J Korean Med Sci.  2020 Apr;35(13):e87. 10.3346/jkms.2020.35.e87.

Prevalence and Risk Factors of Peripheral Arterial Disease in Patients with Lumbar Spinal Stenosis and Intermittent Claudication: CT Angiography Study

• Park JW
• Lee JH

• KMID: 2509603
• DOI: http://doi.org/10.3346/jkms.2020.35.e87

Abstract

Background
It can be difficult to differentiate between vascular and neurogenic intermittent claudication. The exact diagnosis often cannot be made on clinical evidence and ultimately requires imaging. Perioperative screening for peripheral arterial disease (PAD) in lumbar spinal stenosis (LSS) patients is important because untreated PAD increases the risk of severe vascular events. The aims of this study were to study the prevalence of PAD in LSS patients with symptoms of intermittent claudication, and to study the independent risk factors for PAD. We specified the cases where it was necessary to perform computed tomography angiography (CTA) as a preoperative screening tool in surgery for spinal stenosis.
Methods
This study involved a retrospective analysis of 186 consecutive subjects with radiographic evidence of LSS and symptoms of intermittent claudication, who underwent 3D CTA of the lower extremities at our institution during a three-year period. More than 50% luminal narrowing on CT angiograms was determined to be clinically significant and placed in the PAD group.
Results
Thirty-two subjects were diagnosed with PAD and referred to the general vascular team in our hospital, where they received treatment for PAD. In the non-PAD group (154 subjects), 117 underwent definitive surgery for spinal stenosis such as posterior lumbar interbody fusion and a further 37 underwent conservative treatment. Only hypertension, diabetes, and men gender were found to be statistically significant predictors of PAD.
Conclusion
The current study showed that man gender, diabetes and hypertension were the greatest risk factors for PAD. We conclude that man patients with diabetes and/or hypertension should be put under serious consideration for routine CTA examination when under evaluation for LSS and intermittent claudication.

Keyword

Peripheral Arterial Disease; Lumbar Spinal Stenosis; Claudication; Computed Tomography Angiography

Reference

1. Takahashi K, Miyazaki T, Takino T, Matsui T, Tomita K. Epidural pressure measurements. Relationship between epidural pressure and posture in patients with lumbar spinal stenosis. Spine. 1995; 20(6):650–653. PMID: 7604339.

2. Thomé C, Börm W, Meyer F. Degenerative lumbar spinal stenosis: current strategies in diagnosis and treatment. Dtsch Arztebl Int. 2008; 105(20):373–379. PMID: 19626175.

3. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease. Int Angiol. 2007; 26(2):81–157. PMID: 17489079.

4. Stanton PE Jr, Rosenthal D, Clark M, Vo N, Lamis P. Differentiation of vascular and neurogenic claudication. Am Surg. 1987; 53(2):71–76. PMID: 3813219.

5. Nowicki BH, Yu S, Reinartz J, Pintar F, Yoganandan N, Haughton VM. Effect of axial loading on neural foramina and nerve roots in the lumbar spine. Radiology. 1990; 176(2):433–437. PMID: 2367657.

6. Han SH, Jeon CH, Lee DH, Choo HS, Chung NS. Clinical and radiological characteristics of concomitant peripheral arterial obstructive disease in patients with lumbar spinal stenosis. Pain Physician. 2013; 16(5):513–520. PMID: 24077197.

7. Kaboli P, Henderson MC, White RH. DVT prophylaxis and anticoagulation in the surgical patient. Med Clin North Am. 2003; 87(1):77–110. PMID: 12575885.

8. Tanaka M, Oha F, Kanayama M, Iwata A, Hashimoto T, Kaneko K. Efficacy of ankle-brachial index as a preoperative screening in spine surgery. Eur Spine J. 2016; 25(3):814–818. PMID: 26138217.

9. Jeon CH, Han SH, Chung NS, Hyun HS. The validity of ankle-brachial index for the differential diagnosis of peripheral arterial disease and lumbar spinal stenosis in patients with atypical claudication. Eur Spine J. 2012; 21(6):1165–1170. PMID: 22105308.

10. Uesugi K, Sekiguchi M, Kikuchi S, Kanayama M, Takahashi K, Chiba K, et al. Lumbar spinal stenosis associated with peripheral arterial disease: a prospective multicenter observational study. J Orthop Sci. 2012; 17(6):673–681. PMID: 23053583.

11. Fowkes FG. The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys. Int J Epidemiol. 1988; 17(2):248–254. PMID: 3042648.

12. Schernthaner R, Stadler A, Lomoschitz F, Weber M, Fleischmann D, Lammer J, et al. Multidetector CT angiography in the assessment of peripheral arterial occlusive disease: accuracy in detecting the severity, number, and length of stenoses. Eur Radiol. 2008; 18(4):665–671. PMID: 18094974.

13. Werncke T, Ringe KI, von Falck C, Kruschewski M, Wacker F, Meyer BC. Diagnostic confidence of run-off CT-angiography as the primary diagnostic imaging modality in patients presenting with acute or chronic peripheral arterial disease. PLoS One. 2015; 10(3):e0119900. PMID: 25835948.

14. Ichihashi S, Hashimoto T, Iwakoshi S, Kichikawa K. Validation study of automated oscillometric measurement of the ankle-brachial index for lower arterial occlusive disease by comparison with computed tomography angiography. Hypertens Res. 2014; 37(6):591–594. PMID: 24599013.

15. Lawrence JA, Kim D, Kent KC, Stehling MK, Rosen MP, Raptopoulos V. Lower extremity spiral CT angiography versus catheter angiography. Radiology. 1995; 194(3):903–908. PMID: 7862999.

16. Rieker O, Düber C, Schmiedt W, von Zitzewitz H, Schweden F, Thelen M. Prospective comparison of CT angiography of the legs with intraarterial digital subtraction angiography. AJR Am J Roentgenol. 1996; 166(2):269–276. PMID: 8553929.

17. Stoffers HE, Rinkens PE, Kester AD, Kaiser V, Knottnerus JA. The prevalence of asymptomatic and unrecognized peripheral arterial occlusive disease. Int J Epidemiol. 1996; 25(2):282–290. PMID: 9119553.

18. Fowkes FG, Housley E, Cawood EH, Macintyre CC, Ruckley CV, Prescott RJ. Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. Int J Epidemiol. 1991; 20(2):384–392. PMID: 1917239.

19. Williams DT, Harding KG, Price P. An evaluation of the efficacy of methods used in screening for lower-limb arterial disease in diabetes. Diabetes Care. 2005; 28(9):2206–2210. PMID: 16123491.

20. Suominen V, Rantanen T, Venermo M, Saarinen J, Salenius J. Prevalence and risk factors of PAD among patients with elevated ABI. Eur J Vasc Endovasc Surg. 2008; 35(6):709–714. PMID: 18313338.

21. Meijer WT, Hoes AW, Rutgers D, Bots ML, Hofman A, Grobbee DE. Peripheral arterial disease in the elderly: the Rotterdam Study. Arterioscler Thromb Vasc Biol. 1998; 18(2):185–192. PMID: 9484982.

22. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation. 2004; 110(6):738–743. PMID: 15262830.

23. Alzamora MT, Forés R, Baena-Díez JM, Pera G, Toran P, Sorribes M, et al. The peripheral arterial disease study (PERART/ARTPER): prevalence and risk factors in the general population. BMC Public Health. 2010; 10(1):38. PMID: 20529387.

24. Diehm C, Lange S, Darius H, Pittrow D, von Stritzky B, Tepohl G, et al. Association of low ankle brachial index with high mortality in primary care. Eur Heart J. 2006; 27(14):1743–1749. PMID: 16782720.

25. Kock MC, Adriaensen ME, Pattynama PM, van Sambeek MR, van Urk H, Stijnen T, et al. DSA versus multi-detector row CT angiography in peripheral arterial disease: randomized controlled trial. Radiology. 2005; 237(2):727–737. PMID: 16244280.

26. Ouwendijk R, de Vries M, Pattynama PM, van Sambeek MR, de Haan MW, Stijnen T, et al. Imaging peripheral arterial disease: a randomized controlled trial comparing contrast-enhanced MR angiography and multi-detector row CT angiography. Radiology. 2005; 236(3):1094–1103. PMID: 16020559.

27. Imagama S, Matsuyama Y, Sakai Y, Ito Z, Wakao N, Deguchi M, et al. An arterial pulse examination is not sufficient for diagnosis of peripheral arterial disease in lumbar spinal canal stenosis: a prospective multicenter study. Spine. 2011; 36(15):1204–1210. PMID: 21217453.

28. Lautin EM, Freeman NJ, Schoenfeld AH, Bakal CW, Haramati N, Friedman AC, et al. Radiocontrast-associated renal dysfunction: incidence and risk factors. AJR Am J Roentgenol. 1991; 157(1):49–58. PMID: 2048539.