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]; Rim Halaby
Overview
Most patients with peripheral arterial disease (PAD) have a benign course, with the majority of patients being asymptomatic. However, clinical manifestations may progress rapidly in smokers, patients with diabetes and patients with chronic renal failure. Peripheral arterial disease is associated with complications that include ischemic leg pain at rest, ulceration and gangrene. In addition, the mortality rate among patients with peripheral arterial disease is higher than that of the general population. Mortality is mainly due to concomitant coronary artery disease and cerebrovascular disease rather than to the peripheral arterial disease itself.
Natural History
- 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. In fact, 20% to 50% of patients with peripheral arterial disease are asymptomatic.[1]
- The need of revascularization and amputation is relatively low. Lifestyle modifications and medical management is sufficient to treat asymptomatic to mild PAD. However, severe ischemia requires revascularization surgeries as definitive treatment.
- The progression of non critical claudication symptoms is as follows:
Below is an image summarizing the natural history of PAD. To note is that mortality in PAD is related to associated cardiovascular disease rather than PAD per se:
Complications
- Patients with PAD are at a higher risk for major cardiovascular events, especially myocardial infarction (MI), stroke and death which are related to the atherosclerotic pathophysiological basis of PAD and not directly related to PAD itself.
- Patients limb-related complications directly linked to the PAD may include:
- Blood clots or emboli that block off small arteries
- Lower extremity ulcers
- Gangrene
- Need for amputation.
- 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]
Prognosis
Mortality
- Patients with peripheral arterial disease have a 15 to 30 % five year mortality rate, which is two to six times higher than that of 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 correlates strongly with a higher cardiovascular and cerebrovascular mortality rate.[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]
- 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 compared to patients without PAD.
- All patients with PAD should be targeted with the same secondary prevention goals as patients with coronary artery disease.
Shown below is an image depicting the overlap between peripheral artery disease, cardiovascular disease and cerebrovascular disease:
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
- Increase in all causes of mortality
- Location of the arterial occlusive disease:
- Aorticoliliac: 73% five year survival
- Femoral: 80% five year survival[2]
Five Year Primary Patency Rates Following Bypass Grafting
Shown below is a table depicting the five year primary patency rates in affected vessels following angioplasty with or without stenting versus that following bypass grafting:
| 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)