Outcomes at Patient and Limb Levels in Peripheral Artery Disease by the Location of Atherosclerotic Lower Limb Lesions: An Observational Study from a High-Volume German Center

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Abstract
Background: In Peripheral Artery Disease (PAD), there is an association between risk factors, the location of atherosclerotic lesions, and outcomes. Methods: This is a retrospective single-center analysis of adult PAD patients admitted between 2018 and 2021 with a follow-up until the end of 2023. Lesions were allocated to “suprainguinal”, “infrainguinal-to-popliteal”, “infrapopliteal”, “two of three levels” and “all three levels” categories based on angiogram findings. The primary endpoint at the patient level was amputation-free survival and was major adverse limb events (MALEs) at the limb level. Results: A total of 2067 patients with 2633 affected limbs were analyzed, and 28.8% were female. At first admission, the median age was 68, and the most frequent PAD Fontaine stage was IIb (44.9%). Lesions were suprainguinal in 11.6%, infrainguinal-to-popliteal in 18.3%, infrapopliteal in 11.4%, two levels in 36.0%, and all three levels in 8.3%. Over 1020 days as the median follow-up, amputation-free survival was 67.6%, highest (92.5%) for suprainguinal lesions, and lowest (59.3%) for infrapopliteal lesions. At the patient level, the risk of major amputation or death was highest in infrapopliteal lesions and was equally likely in cases of two or three affected locations and was reduced in infrainguinal-to-popliteal lesions (Hazard Ratio, HR 0.62, 95% CI 0.44–0.87, p = 0.007) and suprainguinal lesions (HR 0.42, 95% CI 0.21–0.79, p = 0.008). At the limb level, compared to lesions in all three locations, the risk of MALEs was reduced in infrainguinal-to-popliteal lesions (HR 0.51, 95% CI 0.27–0.98, p = 0.044) and was equally likely in all other cases. Conclusions: Amputation-free survival was lowest in cases of infrapopliteal lesions or multi-level disease. At the limb level, isolated infrainguinal-to-popliteal lesions were associated with the lowest risk of MALEs.

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