Lower limb ischemia in young adults: Prognostic implications

Outcomes of open and endovascular infra-inguinal revascularization are poor in young patients with atherosclerotic peripheral artery disease but do not differ between genders

OBJECTIVES

The effect of gender on the outcomes of revascularization procedures in young patients with premature atherosclerotic peripheral arterial disease (PAD) is not known. The objective of this study was to compare short-term and long-term outcomes between young males and females undergoing infra-inguinal revascularization procedures.

METHODS

We examined postoperative outcomes of male and female PAD patients under the age of 55 who underwent infra-inguinal revascularization procedures at a single tertiary institution from 2011 to 2019. Primary outcomes included 30-day morbidity, patency of the revascularization procedures, and major adverse limb events (MALE). Secondary outcomes included survival, amputation rate, reintervention rate, improvement of ankle-brachial index (ABI), and number of reinterventions.

RESULTS

Eighty-one infra-inguinal revascularization procedures (46 endovascular and 35 open procedures) were reviewed including 45 procedures in 37 males and 36 procedures in 31 females. Fifty-three (65.4%) of the procedures were performed in patients with chronic limb-threatening ischemia symptoms. The rest were treated for life-disabling claudication. The female patients were younger, had higher body mass index, and were more likely to have diabetes, hyperlipidemia, or chronic obstructive pulmonary disease in comparison to males. Thirty-day major adverse cardiovascular event was 0.0% and MALE was 16.0%. Mean follow-up was 806.2 days. At 1 year, primary patency was 34.4 ± 6.2%, primary assisted patency was 52.7 ± 6.5%, secondary patency was 61.8 ± 6.3%, and MALE-free rate was 47.0 ± 6.4%. For secondary outcomes at 1 year, amputation-free rate was 92.5 ± 3.2%, reintervention-free rate was 50.2 ± 6.4%, and survival was 96.2 ± 2.6%. By the end of the study, overall mortality rate was 14.8% and major amputation rate was 13.6%. No major differences were observed between males and females among these outcomes. A smaller improvement in ABI after revascularization was noted in females compared to males (female 0.2 ± 0.2 vs male 0.4 ± 0.2, p = .04). Among patients who required reintervention, females required a higher number of reinterventions than males (female 1.7 ± 2.5 vs male 0.8 ± 1.1, p = .03).

CONCLUSIONS

There were no significant differences in short-term and long-term outcomes between males and females under the age of 55 after infra-inguinal revascularization. Poor patency, high MALE rate, and high mid-term mortality, and amputation rates after revascularization in young PAD patients highlight the need for improved strategies to treat premature PAD.

Hypercoagulability predicts worse outcomes in young patients undergoing lower extremity revascularization

OBJECTIVE

Although we know that young patients with peripheral artery disease (PAD) have worse outcomes than older patients, there is a scarcity of information about the incidence of hypercoagulability in this population. Our aim was to analyze outcomes of young patients diagnosed with a hypercoagulable state (unusual tendency toward thrombosis) after lower extremity revascularization compared with similar patients without hypercoagulability.

METHODS

All patients 50 years of age or younger undergoing an initial procedure for lower extremity PAD from 2000 to 2015 at the Cleveland Clinic were retrospectively analyzed. Patients with a hypercoagulability panel were included and classified into groups as hypercoagulable positive (HP) or hypercoagulable negative (HN). Demographics, preoperative risk factors, form of presentation, level of disease, and type of intervention were analyzed in addition to perioperative complications, early failure, and length of stay. Primary outcomes were limb loss and primary, primary assisted, and secondary patencies. Outcomes were analyzed and Kaplan-Meier curves generated.

RESULTS

Ninety-one patients were included for a total of 118 limbs. Mean follow-up was 32 months; 55% of patients had a hypercoagulable disorder, with 59% having lupus anticoagulant and 32% hyperhomocysteinemia. In the HP group, 71% were men; 49% were men in the HN group. Patients overall had a high prevalence of smoking (86%), hypertension (36%), and hyperlipidemia (33%). Acute limb ischemia was the most common form of presentation for both groups (50% HP, 38% HN). The aortoiliac segment was the most commonly affected (38% HP, 50% HN). The most frequent operation in the HN group was endarterectomy or bypass (32%); in the HP group, it was an endovascular intervention (29%). Perioperative occlusion or failure was 18% in the HN group vs 30% in the HP group (P > .05). Primary patency, primary assisted patency, and secondary patency at 36 months were all better for the HN group (no statistical significance) in all treatment groups. Major amputation at 36 months was significantly worse for the HP group (40% vs 10% in the HN group; P < .005). There was no difference in perioperative complications or length of stay.

CONCLUSIONS

Young patients undergoing lower extremity revascularization for PAD have worse outcomes when associated with hypercoagulability. There are trends to decreased patency of revascularization in these patients, with significantly more major amputations. No clear differences between modalities of treatment were demonstrated.

Lower Extremity Amputations in Adults Less Than Forty Years of Age: An Underestimated Risk from Premature Atherosclerosis

Between 1987 and 1992, 57 patients aged twenty-five to forty (average, 34.0 ±4.5 years) underwent major lower extremity amputations in five community hospitals, including a Level II Trauma Center. Only 19 (33%) patients had traumatic amputations, 3 (5%) had malignant tumors, and 4 (7%) had juvenile-onset diabetes mellitus without atherosclerotic involvement of the large arteries. Thirty (53%) patients had premature atherosclerosis (PAS) of the lower extremities with end-stage renal disease (ESRD) present in half and related to diabetes in 12. All patients with ESRD required continuous dialysis therapy. Overall 19 (33%) patients in this study had diabetes. Of 32 patients < thirty-five years of age, 47% had traumatic amputations, and PAS was diagnosed in 28%. However, PAS was diagnosed in 84% of 25 patients > thirty-six years of age (OR= 14.3; P < 0.001). In total, 67 amputations were done. Twenty-one (68%) of 31 above-knee amputations (AKA) were performed in patients with PAS, and 26% of AKA were related to trauma. Of 10 bilateral amputations, 9 (90%) were done in patients with PAS. Patients with PAS had a high prevalence of risk factors for cardiovascular disease including smoking (87%), diabetes (50%), hypertension (50%), and hyperlipidemia (30%). Nine (30%) of the patients with PAS had hypercoagulable states. PAS was identified as the leading cause for major amputations among young adults in this community and was frequently associated with heavy smoking, diabetes, end-stage renal disease, and hypercoagulability.

Epidemiology of peripheral artery disease

New data on the epidemiology of peripheral artery disease (PAD) are available, and they should be integrated with previous data. We provide an updated, integrated overview of the epidemiology of PAD, a focused literature review was conducted on the epidemiology of PAD. The PAD results were grouped into symptoms, diagnosis, prevalence, and incidence both in the United States and globally, risk factors, progression, coprevalence with other atherosclerotic disease, and association with incident cardiovascular morbidity and mortality. The most common symptom of PAD is intermittent claudication, but noninvasive measures, such as the ankle-brachial index, show that asymptomatic PAD is several times more common in the population than intermittent claudication. PAD prevalence and incidence are both sharply age-related, rising >10% among patients in their 60s and 70s. With aging of the global population, it seems likely that PAD will be increasingly common in the future. Prevalence seems to be higher among men than women for more severe or symptomatic disease. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease, with some differences in the relative importance of factors. Smoking is a particularly strong risk factor for PAD, as is diabetes mellitus, and several newer risk markers have shown independent associations with PAD. PAD is strongly associated with concomitant coronary and cerebrovascular diseases. After adjustment for known cardiovascular disease risk factors, PAD is associated with an increased risk of incident coronary and cerebrovascular disease morbidity and mortality.

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.

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.

The impact of patient age and aortic size on the results of aortobifemoral bypass grafting

OBJECTIVES

On the basis of the widespread belief that aortobifemoral bypass (ABF) represents the optimal mode of revascularization for patients with diffuse aortoiliac disease, vascular surgeons are often aggressive about its application in young adults. We undertook this retrospective evaluation of ABFs performed from 1980 to 1999 to determine whether the results justify this approach. Patients of less than 50 years of age (n = 45) were compared with those aged 50 to 59 years (n = 93) and those aged more than 60 years (n = 146).

RESULTS

Younger patients were more likely to undergo operation for claudication than were older patients (72% versus 59% and 55%; P <.04). Younger patients were significantly more likely to be smokers (87%) but less likely to have diabetes, hypertension, or cerebrovascular disease. Bypasses were constructed in an end-to-end fashion in 71.1% of patients of less than 50 years versus 68.8% and 71.2% of older patients (P = not significant). The mean diameter of aortic grafts was significantly smaller in younger patients (14.6 mm) than in older patients (15.6 mm and 15.5 mm; P <.01). The need for a subsequent infrainguinal reconstruction was highest in the youngest patients (24% versus 17% and 7%; P <.01). Surgical mortality rates were low in all groups (0%, 1%, and 2.0% for increasing age groups; P = not significant). Five-year primary and secondary patency rates increased significantly with each increase in age interval: 5-year primary patency rate: less than 50 years, 66% +/- 8%; 50 to 59 years, 87% +/- 5%; more than 60 years, 96% +/-2% (P <.05 for all comparisons). Five-year secondary patency rates were: less than 50 years, 79% +/- 7%; 50 to 59 years, 91% +/- 4%; more than 60 years, 98% +/- 2% (P <.05 for all comparisons). Five-year survival rate was comparable in all three groups: less than 50 years, 93% +/- 5%; 50 to 59 years, 92% +/- 4%; more than 60 years, 87% +/- 4% (P = not significant).

CONCLUSION

Increased virulence of aortic disease, smaller aortic size, and more progressive infrainguinal disease may all negatively impact the results of ABF in younger patients. Although 5-year results are acceptable, increased caution is warranted in the routine application of ABF in young patients without limb-threatening ischemia.

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.

Efficacy of infrainguinal bypass for limb salvage in young diabetic patients

The efficacy of infrainguinal bypass for limb salvage in young diabetic patients has not been well established. The purpose of this study is to determine the intermediate-term results (patency and limb salvage) of infrainguinal revascularization carried out for limb salvage (rest pain or ulceration) in young (<50 years old) diabetic atherosclerotic patients. Thirty-nine bypasses in 31 patients with a mean age of 44 years were retrospectively reviewed. There were no perioperative deaths. Minor or major complications occurred in 23% of cases. By life table analysis, the 18-month primary patency rate was 60+/-11%, assisted primary patency rate was 78+/-9%, and limb salvage rate was 71+/-9%. Most major amputations (five of nine) were required in patients with functional bypasses, either because of persistent infection or failure of wound healing. The presence of severe stenoses (>70%) in all three major named foot vessels (dorsalis pedis, medial and lateral plantar arteries) was associated with a high likelihood of limb loss despite a patent bypass (p<0.05). We could not identify any other factors statistically predictive of thrombosis, amputation, or the need for graft revision. Infrainguinal revascularization in this patient population can be carried out with acceptable limb salvage rates. However, patients should be made aware of the high incidence of amputation regardless of the success of the revascularization procedure, particularly in the presence of severe occlusive disease within the foot.

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.

Carotid endarterectomy in patients less than 50 years old

PURPOSE

The purpose of this study was to compare the results of carotid endarterectomy (CEA) in a young population with premature atherosclerosis with the results of an older control group, examining perioperative morbidity and mortality data, recurrent stenosis and symptoms, late stroke, and survival data.

METHODS

We retrospectively studied 26 patients less than 50 years old (mean, 43.2 +/- 3.8 years) and 30 patients greater than 55 years old (mean, 69.1 +/- 7.4 years) who underwent CEA during the same time period. Data were obtained regarding demographics, atherosclerotic risk factors, indication for CEA, perioperative complications, recurrent stenosis and symptoms, late stroke, and survival.

RESULTS

Smoking was more prevalent among young patients who underwent CEA (92% vs 70%; p = 0.036). Young patients were also more likely to be symptomatic at presentation (92% vs 57%; p = 0.003). The perioperative mortality rate (0% vs 0%) and neurologic morbidity rate (0% vs 3%; p = 1.000) were low for the study patients. During a mean follow-up of 67 +/- 42.7 months, there was no significant difference in survival rate (5-year survival rate, 93% vs 81%; p = 0.373), rate of late ipsilateral (4% vs 3%) and contralateral (4% vs 3%) stroke, restenosis and occlusion (26.9% vs 14.3%), recurrent symptoms (22% vs 17%), reoperation (11.5% vs 5.7%), or contralateral disease (17% vs 23%) development that required surgery for the study or the control cohorts.

CONCLUSIONS

Our data show that there is a high incidence of smoking and symptomatic presentation among young patients in whom carotid occlusive disease develops. CEA may be performed in young patients with low perioperative morbidity and mortality rates. Recurrent disease, late stroke, and survival rates are not significantly different than for older patients. Follow-up with serial duplex ultrasound and reoperation for symptomatic and high-grade asymptomatic restenosis may decrease the risk of late stroke.

Late outcome of patients with premature carotid atherosclerosis after carotid endarterectomy

BACKGROUND AND PURPOSE

The durability of carotid endarterectomy (CEA) in young adults with premature carotid atherosclerosis has not been adequately assessed. This study examined the late recurrence and mortality rates in young adults undergoing CEA.

METHODS

We studied 42 young patients (mean age, 45.5 +/- 0.5 years) who underwent CEA and compared them with 110 older control subjects (mean age, 65.8 +/- 0.4 years) undergoing CEA during the same period. Data were collected regarding demographics, operative indications, follow-up carotid duplex studies, recurrent symptoms, and deaths.

RESULTS

Demographics and atherosclerotic risk factors were similar between the two groups. During a mean follow-up of 57.9 +/- 6.0 months, 10 (24%) young patients and 3 (3%) control subjects developed significant, recurrent ipsilateral stenoses (> or = 50% diameter loss) (P < .001). Six (14%) young patients and 1 control subject had recurrent ipsilateral symptoms (P = .002). Nine (21%) young patients and 26 (24%) older control subjects required contralateral CEA; 8 (18%) young patients and 18 (16%) older control subjects underwent lower extremity revascularization procedures. Cumulative 5-year survival by life-table analysis was 0.83 (95% confidence interval [CI], 0.71 to 0.95) for study patients and was 0.67 (95% CI, 0.58 to 0.77) for control subjects (P = .06).

CONCLUSIONS

These data demonstrate a trend toward more favorable survival in young versus older patients after CEA; however, survival differences did not achieve statistical significance. Young patients are far more likely to develop recurrent symptoms and recurrent carotid stenoses than older counterparts. Close follow-up with serial duplex ultrasound may be important in young patients after CEA.

Long-term follow-up of patients with early atherosclerosis

PURPOSE

Patients with premature peripheral vascular disease may respond differently than their older counterparts. To determine the impact of early onset of atherosclerosis on outcome, we decided to compare a group of these patients with a group of patients with typical onset of atherosclerosis with regard to early complications, indications for intervention, site of disease at initial presentation (aortoiliac, infrainguinal, or cerebrovascular), and long-term outcomes (secondary revascularization, amputation, and death).

METHOD

All patients younger than 50 years old requiring operative intervention between 1987 and 1992 were retrospectively compared with a group of patients greater than 60 years old, randomly selected from patients who underwent operation during the same time period. Patients were evaluated and compared for indications, risk factors, and early and late outcomes.

RESULTS

Patients with early onset atherosclerosis at the aortoiliac or infrainguinal level had a higher late amputation rate (17% versus 3.9%, p = 0.02) and poorer overall outcome than their older cohorts. Patients with cerebrovascular disease in both cohorts had similarly good prognoses.

CONCLUSION

Aortoiliac or infrainguinal disease diagnosed in patients less than 50 years of age portends a poorer outcome than does similar disease in an older patient population.

A prospective evaluation of atherosclerotic risk factors and hypercoagulability in young adults with premature lower extremity atherosclerosis

PURPOSE

Fifty-one consecutive patients with premature lower extremity atherosclerosis were prospectively evaluated for atherogenic risk factors and primary or acquired hypercoagulability, which might contribute to early ischemia and revascularization failure.

METHODS

Laboratory tests included plasma assays of (1) natural anticoagulants (NAC), lipoprotein (a) (Lp[a]), and anticardiolipin antibodies, and (2) fibrinolytic activators and inhibitors at baseline and stimulated after 20 minutes of upper extremity venous occlusion.

RESULTS

Forty-six (90%) of these 51 patients had laboratory abnormalities. One or more NAC deficiencies were found in 15 (30%) patients and included antithrombin III (n = 5), protein C (n = 8), protein S (n = 4), and heparin cofactor II (n = 2). Hypofibrinolysis was identified as a deficiency of stimulated tissue plasminogen activator in 22 (45%) patients and elevated plasminogen activator inhibitor-1 (PAI-1) in 29 (59%). Elevated Lp(a) was found in 43 (86%) patients. Five (10%) patients had anticardiolipin antibodies. Ten patients had combined NAC deficiency and hypofibrinolysis. Five (10%) patients had no abnormality. NAC deficiencies, especially protein C deficiency, were associated with acute ischemia (p < 0.01), prior vascular intervention (p < 0.01), an increasing number of total vascular procedures (p < 0.01), and major amputation (p < 0.01). PAI-1 was associated with a history of heart disease (p < 0.05) and prior vascular procedures (p < 0.05). Elevated Lp(a) was associated with elevated PAI-1 (p < 0.05). Retesting in 20 patients suggested that 80% of NAC deficiencies were acquired, but abnormalities persisted in 66% of patients with elevated PAI-1 and in 93% of those with elevated Lp(a).

CONCLUSIONS

These data strongly support the hypothesis that the convergence of atherogenic risk factors and hypercoagulability play an important role in early ischemia and poor results reported for lower extremity vascular procedures in young adults.

Results of vascular reconstructions for atherosclerotic arterial occlusive disease of the lower limbs in young adults

OBJECTIVE

To evaluate early and long-term results of vascular reconstructions for arterial atherosclerotic occlusive disease (AOD) of the lower limb in young patients under the age of 40 years.

DESIGN

Retrospective study.

SETTING

University hospital.

MATERIALS

Twenty-nine young adults, who underwent vascular reconstruction for histologically proven AOD of the aortoiliac and/or femoropopliteal segments in a 15-year period.

CHIEF OUTCOME MEASURES

Early and late mortality, failure of vascular reconstructions, additional procedures, other manifestations of atherosclerosis, recurrence of symptoms.

MAIN RESULTS

Nine patients (31%) died, seven related to atherosclerotic disease. In 21 patients (72%) initial vascular reconstruction(s) failed. Twenty-two patients (76%) underwent surgery for failures and/or progression of AOD in other segments of the lower limb. Amputation was performed in five patients (17%). At the end of the follow-up period only 25% of surviving patients were asymptomatic.

CONCLUSION

Young patients undergoing vascular reconstructions for AOD of the lower limbs, in particular those who initially have extensive and progressive atherosclerosis, have a poor outcome in terms of a high mortality and a high operative failure rate. A liberal attitude towards reconstructive surgery, particularly in claudication, is not warranted.

Percutaneous transluminal angioplasty in adults less than 45 years of age with premature lower extremity atherosclerosis

Despite poor results reported with conventional vascular bypasses in young adults with ischemia from premature lower extremity atherosclerosis (PLEA), little attention has been given to alternative revascularization techniques. This study evaluated 32 patients (21 males and 11 females) < 45 years of age with PLEA who underwent 53 primary percutaneous transluminal angioplasty (PTA) procedures for treatment of 46 ischemic limbs. A residual arterial stenosis < 30% was achieved in 83% of PTA sites. Mean degree of stenosis decreased from 79.9% to 24.1% (p < 0.0001). Clinical improvement in ischemic symptoms was obtained in 39 (85%) limbs. Hemodynamic improvement was achieved in 31 (70%) of 40 limbs as documented by ankle/brachial indices. All criteria for early clinical success were met in 70%. Another 13% met all criteria except that the residual stenosis was < 50%. Hematoma and early restenosis were reported in two patients each. Mean follow-up was 27.3 months (range 1 to 84 months). Cumulative patency by life-table analysis was 81% at 1 year, 77% at 2 years, and 71% at 3 years. Thirteen (41%) patients required secondary PTA or bypass; 85% were performed within 1 year. Two patients had adjunctive bypasses; six (19%) were performed after PTA failure. Only one (3%) patient required major amputation. Neither cardiovascular risk factors, treatment indication, location of the diseased arterial segment, nor quality of distal runoff vessels predicted the need for secondary PTA or surgical procedures. PTA of the proximal arteries in young patients with PLEA is an effective primary revascularization technique with results comparable to those of conventional operative revascularization procedures.

The influence of sex and aortic size on late patency after aortofemoral revascularization in young adults

PURPOSE

The purpose of this study was to determine whether aortic size influences late patency of aortofemoral reconstructions in men and women with premature atherosclerosis.

METHODS

We studied 37 consecutive young women (mean age +/- SEM, 44 +/- .7 years) and 36 young men (mean age 44 +/- .8 years) who underwent elective operations for aortoiliac occlusive disease during the past 15 years. Clinical data from patients with occluded versus patent grafts were studied, and angiographic findings in patients with occluded versus patent grafts and in young adult patients in a control group (n = 50) who had nonatherosclerotic conditions were compared.

RESULTS

Twenty (54%) women and 17 (47%) men had limb occlusions within a mean of 31 +/- 6 months. These occlusions resulted in major amputations in 17 (23%) patients. When patients with occluded versus patent grafts were compared no differences were found in age, sex, symptoms, type or number of atherosclerotic risk factors, or operative details. As a whole, patients in the study group had smaller infrarenal aortas than did patients in the control group (p = 0.009). Women with limb occlusions had smaller infrarenal aortas than did women with patent grafts (p = 0.03) or healthy female patients in the control group (p = 0.002). Men with limb occlusions had smaller infrarenal aortas than did men with patent grafts (p = 0.017) or male patients in the control group (p < 0.001). Angiographic outflow scores were not different in men or women with occluded versus patent grafts. Among all variables studied proportional hazards regression analysis indicated that only mean infrarenal aortic diameter was predictive of graft patency.

CONCLUSIONS

These data suggest that late graft failure after aortofemoral reconstruction is common in young adults. Patients with premature atherosclerosis have smaller infrarenal aortas compared with young adults in a control group, making them more vulnerable to symptoms from atherosclerotic lesions. Size of the infrarenal aortic segment is a critical determinant of late graft patency regardless of sex.

Lower extremity ischemia in adults younger than forty years of age: a community-wide survey of premature atherosclerotic arterial disease

A retrospective community-wide survey identified 109 patients younger than 40 years of age with lower extremity ischemia: 72 men and 37 women, mean age 36 years (range 25 to 40 years), black-to-white ratio-1:1. Initially, 66 patients had claudication and 43 had severe ischemia. Cardiovascular risk factors were smoking (85%), hypertension (47%), coronary artery disease (30%), hyperlipidemia (27%), diabetes (25%), and visceral arteriopathy (17%). Unique risk factors included hypercoagulability (15%) and clinical arterial hypoplasia (15%). Twenty-three (21%) patients were treated medically; 74 (68%) underwent primary revascularization and 12 (11%) primary major limb amputation. Forty-six (53%) patients required secondary procedures, of which 34 (74%) were performed within 1 year of primary intervention. A total of 29 (27%) patients ultimately required amputation (10 bilateral). Women had higher prevalence of diabetes (p < 0.01), arterial hypoplasia (p < 0.05), and tendency for more severe ischemia (p = 0.11). No racial differences in severity of symptoms or outcome of treatment were found. By multiple logistic regression analysis, typical cardiovascular risk factors did not predict severity of symptoms, need for surgical treatment, or outcome. However, diabetes was associated with tissue loss (p < 0.05) and primary amputation (p < 0.001). Further, adjusted odds ratios indicate that arterial hypoplasia had a protective effect on distal vasculature (p < 0.05) and predicting need for revascularization (p < 0.05), but not on treatment failure. Hypercoagulability had the highest predictive value for presence of severe ischemia (p < 0.05), need for primary amputation (p < 0.01), and early failure of surgical treatment (p < 0.05).

Coronary artery disease is highly prevalent among patients with premature peripheral vascular disease

PURPOSE

This study was designed to document the prevalence of coronary artery disease (CAD) and associated cardiac complications among patients with symptoms of premature peripheral vascular disease.

METHODS

We studied the peripheral and coronary arterial circulations of 59 consecutive male military veterans diagnosed with premature peripheral vascular disease (age of onset < or = 45 years) affecting the lower extremity. Patients who had not previously undergone coronary angiography underwent exercise stress testing. Patients unable to perform exercise testing and those with abnormal exercise test results underwent coronary angiography.

RESULTS

There was no evidence of CAD in 16 patients (29%) on the basis of normal exercise test results (n = 12) or normal coronary angiography results (n = 4). Forty-three patients (71%) had significant (> or = 50% lesion) CAD by coronary catheterization. Cardiac complications were frequent among the 43 patients. Eleven (65%) of the 17 patients with single-vessel CAD had previously documented myocardial infarctions, as did three (75%) of the four patients with two-vessel CAD and 18 (82%) of the 22 patients with three vessel or greater CAD. Three (18%) patients with one-vessel CAD had undergone coronary artery bypass grafting or percutaneous transluminal coronary angioplasty for symptoms, as had one patient (25%) with two-vessel CAD and 19 patients (86%) with three-vessel or greater CAD. Five patients died during the study period, four of myocardial infarction and one of stroke.

CONCLUSIONS

Premature peripheral atherosclerosis is associated with a high prevalence of CAD. Detection of CAD is important in this group, because cardiac complications are frequent.

Long-term results of arterial reconstruction of the upper extremity

Arterial reconstructive surgery for upper limb ischaemia of non-traumatic non-embolic origin is uncommon in comparison to that of the lower extremities and long-term follow-ups are rare. Forty-eight patients (27 females, 21 males) with a median age of 58 years (range 22-88) were retrospectively analysed for risk factors, survival and patency rates. Seventy-three per cent were smokers, 42% had hypertension and 33% had had previous vascular interventions. Diabetes was only seen in 4% of the cases. Effort fatigue was the dominant cause for surgery followed by micro-embolism and rest pain or gangrene. The left side was more frequently affected with 30 procedures compared to 18 on the right. Bypass with either Dacron, ePTFE or autologous vein was the most frequent procedure in 56% of the cases followed by thrombendarterectomy (23%) and subclavio-carotid transposition (11%). Arm-arm index rose from 0.63 (SD 0.28) preoperatively to 1.02 (SD 0.12) after 1 month and at the end of follow-up (median 75 months) it was 0.96 (SD 0.15). Cumulative survival rates were at 1 month 98%, 1 year 91%, 5 years 81% and at 10 years 73%. Cumulative primary patency rates at the same intervals were 96, 96, 88 and 80%, respectively. Thus the survival rate and patency rate are favourable in comparison with arterial surgical procedures of the lower extremity.

Results of vascular surgery in younger versus older patients

We reviewed the results of reconstructive surgery at the aortoiliac and femoropopliteal levels in two age groups. Although patency rates were similar, when failure occurred, the amputation rate in the group under age 50 was almost three times that in the group over age 60. Practical application can be made in the preoperative preparation of the younger patient presenting with lower limb occlusive disease. More research of arteriosclerosis in the young is needed.

The rise and fall and resurgence of thromboangiitis obliterans (Buerger's disease)

Thromboangiitis obliterans (TAO; or Buerger's disease) is a nonarteriosclerotic, segmental, occlusive inflammatory disease of medium-sized and small arteries and veins of unknown cause, occurring predominantly in young male habitual tobacco users. Less than 2% of the patients with TAO are women or elderly persons. TAO is a treatable disease when diagnosed early and if strict abstinence from tobacco is observed. Otherwise progression and exacerbation of limb ischemia may lead to multiple and repeated amputations, and rarely visceral or cerebral ischemia. Over a 40-year period, 1947 to 1986, the prevalence rate of the diagnosis of TAO has declined steadily from 104/100,000 in 1947 to 13/100,000 in 1986 (an 8-fold decrease) where clinical and pathologic criteria for the diagnosis of TAO have remained unchanged. A similar pattern of decline was observed in two other major medical centers. Twelve women and 97 men with TAO were identified in the 5-year period 1981-1985. The 11% (12 of 109) incidence of female TAO was 10-fold that was previously reported. All 12 women were heavy smokers; 8 (67%) had thrombophlebitis and 6 (50%) had upper limb ischemia. Nine (75%) of 12 women required amputations; delay in diagnosis contributed to additional amputations in 2 patients. The increased prevalence of TAO in women may be attributed to the smoking habit in young women overall, which has increased significantly rather than decreased (as in males) since 1965.

Long-term results after arterial surgery for arteriosclerosis of the lower limbs in young adults

Ninety-nine patients, with a mean age of 40 years, underwent surgery for arteriosclerosis of the lower limbs during 1975-81. The main indication for surgery was claudication and the median observation time 102 months (range 54-138 months). Twenty patients died during the follow-up period and fifteen of these could be related to arteriosclerotic disease. At follow-up, 43 patients had claudication, while 34 patients had developed other arteriosclerotic manifestations. Amputation was performed in 17 patients. At follow-up the number of patients at work remained almost unchanged, whereas the number of patients receiving disablement pension increased. This study shows that younger patients with arteriosclerosis of the lower limbs had a mortality of approximately 20%, during the period of observation of this study. However, many patients became asymptomatic after surgery suggesting that a conservative attitude to arterial surgery in these patients cannot be justified.

Atherosclerosis in the younger patient. Results of surgical management

One hundred fifty-three patients under 50 years of age with atherosclerosis were studied. Hospital and office records were reviewed to determine risk factors, operations performed, postoperative course, and long-term results. These data were then compared with the data in the group of patients over 50 years of age. Results of this study indicate that survival in the younger patient is better than that in the patient over 50. Survival in the younger patient compared favorably to that in the general population through 5 years. Limb salvage rates after aortofemoral bypass and femoropopliteal bypass in both age groups were the same; however, limb salvage after femorotibial bypass in patients under 50 was not as good as in the older patient. Based on these results, the disease process in patients under 50 years of age does not appear more virulent than in those over 50 years of age. Smoking is the most significant risk factor in patients under 50 with atherosclerotic peripheral vascular disease.