Carotid artery stenosis in patients with peripheral arterial disease: the SMART study. SMART study group.

PURPOSE: The prevalence of asymptomatic internal carotid artery stenosis (ICAS) in patients with peripheral arterial disease (PAD) and characteristics that are associated with ICAS were studied. METHODS: We used data from the first 600 patients enrolled in the Second Manifestations of ARTerial disease (SMART) study, a single-center, prospective cohort study among patients referred with a manifestation of cardiovascular disease, diabetes mellitus, hypertension, or hyperlipidemia. Included in the analysis were 162 patients with PAD or a history of PAD, who were not known to have ICAS at the time of referral and who had no history of cerebrovascular symptoms or previous carotid endarterectomy. ICAS was detected with duplex scanning and defined as a peak systolic velocity more than 150 cm/s (diameter reduction 50% or higher) on at least one side. Cardiovascular risk factors were measured. Logistic regression analysis was performed to investigate associations between these characteristics and ICAS. RESULTS: The prevalence of previously unknown ICAS was 14%. A patient age of 67 years or older, body weight of 68 kg or less, and diastolic blood pressure of 75 mm Hg or lower were independently associated with ICAS.The Prevalence Of Icas In Patients With One Of These Characteristics (38% Of The Patients) Was 8%, In Those With Two Characteristics (21% Of The Patients) Was 32%, And In Those With Three Characteristics (6% Of The Patients) Was 50%. CONCLUSIONS: The prevalence of ICAS increases as much as 50% in patients who have PAD and the risk indicators of an age of 67 years or older, a body weight of 68 kg or less, and a diastolic blood pressure of 75 mm Hg or lower, and, therefore, these characteristics may be used as a means of increasing the likelihood of detecting ICAS.     

Carotid intima-media thickness in patients with abdominal aortic aneurysms.

OBJECTIVE: The contribution of atherosclerosis to the development of Abdominal Aortic Aneurysms (AAA) is still controversial. Ultrasound scans can detect intima-media thickening of the carotid arteries as an early sign of atherosclerosis. The aim of this study was to investigate whether patients with Abdominal Aortic Aneurysms (AAAs) have thickened carotid IMT as patients with atherosclerotic peripheral arterial disease (PAD). METHODS: With high-resolution B-mode ultrasonography, the intima-media thickness (IMT) in the carotid arteries (right and left common carotid artery) was measured in AAA patients and compared with that of age and sex-matched patients with atherosclerotic peripheral arterial disease (PAD). A third group of healthy age and sex- matched control subjects were included for comparison. The corresponding carotid artery lumen was also determined in all groups. Comparison of the three groups was made by ANOVA. RESULTS: Fifty-eight AAA patients and 69% were men (mean age of 72.3 years) were studied. Aged and sex-matched groups comprised of 111 PAD patients and 71 healthy. The mean carotid IMT was highest in PAD patients (1.036+/-0.18mm). The values of controls and AAA patients were similar and significantly lower than that of atherosclerotic patients (0.875+/-0.11mm and 0.812+/-0.53mm respectively, both p<0.005 vs. PAD). Narrowing of the corresponding lumen was found in PAD patients compared with that of AAA patients, but no difference can be seen between healthy subjects and AAA patients. The mean carotid IMT was greater in men (P<0.05) in all studied groups, but no similar gender specificity was found in the lumen diameter. CONCLUSIONS: This study shows that the carotid artery IMT of AAA patients is similar to healthy subjects, but not as thick as patients with atherosclerotic disease. As carotid (IMT) is a surrogate marker of atherosclerosis, the findings support the notion that the formation of AAA may not be fully atherosclerosis-dependent. Gender may be a confounding factor for carotid intima-media thickening.     

Four-year follow up of patients with untreated abdominal aortic aneurysms

BACKGROUND: The data in the literature are still controversial describing the outcome of patients not treated for a large abdominal aortic aneurysm (AAA) especially with significant comorbidities. We followed up patients trying to establish their long-term outcome. METHOD: Since 1998, we have prospectively followed all patients referred to our department with AAA. A retrospective analysis was carried out selecting all patients who had an AAA larger than 5 cm, and who declined or were declined for operative repair between February 1998 and November 2001. RESULTS: One hundred and eleven patients were included in the present study. There were 78 men and 33 women. The mean age was 80 years. At the end of the study, 65 patients (59%) were deceased. Ruptured aneurysm occurred in 27 patients (median time to rupture = 14 months) with one patient surviving an emergency repair. Thirty-nine patients died from unrelated illnesses. In the 5-5.9 cm AAA group (n = 58), out of 31 deceased patients, five (16%) have died of ruptured AAA. In the 6 cm and larger AAA group (n = 53), out of 34 deceased patients, 21 (62%) have died of ruptured AAA. There was no significant difference in survival between patients with AAA below and above 6 cm in diameter (P = 0.15). CONCLUSION: In the presence of significant comorbidities, most patients with AAA less than 6 cm died from unrelated illnesses. In the larger AAA group, the likelihood of death from AAA rupture or unrelated illnesses is almost equal.     

Prevalence of and risk factors for peripheral arterial disease in the patients with hypertension among Han Chinese

OBJECTIVES: Peripheral arterial disease (PAD) is associated with morbidity and mortality of coronary heart disease and stroke. Hypertension is an independent risk factor for peripheral arterial disease. However, the prevalence and risk factors of PAD in hypertensive patients have not been studied in China. METHODS: In order to investigate the prevalence of PAD and its risk factors in China, a cross-sectional study was carried out. A total of 4716 patients with hypertension and 833 age-gender matched people without hypertension were recruited; age 40 to 75 years, from seven rural communities. PAD was defined as an ankle-brachial index (ABI) or=140 mm Hg, diastolic blood pressure >or=90 mm Hg, or history of antihypertensive drug use. RESULTS: The prevalence of PAD is 8.7% (n = 408) in patients with hypertension (n = 4716), higher than in people without hypertension (5.0%, n = 833, P = .004). Hypertensive patients with PAD were older, (61 +/- 8.6 vs 58 +/- 8.6, P < .01), had more conventional cardiovascular risk factors including systolic blood pressure (170 +/- 22.6 vs 167 +/- 22.7, P < .01), pulse pressure (72 +/- 19.7 vs 68 +/- 18.9, P < .01), blood glucose (5.8 +/- 2.2 vs 5.6 +/- 1.7, P < .05), total cholesterol (5.7 +/- 1.3 vs 5.5 +/- 1.1, P < .05), and serum uric acid (355 +/- 98.0 vs 293 +/- 86.2, P < .05) than the hypertensive patients without PAD. After adjusting for gender, age, and other cardiovascular risk factors by using multiple logistical regression analysis, PAD was still associated with current smoking (odds ratio [OR] = 1.65, 95% confidence interval [CI] 1.18-2.29), history of stroke (OR = 1.50, 95% CI 1.12-2.00), serum uric acid (OR = 1.21, 95% CI 1.10-1.59), and total cholesterol (OR = 1.12, 95% CI 1.10-1.59). CONCLUSION: This study reports, for the first time, the prevalence of PAD in Chinese patients with hypertension, which is quite different from that in westerners, and that PAD is independently associated with conventional cardiovascular risk factors.     

Peripheral arterial disease in patients with stages IV and V chronic renal failure.

BACKGROUND: Cardiovascular disorders are frequently found among chronic renal failure (CRF) patients due to their higher susceptibility to develop atherosclerosis. However, peripheral arterial disease (PAD), that is associated with a high mortality rate, is not usually assessed in these patients. The aims of this study are to find out the prevalence of PAD affecting lower limbs in a population of CRF patients in stages IV/V, and to assess how much PAD determines the 5-year patient survival. METHODS: The study population (44 males and 29 females) was aged 58 +/- 15 years. They suffered from advanced CRF (18.6 +/- 6.1 ml/min creatinine clearance), but they were not on dialysis. These patients were sequentially referred initially to the predialysis unit over a period of 14 months. The vascular lesions were assessed by carotid and transcranial ultrasound, as well as by ankle-brachial index test (ABI). Routine 24 h blood and urine laboratory tests were performed for each patient. Cardiovascular morbidity and cardiovascular disease risk factors were evaluated through personal interview. RESULTS: Fourteen patients had an ABI index of less than 0.91 (PAD indicative), 11 of them also suffered from intermittent claudication. PAD affected significantly more males (P = 0.001) and diabetics (P = 0.001). Also, PAD prevalence was significantly higher in patients with a previous clinical record of coronary heart disease (P = 0.001), increased clinical record of cerebrovascular disease (P = 0.005), a thickness of the left ventricular posterior wall (P = 0.03) and lower cardiac ejection fraction (P = 0.02). PAD patients had a significantly different protein intake (P = 0.003), calcium-phosphorus product (P = 0.001), risk of coronary heart disease based on the Framingham score (P = 0.001) and 5-year survival rate (P = 0.004). There were no significant differences for PAD patients in terms of body mass index, creatinine clearance, lipid profile, Ca and P. Multivariate risk factor analysis revealed that a previous clinical record of coronary heart disease and diabetes increased the risk of developing PAD, as defined by ABI < 0.91. After 5 years, 21 patients (29%) had died: 64% of patients that suffered PAD (9/14) and 20% of the non-PAD population (12/59). The Cox proportional hazards model demonstrated that older age and a lower ABI increased the risk of death. CONCLUSIONS: The present study, conducted on CRF patients in stages IV and V not undergoing dialysis, showed; (a) that a high percentage of these patients developed PAD (19%) or other vascular pathologies; (b) that there was an associated high mortality rate (29%) after 5 years; (c) that the 5-year mortality rate was significantly higher (P = 0.004) in PAD patients (64 vs 20%).     

Prognosis of Atrial Fibrillation in Patients with Symptomatic Peripheral Arterial Disease: Data from the REduction of Atherothrombosis for Continued Health (REACH) Registry

BackgroundAtrial fibrillation (AF) is a significant risk factor for cardiovascular (CV) mortality. This study aims to evaluate the prognostic implication of AF in patients with peripheral arterial disease (PAD).MethodsThe International Reduction of Atherothrombosis for Continued Health (REACH) Registry included 23,542 outpatients in Europe with established coronary artery disease, cerebrovascular disease (CVD), PAD and/or ≥3 risk factors. Of these, 3753 patients had symptomatic PAD. CV risk factors were determined at baseline. Study end point was a combination of cardiac death, non-fatal myocardial infarction (MI) and stroke (CV events) during 2 years of follow-up. Cox regression analysis adjusted for age, gender and other risk factors (i.e., congestive heart failure, coronary artery re-vascularisation, coronary artery bypass grafting (CABG), MI, hypertension, stroke, current smoking and diabetes) was used.ResultsOf 3753 PAD patients, 392 (10%) were known to have AF. Patients with AF were older and had a higher prevalence of CVD, diabetes and hypertension. Long-term CV mortality occurred in 5.6% of patients with AF and in 1.6% of those without AF (p < 0.001). Multivariable analyses showed that AF was an independent predictor of late CV events (hazard ratio (HR): 1.5; 95% confidence interval (CI): 1.09–2.0).ConclusionAF is common in European patients with symptomatic PAD and is independently associated with a worse 2-year CV outcome.     

The high prevalence of colorectal neoplasms in preoperative patients with abdominal aortic aneurysm or peripheral artery disease.

OBJECTIVE: In Japan, the incidence of both colorectal carcinoma and vascular disease is increasing. We screened preoperative patients with abdominal aortic aneurysm (AAA) or peripheral artery disease (PAD) for colorectal cancer. DESIGN OF STUDY: This study was retrospective and cross-sectional. MATERIALS: The subjects were 492 patients admitted for elective surgery of AAA or PAD. METHODS: The patients underwent immunochemical faecal occult blood tests (FOBT) before operation, and those with positive results underwent investigations for colorectal neoplasm. We compared the results with that of screening programmes performed on the general population. RESULTS: Of the 408 patients that underwent FOBT, 104 (25.5%) were positive. After colonoscopy, six (1.5%) had colorectal carcinoma and 16 (3.9%) had advanced adenoma. These values were several folds higher than that for the general population in Japan. CONCLUSIONS: Patients with AAA or PAD carry a high risk for colorectal neoplasm.     

Decreased wall shear stress in the common carotid artery of patients with peripheral arterial disease or abdominal aortic aneurysm: relation to blood rheology, vascular risk factors, and intima-media thickness

BACKGROUND: Wall shear stress, a local risk factor of atherosclerosis, is decreased in the common carotid artery of patients with vascular risk factors. We evaluated wall shear stress in the common carotid artery of patients with symptomatic peripheral arterial occlusive disease (PAD) and abdominal aortic aneurysm (AAA). As blood viscosity is a determinant of wall shear stress, we further investigated the impact of rheologic variables on wall shear stress in relation to vascular risk factors and intima-media thickness. METHODS: High-resolution ultrasonography scans were used to study intima-media thickness, internal diameter, and blood velocity in the common carotid artery of 31 patients with PAD, 36 patients with AAA, and 37 controls. Furthermore, major hemorheologic variables and vascular risk factors were evaluated, and wall shear stress was calculated. RESULTS: Wall shear stress was lower in patients with PAD (median [IQR], dynes/cm(2): 14.4 [10 to 19]) and with AAA (12.1 [9 to 15]) than in healthy controls (20.6 [17 to 24]; P < .0001). Wall shear stress was inversely related to red cell aggregation (P = .01), fibrinogen (P = .003), leucocyte count (P = .001), plasma viscosity (P = .04), and intima-media thickness (P < .0001). Furthermore, wall shear stress was negatively associated with age, smoking, and triglycerides, but positively correlated with high-density lipoprotein cholesterol (all P < .001). When the influence of all these predictors were simultaneously taken into account in a multiple regression model, only age (P < .0001), smoking (P = .005), and triglycerides (P = .003) remained significantly associated with wall shear stress. CONCLUSIONS: This is the first report, to our knowledge, showing that wall shear stress of the common carotid artery is decreased in patients with symptomatic PAD and in patients with AAA. Rheologic variables are less important in predicting wall shear stress than age, triglycerides, and smoking.     

Subclinical peripheral arterial disease in patients with chronic kidney disease: prevalence and related risk factors

BACKGROUND: Atherosclerotic artery disease is a common condition in patients with chronic kidney disease (CKD); however, there are few published data on the prevalence of peripheral arterial disease (PAD) in nondialyzed patients with renal insufficiency. The ankle-brachial index (ABI) is a simple, noninvasive, and reliable method to assess PAD. METHODS AND RESULTS: Prevalence of PAD using ABI was investigated in 102 patients referred for the first time to a nephrology clinic with CKD in stages 3 to 5 of the K/DOQI classification, and with no previous diagnosis of PAD. Patients with ABI <0.9 were considered positive for PAD. A total of 64% of the patients were male. The mean age was 70 +/- 11 (range 58-84) years, and the estimated creatinine clearance (CrCl) was 35 +/- 12 (range 6-59) mL/min(-1). Of the total sample, 26% were diabetics, 10% active smokers, 48% ex-smokers, and 29% had a diagnosis of coronary heart disease (CHD), 15% had been previously diagnosed of stroke, and 17% had signs and symptoms compatible with intermittent claudication, which had passed unnoticed. Thirty-two percent of patients had an ABI <0.9 (mean 0.64 +/- 0.25). Of these patients with PAD, 84% were men (P < 0.005), and only 30% presented a clinical picture compatible with intermittent claudication. Absolute risk of CHD according to the Framingham 1998 score was higher in the PAD group (19.3% +/- 6 vs. 13.1% +/- 8; P= 0.01). Patients with PAD were older (75 +/- 6 vs. 66 +/- 11 years, P= 0.000), and had worse renal function (CrCl 30.8 +/- 12 vs. 37 +/- 10.7 mL.min(-1), P= 0.016) compared to patients without PAD, but no differences were found in cholesterol levels (total, HDL, LDL), calcium, phosphorus, or PTH. In the logistic regression analysis, independent indicators of PAD risk were male sex, age, and lower CrCl. Twelve percent of patients had an ABI > or =1.3, suggestive of parietal arterial calcifications. In these patients, systolic blood pressure and pulse pressure were lower (126 +/- 18 vs. 150 +/- 27, P= 0.005, and 52 +/- 13 vs. 68 +/- 25 mm Hg, P= 0.044), i-PTH levels were higher (228 +/- 267 vs. 117 +/- 63 pg/mL, P= 0.01), and a larger proportion of this group was treated with calcitriol (34% vs. 13%) compared to patients with a normal ABI. CONCLUSION: A high prevalence of PAD, considered as an ABI <0.9, was demonstrated in nondialyzed patients with CKD. This was related with age, male sex, and higher degree of renal insufficiency, while the presence of ABI > or =1.3 was associated with a greater degree of hyperparathyroidism. These data show the need to carry out routine ABI determinations in patients with CKD for early detection of peripheral arterial disease.     

Association of cardiovascular risk factors with pattern of lower limb atherosclerosis in 2659 patients undergoing angioplasty.

OBJECTIVES: Aim of this study is to correlate distribution pattern of lower limb atherosclerosis with cardiovascular risk factor profile of patients with peripheral arterial occlusive disease (PAD). PATIENTS AND METHODS: Analysis is based on a consecutive series of 2659 patients (1583 men, 1076 women, 70+/-11 years) with chronic PAD of atherosclerotic origin undergoing primary endovascular treatment of lower extremity arteries. Pattern of atherosclerosis was grouped into iliac (n=1166), femoropopliteal (n=2151) and infrageniculate (n=888) disease defined according to target lesions treated. A multivariable multinomial logistic regression analysis was performed to assess relation with age, gender and classical cardiovascular risk factors (diabetes mellitus, arterial hypertension, hypercholesterolemia, cigarette smoking) using femoropopliteal disease as reference. RESULTS: Iliac disease was associated with younger age (RRR 0.95 per year of age, 95%-CI 0.94-0.96, p<0.001), male gender (RRR 1.32, 95%-CI 1.09-1.59, p=0.004) and cigarette smoking (RRR 2.02, 95%-CI 1.68-2.42, p<0.001). Infrageniculate disease was associated with higher age (RRR 1.02, 95%-CI 1.01-1.02, p<0.001), male gender (RRR 1.23, 95%-CI 1.06-1.41, p=0.005) and diabetes mellitus (RRR 1.68, 95%-CI 1.47-1.92, p<0.001). Hypercholesterolemia was less prevalent in patients with lesions below the knee (RRR 0.82, 95%-CI 0.71-0.94, p=0.006), whereas no distinct pattern was apparent related to arterial hypertension. CONCLUSION: Clinical phenotype of peripheral atherosclerosis varies with prevalence of cardiovascular risk factors suggesting differences in mechanisms involved in iliac as compared with infrageniculate lesions. Identification of molecular mechanism might have influence on future therapeutic strategies in PAD patients.     

Ethnicity and Peripheral Arterial Disease

INTRODUCTION: the prevalence of peripheral arterial disease (PAD) is relatively well defined for the Caucasian population. Given the susceptibility of Asians and Afro-Caribbeans to coronary heart disease and stroke respectively, and the high prevalence of cardiovascular risk factors in both groups, one would expect a high prevalence of peripheral arterial disease. METHODS: a search of MEDLINE (1966-2002) was undertaken for studies on the incidence and prevalence of PAD, abdominal aortic aneurysms (AAA) and cerebrovascular disease in different ethnic groups. RESULTS: there are very few population-based prevalence studies assessing PAD, AAA or cerebrovascular disease in non-Caucasians. A review of hospital-based series demonstrates different patterns of PAD between ethnic groups. Blacks and Asians have a tendency towards more distal occlusive disease and AAA appear to be predominantly a disease of Caucasians. It is not clear whether these studies provide a true representation of the prevalence of arterial disease in various ethnic groups or are the result of an unmet health care need. CONCLUSIONS: further studies are required to establish the prevalence, natural history and response to treatment of PAD, AAA and cerebrovascular disease in non-Caucasians. Only when this has been achieved, can clinically and cost-effective health care be delivered to affected individuals from different ethnic groups.     

The low incidence of surgery for non-cardiac vascular disease in UK Asians may be explained by a low prevalence of disease.

AIMS: Firstly, to compare rates of surgery for non-cardiac vascular disease in Caucasians and Asians and secondarily to assess the prevalence of peripheral arterial disease (PAD) and abdominal aortic aneurysm (AAA) in the male UK Asian population. METHODS: Analysis of a prospective database followed by an epidemiological survey of 100 unselected Pakistani males, in which demographic and anthropometric data were collected alongside aortic ultrasonography and measurement of ankle: brachial pressure index (ABPI). RESULTS: Although 14.1% of our catchment area is Asian, after correction for age, they only accounted for 64/2268 (2.8%) of procedures for PAD and AAA. Specifically, Asians were 10 times less likely to undergo AAA repair and 3 times less likely to undergo procedures for lower limb peripheral bypass, amputation and endovascular intervention. In the epidemiological study, 26 subjects had a significant history of ischaemic heart disease, 21 were diabetic, 32 had hypertension and 60 were current or ex-smokers. Median aortic diameter [IQR] was 17.6 mm [16.3-19.1 mm] and no subject had an AAA. In 200 limbs, median ABPI [IQR] was 1.12 [1.04-1.21]. Only 2 patients had an ABPI < 0.9. CONCLUSION: Despite a high prevalence of cardiovascular risk factors and ischaemic heart disease, the prevalence of PAD and AAA is much lower than would have been expected in an age- and sex-matched Caucasian population. These data suggest that the reduced incidence of surgery for PAD and AAA in UK Asians is due to a low prevalence of disease.     

Influence of age, aneurysm size, and patient fitness on suitability for endovascular aortic aneurysm repair

Prior to approval by the U.S. Food and Drug Administration of larger endografts (main body diameters up to 36 mm), small abdominal aortic aneurysms (AAAs, <5.5 cm) were shown to be more suitable for endovascular repair (EVAR) than large AAAs (> or =5.5 cm). The purpose of this study was to assess changes in EVAR suitability with the potential use of larger endografts in unselected consecutive patients. The influence of age, aneurysm size, and patient fitness on EVAR suitability was also assessed. We studied 186 male patients referred for evaluation of nonruptured AAAs who underwent contrast-enhanced computed tomographic scans with three-dimensional reconstructions. Morphologicall AAA features and neck characteristics were measured according to Society for Vascular Surgery reporting standards to determine EVAR suitability. Patient fitness for repair was assessed using the customized probability index, a validated fitness score for vascular surgery procedures. Suitability for EVAR was determined by neck anatomy, iliac artery morphology, and total aortic aneurysm angulation and tortuosity according to the clinicians' experience and current practice. The median age of the study cohort was 72 years (interquartile range [IQR] 65-79 years). The median maximum AAA diameter was 5.4 cm (IQR 4.1-5.9). Median fitness score was +7 (IQR -7 to +14). EVAR suitability for large AAAs significantly increased with larger endografts (35-63%, p<0.001). Changes in EVAR suitability for small AAAs were not significant (69-75%, p=0.06). Maximum AAA diameter was not an independent predictor for EVAR suitability with larger endografts after adjusting for neck anatomy. Aortic neck length (odds ratio [OR]=1.2, 95% confidence interval [CI] 1.1-1.2) and diameter (OR=0.78, 95% CI 0.63-0.96) were the only independent predictors for EVAR suitability with larger endografts. Age, AAA size, and fitness did not differ between patients suitable and unsuitable for EVAR with larger endografts. In conclusion, introduction of larger endografts (up to 36 mm in main body diameter) in the United States has resulted in significantly increased anatomic suitability for EVAR for large AAAs. Conversely, suitability has not significantly changed for small AAAs. Overall, EVAR suitability is not influenced by age, aneurysm size, or patient fitness.     

The natural history of isolated carotid siphon stenosis

Between August 1978 and July 1983, 93 patients (71 with unilateral and 22 with bilateral isolated carotid siphon stenosis) were identified from a review of 885 consecutive cerebral arteriograms. This yielded 115 cerebral hemispheres at risk. At the time of arteriography, 93 hemispheres were asymptomatic regarding the hemisphere with siphon stenosis (group I), whereas 22 hemispheres in 22 patients had had neurologic events referable to the hemisphere with siphon stenosis (group II). During follow-up (range 1 to 62 months, mean 22.5 months), 64.5% of initially asymptomatic hemispheres remained asymptomatic, 6.5% experienced transient ischemic attacks (TIAs), and 4.3% developed strokes. During the same follow-up period, 63.6% of initially symptomatic hemispheres became asymptomatic, 9.1% had recurrence of TIAs, and 9.1% developed strokes. Sixteen of 71 group I patients (22.5%) and 5 of 22 group II patients (22.7%) died during follow-up. The overall incidence of nonfatal stroke and TIAs was 6.5% and 8.6%, respectively. Myocardial infarction (MI) and stroke accounted for deaths in 6.5% and 4.3% of patients, respectively. There was no significant difference in the incidence of TIA, stroke, or death between group I and group II. The percentage of siphon stenosis in all patients experiencing stroke or TIA (35.4 ± 14.4%) was not significantly different from that in patients who remained asymptomatic (32.3 ± 10.6%). Patients with carotid siphon stenosis are at an increased risk of death, stroke, and TIAs compared with the population at large. However, the risk of stroke is less than the risk of stroke in patients with TIAs assumed to be caused by carotid bifurcation disease. The risk of fatal MI is similar to the annual incidence of MI in patients with other manifestations of atherosclerosis. (J VASC SURG 1984;1:744-749.)     

Abdominal aortic aneurysm in women: prevalence, risk factors, and implications for screening

OBJECTIVE: Accurate data regarding the prevalence and associated risk factors for aneurysmal disease is essential when determining the appropriateness of screening for abdominal aortic aneurysms (AAA). Although women are poorly represented in most large studies of AAA prevalence, the US Preventative Services Task Force recently recommended against primary screening for AAA in women. The purpose of this analysis was to define the prevalence and risk factors associated with the development of AAA in women. METHODS: A free duplex ultrasound screening was offered to men and women with cardiovascular risk factors or a family history of AAA. Patients were recruited through advertising at local screening centers and screenings were performed between 2004 and 2006. Demographic information and cardiovascular and aneurysmal disease risk factors were obtained for each patient through a questionnaire. A total of 17,540 subjects were screened for AAA, including 10,012 women (mean age 69.6 years) and 7528 men (mean age 70.0 years). Univariate and multivariable logistic regression analysis was performed on the subset of women that were screened to determine risk factors for and prevalence of AAA. RESULTS: Seventy-four aneurysms were detected in women (including four aneurysms >5 cm diameter and 70 aneurysms 3 to 5 cm diameter) while 291 were detected in men, resulting in prevalence rates of 0.7% and 3.9%, respectively. Increasing age (odds ratio [OR]= 4.57, 95% confidence interval [CI] 1.98 to 10.54, P < .0001), history of tobacco use (OR = 3.29, 95% CI 1.86 to 5.80, P < .0001), and cardiovascular disease (OR= 3.57, 95% CI 2.19 to 5.84, P < .0001) were independently associated with AAA in women on univariate and multivariable analysis. Women with multiple atherosclerotic risk factors were more commonly found to have AAAs and had a prevalence rate of AAA as high as 6.4%. CONCLUSION: Although the medical literature suggests a low prevalence rate of AAA in women in the general population, specific risk factors are associated with the development of AAA, and subgroups of women can be identified that are at a substantially increased risk of aneurysmal disease. In particular, elevated rates of AAA were found among women of advanced age (> or =65 years) with a history of smoking or heart disease. These data support the notion that women with such risk factors should be considered for AAA screening.     

Management of patients with concomitant lung cancer and abdominal aortic aneurysm

BACKGROUND: Management of patients with an abdominal aortic aneurysm (AAA) and malignancy is challenging. We aimed to define the coincidence of AAA and lung cancer and to determine a treatment strategy. METHODS: The outcomes for patients diagnosed with AAA and lung cancer between 1991 and 2004 at our institution were reviewed retrospectively. RESULTS: We identified 75 patients with both lesions among 1,096 AAA and 1,875 lung cancer patients. Survival correlated with cancer stage; only 3 deaths were directly attributable to the patient's AAA. Of 59 patients who did not have AAA repair at the time of cancer diagnosis, 12 were repaired. Twenty-seven of those 59 patients had a 5.0-cm or larger AAA; only 1 patient with a 7.5-cm AAA had a rupture 5 months after thoracotomy and died. CONCLUSIONS: The co-existence of AAA and lung cancer is not rare; prognosis is poor and largely determined by the lung cancer stage. Open or endovascular repair of AAA rarely is justified in patients with advanced disease unless the AAA is symptomatic or large (>7 cm). Treatment for AAAs greater than 5.5 cm should be based on stage, histology, and patient comorbidities.     

Prevalence of abdominal aortic aneurysms in over 65-year-old men with inguinal hernias

INTRODUCTION

The aim of this study was to determine the prevalence of abdominal aortic aneurysms (AAAs) in over 65-year-old men who have inguinal hernias and discuss if pre-operative selective screening of this population is appropriate.

PATIENTS AND METHODS

A prospective study on 70 consecutive male patients with an age range of 65–88 years (mean, 74 years) who were referred to a single vascular consultant''s out-patient clinic with an inguinal hernia were screened for the presence of an AAA with an ultrasound scan before hernia repair over a period of 3 years.

RESULTS

Two patients were found to have an AAA measuring 3.8 cm and 6.0 cm giving an AAA prevalence of 3% (exact 95% confidence interval = 0–10%).

CONCLUSIONS

This study does not demonstrate an increased AAA prevalence in over 65-year-old male patients with inguinal hernias, scanned pre-operatively when compared to screening programmes. Selective screening of this cohort cannot be justified on this evidence.     

Coronary artery disease in patients with abdominal aortic aneurysm

Selective coronary angiography to determine the prevalence of coronary artery disease (CAD) has been performed in patients with abdominal aortic aneurysm (AAA). Thirty patients in this series consisted of 26 men and 4 women with an age range of 48-87 years (mean +/- SD: 67.5 +/- 8.2 years). As the atherosclerotic risk factors, cigarette smoking was present in 19 patients (63.3%), hypertension was in 18 (60%), hypercholesteremia was in 10 (33.3%), and diabetes mellitus was in 2 (6.7%). Cerebral vascular disease was present in 11 patients (36.7%). Regarding CAD, angina pectoris or old myocardial infarction was found in 9 patients (30%), and abnormal electrocardiography (ECG) was in 16 patients (53.3%). Coronary angiography prior to operation of AAA was performed to 22 patients (73.3%), and 15 patients (68.2%) among them had significant coronary artery stenosis, and 9 patients underwent myocardial revascularization (4 CABG, 5 PTCA). CAD was frequently complicated both in patients without symptoms or ECG abnormalities and in less than 65-year patients. In order to prevent fatal myocardial infarction, we recommend routine coronary angiography to patients with AAA. And if necessary, myocardial revascularization must be indicated prior to aneurysmectomy.     

Secondary prevention of atherosclerosis through chlamydia pneumoniae eradication (SPACE Trial): a randomised clinical trial in patients with peripheral arterial disease.

BACKGROUND: Sero-epidemiological and experimental studies suggest that Chlamydia pneumoniae infections play an important role in the development of atherosclerosis. Clinical trials have shown contradictory results regarding the efficacy of antibiotics to prevent atherosclerosis-related complications in patients with coronary artery disease. Our aim was to study the effect of a short course of azithromycin on the incidence of cardiovascular events and peripheral vascular function in patients with stable peripheral arterial disease (PAD). PATIENTS AND METHODS: Five hundred and nine PAD-patients were randomised to receive either a 3-day course of azithromycin (500 mg daily) or placebo, with 2 years of follow-up. C. pneumoniae serology was determined at baseline. Clinical endpoints were death, coronary events (myocardial infarction, unstable angina, and/or coronary revascularization procedures), cerebral events (stroke, TIA, and/or carotid endarterectomy) and peripheral arterial complications (increased PAD-symptoms with decreased ankle-brachial index (ABPI, 0.1-point decrease after 12 months), and/or peripheral revascularization procedures). RESULTS: Five hundred and nine patients (160 women) with an atherosclerotic risk factor profile were randomised, 257 patients to azithromycin and 252 to placebo. Four hundred and forty nine patients (88%) had intermittent claudication and 60 (12%) had critical limb ischemia. By 24-month follow up, 182 patients (36%) developed 252 complications (45 deaths, 34 coronary events, 34 cerebral events and 139 peripheral arterial complications). C. pneumoniae IgA-titres were associated with the development of cardiovascular events. Nevertheless, the number of complications (131 in the azithromycin group vs. 121 in the placebo group) and the number of patients that developed complications (98 (38%) in the azithromycin vs. 84 (33%) in the placebo group) was comparable in both treatment groups. Life table analysis showed no effect of azithromycin on survival or ABPI. CONCLUSION: A short-term course of azithromycin offers no benefits for survival or ankle pressure in PAD-patients.