Epidemiology and Clinical Presentation

of PAD in The Arab World

AMR GadProf. Vascular Surgery

Cairo University

Epidemiology Of PADin the Arab world

• The Arab world is a mix of countries that bind together on many common themes and history.

• The heavy burden of peripheral vascular disease (PVD) relates to the high prevalence of risk factors including diabetes , obesity , hypertension, smoking, dyslipidemia and sedentary lifestyle

Epidemiology Of PADIn the Arab world

The incidence of obesity, a risk factor for several health problems, is surprisingly high in the Arabs especially female population.

Hypertension and Dyslipidemia are also common in the Arab population.

Smoking is extremely prevalent in Arab males. Al Thani ,2012

Epidemiology Of PAD In the Arab world

•The increased sedentary lifestyle, •Lack of well-developed public health and,•Suboptimal medical management,

Have contributed to the rapid rise in both risk factor prevalence and subsequent vascular complications in the Middle East region

Epidemiology of PADDiabetes & Arab world

Basic epidemiologic statistics, from the (WHO)

outline a very challenging pathway for the region Six of the worlds top 10 countries with diabetes are in the Middle East (WHO) (Shantouf ,2002 )

The 34.6 million (9.2%) (worldwide 8.3%) (2013 figure) adults with diabetes in the Arab world , are expected to double to 67.9 million (11.6% ) by year 2030.

( IDF , 2013)

Epidemiology of PAD Diabetes and Arab world

Prevalence of PADDiabetes and The Arab World

(IDF,6th ed. ,2013)

Top 10

(IDF , 6th ed ,2013)

Diabetes & Arab world

Diabetes & Arab world ( IDF ,6thed. ,2013)

Diabetes & Arab world IDF, 6th ed., 2013

Diabetes & Arab world IDF,6th ed. , 2013

Epidemiology of PADSmoking in the Arab world

Extremely prevalent in Arab World

• Jordanian males (61% / 8th rank )• Tunisian males (58% / 11th rank )• Oman males (20% / Lowest in Arabs )• US males (25% )• Jordanian , Lebanese ,& Tunisian women (10%,7%,7% / Highest ) ( Shantouf , 2012 )

Epidemiology of PADObesity in the Arab world

• In 1996 Egypt had the highest average BMI (26.3) in the world . (Martorell,2000)

• 64.5% of Arab males are obese and 76% adult females (New world syndrome). (WHO,2010)

• Factors :- Rapid urbanization , sedentary lifestyle - Increased caloric & fat intake - Exercise is not a part of culture - Cultural appreciation of female plumpness (WHO 2010)

Epidemiology of PAD Obesity in the Arab world WHO(2010)

Epidemiology of PAD

Epidemiology of PAD

PAD in The Arab World

Alwahbi, Saudi Med J 2006

Epidemiology of PAD

Clinical PresentationPATHOLOGY OF PAD

ATHEROSCLEROSISThe main risk factors for atherosclerosis – DM, smoking, dyslipidemia and hypertension – are associated with endothelial dysfunction in various arterial systems (M. Lafitte, 2010)

INFLAMMATORY-Beurger’s disease-Behcet, s disease-Non-specific arteritis-Takayso aortitis

Clinical presentation (Atherosclerosis)

Type of Patient

• Patients with PAD are in the age group of 56+/- 11 years• Mostly males.• Mostly smokers.• 28% to 77% are hypertensive (according to different

countries).• 31% to 65% are dyslipidaemic.• 52% to 91% are diabetics.

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Clinical presentation(Beurger’s Disease)

* Race : common in the Middle east & Asians* Incidence : rare (1/8000 people) * Age : 20 - 40 y* Sex : males (99%)* Smoking : significant contributing factor* Site : more in the lower limb* Size of artery : small and medium sized vessel

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In the early sixties of the last century (20th) , when we started reconstructive arterial surgery , we met many cases which were not atherosclerotic but inflammatory in nature (18%) . Also these were non Beurger , non Behcet in origin. (Hammam ,CX ,2003)

Clinical presentation(Non-specific Arteritis)

CLINICAL PRESENTATION PAD

• Intermittent claudication • Critical Limb Ischemia -Tissue loss -Non healing ulcers, gangrene -Rest pain -Diabetic foot infection

Clinical presentation THE CONSENSUS DOCUMENT OF THE EUROPIAN WORKING GROUP DEFINED

CLI as:( The Most Severe Clinical Manifestation Of PAD )

• Persistent rest pain ( 74%) : Requiring analgesics for 2 weeks Resting Ankle pressure < 50 mmHg Resting Toe pressure < 30 mmHg

OR

• Presence of gangrene (34%) or ulcer (32%) of the foot / toes : With the same resting pressure

Clinical presentationPTA for Femoro-Popliteal Segment

(Cairo university Study,2013)

• 136 limbs• Males (67.64%)• Mean age : 62.5(50-75Y)• Diabetics : 63.23%• TASC Class : A ( 0.00% ) B (22.05%) C (22.05%)

D(55.90%)

Clinical presentationPTA of BTK vessels

Cairo university study 2013

• 126 limbs • Males : 72.2%• Mean age : 62.5 (50-75 Y)

• Diabetics : 91.2%• TASC Class A (9.50%) B (19.5%)

C (38.1%)

D (33.3%)

Clinical presentation

TASC D Aorto iliac Disease

Clinical presentationAorto-Bi femoral Bypass (TASC D)

Before After

Clinical presentation Pedal Bypass (TASC D)

Before After

Infra Popliteal Revascularization

By PTA

Infra-popliteal Revascularization By PTA

Before AfterBefore After

Prevalence of Multilevel Disease(Cairo University Study, 2013)

Multilevel occlusion

No. 53

% 20.23Prim. Patency 75.47% ( 1Y) 50.94% (2Y)

Second. Patency

81.13% ( 1Y) 66.03% (2Y)

Outcome of endovascular treatment of Multilevel disease .

Distal Runoff Status(Cairo University Study ,2013)

No. of runoff Vessels

Frequency Percentage Limb salvage at 2 years

1 125 47.7% 80.00%

2 39 14.9% 85.22%

3 98 37.4% 100.00%

Runoff status as a prognostic factor in outcome of endovascular intervention:

Summary - Diabetes , obesity , & smoking are more prevalent in the Arab world , especially in Egypt and Gulf countries .

- PAD is slightly more common .

- Approximately 52% to 91% of PAD are diabetics , the lowest in aorto iliac lesions & the highest in infra popliteal disease.

- Multi level disease is common ( 20% ).

- Single runoff vessel comprise about 50%.

- High prevalence of TASC (D) group.

- Diabetic foot infection is common in Arabs.

- Inflammatory arterial disease (Behcet ,Beurger & non sp. Arteritis) are prevalent in the middle east.

- Nationwide screening programs & registry in the Arab world is urgently required

Thank You

Cairo University