Characteristics of lower-limb peripheral arterial disease in women
DOI:
https://doi.org/10.48750/acv.584Keywords:
Peripheral arterial disease, Gender, Critical limb ischaemia, Chronic Limb Threatening Ischaemia, Intermittent claudicationAbstract
INTRODUCTION: Peripheral Arterial Disease (PAD) affects more than 200 million people. Its estimated prevalence in women ranges from 3% to 29%. Asymptomatic PAD is more common in women than in men. However, when symptomatic, females present a more complex disease, severe critical limb-threatening ischemia (CLTI), and worse outcomes. This study aims to characterize PAD in hospitalized women, evaluating risk factors, clinical presentation, therapeutic strategies, and outcomes.
METHODS: An observational, retrospective, longitudinal study of a single institution was conducted. The study included consecutive patients admitted with a clinical diagnosis of PAD (intermittent claudication or CLTI), confirmed by the ankle-brachial index (ABI), between January 2018 and December 2019. Recorded data comprised: clinical presentation, comorbidities, chronic medication, length of stay, type of admission, type of treatment (medical; surgical revascularization; endovascular treatment; major amputation; minor amputation), outcomes: discharge destination, successful revascularization, 30-day mortality, and amputation-free survival.
RESULTS: We analyzed 158 patients (51 females). Women had a higher mean age (76.5±10.4 years vs 69.5±10.6 years; p<0.001). Women also had lower smoking habits (4.0% vs 58.9%, p<0.001), higher prevalence of arterial hypertension (90.2% vs 73.8%, p=0.021), diabetes mellitus (74.5% vs 57.0%, p=0.036) and depression (7.0% vs 0.9%, p=0.002). Females presented with higher rates of CLTI (98.0% vs 87.9% p=0.038) and decreased functional status on admission (28.0% vs 4.3%, p<0.001). Females had fewer aortoiliac interventions (18.0% vs 50.0% p=0.012). In patients with CLTI, men were more often revascularized by conventional surgery (18.0% vs 41.5%, p=0.005). On the other hand, the major amputation rate was higher in women (40.0% vs 21.3%, p=0.020). Through univariate analysis, it was found that women with CLTI had a 2.47 times higher risk of major amputation than men with CLTI (p=0.018). However, in multivariate analysis, gender was not considered an independent predictor of major amputation, with age being the main factor. In patients revascularized for CLTI (21 females and 54 males), the successful revascularization rate was similar between genders (90.5% in females and 90.7% in males, p>0.99). Regarding 30-day mortality for CLTI, we found that 6 women (12.0%) and 5 men (5.3%) died. No statistically significant differences were found (p=0.191). No significant differences were found between genders, concerning the outcomes: length of stay, discharge destination, and amputation-free survival.
CONCLUSION: Females were older, more dependent, and more frequently admitted with CLTI, with a consequently higher major amputation rate. Besides prompt diagnosis, and intervention, public and social health measures are needed to improve functional status in elderly women to reduce female amputation rates.
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Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382: 1329–40.
Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000. Circulation. 2004;110:738-43
Blinc A, Kozak M, Sabovic M, Bozic Mijoversuski M, Stegnar M, Poredos P, et al: Survival and event-free survival of patients with peripheral arterial disease undergoing prevention of cardiovascular disease. Int Angiol. 2017;36:216-27.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45:S5-67.
Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:480–6.
Higgins JP, Higgins JA. Epidemiology of peripheral arterial disease in women. J Epidemiol. 2003;13:1–14.
Sigvant B, Wiberg-Hedman K, Bergqvist D, Rolandsson O, Andersson B, Persson E, et al. A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. J Vasc Surg. 2007;45:1185–91.
Nguyen L, Liles DR, Lin PH, Bush RL. Hormone replacement therapy and peripheral vascular disease in women. Vasc Endovasc Surg. 2004;38:547–56.
Jackson EA, Munir K, Schreiber T, Rubin JR, Cuff R, Gallagher KA, et al. Impact of sex on morbidity and mortality rates after lower extremity interventions for peripheral arterial disease: observations from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. J Am Coll Cardiol. 2014;63:2525–30.
Brevetti G, Bucur R, Balbarini A, Melillo E, Novo S, Muratori I, et al. Women and peripheral arterial disease: same disease, different issues. J Cardiovasc Med. 2008;9:382–8.
Behrendt CA, Sigvant B, Kuchenbecker J, Grima MJ, Schermerhorn M, Thomson IA, et al. Editor's Choice - International Variations and Sex Disparities in the Treatment of Peripheral Arterial Occlusive Disease: A Report from VASCUNET and the International Consortium of Vascular Registries. Eur J Vasc Endovasc Surg. 2020;60:873-80.
Jelani QU, Petrov M, Martinez SC, Holmvang L, Al-Shaibi K, Alasnag M. Peripheral Arterial Disease in Women: an Overview of Risk Factor Profile, Clinical Features, and Outcomes. Curr Atheroscler Rep. 2018;20:40.
Conte MS, Bradbury AW, Kolh P et al. Global Vascular Guidelines on the Management of Chronic Limb Threatening Ischemia. Eur J Vasc Endovasc Surg. 2019; 58: S1-S109-33;
Teodorescu VJ, Vavra AK, Kibbe MR. Peripheral arterial disease in women. J Vasc Surg. 2013;57:18S-26S
Srivaratharajah K, Abramson BL.Women and Peripheral Arterial Disease: A Review of Sex Differences in Epidemiology, Clinical Manifestations, and Outcomes. Can J Cardiol. 2018;34:356–61.
Egorova N, Vouyouka AG, Quin J, Guillerme S, Moskowitz A, Marin M, et al. Analysis of gender-related differences in lower extremity peripheral arterial disease. J Vasc Surg. 2010;51:372–9.
Feinglass J, McDermott MM, Foroohar M, Pearce WH. Gender differences in interventional management of peripheral vascular disease: evidence from a blood flow laboratory population. Ann Vasc Surg. 1994;8:343-9
Schramm K, Rochon P. Gender Differences in Peripheral Vascular Disease. Semin Intervent Radiol. 2018;35:9–16
McDermott MM, Guralnik JM, Ferrucci L, Tian L, Liu K, Liao Y, et al. Asymptomatic peripheral arterial disease is associated with more adverse lower extremity characteristics than intermittent claudication. Circulation. 2008. 117;2484–91.
Lo RC, Bensley RP, Dahlberg SE, Matyal R, Hamdan AD, Wyers M,et al. Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease. J Vasc Surg. 2014;59:409–18.
Barochiner J, Aparicio LS, Waisman GD. Challenges associated with peripheral arterial disease in women. Vasc Health Risk Manag. 2014;M10:115-8.
Correia R, Catarino J, Vieira I, Bento R, Ferreira M, et al. Gender diferences in chronic lower limb ischemia presentation and revascularization outcomes. Angiol Vasc Surg. Angiol Vasc Surg. 2021;17:110-7
Paquet M, Pilon D, Tetrault JP, Carrier N. Protective vascular treatment of patients with peripheral arterial disease: guideline adherence according to year, age and gender. Can J Public Health. 2010.101:96–100
Buckley B, Holden A, Merrilees S, Rukshan F, Expert Radiology,Image-Guided Interventions (Third Edition), Revascularization: Aortoiliac. Elsevier. 2020.
Rowe VL, Weaver FA, Lane JS, Etzioni DA. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States. J Vasc Surg. 2010 51:21S–6S.
Doshi R, Changal KH, Gupta R, Shah J, Patel K, Desai R, et al. Comparison of Outcomes and Cost of Endovascular Management Versus Surgical Bypass for the Management of Lower Extremities Peripheral Arterial Disease. Am J Cardiol. 2018;122:1790–6.
Hirsch AT, Allison MA, Gomes AS. A call to action: Women and peripheral artery disease: A scientific statement from the American Heart Association. Circulation. 2012;125:1449-72
Vouyouka AG, Egorova NN, Salloum A, Kleinman L, Marin M, Faries PL, et al. Lessons learned from the analysis of gender effect on risk factors and procedural outcomes of lower extremity arterial disease. J Vasc Surg. 2010;52:1196–202
Peek ME. Gender differences in diabetes-related lower extremity amputations. Clin Orthop Relat Res; 2011.469:1951-5.
Kashyap VERSUS, Pavkov ML, Bena JF, et al. The management of severe aortoiliac occlusive disease: Endovascular therapy rivals open reconstruction. J Vasc Surg. 2008.48:1451-7
Harthun NL, Cheanvechai V, Graham LM, Freischlag JA, Gahtan V. Arterial occlusive disease of the lower extremities: do women differ from men in occurrence of risk factors and response to invasive treatment?.J Thorac Cardiovasc Surg. 2004;127:318–21.
Ballotta E, Gruppo M, Lorenzetti R, Piatto G, Dagiau G, Toniato A. The impact of gender on outcome after infrainguinal arterial reconstructions for peripheral occlusive disease. J Vasc Surg. 2012;56:343-52.
Hultgren R, Olofsson P, Wahlberg E. Sex-related differences in outcome after vascular interventions for lower limb ischemia. J Vasc Surg. 2002;35:510–6.
McCoach CE, Armstrong EJ, Singh S, Javed U, Anderson D, Yeo KK, et al. Gender-related variation in the clinical presentation and outcomes of critical limb ischemia. Vasc Med. 2013;18:19–26.
Roddy SP, Darling RC, Maharaj D, Chang BB, Paty PS, Kreienberg PB, et al. Gender-related differences in outcome: an analysis of 5880 infrainguinal arterial reconstructions. J Vasc Surg. 2003;37:399-402
Hedayati N, Brunson A, Li CS, Baker AC, Pevec WC, White RH, Romano PS. Do Women Have Worse Amputation-Free Survival Than Men Following Endovascular Procedures for Peripheral Arterial Disease? An Evaluation of the California State-Wide Database. Vasc Endovasc Surg. 2015;49:166-74.
M. Engelhardt, J. Boos, H. Bruijnen, W. Wohlgemuth, C. Willy, M. Tannheimer, K. Wölfle. Critical Limb Ischaemia: Initial Treatment and Predictors of Amputation-free Survival. Eur J Vasc Endovasc Surg. 2012;43:55-61.
Baldaia L, Antunes LF, Silva CG, Silva M, Silva E, Nunes C, et al. Sex disparities in peripheral arterial occlusive disease. Angiol Vasc Surg. 2023;19:27-32
