Lower limb ischemia in young adults: Prognostic implications

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1 Lower limb ischemia in young adults: Prognostic implications Peter C. Pairolero, M.D., John W. Joyce, M.D., Clay R. Skinner, M.D., Larry H. HoUier, M.D., and Kenneth J. Cherry, Jr., M.D., Rochester, Minn. Fifty patients (41 men and nine women) less than 36 years of age were evaluated for lower limb ischemia. Claudication was the presenting symptom in 30 patients (60%) and distal ulceration in 20 (40%). The mean age was 28.3 years. Premature atherosclerosis was present in 24 patients (48%) and thromboangiitis obliterans in 12 (24%). Other causes included a variety of unusual etiologies. Risk factors were analyzed. Twenty-two patients with claudication underwent arterial reconstruction; three had sympathectomy. Arterial reconstruction was possible in only three patients with ulceration; 17 had sympathectomy. No operative deaths or early amputations occurred. Follow-up averaged 13.5 years. Twenty-four patients with daudication were improved, three were unchanged, one developed ulceration, one required late amputation, and one was lost to follow-up. Four patients with ulceration were improved, one was unchanged, 14 required late amputation, and one was lost to follow-up. Ten patients, all with atherosclerosis obliterans, developed coronary artery disease; five died of myocardial. No patient developed cerebrovascular disease. We conclude that reconstructive arterial surgery for claudication can be performed with low risk and a strong likelihood of long-term improvement. Most patients presenting with ulceration, however, will ultimately require amputation. Patients with atherosclerosis obliterans are at risk for coronary artery disease and death of myocardial. (J VASC SURG 1984; 1: ) Lower limb ischemia is rare in young adults and usually raises the question of rare etiologies. However, it is most commonly associated with premature atherosclerosis obliterans or thromboangiitis obliterans. 1"2 Other causes include a varicty of unusual etiologies? -13 The purpose of this review is to document our experience with lower limb ischemia in young adults during a recent 28-year period. -MATERIAL AND METHODS The records of all patients 35 years of age or less undergoing arteriographic evaluation for lower limb ischemia at the Mayo Clinic from 1953 to 1981 were reviewed. Excluded from analysis were those patients presenting with arterial trauma. Arteriography was performed by translumbar or transfemoral techniques. The arteriograms were reviewed with respect to location and extent of disease. Disease was considered localized if it involved only one arterial segment at one level. Multilevel involvement From the Section of Thoracic and Cardiovascular Surgery and the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation. Presented at the Seventh Annual Meeting of the Midwestern Vascular Surgical Society, Chicago, Ill., Sept , Reprint requests: Peter C. Pairolero, M.D., Mayo Clinic, 200 First St. Southwest, Rochester, MN or involvement of more than one arterial segment was considered diffuse disease. The records of these patients were analyzed for age, sex, presenting symptoms, risk factors, etiology, treatment, and resuits of long-term follow-up. RESULTS During this 28-year period 50 patients presenting with lower limb ischemia were evaluated. Forty-one patients were male (82%) and nine female (18%). Ages ranged from 20 to 35 years (mean 28.3 years). Forty-nine patients were white and one was black. Claudication was the presenting symptom in 30 patients (60%) and distal ulceration in 20 (40%). Follow-up was complete in 48 of 50 patients and ranged from 2 to 27 years (mean 13.5 years). Premature atherosclerosis obliterans was diagnosed in 24 patients (48%) and thromboangiitis obliterans in 12 (24%). The remaining 14 patients had a variety of uncommon etiologies. Atherosclerosis obliterans. Twenty-four patients (18 male and six female) were diagnosed as having premature atherosclerosis obliterans. Ages ranged from 21 to 35 years (mean 30 years). One patient was black. Only one patient had a history suggestive of coronary artery disease. Fourteen patients presented with lower extremity claudication and 10 with ulceration. 459

2 460 Pairolero et al. Journal of VASCULAR SURGERY Table I. Risk factors in 50 patients less than 36 years of age with lower limb ischemia Atherosclerosis Thromboangiitis Uncommon obliterans obliterans etiologies (24) (12) (14) Smoking Diabetes mellitus Hyperlipidemia Hypertension Positive family history Contraceptives All 24 patients had at least one atherosclerotic risk factor, and 17 had two or more (Table I). The mean number of risk factors per patient was 2.4 (women 3.3; men 2.1). All six women smoked at least one pack of cigarettes per day, four were taking oral contraceptives (average 2.2 years), four had hyperlipidemia, three had juvenile-onset diabetes mellitus, two had a positive family history, and one was hypertensive. Three women presented with claudication. Atherosclerosis was localized in 10 patients and diffuse in 14. The aortofemoral arteries were involved in five patients with localized disease and the femoropopliteal arteries in the remaining five patients. No patient had tibioperoneal occlusive discase. Seven of the 14 patients with diffuse disease had involvement of the aortotibial arteries. The remaining seven patients had diffuse disease limited to the femorotibial arteries. All 14 patients had tibioperoneal occlusive disease. Claudication was the presenting symptom in all 10 patients with local disease. However, only four patients with diffuse disease presented with claudication. The remaining 10 patients presented with lower extremity ulceration. The mean number of risk factors per patient with local disease was 2.0, as opposed to 2.7 for patients with diffuse disease. All 14 patients with diffuse disease were smokers, eight had juvenile-onset diabetes mellitus, six had hyperlipidemia, four were hypertensive, four had a positive family history, and two were taking oral contraceptives. Four patients with diffuse disease were women. Seventeen patients underwent reconstructive arterial surgery: 14 for claudication and three for ulceration (Table II). There were no operative deaths. All 10 patients with localized disease had arterial reconstruction for claudication (Table III). Seven of the 14 patients with diffuse disease underwent reconstructive arterial surgery: four for claudication and three for ulceration. The remaining seven pa- tients with diffuse disease had tissue loss, and all were considered unsuitable for reconstructive surgery because of severe tibioperoneal occlusive disease. All seven underwent sympathectomy. Follow-up was complete in 23 of 24 patients and averaged 15 years (range 2 to 25 years). The one patient lost to follow-up presented with ulceration and had diffuse atherosclerosis of the femorotibial vessels. This patient did not undergo any reconstructive procedure. No patient quit smoking during follow-up. Complete and prolonged relief of claudication occurred in 9 of the 10 patients with localized disease, and improvement occurred in the tenth patient. However, in patients with diffuse occlusive disease undergoing reconstructive surgery, claudication was relieved in only two of four patients. Claudication was unchanged in the remaining two patients, ar'~ one developed ulcerations 3 years later, which eventually required amputation. Ulcerations healed in two of three patients who had arterial reconstruction. Amputation was eventually required in the third. Only one of seven patients unsuitable for reconstruction experienced healing of the ulcer following sympathectomy; five (22%) eventually came to amputation, and one was lost to follow-up. No patient developed either cerebrovascular or renovascular disease during follow-up. Ten patients" (43%), however, developed signs and symptoms of coronary artery disease. All had angina pectoris and eight had at least one myocardial. At the time of initial evaluation, all 10 patients had multiple atherosclerotic risk factors (mean 2.8), and seven presented with lower extremity ulceration. Seven of" the 23 patients (30%) died during follow-up. Cause of death was myocardial in five patient~ (22%), four of whom had diffuse disease at initial evaluation (Table IV). Thromboangiitis obliterans. Twelve patients, all men, were diagnosed as having thromboangiitis ~ obliterans (Buerger's disease). Ages ranged from 20 to 32 years (mean 28.0 years). All patients smoked more than one pack of cigarettes per day, and five smoked more than two packs per day. No patient had any other atherosclerotic risk factors. Only one patient was Jewish. Ten patients presented with'- lower extremity ulceration and two with claudication. Five patients also had recurring superficial thrombophlebitis. Arteriography demonstrated abrupt segmental occlusions of small- and medium-sized arteries of the lower extremity. Corkscrew collateralizatior~ around the occluded segments was commonly seen.

3 Volume 1 Number 3 May 1984 Lower limb ischemia in young adults 461 Table II. Treatment and late resuks in 50 patients less than 36 years of age presenting with lower limb ischemia Diagnosis No. of patients Treatment Late results Claudication (30) Atherosclerosis obliterans 14 Reconstruction (14) Thromboangiitis obliterans 2 Sympathectomy (2) Arterial emboli 5 Reconstruction (2) Embolectomy (3)* Sympathectomy (1)* Radiation fibrosis 3 Reconstruction (2) Observation (1) Aortic coarctation 2 Reconstruction (2) Popliteal entrapment 2 Reconstruction' (1) Release muscle (1) Popliteal aneurysm 1 Reconstruction (1) Pcriarteritis nodosa 1 Embolectomy (1) Ulceration (20) Atherosclerosis obliterans 10 Reconstruction (3) Sympathectomy (7) Thromboangiitis obliterans 10 Sympathectomy (10) *One patient underwent both embolectomy and sympathectomy. Improved (12) Amputation (1) Ulceration (1) Lost to follow-up (1) Improved (5) Improved (2) Improyed (2) Improved (2) Improved (1) Improved (3) Amputation (6) Lost to follow-up (1) Improved (1) Amputation (8) Table III. Location of disease and method of treatment in 24 patients with )remature atherosclerosis obliterans Localized disease (10) Aortofemoral arteries Proximal bypass Endarterectorny Femoropopliteal arteries Distal bypass Diffuse disease (14) Aortotibial arteries Proximal bypass Nonreconstructible Femorotibial arteries Distal bypass Nonreconstructible No. of patients Table IV. Cause of death in seven patients with premature atherosclerosis obliterans Age at No. of diagnosis risk Presenting Cause of Age at Sex (yr) factors symptoms death death M 30 4 Ulceration Myocardial 41 F 31 3 Ulceration Myocardial 36 M 32 3 Claudication Myocardial 35 F 33 4 Ulceration Myocardial 39 M 34 3 Claudication Myocardial 50 M 28 2 Claudication Motor vehicle 32 accident M 31 2 Claudication Cancer 49 All 12 patients had tibioperoneal artery involvement, 11 bilaterally. Four patients also had involvement of the superficial femoral and popliteal arteries. Upper extremity arterial involvement occurred in four patients; none, however, had tissue loss. All 12 patients were considered unsuitable for reconstructive arterial surgery because of severe tibioperoneal occlusive disease. All 12 patients, however, underwent lumbar sympathectomy. One of the two patients with claudication was lost to follow-up. The other was followed up for 5 years and eventually developed lower extremity ul- ceration. He currently continues to smoke and declines further treatment. The remaining 10 patients were followed up from 2 to 27 years (mean 13 years). There were no deaths. No patient developed signs or symptoms of either coronary artery, cerebrovascular, or renovascular disease. Only one patient stopped smoking. He was the only patient who experienced healing of the ulcers. Eight of the nine remaining patients eventually came to amputation. Uncommon etiologies. Fourteen patients (11 men and three women) had uncommon etiologies, including arterial emboli (five patients), radiation

4 462 Pairolero et al. Journal of VASCULAR SURGERY fibrosis of the aorta (three), coarctation of the aorta (two), popliteal artery entrapment (two), and popliteal artery aneurysm and periarteritis nodosa (one each) (Table II). Ages ranged from 21 to 35 years (mean 25.8 years). All 14 patients presented with claudication. None presented with lower extremity ulceration. Risk factors were present in nine patients (Table I). Three patients, however, had two risk factors each. The location of arterial pathology was in the aortoiliac arteries in seven patients and in the femoropopliteal arteries in seven patients. No patient had involvement of the tibioperoneal arteries. Arterial reconstruction was done in eight patients, embolcctomy in four, and popliteal muscle release in one. One patient declined operation. Follow-up was complete in all patients and ranged from 3 to 19 years (mean 10.2 years). Complete and prolonged relief of claudication occurred in 12 patients and was unchanged in two. No patient required amputation. Four patients had died. Three deaths occurred in patients with arterial emboli, all of complications of mitral valve disease. Cause of death in the fourth patient was pancreatitis. No patient developed coronary, cerebrovascular, or renovascular disease. DISCUSSION Except for patients with arterial trauma, lower limb ischemia in young adults is unusual and, most often, has been reported to be secondary to either atherosclerosis obliterans or thromboangiitis obliterans? "2 Our study substantiates this finding. Approximately 50% of our patients had atherosclerosis obliterans, and 25% had thromboangiitis obliterans. Other reported uncommon causes include arterial embolism, radiation fibrosis of the aorta, coarctation of the aorta, neurofibromatosis of the aorta, Takayasu's arteritis, fibromuscular dysplasia, aneurysms with embolization, adventitial cystic disease of the popliteal artery, popliteal artery entrapment syndrome, homocystinemia, ergotism, and collagen vascular diseases Approximately 25% of our patients with lower limb ischemia presented with uncommon etiologies. There was no predominance of any one entity and, in evaluation of these patients, all these unusual causes must be considered. Some etiologies occur predictably in certain age groups. Popliteal artery entrapment syndrome, for example, should be suspected in male patients in their teens and early twenties. Adventitial cystic disease of the popliteal artery, on the other hand, occurs more commonly in patients in their thirties and forties. Although other uncommon entities can be suspected on past history and clinical findings, arteriography is required in all young adults presenting with lower limb occlusive disease. Aortography with bilateral lower limb runoff is essential for diagnosis since some disease processes, such as popliteal artery aneurysm or entrapment syndrome, involve both limbs, even though only one may be symptomatic. Identification of patients with uncommon etiologies is important. Most of these patients present with only clandication. Few have any risk factors. Most importantly, nearly all patients will have longterm improvement after arterial repair. Thus we believe that arterial reconstruction is indicated in all these patients. Although atherosclerosis is a generalized disease process, its location, extent, and rate of development vary greatly among individuals.'4 This variation m, ~ ~ be secondary to a different risk factor profile and/or hereditary influences. All our patients with premature atherosclerosis had multiple risk factors. Smoking was significant, with 95% of patients smoking at least one pack of cigarettes per day. In addition, 70% of patients had two or more risk factors, most commonly diabetes mellitus, hyperlipidemia, or hypertension. Symptomatic atherosclerosis obliterans is unusual in women. In two large series only 10% of patients were women, and most were >50 years of age. 14,a5 In our study, however, young adult women had a sex incidence of approximately 25%. Young women who develop atherosclerosis obliterans may do so because of either an increase in the number of risk factors or a change in hormonal protection. 16'17 All our women patients had multiple risk factors (mean 3.3). Holmes et al. 16 also demonstrated ~i-; increase in risk factors. In their study the mean number of risk factors was 2.6. Symptomatic atherosclerosis in young adults has been reported as a poor prognostic finding, both because of multiple vascular bed involvement and the accelerated nature of the disease process. 18 Our study, in general, confirms this observation. Coronary artery disease subsequently developed in 43% of our patients with premature atherosclerosis. Eighty percent of patients who developed coronary artery disease had a myocardial ; 63% died of the event. Most importantly, women with premature atherosclerosis obliterans who presented with lower extremity ulceration were at the greatest risk for coronary artery disease (100%) and death (67%). Clinical cerebrovascular or renovascular disease did not occur in any of our patients.

5 Volume 1 Number 3 May 1984 Lower limb ischemia in young adults 463 Although our study confirms the accelerated nature of atherosclerosis oblkerans in young adults, it also suggests that there are two different types of involvement, each with a different natural history. Forty-two percent of our patients had localized disease by arteriography. All these patients presented with claudication, all were successfully revascularized, none came to amputation, only 10% developed coronary artery disease, and only 10% died of myocardial. Contrariwise, our patients with diffuse disease had a more ominous prognosis. Seventy-one percent of these patients presented with lower extremity ulceration; only 31% were successfully revascularized, and 54% ultimately required amputation. Sixty-nine percent of these patients developed coronary artery disease, and 31% died of myocardial. ~-" Because of the difference in prognosis between patients with localized and diffuse atherosclerosis, we believe that arterial revascularization should be considered in young patients with localized disease who present with claudication. Many of these patients will have proximal disease amenable to bypass, and few, if any, will have tibioperoneal occlusive disease. However, patients with diffuse disease are unlikely to have long-term improvement following operation. Repair in these patients should be reserved for those patients presenting with impending tissue loss. Moreover, because of the high incidence of subsequent coronary artery disease, coronary arteriography should be done in all young patients with atherosclerosis obliterans. If correctable disease is demonstrated, consideration should be given to coronary artery bypass grafting. Thromboangiitis obliterans has been defined as a i~gmental inflammatory occlusive disease that primarily affects small- or medium-sized arteries and veins in the extremities of adults, usually males? The most frequent cfinical manifestation of this disease process is ischemia of one or both feet with reduced pedal pulsations. There may also be evidence of upper extremity digital ischemia, Raynaud's phenomenon, and episodes of recurrent thrombophlebitis. There appears to be a relationship between smoking and the occurrence or exacerbation of the disease? All our patients were heavy cigarette smokers. Only one patient stopped smoking during follow-up, and this was the only patient who experienced healing of lower extremity ulceration. The prognosis for patients with thromboangiitis obliterans is different from that for patients with atherosclerosis obliterans. None of our patients with thromboangiitis obliterans developed either clinical coronary artery, cercbrovascular, or rcnovascular disease; and no patient died during the time of follow-up in this study. Moreover, arterial reconstruction was not possible in any patient, and 73% of patients eventually came to lower limb amputation. In contrast, only 30% of all patients with atherosclerosis obliterans required amputation. However, the amputation rate in atherosclerotic patients increased with more advanced disease and was required in 54% of patients with diffuse disease and in 67% of patients with diffuse disease presenting with ulceration. Thus, while limb loss is likely in young patients with either athcrosclerosis oblkerans or thromboangiitis obliterans who continue to use tobacco and present with lower extremity ulccration, patients with thromboangiitis obliterans do not demonstrate an increased incidence of coronary artery disease. REFERENCES 1. 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6 464 Pairolero et al. Journal of VASCULAR SURGERY erans: Review of 520 cases with special reference to pathogenic and prognostic factors. Circulation 1960; 21: Bloor K. Natural history of arteriosclerosis of the lower extremities. Ann R Coll Surg Engl 1961; 28: Holmes Jr DR, Burbank MK, Fulton RE, Bernatz PE. Arteriosclerosis obliterans in young women. Am J Med 1979; 66: Van Vroonhoven TJMV. Intermittent claudication in premenopausal women: A correlation with the long-term use of oral contraceptives? J Cardiovasc Surg 1977; 18: Nunn DB. Symptomatic peripheral arteriosclerosis of patients under age 40. Am Surg 1973; 39: BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the JOURNAL OF VASCULAR SURGERY for 1984 are available to subscribers only. Active members of the two sponsoring societies will automatically receive a complimentary bound volume. They may be purchased from the publisher at a cost of $24.75 ($32.50 international) for Vol. I (January to December). Price includes shipping charges. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Circulation Fulfillment, The C. V. Mosby Company, Westline Industrial Drive, St. Louis, MO 63146, USA. In the United States call toll free: (800) , ext In Missouri call collect: (314) , ext Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.