Should Incidental Asymptomatic Angiographic Stenoses and Occlusions Be Treated in Patients with Peripheral Arterial Disease?
Received 13 October 2008; received in revised form 18 May 2009; accepted 20 May 2009. published online 29 July 2009.
Purpose
The clinical importance of angiographically detected asymptomatic lower-limb stenoses and occlusions is unknown. This study aims to (i) assess the clinical outcome of asymptomatic lesions in the lower limb, (ii) identify predictors of clinical deterioration, and (iii) determine which asymptomatic lower-limb lesions should be treated at presentation.
Materials and Methods
All 918 patients undergoing peripheral angiography with or without angioplasty over a period of 7.5 years (January 1999 through June 2006) at a single institution were retrospectively evaluated. One hundred twenty-two patients (54% men; mean age, 70.3 years; age range, 41–91 y) with angiographic stenoses (≥50%) or occlusions on the asymptomatic leg were included. The composite endpoint of interest was major adverse clinical outcome (MACO) of the asymptomatic limb at clinical follow-up, which was defined as the development of intermittent claudication (IC), critical limb ischemia (CLI), or need for subsequent endovascular or surgical revascularization. Actuarial freedom from MACO was assessed with Kaplan-Meier curves and multivariable Cox proportional-hazards regression.
Results
During a 4.2-year mean follow-up in 122 patients with significant concomitant asymptomatic disease, 32.8% of patients developed symptoms (13.9% with IC, 18.9% with CLI); 42.5% of these cases required revascularization. Cox regression revealed two independent predictors of MACO on the asymptomatic side: contralateral below-knee amputation (BKA; hazard ratio, 2.93; 95% CI, 1.21–7.10; P = .01) and statin treatment (hazard ratio, 3.56; 95% CI, 1.56–8.13; P = .003).
Conclusions
Asymptomatic peripheral angiographic stenoses and occlusions become symptomatic in one third of patients, necessitating treatment in 13.9% overall. Previous contralateral BKA and statin use were independent predictors of adverse outcome in this population. Close clinical follow-up and appropriate risk factor modification are recommended.
cDepartment of Biosurgery and Surgical Technology, Surgical Epidemiology and Quality Unit, Imperial College London, St. Mary's Hospital, London, United Kingdom
Address correspondence to M.J.L.
None of the authors have identified a conflict of interest.
ABSTRACT