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.

A scoping review of female sex-related outcomes after endovascular intervention for lifestyle-limiting claudication and chronic limb-threatening ischemia

Peripheral arterial disease (PAD) is on the rise, with a growing prevalence in an aging population and increasing rates of diabetes. Chronic limb-threatening ischemia poses a significant risk of limb loss. PAD is common in females, particularly after menopause, with a 35% prevalence rate in females older than 65 years. Studies have suggested that females have inferior outcomes compared with men after endovascular revascularization for PAD. With the rising utilization of endovascular interventions for the treatment of PAD, we sought to perform a review of sex-based outcomes of peripheral endovascular interventions for the treatment of symptomatic PAD. A scoping literature review was conducted to evaluate outcomes in females patients undergoing endovascular peripheral interventions for PAD. Eligibility criteria included studies focusing on adult females with lifestyle-limiting claudication or chronic limb-threatening ischemia who underwent endovascular intervention. Various endovascular procedures were considered and outcomes of interest included mortality, amputations, reinterventions, bleeding complications, and major adverse cardiac events. A systematic search was conducted in PubMed, Embase, Web of Science, and Cochrane Library databases. Sixteen studies were included in the review. Females patients undergoing endovascular interventions were associated with bleeding complications, higher rates of reintervention, and a risk of nonfatal strokes. However, females sex was not linked to higher rates of amputation or conclusively higher mortality rates post intervention. The comprehensive scoping review reveals important sex-related disparities in outcomes after endovascular procedures for symptomatic PAD. Females patients have been reported to experience worse outcomes in terms of reinterventions and bleeding complications. These findings emphasize the need for future trials focusing specifically on females patients to develop sex-inclusive treatment recommendations for advanced PAD.

Association between sex and long-term outcomes of endovascular treatment for peripheral artery disease

BACKGROUND

Endovascular peripheral vascular intervention (PVI) has become the primary revascularization technique used for peripheral artery disease (PAD). Yet, there is limited understanding of long-term outcomes of PVI among women versus men. In this study, our objective was to investigate sex differences in the long-term outcomes of patients undergoing PVI.

METHODS

We performed a cohort study of patients undergoing PVI for PAD from January 1, 2010 to September 30, 2015 using data in the Vascular Quality Initiative (VQI) registry. Patients were linked to fee-for-service Medicare claims to identify late outcomes including major amputation, reintervention, major adverse limb event (major amputation or reintervention [MALE]), and mortality. Sex differences in outcomes were evaluated using cumulative incidence curves, Gray's test, and mixed effects Cox proportional hazards regression accounting for patient and lesion characteristics using inverse probability weighted estimates.

RESULTS

In this cohort of 15,437 patients, 44% (n = 6731) were women. Women were less likely to present with claudication than men (45% vs. 49%, p < 0.001, absolute standardized difference, d = 0.08) or be able to ambulate independently (ambulatory: 70% vs. 76%, p < 0.001, d = 0.14). There were no major sex differences in lesion characteristics, except for an increased frequency of tibial artery treatment in men (23% vs. 18% in women, p < 0.001, d = 0.12). Among patients with claudication, women had a higher risk-adjusted rate of major amputation (hazard ratio [HR] = 1.72, 95% confidence interval [CI]: 1.18-2.49), but a lower risk of mortality (HR = 0.86, 95% CI: 0.75-0.99). There were no sex differences in reintervention or MALE for patients with claudication. However, among patients with chronic limb-threatening ischemia, women had a lower risk-adjusted hazard of major amputation (HR = 0.79, 95% CI: 0.67-0.93), MALE (HR = 0.86, 95% CI: 0.78-0.96), and mortality (HR = 0.86, 95% CI: 0.79-0.94).

CONCLUSION

There is significant heterogeneity in PVI outcomes among men and women, especially after stratifying by symptom severity. A lower overall mortality in women with claudication was accompanied by a higher risk of major amputation. Men with chronic limb-threatening ischemia had a higher risk of major amputation, MALE, and mortality. Developing sex-specific approaches to PVI that prioritizes limb outcomes in women can improve the quality of vascular care for men and women.

Incidence of venous thromboembolism in patients with peripheral arterial disease after endovascular intervention

OBJECTIVE

Venous thromboembolism (VTE) is a well-known postoperative complication; however, the incidence of VTE after peripheral vascular intervention (PVI) has not been well described. Despite the minimally invasive nature of these procedures, the patients undergoing PVI have significant risk factors for the development of VTE. In the present study, our objective was to describe the short-term incidence of VTE after PVI, identify differences between sexes, and examine the periprocedural antiplatelet and anticoagulation regimens.

METHODS

We identified adults (age >66 years) who had undergone PVI from January 1, 2008 to September 30, 2015 from the inpatient Medicare claims data. The patients were followed for 365 days after the procedure. VTE events during follow-up were identified using the International Classification of Diseases, 9th revision, diagnosis codes. The covariate-standardized 30- and 90-day cumulative incidence of VTE events, overall and stratified by sex, were estimated using Aalen-Johansen estimators, accounting for death as a competing risk. Differences in sex between females and males were identified using Gray's test. Any antiplatelet or anticoagulant prescription fill was defined as any fill from 14 days before the endovascular intervention through the date of the VTE event. Persistence with antiplatelet and anticoagulant therapy was assessed by creating daily logs of antiplatelet and anticoagulant coverage using the dispensing dates and days of supply. Over-the-counter medications (ie, aspirin) were not evaluated.

RESULTS

We identified 31,593 qualifying patients with a mean age of 76.8 ± 7.4 years. Of the 31,593 patients, 46% were male, and 12% had a history of VTE. After the procedure, deep vein thrombosis (DVT) was a commonly diagnosed complication (3.8% and 4.8% at 30 and 90 days, respectively). The cumulative incidence of pulmonary embolism was 0.9% and 1.2% at 30 and 90 days after the procedure, respectively. Throughout the 90-day postoperative period, females had had a slightly increased risk of DVT compared with males (30-day risk difference, 0.007; P < .01; 90-day risk difference, 0.008; P = .02). We found no sex-based differences in the risk of pulmonary embolism. Of the patients who had developed VTE at 90 days, 970 (55%) had had no prescription fill for an antiplatelet or anticoagulant. Assuming all the patients had been taking aspirin, only 15% of the patients who had developed VTE had been taking prescribed dual antiplatelet medication persistently after PVI. In addition, among the patients who had developed VTE at 90 days, females were less likely to have had a prescription fill for an anticoagulant.

CONCLUSIONS

The findings from our study have demonstrated that the incidence of VTE after PVI is high, with an increased risk of deep vein thrombosis for females. We also found that females were less likely to have been prescribed an anticoagulant after PVI. Future studies are needed to characterize the variables associated with an increased risk of VTE after PVI and to identify strategies to increase dual antiplatelet therapy or anticoagulant prescription adherence to reduce the risk of VTE.

Increased long-term bleeding complications in females undergoing endovascular revascularization for peripheral arterial disease

OBJECTIVE

Females with peripheral arterial disease (PAD) treated with endovascular interventions have increased limb-based procedural complications compared with males. Little is known regarding long-term bleeding risk in these patients who often require long-term antiplatelet or anticoagulation therapy. We hypothesize that females have a higher incidence of bleeding events compared with males in the year after endovascular intervention for PAD.

METHODS

Adults (aged ≥65 years) who underwent endovascular revascularization for PAD between 2008 and 2015 in Medicare claims data were identified. Patients were allocated by prescribed postprocedural antithrombotic therapy, including (1) antiplatelet therapy, (2) anticoagulation therapy, (3) dual antiplatelet and anticoagulation therapy, and (4) no prescription antithrombotic therapy. Bleeding events were classified as gastrointestinal, intracranial, hematoma, airway, or other. Crude and covariate-standardized 30-, 90-, and 365-day cumulative incidence of bleeding events, overall and by sex, were estimated using Aalen-Johansen estimators accounting for death as a competing risk. Sex differences were identified using Gray's test.

RESULTS

Of 31,593 eligible patients, 54% were females. Females were older (77.9 years vs 75.5 years) and tended to use antiplatelet therapy more often at 30, 90, and 365 days after the intervention. Clopidogrel was the most prescribed antiplatelet, and 32% of patients continued its use at 365 days. Anticoagulants were prescribed to 26.0% of patients at the time of the procedure, and only 8.8% continued anticoagulation at 365 days. Thirty-one percent of patients were diagnosed with a bleeding event within 1 year after the intervention. The cumulative incidence of any bleeding event during the postintervention period was higher in females compared with males with a risk difference of 3% between the sex cohorts (P < .01). Specifically, females had a higher incidence of gastrointestinal bleeding and hematoma (P < .01), but a lower incidence of airway-related bleeding at each time point as compared with males (P < .01).

CONCLUSIONS

Sex disparities in bleeding complications after endovascular intervention for PAD persist in the long term. Females are more likely to be readmitted with a bleeding complication up to 1 year after the procedure. Antithrombotic therapy disproportionately increases the risk of bleeding in females. Further research is necessary to understand the mechanisms responsible for abnormal coagulopathy in females after endovascular therapy.

Supervised physical activity in patients with symptomatic peripheral arterial disease: protocol for a randomized clinical trial (ARTPERfit Study)

INTRODUCTION

Peripheral arterial disease (PAD) is a marker of cardiovascular morbidity, causing disability, loss of mobility and poor quality of life, manifesting clinically in the form of intermittent claudication (IC). Physical exercise increases the distance walked and improves quality of life. The aim of our study will be increased walking distance prolonging the time of onset of pain in patients with symptomatic PAD (IC).

METHODS AND ANALYSIS

This study will be performed in Mataró Hospital's vascular surgery service and School of Health Sciences, TecnoCampus. This population comes from 15 primary healthcare centres ofNorth Barcelona, Spain (450 000 inhabitants).This study will be a four-group parallel, longitudinal, randomised controlled trial, blind to analysis.The main primary outcome of this study will be the improvement in pain-free walking distance. Others primary objectives are and improvement in functional status, quality of life and Ankle-Brachial Index (ABI). Secondary outcomes will be the analysis of cardiorespiratory fitness, evaluation of muscle fitness, determine the maintenance of primary objectives at 6 and 12 months.We will be included 124 patients (31 per group). The changes of the outcome (Barthel, SF-12, VascQOL-6, ABI) of the three intervention groups vs the control group at 3, 6 and 12 months will be compared, both continuously (linear regression) and categorically (logistic regression). A person who has not performed at least 75% of the training will be considered to have not completed the intervention.

ETHICS AND DISSEMINATION

The study will be conducted according to the Declaration of Helsinki . It was approved by the Ethics Committee of the Research Institute Primary Health IDIAP Jordi Gol (20/035 P),Barcelona 6 October 2020. Informed consent will be obtained from all patients before the start of the study. We will disseminate results through academic papers and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04578990.

Safety and feasibility of arterial wall targeting with robot-assisted high intensity focused ultrasound: a preclinical study

PURPOSE

High-intensity focused ultrasound (HIFU) is a potential noninvasive thermal ablation method for the treatment of peripheral artery disease. Dual-mode ultrasound arrays (DMUA) offer the possibility of simultaneous imaging and treatment. In this study, safety and feasibility of femoral artery robot-assisted HIFU/DMUA therapy was assessed.

METHODS

In 18 pigs (∼50kg), angiography and diagnostic ultrasound were used to visualize diameter and blood flow of the external femoral arteries (EFA). HIFU/DMUA-therapy was unilaterally applied to the EFA dorsal wall using a 3.5 MHz, 64-element transducer, closed-loop-control was used to automatically adjust energy delivery to control thermal lesion formation. A continuous lesion of at least 25 mm was created by delivering 6-8 HIFU shots per imaging plane perpendicular to the artery spaced 1 mm apart. Directly after HIFU/DMUA-therapy and after 0, 3 or 14 days follow up, diameter and blood flow were measured and the skin was macroscopically examined for thermal damage. The tissue was removed for histological analysis.

RESULTS

No complications were observed. The most frequently observed treatment effect was formation of scar tissue, predominantly in the adventitia and the surrounding tissue. No damage to the endothelium or excessive damage of the surrounding tissue was observed. There was no significant decrease in the mean arterial diameter after HIFU/DMUA-therapy.

CONCLUSION

HIFU/DMUA therapy successfully targeted the vessel walls of healthy porcine arteries, without causing endothelial damage or other vascular complications. Therefore, this therapy can be safely applied to healthy arterial walls in animals. Future studies should focus on safety and dose-finding in atherosclerotic diseased arteries.

Role of Sex in Determining Treatment Type for Patients Undergoing Endovascular Lower Extremity Revascularization

Background Limited data exist to describe factors that influence the use of different endovascular treatments for peripheral arterial disease. Therefore, we studied sex differences in the utilization of endovascular treatment modalities and their impact on arterial patency. Methods and Results We analyzed procedures from 2010 to 2016 in the Vascular Quality Initiative for arteries treated with percutaneous transluminal angioplasty (PTA) alone, stenting (with/without PTA), and atherectomy (with/without PTA). We explored sex differences in treatment modality by arterial segment (iliac, femoropopliteal, and tibial) with multivariable logistic regression. We used Kaplan-Meier survival analysis and multivariable Cox regression to study sex differences in arterial reintervention and occlusion. In this cohort, patients (n=58 247, mean age 68 years, 41% women,) had 106 073 arteries treated (median=2 arteries, interquartile range=1-3). Half (50%) of these arteries were treated with stents, 39% with PTA alone, and 11% with atherectomy. After risk adjustment, women were less likely to undergo stenting or atherectomy (versus PTA alone) in the femoropopliteal (stent risk ratio=0.78 [0.74-0.82]; atherectomy risk ratio=0.69 [0.58-0.82]) and tibial arteries (stent risk ratio=0.70 [0.55-0.89]; atherectomy risk ratio=0.87 [0.70-1.07]). In the iliac arteries there was no sex difference in stenting, and atherectomy was rarely used (0.2%). Women underwent reintervention in the femoropopliteal arteries (hazard ratio=1.28 [1.17-1.40]) or developed an occlusion in the iliac (hazard ratio=1.42 [1.12-1.81]) and femoropopliteal arteries (hazard ratio=1.19 [1.06-1.34]) more frequently than men. Conclusions Women were less likely to undergo stenting or atherectomy and had higher rates of occlusion and reintervention, especially in the femoropopliteal arteries. Evidence-based guidelines are needed to guide optimal use of endovascular treatments for men and women.

Sex-Based Assessment of Patient Presentation, Lesion Characteristics, and Treatment Modalities in Patients Undergoing Peripheral Vascular Intervention

BACKGROUND

Limited evidence suggests that women and men might be treated differently for peripheral arterial disease. This analysis evaluated sex-based differences in disease presentation and its effect on treatment modality among patients who underwent endovascular treatment for peripheral arterial disease.

METHODS AND RESULTS

Using national registry data from the Vascular Quality Initiative between 2010 and 2013, we examined patient, limb, and artery characteristics by sex through descriptive statistics. We studied 26 750 procedures performed in 23 820 patients to treat 30 545 limbs and 44 804 arteries. Women presented at an older age (69 versus 67 years; P<0.001) and were less often current or former smokers (72% versus 85%; P<0.001). Transatlantic Inter-Society Consensus classification was similar among men and women (Transatlantic Inter-Society Consensus C or D: 37% in men versus 37% in women; P=0.81), as was mean occlusion length (4.5 cm in men versus 4.6 cm in women; P=0.04), even after accounting for lesion location. Women more frequently underwent treatment for rest pain (11% in men versus 16% in women; P<0.001) versus claudication (59% in men versus 53% in women; P<0.001) or tissue loss (28% in men versus 27% in women; P=0.75). Treatment modality did not differ by sex but was associated with disease severity (P for trend <0.001) and lesion location (P for trend <0.001).

CONCLUSIONS

Women undergo peripheral endovascular intervention for peripheral arterial disease at an older age with critical limb ischemia. Treatment modalities do not vary by sex but are determined by disease severity and site. Although there exist sex differences in presentation, these differences do not lead to differential treatment for women with peripheral arterial disease.

Gender Differences in Peripheral Vascular Disease

In the past 20 years, peripheral artery disease (PAD) has been increasingly recognized as a significant cause of morbidity and mortality in the United States. PAD has traditionally been identified as a male-dominant disease; however, recent population trends and studies in PAD suggest that women are affected at least as often as men. Women comprise a larger population of the elderly than men, as well as an increasing proportion of patients with PAD. Much of the existing research on PAD has focused on whole populations, and gender-specific data on PAD is sparse. This review focuses on gender-specific differences in presentation, management, and outcomes of PAD intervention that are important considerations for the interventional radiologist.

Gender disparities among patients with peripheral arterial disease treated via endovascular approach: A propensity score matched analysis

BACKGROUND

Remarkable improvement in the treatment of Peripheral Arterial Disease (PAD) has led to changes in revascularization strategies from traditional open surgery to less invasive endovascular management. However, few studies are available on gender disparities in patients with PAD treated via an endovascular approach. This study was designed to analyze gender related differences with respect to in-hospital outcomes in PAD patients.

METHODS

Our data was obtained from National Inpatient Sample (NIS) 2012 through 2014. We used International Classification of Diseases, 9th Revision, Clinical Modification diagnostic and procedural codes appropriate for PAD and endovascular treatment. Endovascular treatment included drug eluting stent, bare metal stent, atherectomy or angioplasty of lower extremity arteries. A propensity score matching was performed to adjust for imbalances between variables.

RESULTS

Females presented late with more comorbidities and underwent more emergent/urgent procedures. After performing propensity score matched analysis, 25 758 patients were included in each group. There was no difference in in-hospital mortality between males and females in matched cohorts (2.3% vs 2.4%, P = 0.25). Acute renal failure, gangrene, infection, and composite of all complications were higher in males. Only blood transfusion was noted higher in females.

CONCLUSION

This study revealed no difference in in-hospital mortality between males and females undergoing endovascular peripheral intervention. Males have a higher rate of complications compared to females which explains the higher cost of care in males. Further research with long-term follow up is needed to see if there is any difference with regards to long-term outcomes and re-admission.

Comparison of Lower Extremity Endovascular Intervention Outcomes in Women Versus Men

This study examined a gender difference in 12-month patient outcomes after endovascular intervention for symptomatic peripheral artery disease (PAD) utilizing propensity score-matched Excellence in Peripheral Artery Disease registry data. Mortality and repeat intervention outcomes after endovascular treatment in women compared with men in the existing literature are inconsistent and confounded by other risk factors. The study included 1,084 patients who underwent 1,702 endovascular procedures, at 8 non-Veterans Administration hospitals from January 2005 to October 2015. Frailty hazard ratios by gender for time-to-event analysis were estimated. Women made up about 40% of the study population. After propensity score matching, 449 women and 449 men were included in the analysis, in which women had similar baseline patient and lesion characteristics, laboratory data, procedural characteristics, and medical therapy as men. Within 12-month postintervention, women were at a lower risk of mortality than men (p = 0.05); however, they underwent significantly more frequent repeat revascularization procedures (p = 0.04). In subgroup analysis, women with superficial femoral artery disease were also at higher risk of 12-month repeat intervention than men (p <0.01) and had a higher mortality risk, albeit with an attenuated significance (p = 0.07). Women with PAD are at a higher risk of 12-month repeat intervention than men.

Intermediate Outcomes of Femoropopliteal Stenting in Women: 3-Year Results of the DURABILITY II Trial

BACKGROUND

This study investigated the effects of gender on the 3-year outcomes of the StuDy for EvalUating EndovasculaR TreAtments of Lesions in the Superficial Femoral Artery and Proximal Popliteal By usIng the Protege EverfLex NitInol STent System II (DURABILITY II) trial.

METHODS

A total of 287 patients enrolled in the DURABILITY II trial (prospective and nonrandomized trial) were stratified by gender and evaluated for primary, primary assisted, and secondary patency at 3 years. Clinical scores including changes in ankle-brachial index (ABI) and walking impairment questionnaire (WIQ) scores were evaluated.

RESULTS

Overall 190 male and 97 female patients were included for analysis. The 3-year primary, assisted primary, and secondary patency rates for women versus men were 62.5% vs. 58.8%, 68.5% vs. 64.9%, and 72.1% vs. 67.2%, respectively (P < 0.05). Although ABIs at presentation were similar between women versus men (0.64 vs. 0.65, P < 0.05), women had lower ABI scores at 3 years compared with men (0.85 vs. 0.92, P = 0.03). Women versus men had inferior walking distance scores at presentation (13.6 vs. 25.7, P < 0.001), scores were equalized by 2 years (51.6 vs. 60.8, P < 0.05); however, 3-year follow-up demonstrated less durable results for women versus men (37.3 vs. 58.8, P < 0.05). In addition, women had worse WIQ scores for pain, walking speed, and stair climbing. However, the relative change in scores between men and women were comparable, with both groups seeing similar improvements from baseline for these parameters.

CONCLUSIONS

Women continue to see clinical improvement after intervention, achieving comparable ABIs and walking distance to men at 2 years. These benefits are diminished at 3-year follow-up with women achieving lower absolute ABI and WIQ parameters compared with men, but improved overall compared with scores at presentation.

Clinical Outcomes after Endovascular Treatment Failure in Patients with Femoropopliteal Occlusive Disease

BACKGROUND

To analyze the clinical impact derived from endovascular treatment failure on patients with femoropopliteal occlusive disease (FPOD) regarding their preoperative clinical stage.

METHODS

Retrospective review for primary endovascular procedures for FPOD from 2008 to 2013. Primary end point included clinical deterioration defined as acute limb ischemia (ALI) or clinical worsening by, at least, one Rutherford's classification category, related to procedure's failure (restenosis >70% or occlusion).

RESULTS

Ninety procedures were analyzed in 85 patients, 87.8% operated due to critical limb ischemia. The lesion treated was classified as Trans-Atlantic Inter-Society Consensus (TASC)-A/B in 76.7%, with a mean length of 98.5 ± 54 mm. Covered stent graft (SG) was used in 31.1% of the cases. Median follow-up was 14.5 months and treatment failure occurred in 33.3% of cases (n = 30, 9 restenosis and 21 occlusions). Clinical worsening was assessed in 40% of treatment failures and 6 of 21 (28.6%) presented as ALI. Twenty-two major adverse limb events (MALEs) were recorded and 8 major amputations. Regarding the type of stent, more occlusions were recorded on patients treated with SG compared with bare metal stent (39.3% vs. 16%; P = 0.02). However, no differences were found between groups regarding clinical worsening attributable to treatment failure (HR, 1.33; CI 95%, 0.5-3.5; P = 0.5). On multivariate analysis, TASC-C/D lesions (HR, 5.5; CI 95%, 2.3-13.3; P < 0.001) and female sex (HR, 4.9; CI 95%, 1.9-12.5; P = 0.001) behaved as significant predictors for failure and dual-antiplatelet therapy as a protective factor (HR, 0.3; CI 95%, 0.3-0.13; P = 0.03). No predictors were obtained regarding clinical worsening and occurrence of MALEs in our series.

CONCLUSIONS

Patients with failure of endovascular procedures on FPOD appeared with clinical worsening in a no negligible number of cases in our sample regarding their preoperative clinical situation. Thus, we believe that endovascular treatment should be carefully deliberated.

Pooled Analysis of the CONFIRM Registries

Purpose: To compare the acute procedure and angiographic outcomes of peripheral artery disease (PAD) patients treated with orbital atherectomy stratified by gender. Methods: The CONFIRM I, II, and III registries are US multicenter, nonrandomized, all-comers registries of PAD patients who were treated with orbital atherectomy. All patients with gender specified in the registry database were included in the current analysis, which compared the final residual stenosis achieved after atherectomy and the rate of acute complications in female and male patients. The 3 registries included 3131 patients with 4761 lesions: 1261 women (mean age 73.2±10.7 years) with 1874 lesions and 1870 men (mean age 70.4±10.2) with 2887 lesions. Results: The women were older (p<0.001) and had a higher but nonsignificant prevalence of critical limb ischemia (p=0.075). After treatment, the final residual stenosis in women vs. men was 9%±11% vs. 11%±11%, respectively (p<0.001). Women had a higher rate of all types of dissection (13.3% vs. 9.9%, p<0.001). However, both genders had similar rates of flow-limiting dissections (1.6% vs. 1.4%, p=0.61), perforation, slow flow, vessel closure, spasm, embolism, and thrombus formation. Conclusion: The gender analysis of the CONFIRM registries revealed that there was successful lesion modification with orbital atherectomy in both men and women; however, women had a higher rate of dissection (all types). This difference is likely because of the older age and higher percentage of critical limb ischemia in women in this cohort. These results, however, suggest that additional studies should be completed to further understand the increased risks for women vs. men during endovascular procedures.

Gender-specific risk factors for peripheral artery disease in a voluntary screening population

Background

Women have high rates of peripheral artery disease (PAD) despite fewer cardiovascular disease (CVD) risk factors, compared to men. We sought to determine the gender‐specific prevalence of low ankle brachial index (ABI) and the relationship to C‐reactive protein (CRP) levels and CVD risk factors in the Life Line Screening population.

Methods and Results

Between April 2005 and August 2011, 133 750 women and 71 996 men had ABI and CRP measured at a Life Line Screening Center. Women were slightly older than men, whereas men were more likely to be current smokers, have diabetes mellitus (DM), and coronary artery disease (CAD) (P<0.001 for each). Women were more likely to have ABI≤1.0, compared to men (26.6% versus 14.4%, respectively; P<0.001), as well as ABI≤0.9 (4.1% women versus 2.6% men; P<0.001). Women had higher median CRP levels (1.94 mg/L; interquartile range [IQR], 0.89, 4.44 mg/L), compared to men (1.35 mg/L; IQR, 0.73, 2.80 mg/L; P<0.001). Men and women shared similar risk factors for ABI≤0.9, including older age, black race, smoking, DM, hypertension, hypercholesterolemia, CAD, and elevated CRP levels. In an adjusted model, there were significant interactions between gender and age (P<0.001), CRP (P<0.001), CAD (P=0.03), and DM (P=0.06) with ABI as the outcome. The associations between age, CRP, CAD, and DM with ABI≤0.9 were stronger in men than in women.

Conclusions

Women participating in the Life Line Screening had higher CRP levels and a higher prevalence of PAD, compared to men. Neither higher CRP levels nor conventional CVD risk factors explained the excess prevalence of PAD in women.

Limb salvage in women

The prevalence of peripheral arterial occlusive disease (PAD) in women and men is equal. Studies to date present conflicting data of gender effects on the risk factors, clinical presentation, and treatment outcomes. Clinical trials have often failed to analyze results by gender or to recruit sufficient women to enable such an analysis. This review summarizes the management and outcome of limb salvage therapy with a particular focus in women.

The impact of sex on angioplasty and primary stenting for femoropopliteal occlusive disease: results of the DURABILITY II trial

BACKGROUND

This study investigates the impact of sex on angioplasty and primary stenting for the treatment of claudicants with femoropopliteal occlusive disease (FPOD).

METHODS

Two hundred eighty-seven patients enrolled in the Safety and Effectiveness Study of EverFlex Stent to Treat Symptomatic Femoral-popliteal Atherosclerosis (DURABILITY II) trial (a prospective, nonrandomized, core laboratory audited, and independently adjudicated investigational device exemption trial) were stratified by sex (190 men and 97 women) and reviewed.

RESULTS

Women presented with FPOD at an older age than men (71.3 ± 11.2 vs. 65.9 ± 9.9 years; P < 0.001). Men were more likely to be hyperlipidemic (89.5% vs. 79.4%; P = 0.030). No other statistically significant differences were observed with regard to periprocedural comorbidities and demographics. Clinically, women presented more often with severe claudication (64.9% vs. 51.1%; P = 0.033) as compared with men that had more moderate claudication (44.2% vs. 29.9%; P = 0.022). The incidence of rest pain and tissue loss was low and did not vary between sexes. Angiographically, women had smaller reference vessels (4.4 ± 0.8 mm vs. 5.0 ± 0.9 mm; P < 0.001). Longer lesions (91.6 ± 46.8 mm vs. 87.8 ± 43.9 mm) and higher primary (79.0% vs. 76.5%), primary-assisted (90.6% vs. 85.1%), and secondary patency (90.6% vs. 85.7%) rates in women did not achieve statistical significance (P = NS). Mean percent stenosis and occlusion rates were similar between groups, but men were more likely to have severe calcification (47.9% vs. 34.0%; P = 0.020). Inter-Society Consensus for the Management of Peripheral Arterial Disease II classifications were similar between groups. The target lesion revascularization, major adverse event, and mortality rates were similar between groups. At baseline, the absolute claudication distance was 0.29 miles for men, while women only reached 0.14 miles (P < 0.0001). Walking improvement questionnaire scores were also compared; women had significantly lower scores at baseline and at 1 year.

CONCLUSIONS

Despite presenting with FPOD at a later age, with more severe claudication, a shorter absolute claudication distance, and smaller vessels than men, women achieved equal patency rates using angioplasty and primary stenting with similar target lesion revascularization, major adverse event, and mortality rates. Despite these findings, women subjectively have worse symptoms at baseline and at 1 year.

Gender-related variation in the clinical presentation and outcomes of critical limb ischemia

Critical limb ischemia (CLI) is a major cause of limb loss and mortality among patients with advanced peripheral artery disease. Our objective was to evaluate the gender-specific differences in patient characteristics and clinical outcomes among patients with CLI. We performed a retrospective analysis of 97 women and 122 men presenting with CLI who underwent angiography from 2006 to 2010. Baseline demographics, procedural details, and lesion characteristics were assessed for each patient. Kaplan-Meier analysis was used to assess long-term patient and lesion-level outcomes. Cox proportional hazard modeling was used to evaluate the relationship between gender and major adverse cardiovascular events (MACE). Compared to men, women were less likely to have a history of coronary artery disease (39% vs 54%, p = 0.02) or diabetes (57% vs 70%, p = 0.05) but had similar baseline medical therapy. At angiography, women were more likely to have significant femoropopliteal (77% vs 67%, p = 0.02) and multi-level infrainguinal disease (63% vs 51%, p = 0.02). Women were also more likely to undergo multi-vessel percutaneous intervention (69% vs 55%, p = 0.05), but had similar rates of limb salvage after percutaneous intervention or surgical bypass (HR 0.94 [95% CI 0.45-1.94], p = 0.9). During follow-up, women had higher rates of subsequent major adverse cardiovascular events (HR 1.63 [95% CI 1.01-2.63], p = 0.04). In conclusion, women with CLI are more likely to present with femoropopliteal and multi-level infrainguinal disease. Despite similar rates of limb salvage, women with CLI have an increased rate of subsequent major adverse cardiovascular events.

Diagnosis and management of peripheral artery disease in women

Peripheral artery disease (PAD) is a significant cause of morbidity and mortality in the USA. Not only is it a major cause of functional impairment and limb loss, but it is also strongly associated with an increased risk of myocardial infarction, stroke, and death. Large population studies have demonstrated high rates of PAD in women, but this is not widely recognized by the public or by clinicians. One potential reason for this is that women with PAD are more likely than men to be asymptomatic or have atypical symptoms. In addition, women with PAD experience higher rates of functional decline and may have poorer outcomes after surgical treatment for PAD compared with men. Currently, it is not known if there are sex-specific differences in risk factors for the onset, progression, and surgical outcomes of PAD. This review will focus on the diagnosis and management of PAD in women and examine sex-specific differences in the prevalence, risk factors, presentation, and outcomes of this disease.