Invited commentary

Abstract

Symptomatic lower extremity arterial disease usually occurs in elderly patients and, to be severe, requires lesions in at least two segments of the arterial tree. Isolated, symptomatic, infrarenal aortic occlusive atherosclerosis without iliofemoral or femoral-popliteal involvement is distinctly uncommon, as reflected by the fact that this study by Monastiriotis and colleagues required 10 years and three institutions to accumulate its 17 patients. The study was undertaken because the authors were interested in how atherosclerosis affects the aorta in younger patients, and indeed, all of their patients were younger than 50 years. All had significant symptoms of incapacitating claudication or distal embolization but none had limb-threatening ischemia. There was excellent anatomic (imaging) and physiologic documentation of the focal aortic lesions, and all patients underwent successful endovascular treatment with excellent patency and symptom relief at a mean follow-up of >4 years. Treating occlusive aortic disease with balloon angioplasty and stents is certainly not a new concept. As shown in Table II of this paper, 12 patients so treated were described by Ingrisch et al >30 years ago (see article's reference 4). That only bare-metal balloon-expandable stents were used, in preference to covered stents, is a debatable technical point, particularly in those patients with embolizing lesions, but this does not detract from the study's importance. There are a number of features of this study that deserve emphasis. First of all, the 17 patients in this study all possessed a distinct combination of risk factors: all were women, and these women do not appear to fit the diagnosis of hypoplastic aorta (a group that does not ideally lend itself to endovascular therapy). In addition, nearly all (15/17 [88%]) were hyperlipidemic, and all but one were heavy smokers. The extent of smoking is noteworthy in that all patients had started smoking before the age of 17 years and had smoked for >20 years. This is distressing because the vigorous public health emphasis on smoking cessation has resulted in a large decrease in smoking in the United States, although not as much in women as in men. Unfortunately, smoking continues to increase in many other countries and, in many of them, even more so in women. It may well be that there are a lot more patients in other populations like those in this study. Also, none of the women in this study were taking antiplatelet medications before their vascular assessment, and no information is provided about whether any were taking lipid-lowering medications. Even though it is impossible to know for certain if such medications would have prevented or lessened the severity of the atherosclerotic process, but I believe there is sufficient evidence to suggest that they would. Unfortunately, these patients had not been seen by physicians on a regular basis, so their vascular risk factors were unknown, supporting the importance of primary care at an early age. It would have been interesting if the authors had provided information about the 23 patients excluded from this analysis because they were older than 50 years to determine whether age and gender are really defining factors. It would also be interesting to know whether there were any excluded patients who had embolizing but nonstenotic lesions (I have seen only a few in my 41-year career). Nevertheless, this study highlights a small group of patients who can benefit from aggressive vascular surgical care and lifelong follow-up. Clinical characteristics and outcome of isolated infrarenal aortic stenosis in young patientsJournal of Vascular SurgeryVol. 67Issue 4PreviewThe objective of this study was to identify young patients with isolated infrarenal aortic atherosclerotic stenosis and to determine the clinical characteristics and midterm results of angioplasty and stenting. Full-Text PDF Open Archive