DR. AMR GAD

2. Epidemiology Of PAD
in 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

3. Epidemiology Of PAD
In 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

4. 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

5. Epidemiology of PAD
Diabetes & 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)

6. Epidemiology of PAD
Diabetes and Arab world

7. Prevalence of PAD
Diabetes and The Arab World
(IDF,6th ed. ,2013)
Top 10

8. (IDF , 6th ed ,2013)
Diabetes & Arab world

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

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

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

12. Epidemiology of PAD
Smoking 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 )

13. Epidemiology of PAD
Obesity 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)

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

15. Epidemiology of PAD

16. Epidemiology of PAD

17. PAD in The Arab World

18. Alwahbi, Saudi Med J 2006
Epidemiology of PAD

19. Clinical Presentation
PATHOLOGY OF PAD
ATHEROSCLEROSIS
The 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

20. 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.

21. 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
21

22. 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)
22
Clinical presentation
(Non-specific Arteritis)

23. CLINICAL PRESENTATION
PAD
• Intermittent claudication
• Critical Limb Ischemia
-Tissue loss
-Non healing ulcers, gangrene
-Rest pain
-Diabetic foot infection

24. 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

25. Clinical presentation
PTA 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%)

26. Clinical presentation
PTA 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%)

27. Clinical presentation
TASC D Aorto iliac Disease

28. Clinical presentation
Aorto-Bi femoral Bypass (TASC D)
Before After

29. Clinical presentation
Pedal Bypass (TASC D)
Before After

30. Infra Popliteal
Revascularization
By PTA

31. Infra-popliteal Revascularization By PTA
Before After
Before After

32. Prevalence of Multilevel Disease
(Cairo University Study, 2013)
Multilevel occlusion
No. 53
% 20.23
Prim. Patency 75.47% ( 1Y) 50.94% (2Y)
Second.
Patency
81.13% ( 1Y) 66.03% (2Y)
Outcome of endovascular treatment of Multilevel
disease .

33. 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:

34. 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