BAD transmission and SAD distribution: A new scenario for critical limb ischemia

Background: Most of the studies on peripheral artery disease (PAD) focused on above-the-ankle artery disease, while less is known about foot artery disease. We hypothesize a scenario were two different diseases can be present in PAD patients, big artery disease (BAD) and small artery disease (SAD), overlapping at the foot level; the aim of this study is to evaluate their prevalence and their correlation with risk factors and critical limb ischemia (CLI) in a large cohort of patients with symptomatic PAD. Methods: We retrospectively reviewed 1915 limbs of 1613 patients (502 females, mean age 72.4±10.8 years) who underwent angiography between September 2009 and November 2013. Age, sex, diabetes, smoke history, high blood pressure, dialysis and BMI were considered as risk factors. Logistic regression was performed to test the association of arterial lesions patterns and CLI, and to evaluate the association between risk factors and lesion localization. Results: SAD was present in 414 patients (25.2%). Patients with disease of any of plantar, dorsalis pedis arteries and SAD faced higher risk of CLI (OR=13.25, 95% CI: 1.69-104.16). SAD was associated with diabetes and dialysis (both: OR=4.85; dialysis only: OR=3.60; diabetes only: OR=1.70; none: reference OR; P<0.01), weight (underweight: OR=1.10; normal: reference OR; overweight: OR=0.81; obese: OR=0.60; P=0.03), while women and tobacco smokers were less likely to have SAD (women: OR=0.68; P<0.01; tobacco use: OR=0.54; P<0.01). Conclusions: SAD was strongly and independently associated with CLI, diabetes and dialysis. Thus, SAD should be regarded as a leading actor in CLI.