Peripheral arterial disease natural history, complications and prognosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Aarti Narayan, M.B.B.S [3]
Overview
Most patients with peripheral arterial disease have a benign course, with majority being asymptomatic. However, clinical manifestations may progress rapidly in smokers, and those with diabetes or chronic renal failure.
Natural History
Progression of Symptoms
- Patients with peripheral arterial disease can be asymptomatic, have non critical symptoms or have critical symptoms that include ischemic leg pain, leg ulcers and gangrene.
- 20% to 50% of patients with peripheral arterial disease are asymptomatic [1]
- The progression of non critical claudication symptoms is as follows:
- The need of revascularization and amputation is relatively low. In fact, lifestyle modifications and medical management is sufficient to treat asymptomatic to mild PAD. However, severe ischemia requires revascularization surgeries as definitive treatment.
Amputation
- The rate of amputation is relatively low in patients with PAD and it is estimated to be almost 1 % per year.
- Patients who do not quit smoking have two fold higher risk of amputation than patients who quit smoking.
- Patients who have diabetes have 25% risk of amputation within 10 years.
- Patients who present with acute critical limb ischemia have 10 to 30% risk of amputation within 30 days[3]..
Mortality
- Patients with peripheral arterial disease have a 15 to 30 % five year mortality rate, which is two to six times higher than the general population.
- The mortality associated with the peripheral vascular disease is rarely directly related to the disease itself but it is rather related to the co-existing coronary and cerebrovascular diseases[3].
- Presence of peripheral arterial disease in a patient corelates strongly with high cardiovascular and cerebrovascular mortality [4]
- 30 to 50% of the patients with symptomatic PAD have evidence of coronary artery disease, whereas 15% to 25% of symptomatic PAD patients have evidence of significant carotid artery stenosis [5].
The factors that influence the mortality in PAD
- Severity of symptoms:
- Non critical claudication: 15-30% five year mortality rate
- Critical claudication (Limb rest pain, ulcers, gangrene): 25% one year mortality rate
- ABI:
- Tobacco use:
- Two fold increase in mortality
- Diabetes:
- Increase in all causes of mortality
- Location of the arterial occlusive disease:
- Aorticoliliac: 73% five year survival
- Femoral: 80% five year survival [2]
Complications
- Blood clots or emboli that block off small arteries
- Coronary artery disease
- Impotence
- Open sores (ischemic ulcers) on the lower legs
- Tissue death (gangrene)
Prognosis
- The diagnosis of PAD places a patient at high risk of major cardiovascular events, specifically myocardial infarction (MI), stroke and death.
- Patients with PAD have a twofold to fourfold increase in the risk of all-cause mortality and a threefold to sixfold increase in the risk of cardiovascular death relative to patients without PAD
- Patients with PAD also have a higher risk of an MI or a stroke than of a limb-related event, such as:
- Lower extremity ulcer
- Gangrene
- Need for amputation
- The risk of a major cardiovascular event is highest among patients with the most severe PAD, such as those with critical limb ischemia, in whom 1-year event rates are as high as 20% to 25%
- All patients with PAD should be targeted with the same secondary prevention goals as patients with coronary artery disease.
- Peripheral arterial disease is a true coronary risk equivalent
5 year primary patency rates
| Location | Angioplasty ± Stenting | Bypass grafting |
| Distal aorta/ Proximal common iliac artery | 51 - 88% | 80 - 90% |
| Distal common iliac artery | 56 - 65% | Vein: 60 - 75%, Synthetic: 55 - 62% |
| Proximal external iliac artery | 40 - 56% | Vein: 60 - 70%, Synthetic: 55 - 62% |
| Distal external iliac artery | 10 - 40% | Vein: 50 - 60%, Synthetic: 10 - 15% |
References
- ↑ McDermott MM, Guralnik JM, Ferrucci L; et al. (2008). "Asymptomatic peripheral arterial disease is associated with more adverse lower extremity characteristics than intermittent claudication". Circulation. 117 (19): 2484–91. doi:10.1161/CIRCULATIONAHA.107.736108. PMID 18458172. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M,Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013
- ↑ 3.0 3.1 Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.
- ↑ Dhaliwal G, Mukherjee D (2007). "Peripheral arterial disease: Epidemiology, natural history, diagnosis and treatment". The International Journal of Angiology : Official Publication of the International College of Angiology, Inc. 16 (2): 36–44. PMC 2733014. PMID 22477268.
- ↑ Mendelson G, Aronow WS, Ahn C (1998). "Prevalence of coronary artery disease, atherothrombotic brain infarction, and peripheral arterial disease: associated risk factors in older Hispanics in an academic hospital-based geriatrics practice". Journal of the American Geriatrics Society. 46 (4): 481–3. PMID 9560072. Unknown parameter
|month=ignored (help)