Peripheral Arterial Disease with focus on Intermittent Claudication. Outcome after Invasive Treatment

Background and aims: Peripheral arterial disease (PAD) is common, affecting about 200 million individuals worldwide. Gender differences in treatment indication and results are debated. Incidence and results of invasive treatment of infrainguinal intermittent claudication (IC) in Sweden, as well as prevalence and impact of concomitant chronic widespread pain (CWP) in patients with PAD have not been established. The use of minimal invasive endovascular treatment is increasing, and there is a need to study results of primary stenting of infrainguinal IC, commonly caused by lesions in the superficial femoral artery (SFA), and to establish influence of concomitant CWP on treatment results. Methods: Cohort study of 112 consecutive patients undergoing SFA stenting for IC and critical limb ischemia (CLI) analyzed 12 months after treatment (paper I). One year follow-up study of all 775 patients undergoing 843 infrainguinal procedures for IC during one year in Sweden (paper II). Analysis of 240 patients hospitalized for treatment of symptomatic PAD regarding health related quality of life (HRQoL) and concomitant CWP at baseline, and at 12 months after treatment (paper III). Prospective randomized study of 100 patients suffering from stable IC randomized to primary SFA stenting or continued best medical treatment (BMT) only, with HRQoL as primary, and ABI, walking distance, and influence of CWP on HRQoL analyzed after six months, as secondary outcome measures (paper IV). Results: When undergoing SFA stenting women presented with more severe CLI and female gender was an independent risk factor for amputation. One year amputation-free survival was 67% (paper I). The Swedish annual incidence of invasive treatment of infrainguinal IC was 8.9/100,000 inhabitants, and treatment resulted in clinical improvement after 12 months in 73.2 % of patients (paper II). CWP was twice as common in patients with PAD as in the general population, affecting 29% of patients scheduled for invasive treatment, and was associated with reduced HRQoL. Invasive treatment led to significant improvement of HRQoL in all patients, although to a lower level in patients with CLI and CWP than in patients with IC and without CWP at baseline (paper III). Primary stenting in patients with IC due to lesions in the SFA led to significant improvement in HRQoL, ankle-brachial index (ABI), and walking distance. In patients with concomitant CWP primary SFA stenting led to improvement in ABI and walking distance, but not in HRQoL (Paper IV). Conclusion: Paper I revealed an increased risk of amputation in women, but successive studies did not indicate that invasive PAD treatment is less favourable for women. Invasive treatment of infrainguinal IC was frequently performed in Sweden, leading to improvement in three out of four patients. CWP was twice as common in patients with PAD as in the general population. Invasive treatment of PAD led to significant improvement of HRQoL in all patients, but to a lower level in patients with CWP. Primary stenting of SFA lesions in patients with IC led to significant improvement in HRQoL, ABI, and walking distance.