ABSTRACT: Objective: Peripheral arterial disease (PAD) can be treated with percutaneous transluminal angioplasty (PTA). Data comparing the outcomes of females to males with PAD who undergo PTA is limited. We compared the clinical outcomes of male and female patients with PAD who underwent PTA. Methods: In a single-center, prospective registry, the outcomes of 239 consecutive patients who underwent PTA for symptomatic PAD stratified by gender were analyzed. The primary endpoint was restenosis at 8 months. The secondary end points were repeat PTA, target lesion revascularization, target extremity revascularization, and amputation at a follow-up of 2 years. Results: Female patients were older (69.5±11.1 vs 65±11.6 years of age, P=.04) and had a trend toward a higher percentage of diabetic foot wound (58.1% vs 44.5%, P=.076) and PTA of tibial artery lesions (63.6% vs 53.8%, P=.064). Females had higher incidence of major hematoma (≥4 cm; 18.1% vs 8.1%, P=.033). No significant differences were observed between females and males for binary restenosis at 8 months and clinical events at 2 years. Conclusions: Female patients were older and had trends toward a higher percentage of diabetic foot wound as the initial diagnosis for PTA and PTA of tibial artery lesions. Despite having a higher incidence of major hematoma, females who underwent PTA had no significant differences in restenosis and 2-year clinical outcomes. PTA represents a viable treatment option for female patients with symptomatic PAD.

VASCULAR DISEASE MANAGEMENT 2015;12(7):E117-E125

Key words: peripheral vascular disease, angioplasty, percutaneous transluminal angioplasty, endovascular therapy

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Peripheral arterial disease (PAD) is associated with significant morbidity and mortality including increased risk of cardiovascular events including death, myocardial infarction, and stroke.^1-4 Female patients who undergo percutaneous coronary intervention (PCI) have higher rates of stroke, vascular complications, and repeat revascularization compared with male patients.^5-7 However, the data on outcomes of female patients who undergo percutaneous transluminal angioplasty (PTA) are limited. We prospectively evaluated the outcomes of female and male patients in patients with symptomatic PAD who were treated with endovascular revascularization. 

Methods

The study population included a total of 239 (55 females and 184 males) consecutive patients with symptomatic PAD who underwent PTA of the iliac, femoral, popliteal, tibial, and peroneal arteries from September 2004 to October 2011 at Korea University Guro Hospital, Seoul, Korea. Data on baseline clinical and procedural characteristics as well as clinical outcomes were prospectively collected on a dedicated database. The Institutional Review Board approved the study protocol. 

The primary end points were binary restenosis rate at 8-month follow-up, as determined by computed tomographic angiography or digital subtraction angiography. The secondary end points were repeat PTA, target lesion revascularization, target extremity revascularization, and amputation, at a follow-up of 2 years. Binary restenosis was defined as ≥50% angiographic stenosis in the treated segment after PTA. A graft is considered to have primary patency if it has had uninterrupted patency with either no procedure performed on it or a procedure (endovascular or surgical revascularization) to treat the disease in the adjacent native vessel.  Primary assisted patency expresses cases in which a revision of the PTA is applied to prevent impending occlusion or progression of stenosis. Secondary patency was defined as patency of the initially treated vessel following a repeat PTA to restore patency after occlusion. Target lesion revascularization was defined as a repeat revascularization to treat a luminal restenosis that was treated during the index PTA. Target extremity revascularization was defined as a repeat revascularization to treat any luminal restenosis in target extremity that was treated during the index PTA. Critical limb ischemia was defined as ischemic pain at rest, ulcer, or gangrene in one or both legs attributed to objectively proven arterial occlusive disease.  

Noninvasive assessment with ankle-brachial index and arterial duplex of the lower extremities were performed on all patients in the vascular laboratory of the Korea University Guro Hospital. Standard techniques were used for PTA. For below-the-knee lesions, a 5 Fr Heartrail guiding catheter (Terumo) was used and .014” guidewire was used to traverse the lesions. Once intraluminal wiring failed, subintimal angioplasty or retrograde approach was performed. After the guidewire crossing, prolonged balloon inflations (120-180 seconds) with balloon sizes ranging from 1.5 to 3.5 mm were used. Provisional stenting was performed using self-expanding nitinol stents (Xpert; Abbott Vascular or Maris Deep; Medtronic) if balloon angioplasty results were suboptimal. 

For the superficial femoral artery (SFA) and iliac artery, true lumen angioplasty was attempted for chronic total occlusion (CTO) by dedicated .018˝ CTO wires. If unsuccessful, subintimal angioplasty using .035˝ soft Terumo wire (1.5 J curve) under the 5 Fr angiocatheter support was performed for longer CTO lesions with provisional spot stenting using self-expanding nitinol stents while wiring of the true lumen was performed for shorter CTO lesions. Reentry by CTO wires or reentry device (Outback catheter, Cordis) was used if the subintimal wiring was failed to reenter the distal true lumen for femoropopliteal CTO lesions. Retrograde approach from the distal SFA, popliteal, or infrapopliteal arteries was performed in selected cases. 

Statistical Analysis

Discrete variables were expressed as counts and percentages and analyzed with chi-squared or Fisher’s exact test. Differences between the 2 groups were evaluated by unpaired t test or Mann-Whitney rank test for continuous variables. A two-tailed P value of <.05 was considered to be statistically significant. Data were expressed as mean ± standard deviations. Statistical analyses were performed using SPSS 20.0 (SPSS Inc.).

Results

Baseline Characteristics

When compared with male patients, female patients were older (69.5 ± 11.1 vs 65 ± 11.6 years of age, P=.04), and had a trend toward a higher percentage of diabetic foot wound (58.1% vs 44.5%, P=.076). However, male patients had a trend toward a higher percentage of rest pain (27.1% vs 14.5%, P=.055) (Table 1). There were no significant differences in the extent of coronary artery disease in both groups (Table 2). Female patients had a higher trend toward PTA of tibial artery lesions (63.6% vs 53.8%, P=.064) (Table 3). There were no significant differences in the use of medications for the treatment of PAD (Table 4). The total cholesterol level was higher in females (173 ± 45 mg/dL vs 153 ± 44 mg/dL, P=.005) (Table 5). 

Procedural and Clinical Follow-up Data

Female patients had higher incidence of major hematoma (≥4 cm) (18.1% vs 8.1%, P=.033) (Table 6). The binary restenosis rate was similar in male and female patients (37.0% vs 26.7%, P=.267) (Table 7). Similarly, there were no significant differences in 2-year death, repeat PTA, target lesion revascularization, target extremity revascularization, and amputation. 

Discussion

The results of our study demonstrated that despite females being older and having a trend toward a higher percentage of diabetic foot wound and PTA of tibial artery lesions, the rate of binary restenosis as well as clinical outcomes compared favorably with male patients. Furthermore, clinical events including death, repeat PTA, and amputation were similar at a follow-up of 2 years. 

Female patients presented for PTA at an older age than male patients. This is an important difference in baseline characteristics because age can confound the differences in complications and clinical outcomes. This finding is consistent with previous studies of patients who underwent PTA, which showed that female patients were older than their male counterparts.^8-11 

In a large real-world registry, female patients more commonly presented with critical limb ischemia compared to male patients.⁸ We also observed a trend for this finding. The reason that females present more commonly with critical limb ischemia is unclear but may be related to comorbidities like osteoporosis and arthritis, which may confound the assessment of claudication in females.¹¹ In addition, females may have late presentation of PAD and therefore be more likely to have critical limb ischemia. The difference in procedural complications can be attributed to advanced age and multivessel involvement.  

Similar to other studies, vascular complications were higher for female patients compared with male patients in our study.^8,9,12 A database review of hospital discharges from New York, New Jersey, and Florida observed increased bleeding complications after vascular procedures for PAD in female patients compared with male patients.⁹ The higher risk of vascular complications may be related to the pretreatment with heparin prior to PTA that was given for critical limb ischemia.^8,13 The increased risk of bleeding complications observed in females who undergo PTA is consistent with data for PCI.¹⁴ However, the rate of in-hospital and procedural complications including cerebral infarction, intracranial hemorrhage, acute renal failure, minor hematoma, gastrointestinal bleeding, retroperitoneal bleeding, acute thrombosis, and reocclusion were similar in the 2 study groups.  

Current recommendations for the treatment of PAD include antiplatelet therapy and statin.¹⁵ All patients received aspirin and a high percentage received clopidogrel. However, despite the guideline recommendation, only 60% of females were treated with a statin, representing room for improvement. Furthermore, the use of beta-blockers was low in both groups (less than one-third of patients) despite a high prevalence of coronary artery disease (nearly two-thirds in both groups).

Limitations

This was a small, single-center, nonrandomized study with short-term follow-up. This study was not designed for comparison with a control group or against other available treatment modalities. The treatment groups were not blinded and likely subjected to observational bias. The analysis included a heterogeneous group of patients including patients with claudication and critical limb ischemia.

Conclusions

Female patients were older and had trends toward a higher percentage of diabetic foot wounds and PTA of tibial artery lesions. Despite having a higher incidence of incidence of major hematoma, females who underwent PTA had no significant differences in restenosis and clinical outcomes compared with male patients. PTA represents a viable treatment option for female patients with symptomatic PAD.  

Editor’s note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no disclosures related to the content herein.

Manuscript received January 22, 2015; manuscript accepted March 10, 2015. 

Address for correspondence: Michael S. Lee, MD, UCLA Medical Center, 10922 Verano Road, Los Angeles, CA 90077, United States. Email: MSLee@mednet.ucla.edu.

References

1. Hirsch AT, Duval S. The global pandemic of peripheral artery disease. Lancet. 2013;382(9901):1312-1314.
2. Fowkes FG, Rudan D, Rudan I, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329-1340.
3. Malyar N, Fürstenberg T, Wellmann J, et al. Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population based analysis. Eur Heart J. 2013;34(34):2706-2714.
4. Fowkes FG, Murray GD, Butcher I, et al. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA. 2008;300(2):197-208.
5. Bairey Merz CN, Shaw LJ, Reis SE, et al. Insights from the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol. 2006;47(3):S21-S29.
6. Argulian E, Patel AD, Abramson JL, et al. Gender differences in short-term cardiovascular outcomes after percutaneous coronary interventions. Am J Cardiol. 2006;98(1):48-53.
7. Jackson EA, Munir K, Schreiber T, et al. Impact of sex on morbidity and mortality rates after lower extremity interventions for peripheral arterial disease: observations from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. J Am Coll Cardiol. 2014;63(23):2525-2530.
8. Vouyouka AG, Egorova NN, Salloum A, et al. Lessons learned from the analysis of gender effect on risk factors and procedural outcomes of lower extremity arterial disease. J Vasc Surg. 2010;52(5):1196-1202.
9. Abando A, Akopian G, Katz SG. Patient sex and success of peripheral percutaneous transluminal arterial angioplasty. Arch Surg. 2005;140(8):757-761.
10. Vouyouka AG, Kent KC. Arterial vascular disease in women. J Vasc Surg. 2007;46(6):1295-1302.
11. Kawamura A, Piemonte TC, Nesto RW, Bilazarian SD, Riskalla NS, Chauhan MS. Impact of gender on in-hospital outcomes following contemporary percutaneous intervention for peripheral arterial disease. J Invasive Cardiol. 2005;17(8):433-436.
12. Kasapis C, Gurm HS, Chetcuti SJ, et al. Defining the optimal degree of heparin anticoagulation for peripheral vascular interventions: insight from a large, regional, multicenter registry. Circ Cardiovasc Interv. 2010;3(6):593-601.
13. Jackson EA, Moscucci M, Smith DE, et al. The association of sex with outcomes among patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction in the contemporary era: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Am Heart J. 2011;161(1):106-112.
14. Rooke TW, Hirsch AT, Misra S, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHAGuideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(14):1555-1570.