviewed retrospectively. Forty-two patients younger than age 50 (mean age = 45 y) at the time of stent placement were included in the study population. Presenting symptoms included claudication (47%), rest pain (17%), ulceration/tissue loss (31%), and blue toe syndrome (5%). Anatomic, hemodynamic, and clinical success rates of the stent placement procedure were assessed. Stent patency rates were calculated by life-table methods.

RESULTS

Fifty-nine iliac lesions were treated with stents; 62% of patients underwent treatment of a single lesion whereas 38% had multiple lesions treated. Thirty-one percent were treated after a failed angioplasty procedure and 69% were treated with stent placement primarily. After stent placement, 34 patients (82%) experienced symptomatic relief, although eight of these patients (19%) underwent a planned ipsilateral infrainguinal bypass procedure during the same hospitalization. During follow-up, five patients (12%) required a bypass procedure as a result of stent failure and two patients (5%) required below-knee amputation. Seven patients (17%) required endovascular stent revision, with none requiring additional surgery. At 1, 2, and 3 years, the primary patency rates were 86%, 72%, and 65%, and the secondary patency rates were 90%, 88%, and 88%, respectively.

CONCLUSIONS

Iliac stent placement successfully addresses the presenting symptoms of young patients with peripheral vascular disease and results in patency rates that are similar to those reported in a more general population. With appropriate postprocedural surveillance, restenosis can be addressed in many patients with use of endovascular techniques, limiting the need for surgical revision.

Premature lower extremity atherosclerosis: clinical aspects

Peripheral arterial disease (PAD) involving the lower extremities is presumably a disease of the elderly. The awareness of PAD in the general population, and in younger adults in particular, is low. Atherosclerosis is the major cause of lower limb ischemia in the young. Young adults with clinical manifestations of premature lower extremity atherosclerosis (PLEA) typically have multiple cardiovascular risk factors and the majority are smokers, with strong family history of cardiovascular disease, and typically have chronic symptoms of claudication at diagnosis. Frequently these symptoms are either not reported in a timely manner by the patients or are attributed to other, presumably more common causes of leg pain in the young. More than 70% of patients with PLEA have angiographic evidence of severe aortoiliac disease. The results of surgical revascularizations in young adults are inferior to those reported in older patients. Younger adults typically require multiple revascularizations with relatively high amputation rate. We conclude that PAD should be considered in adults with multiple risk factors regardless of their age if appropriate symptoms are present. There is a need for increased public health awareness for premature lower extremity atherosclerosis.

The progressive nature of peripheral arterial disease in young adults: a prospective analysis of white men referred to a vascular surgery service

OBJECTIVE

The onset of symptomatic peripheral arterial disease at a young age (premature PAD) has been associated with rapid progression, bypass graft failure, and amputation. This study was performed to document the incidence of these complications and to determine the risk factors for poor outcome in patients with premature PAD.

METHODS

This study was designed as a prospective longitudinal analysis, with patients who were ambulatory or hospitalized at a single vascular referral institution. The subjects were 51 white men with onset of PAD symptoms before the age of 45 years (mean age of onset, 41 +/- 0.5 years) and represented consecutive patients who were seen at the vascular surgery service during a 4-year period. Thirty of the study subjects (58%) were recruited during the first 2 years. The main outcome measures were number and type of lower extremity revascularization procedures or amputations that were necessitated during the follow-up period.

RESULTS

During a mean follow-up period of 73 +/- 6 months, 15 patients (29%) had PAD that remained stable without interventions and 15 (29%) had PAD that remained stable for a mean of 76 +/- 13 months after a single intervention. Twenty-one patients (41%) required multiple operations or major amputations. In a comparison of the 30 PAD patients whose conditions were stable with or without a single intervention with the 21 PAD patients who required multiple interventions (REDO), there were no differences in smoking, hypertension, diabetes, or dyslipidemias. The REDO group had a younger mean age at the onset of symptoms (39 +/- 1 years vs 43 +/- 2 years; P <.001). At entry, the REDO patients had a higher prevalence of infrainguinal or multilevel disease (57% vs 20%; P =.03), a lower mean ankle brachial index (0. 44 +/- 0.04 vs 0.56 +/- 0.03; P =.02), and more frequent tissue loss (24% vs 0; P =.005). The REDO patients had a higher mean lipoprotein (a) level than did the patients with stable conditions (51 +/- 11 mg/dL vs 27 +/- 5 mg/dL; P =.03), but there were no significant differences in the mean plasma homocysteine levels (19 +/- 2 micromol/L vs 16 +/- 1 micromol/L) or in the proportion of patients with hypercoagulable states (33% vs 30%). The only predictive variables that were selected with stepwise logistic regression analysis were age at onset (P <.002; odds ratio, 1.4; 95% confidence interval, 1.11 to 1.81) and ankle brachial index of less than 0.5 (P <.008; odds ratio, 6.4; 95% confidence interval, 1.5 to 27.3).

CONCLUSION

Although 60% of the white men with premature PAD who were referred to a vascular surgery service had conditions that appeared to remain stable, these data show that approximately 40% of the patients will require multiple interventions because of disease progression or bypass graft failure. Clinical indicators, not serum markers, are predictors of poor outcome in patients with premature PAD. The results of this study suggest that patients with onset of PAD before the age of 43 years who have objective evidence of advanced disease are predisposed to multiple interventions.

Normohomocysteinaemia and vitamin-treated hyperhomocysteinaemia are associated with similar risks of cardiovascular events in patients with premature peripheral arterial occlusive disease. A prospective cohort study

OBJECTIVES

Mild hyperhomocysteinaemia (HHC), fasting or after methionine loading, is associated with an increased risk and severity of atherosclerotic vascular disease. Post-methionine and fasting HHC are responsive to treatment with vitamin B, and folic acid. We performed a prospective cohort study amongst normohomocysteinaemic and vitamin-treated (vitamin B6, 250 mg plus folic acid, 5 mg daily) hyperhomocysteinaemic patients with premature peripheral arterial occlusive disease and assessed the incidence of cardiovascular events.

DESIGN

We studied 273 consecutive patients with clinically manifest peripheral arterial occlusive disease with onset before the age of 56, 79 (28.9%) of whom had postmethionine HHC. Follow-up was obtained in 232 (85'%o) patients. At baseline, 70 (30')/) were hyperhomocysteinaemic after methionine loading and started treatment with vitamin B, and folic acid; 162 (70%) were normohomocysteinaemic (reference group).

RESULTS

During the follow-up period (median 20, range 1-63 months), 48 (29.6%) and 23 (32.9%) of the normo- and the hyperhomocysteinaemic patients, respectively, had a new cardiovascular event. Most (75%) involved the peripheral arterial system. The crude incidence rate for any cardiovascular event was 0.16 (95% CI, 0.12-0.21) per person per year in the normohomocysteinaemic and 0.16 (95% CI, 0.09-0.22) per person per year in the hyperhomocysteinaemic group. Multivariate Cox regression analyses showed that higher plasma homocysteine levels were associated with an increased risk of new cardiovascular events in the normohomocysteinaemic patients (relative risk [RR] per 1 micromol L(-1), 1.17 [CI, 1.05-1.30] for fasting and 1.06 [CI, 1.01-1.12] for postmethionine levels), but not in the hyperhomocysteinaemic (vitamin-treated) patients. The adjusted RR for new cardiovascular events in the hyper- as compared to the normohomocysteinaemic patients was 0.76 (CI, 0.33-1.74).

CONCLUSIONS

These data are consistent with a protective effect of treatment with vitamin B6 and folic acid in patients with premature peripheral arterial occlusive disease and postmethionine HHC. Double-blind randomized trials are necessary to confirm this.

Risk factors for premature atherosclerosis

OBJECTIVES

to investigate the prevalence of risk factors in patients with premature atherosclerosis.

DESIGN

retrospective controlled study.

MATERIALS

135 consecutive patients with premature atherosclerosis </= 55 years (group I) were investigated. A control group comprised 107 consecutive patients >/= 65 years (group II) with atherosclerosis. Statistical analysis was performed with Chi-squared test and logistic regression analysis.

RESULTS

group I versus group II: diabetes 11% vs. 27% (p=0.001), smoking 84% vs. 67% (p=0.002), hypertension 36% vs. 58% (p=0.001), hypercholesterolaemia 47% vs. 34% (p=0.04), family history of cardiovascular disease 53% vs. 42% (p=0.08). In group I hyperhomocysteinaemia was present in 24 of the 108 patients tested, anticardiolipin antibodies were present in four of the 34 tested and coagulation abnormalities were found in four of the 22 patients tested.

CONCLUSION

the difference in the prevalence of the different risk factors between the two groups suggests that either certain risk factors are more likely to cause premature atherosclerosis, or that other risk factors must be present in addition to the known risk factors in order to induce premature atherosclerosis.

Aortoiliofemoral bypass graft in young adults: long-term results in a series of sixty-eight patients

BACKGROUND

The aim of this study was to investigate surgical indications and the long-term outcomes of aoroiliofemoral reconstructions in adults younger than 45 years.

METHODS

Between 1973 and 1990, 1256 patients underwent infrarenal abdominal aortic reconstruction for aortoiliofemoral occlusive disease. Sixty-eight (5.4%) patients (group 1) were less than 45 years old and form the basis of the analysis. They were retrospectively compared with two additional groups of patients 45 years and older selected from the entire series. Patients in group 2 (n = 100) were randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcomes. Patients in group 3 (n = 70) were matched with those in group 1 for gender, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcomes of aortoiliofemoral reconstructions.

RESULTS

Postoperative mortality rates (1.5%, 4%, and 4.3% for groups 1, 2, and 3, respectively) and major complication rates (4.4%, 7%, and 7.1% for groups 1, 2, and 3, respectively) were comparable among the three groups. Ten-year secondary patency rates were 84.6%, 70.6%, and 80.3%, for groups 1, 2, and 3, respectively (p = not significant). Ten-year limb salvage rates were 86.9%, 78.2%, and 80.6%, for groups 1, 2, and 3, respectively (p = not significant). During follow-up a significantly higher percentage of myocardial infarction was recorded in group 1 as compared with group 2 (p < 0.03) and group 3 (p < 0.04). The 10-year survival rate for group 1 was significantly lower than that of group 2 (29.0% versus 46.9%; p < 0.005).

CONCLUSIONS

Aortoliofemoral reconstruction in patients younger than 45 years is a safe procedure with low operative risks and good long-term results in patency and limb salvage rates. However, life expectancy is poor because of the high incidence of deaths related to coronary artery disease.