Our debaters have argued their preferred approaches for younger patients with symptomatic peripheral arterial disease (PAD) and have included such issues as procedure related morbidity, patency and durability, reinterventions and life expectancy. A similar discussion could occur regarding younger patients with abdominal aortic aneurysms and the comparative value of an endovascular or open repair. However, this analogy is not entirely appropriate. Whereas durability of the repair and need for reintervention are especially relevant in these young aneurysm patients, with their longer life expectancies, young PAD patients represent a group with more aggressive systemic atherosclerotic disease. At best, these younger patients can expect an absolute life expectancy similar to their older symptomatic PAD counterparts.
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The early presentation of symptomatic PAD is a marker of coinciding premature atherosclerotic disease in the coronary and carotid circulations. Medical therapy and risk factor modification is especially vital in these patients regardless of the operative or interventional approach used for their PAD. Specific risk factors, including Lp (a) lipoprotein level >30 mg/dl, have been identified as risk factors for premature PAD, especially in men.
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Despite adequate medical therapy and diabetes management, these patients are at increased risk for major cardiovascular events. Recent evidence would suggest that young women with PAD are especially susceptible to cardiovascular events compared to men, whereas risks are more similar in older age groups.3
Along with a more aggressive form of systemic atherosclerotic disease, young PAD patients appear to be predisposed to multiple procedures or interventions. In a review of a group of younger men with symptomatic PAD, 40% required multiple interventions because of progression of their disease or bypass graft failure.
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Predictors of treatment failure have been investigated recently. In a cohort of Chinese patients, 38% of young PAD patients had thrombophilia that proved to be an independent predictor of graft thrombosis and major amputation at 30 days, and decreased patency and limb salvage after one year.4
Young patients with symptomatic PAD represent an especially challenging group of patients for vascular surgeons. As with older patients they represent a population with aggressive systemic atherosclerosis and a somewhat limited life expectancy. Aggressive medical therapy and risk factor modification is mandatory, and the choice of bypass or endovascular therapy for their PAD needs to reflect this limited life expectancy. In PAD patients of all ages in the BASIL trial,
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bypass with adequate greater saphenous vein was found to be superior to angioplasty in those with a life expectancy beyond two years. Regardless, the optimal therapy should limit periprocedural morbidity and mortality, should be durable and require few, if any, reinterventions and be successful in resolving symptoms and avoiding major amputation. These are complex decisions and should be individualized to the patient's symptoms, anatomy and comorbidities and require consideration of both open and endovascular therapies by vascular surgeons.References
- The progressive nature of peripheral arterial disease in young adults: a prospective analysis of white men referred to a vascular surgery service.J Vasc Surg. 1999; 30: 436-444
- Lipoprotein (a), homoscysteine, and hypercoaguable states in young men with premature peripheral atherosclerosis: a prospective, controlled analysis.J Vasc Surg. 1996; 23: 53-61
- Young women with PAD are at high risk of cardiovascular complications.Eur J Vasc Endovasc Surg. 2012; 43: 441-445
- Role of thrombophilia in premature peripheral arterial obstructive disease – experience of a vascular centre in China.Eur J Vasc Endovasc Surg. 2012; June 1; ([Epub ahead of print])
- Bypass versus angioplasty in severe ischaemia of the leg (BASIL) trial: a survival prediction model to facilitate clinical decision making.J Vasc Surg. 2010; 51: 52S-68S
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