epidemology and clinical presentation in arab world
TRANSCRIPT
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Epidemiology and Clinical Presentation
of PAD in The Arab World
AMR GadProf. Vascular Surgery
Cairo University
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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
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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
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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
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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)
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Epidemiology of PAD Diabetes and Arab world
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Prevalence of PADDiabetes and The Arab World
(IDF,6th ed. ,2013)
Top 10
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(IDF , 6th ed ,2013)
Diabetes & Arab world
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Diabetes & Arab world ( IDF ,6thed. ,2013)
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Diabetes & Arab world IDF, 6th ed., 2013
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Diabetes & Arab world IDF,6th ed. , 2013
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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 )
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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)
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Epidemiology of PAD Obesity in the Arab world WHO(2010)
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Epidemiology of PAD
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Epidemiology of PAD
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PAD in The Arab World
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Alwahbi, Saudi Med J 2006
Epidemiology of PAD
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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
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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)
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CLINICAL PRESENTATION PAD
• Intermittent claudication • Critical Limb Ischemia -Tissue loss -Non healing ulcers, gangrene -Rest pain -Diabetic foot infection
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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
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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%)
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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%)
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Clinical presentation
TASC D Aorto iliac Disease
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Clinical presentationAorto-Bi femoral Bypass (TASC D)
Before After
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Clinical presentation Pedal Bypass (TASC D)
Before After
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Infra Popliteal Revascularization
By PTA
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Infra-popliteal Revascularization By PTA
Before AfterBefore After
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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 .
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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:
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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
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Thank You
Cairo University