Prevalence of asymptomatic visceral occlusive disease in patients admitted for chronic lower limb ischemia: A cross-sectional study.
Keywords:Prevalence, Visceral occlusive disease, Mesenteric stenosis, celiac stenosis, epidemiology, lower limb chronic ischemia, peripheral arterial disease, cross-sectional
INTRODUCTION: Occlusive disease of the visceral vessels, when complicated, may lead to a high mortality rate. Current data regarding the co-prevalence of atherosclerotic disease of the lower limbs and visceral vessels is scarce. The aim of this study was to analyze the prevalence of splanchnic and renal visceral occlusive disease in patients admitted for chronic lower limb ischemia (CLLI).
METHODS: A cross-sectional study was performed including 100 aleatory patients admitted for CLLI between 2015 and 2020, without previous or current history of mesenteric ischemia, and who were submitted to an abdominal computer tomography angiography (CTA) as part of the pre-operative work-up. The presence of splanchnic (celiac artery, superior and inferior mesenteric arteries) and renal atheromatous disease was defined as mild (30- 50% stenosis), moderate (50-70%) and severe (>70% or occlusion), measured by CTA. Outcomes analyzed included prevalence of splanchnic and renal visceral occlusive disease, evaluation of predictive factors for visceral occlusive disease and its relationship with the pattern of lower limb atherosclerotic disease.
RESULTS: Mean age was 68.5 years old (SD: 9.7) and 77% were men. Admission diagnosis was incapacitating claudication (Rutherford stage 3) in 19%, and chronic lower limb threating ischemia (CLTI) in 81% (21% with stage 4 Rutherford and 60% with stage 5/6). Seventy-five percent presented aorto-iliac disease (AOID) and 97% presented infra-inguinal disease. Overall prevalence of visceral disease (mild, moderate or severe) was 65%. Severe disease was seen in at least one vessel in 60%. 34% of patients presented severe disease in only one visceral artery, 26% presented in ≥2 visceral vessels and 22% presented severe disease in all three splanchnic arteries. Regarding renal disease, 33% presented severe disease in at least one renal artery and 20% presented with bilateral disease. CLTI was significantly associated with a higher prevalence of severe stenosis in ≥2 splanchnic vessels, p=0.004. After logistic regression, we observed as predictive factor associated with severe disease in ≥2 splanchnic vessels the age, with an OR of 2.01 for every 10-year difference, p= 0.039; and AOID, OR: 14.6 (p=0.011). When analyzed the presence of at least one severe splanchnic vessel stenosis, AOID (OR 5.4, p=0.008) and coronary disease (OR:3.9, p=0.035) were predictive factors. Regarding renal disease, and association was found with age (OR of 3.90 for every 10-year difference, p<0.001); AOID (OR of 25.6, p=0.004) and carotid artery disease (OR: 9.24, p=0.005).
CONCLUSION: Our study showed a high prevalence of multi-visceral and renal occlusive disease in patients admitted for chronic lower limb ischemia. We found an association between coronary and carotid disease with splanchnic and renal disease, respectively. Age was also associated with more severe stages of visceral and renal artery disease. More studies are needed to analyze the clinical impact of our findings regarding planning and follow-up for these patients.
Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, et al. REACH Registry Investigators. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006;295:180-9.
Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, et al. Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55:305-68.
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg. 2019;58:S1-S109
Krishnamurthy G, Menon A, Kannan K, Prakash S, Rajendran A, Philips D. Coronary artery disease and mesenteric artery stenosis - Two sides of the same coin? - Long term prospective analysis. Intractable Rare Dis Res. 2019;8:245-51.
Roobottom CA, Dubbins PA. Significant disease of the celiac and superior mesenteric arteries in asymptomatic patients: predictive value of Doppler sonography. AJR Am J Roentgenol. 1993;161:985-8.
Thomas JH, Blake K, Pierce GE, Hermreck AS, Seigel E. The clinical course of asymptomatic mesenteric arterial stenosis. J Vasc Surg. 1998;27:840-4.
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg. 2014;12:1495-9
Collet JP, Cayla G, Ennezat PV, Leclercq F, Cuisset T, Elhadad S, et al. Systematic detection of polyvascular disease combined with aggressive secondary prevention in patients presenting with severe coronary artery disease: The randomized AMERICA Study. Int J Cardiol. 2018;254:36-42.