Arteriosclerosis obliterans in young women

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.

Prevalence of intermittent claudication and its effect on mortality

The prevalence of symptoms of intermittent claudication and their association with 5-year mortality were examined in a population study in Finland. A number of 5738 men and 5224 women, aged 30-59 years, from 4 geographic areas of the country were studied. According to a structured interview, 2.1% of the men and 1.8% of the women reported typical symptoms of intermittent claudication. Claudication was most prevalent in East Finland and among persons with agricultural occupations. The symptoms were more frequent in diabetics and persons with symptoms and signs of coronary heart disease (CHD) than in persons without these diseases. High serum cholesterol and smoking were associated with these symptoms but high blood pressure was not. The risk of death from cardiovascular causes was nearly 3-fold in men with claudication compared to men without claudication. Symptoms of chest pain and smoking increased significantly the mortality risk of male claudicants. The validity of symptoms was poorer in women than in men and they were also less reliable predictors of death in women. A small part of the effect of claudication on mortality was due to its association with conventional CHD risk factors. However, after adjusting for symptoms and signs of CHD, claudication had no independent effect on mortality in men.

Does Gender Influence the Patency of Infrainguinal Bypass Grafts?

Infrainguinal revascularization is an effective method of treatment for femoropopliteal/tibial occlusive diseases. However, these bypass grafts are prone to stenosis. In this retrospective study, the authors investigate the association of gender with patency of infrainguinal bypass grafts. The outcomes for consecutive 375 male and 200 female patients who underwent infrainguinal bypass surgery for arterial occlusive disease are compared, and associations with characteristics of the patients, surgical procedure, and graft stenosis are determined. It is found that several demographic, biochemical, and etiological factors could influence the patency of bypass procedures in different genders. However, infrainguinal arterial reconstruction procedures performed in women have a worse outcome when compared with that in men.

Novel risk factors for peripheral arterial disease in young women

PURPOSE

To investigate traditional and novel risk factors (homocysteine and C-reactive protein levels, and exposure to infections) for peripheral arterial disease in young women.

SUBJECTS AND METHODS

In a multicenter, population-based, case-control study, 212 young women (mean [+/- SD] age, 48.2 +/- 7.0 years) with peripheral arterial disease and 475 healthy control women (mean age, 45.5 +/- 8.1 years) completed a standardized questionnaire and provided blood samples. Peripheral arterial disease was angiographically confirmed if a stenotic lesion (more than 50% reduction of the lumen) was present in at least one major peripheral artery. Hyperhomocysteinemia was defined as a nonfasting plasma homocysteine level exceeding the 90th percentile of the control group. History of infectious diseases was determined by questionnaire.

RESULTS

Elevated C-reactive protein levels were associated with an increased likelihood of peripheral arterial disease (odds ratio [OR] = 3.9; 95% confidence interval [CI]: 1.8 to 8.5 for women in the third quartile; OR = 3.1; 95% CI: 1.4 to 6.8 for women in the fourth quartile; both comparisons with women in the first quartile). Hyperhomocysteinemia was not associated with a significantly increased risk of peripheral arterial disease (OR = 1.6; 95% CI: 0.9 to 3.0). A history of chickenpox, shingles, mumps, pneumonia, chronic bronchitis, peptic ulcer, or periodontitis was independently related to peripheral arterial disease, with adjusted odds ratios varying from 1.7 (95% CI: 1.0 to 3.1) for mumps to 3.4 (95% CI: 1.5 to 7.7) for peptic ulcer. The risk of peripheral arterial disease increased with the number of these infections; exposure to five or more infections increased the odds 3.7-fold (95% CI: 1.7 to 8.2). This association was not affected by the level of C-reactive protein.

CONCLUSION

Our results do not support a strong relation between homocysteine and peripheral arterial disease in young women. However, an elevated C-reactive protein level and several types of symptomatic infection were associated with peripheral arterial disease.

Late outcome of coronary artery bypass grafting in young versus older patients

BACKGROUND

We compared long-term results of coronary artery bypass grafting between 1976 and 1988 in 176 patients 40 years old or younger with a matched control group of 176 patients 25 to 30 years older.

METHODS

Mean age was 37.4 +/- 2.7 years (+/- standard deviation) in the study group and 64.2 +/- 2.9 years in the control group. Matching criteria were age, sex, left ventricular ejection fraction, number of bypass grafts, and year of operation.

RESULTS

The study group had more smokers (p = 0.000) and more patients with hypercholesterolemia (p = 0.026), unstable angina (p = 0.003), and preoperative myocardial infarction (p = 0.009); fewer patients had hypertension (p = 0.000) and diabetes (p = 0.005) in this group than in the control group. The internal mammary artery was used in 31% of the study patients and in 30% of the controls. The actuarial survival rates after 5, 10, and 15 years were 92%, 86%, and 72% in the study group and 92%, 86%, and 66% in the control group (p = 0.202). Young age was a predictor of cardiac reoperation.

CONCLUSIONS

Late survival is similar for young and older patients, but the reintervention rate is higher in the younger group. The absence of unstable angina, a left ventricular ejection fraction greater than 0.45, and the use of internal mammary artery grafts increase survival in all patients.

Young women with advanced aortoiliac occlusive disease: new insights

We identified a group of 24 young (less than 50 years of age) women with isolated, premature atherosclerotic aortoiliac occlusive disease and attempted to identify distinguishing hemostatic characteristics. Most of these patients (62%) presented with acute thromboembolic events (blue toe syndrome, n = 6; macroemboli, n = 6; or aortoiliac thrombosis, n = 3). Aortoiliac reconstruction (aortoiliac endarterectomy, n = 10, aortobifurcation bypass grafts, n = 6; and percutaneous angioplasty, n = 4) was complicated by early thrombosis in 6 of 20 cases (30%), (1 of 10 endarterectomies, 4 of 6 bypass grafts, and 1 of 4 angioplasties). Fresh thrombus overlying an atherosclerotic plaque was a common finding at surgery. This observation and the relatively high incidence of thromboembolic events led us to hypothesize that a characteristic hemostatic profile might underlie the remarkably similar clinical presentations of these women. Levels of antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant), plasminogen activator inhibitor-1, fibrinogen, antithrombin III, protein C, protein S, plasminogen, prothrombin fragment F1 + 2, and D-dimer were determined for these young women and for 21 age-matched white female control subjects without vascular disease and nine white male patients with aortoiliac occlusive disease (mean 61 years, range 43 to 74 years). The incidence of anticardiolipin antibodies was 42% (8 of 19) in the female patients, which was significantly elevated (p = 0.028). The female (62.5%) and male (100%) patients had significantly elevated D-dimer levels (p < 0.001). Deficiencies of antithrombin III, protein C, and protein S were rare. A unique pattern of premature aortoiliac atherosclerosis exists in some young women. Intra-arterial thromboembolic events are common at presentation and complicate surgical management. The role of antiphospholipid antibodies remains uncertain.

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.

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.

Risk factors for atherosclerotic aortoiliac occlusive disease

Notwithstanding the difficulties in analysis because of the small number of studies available, patients with aortoiliac atherosclerosis, irrespective of their sex, have a particular "risk profile" that includes tobacco use, young age, diabetes (rare), frequent hypercholesterolemia, and limited atheroma. It must be remembered, however, that most studies have not dealt with the specific risk factors of lower limb arterial disease and the location of disease in the aortoiliac vessels. It is possible that the classical analysis of the vascular risk factors has overlooked one or more major factors such as hyperhomocysteinemia. This underscores the necessity to conduct further prospective studies specifically focused on the various aspects of lower limb and aortoiliac arterial disease in particular.

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.

A relationship between claudication of the cauda equina and the small aorta syndrome

Two cases of claudication of the cauda equina due to ischaemia secondary to distal aortic disease in the Small Aorta syndrome are reported. The association has not been previously reported and the appropriate management is discussed.

Age, diabetes and smoking in lower limb amputation for arterial occlusive disease

The increased number of amputations for arterial occlusive disease noted in western countries is only partly explained by increasing numbers of the elderly. A prospective analysis of the influence of diabetes and smoking habits was therefore carried out. In 1978-81, 188 lower limb amputees in Lund were examined and classified as non-smokers, ex-smokers, light smokers and heavy smokers. These figures were compared with corresponding figures among age-correlated controls and to a group of hip fracture patients. The material was divided into men and women and into non-diabetics and diabetics. Smokers had much lower mean age at amputation. Out of 188 amputees only 23 were not either a diabetic, a smoker or 80 years or more. The population study indicates a correlation between smoking and amputation for ichaemia. The coincident increase in cigarette consumption in Sweden is illustrated and it is suggested that smoking should be noted as routinely as diabetes at amputations.

Hemiplegia and peripheral gangrene secondary to large and medium size vessels involvement in C.R.E.S.T. syndrome

A woman with CREST syndrome since the age of 35, had 11 and 13 years respectively after her disease onset, two episodes of CVA with residual right side hemiplegia. The angiography revealed segmented stenosis in the left common carotid, right subclavian and left renal arteries. At the age of 49 she developed gangrene of the right foot, requiring below the knee amputation. Pathological examination of the surgical specimen, showed extensive intimal fibrosis of the vessel walls in large and medium size arteries. Involvement of large and medium size arteries is infrequent in scleroderma. The case described illustrates this severe and unusual complication.