A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review: Part I-Epidemiology, Risk Factors, and Atherosclerosis-Related Diversities in Elderly Patients

Abstract

Atherosclerosis is a generalized and progressive disease. Ageing is a key risk factor for atherosclerosis progression that is associated with the increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity and quality of life, and it is associated with reduced life expectancy. Although there is evidence on coronary artery disease management in the elderly, there is insufficient data on the management in older patients presented with atherosclerotic lesions outside the coronary territory. Despite this, trials and observational studies systematically exclude older patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment and referral for endovascular or surgical interventions. Therefore, we attempted to gather data on the prevalence, risk factors, and management strategies in patients with extra-coronary atherosclerotic lesions.

Keywords: atherosclerosis; biomarkers; cardiovascular events; cardiovascular risk; carotid artery lesions; elderly patients; extra coronary arterial disease; peripheral arterial disease; prognostic factors; renal artery stenosis.

Figure 1

(A–C) Diagnostic images of peripheral arterial disease (PAD) in patients with advanced atherosclerosis, obtained with computed tomography angiography (CTA). (A) CTA image obtained in a 73-year-old hypertensive man with asymptomatic PAD showing long occlusions of both superficial femoral arteries (SFA). Please note a very well developed collateral circulation (pink arrows) from deep femoral arteries and white spots along both SFAs corresponding to calcifications (white arrow). (B) CTA image obtained in a 78-year-old hypertensive man with moderately symptomatic PAD showing occlusions of both SFA in the Hunter channel. Please note a very excessive calcifications in iliac and femoral arteries (white arrows). (C) CTA image obtained in a 78-year-old hypertensive woman with type 2 diabetes, as well as a critical PAD causing rest pain resulting from ruptured calcified plaque (white arrow) in the left popliteal artery (LPA), with a recent vessel thrombosis below the calcified plaque (red arrow). Please note the lack of collateral circulation.

Figure 2

(A–H) Diagnostic images obtained in a 73-year-old hypertensive woman with type 2 diabetes before renal artery angioplasty with stent implantation (PTA) for the left renal artery stenosis (RAS). The patient was referred to renal PTA because of resistant hypertension, with blood pressure values above 200/120 mmHg despite five blood-lowering agents in maximally tolerated doses, after the patient developed acute renal failure following treatment initiation with empagliflozin. At the six-month follow-up period following PTA, the patients was still on five blood lowering agents with blood pressure values not exceeding 150/75 mmHg, with a stable renal function with an eGFR of 27 mL/min/1.73 m². (A) Pre-intervention diagnostic magnetic resonance angiography (MRA) showing quantity alterations in right kidney (RK) and left kidney (LK) dimensions and unequal renal parenchymal signal intensity. (B,C) Transverse scans of the aorta, renal arteries, renal veins (blue arrows), and both kidneys on MRA. Images display, in early and late gadolinium-contrast phases, the small size of the RK, low signal in the RK, and unclear corticomedullary boundary in both kidneys. Please note the intensive calcifications in the abdominal aorta (white arrow), and the critical non-calcified, presumably soft ostial lesion of the left renal artery (orange arrow). Perfusion of the LK is preserved as yet, while the RK shows features of cirrhosis. (D) Renal catheter angiography confirmed an ostial 95% left RAS (orange arrow), and absent right renal artery (white arrow). Thus, the patient is presented with a stenosis of a single functional kidney. Please note the total occlusion (red arrow) of the distal part of abdominal aorta and both common iliac arteries. Pink arrow indicates collateral pathway. (E) The final result of PTA in renal artery (yellow arrow). Please note that the PTA procedure was performed via a transradial access route due to the total occlusion of the distal part of abdominal aorta and both common iliac arteries (Leriche’s syndrome). Pink/violet arrow indicates the large collateral artery providing blood supply to the pelvis and lower extremities. White arrow is for the total occlusion of the right renal artery. (F) Final angiography of aorta displaying numerous collaterals (pink arrows) from cephalic trunk, mesenteric arteries, to abdominal and pelvis organs. Yellow arrow indicates the final effect of RAS procedure, whereas white arrow desplays occluded right renal artery. (G) Color Doppler ultrasound showing reduced intrarenal flow in the LK before PTA. (H) Color Doppler ultrasound showing restoration of the intrarenal flow in the LK after PTA, yellow arrow indicates the final effect of RAS procedure.

Figure 3

(A–C) Diagnostic images obtained in an 83-year-old man before carotid endarterectomy on the right internal carotid artery (RICA) stenosis. (A) Color Doppler ultrasound showing abnormal turbulent flow in the proximal segment of the RICA. Carotid plaque is hyperechogenic, massively calcified with a typical shadowing below calcifications (white arrows). (B) Pulse Doppler showing a significant increase in the peak systolic and the end-diastolic velocities of 330 cm/s and 101 cm/s, respectively, consistent with severe stenosis of the proximal segment of RICA that corresponded to lumen stenosis of more than 90%. (C) Carotid catheter angiography confirmed a 2 cm long 95% RICA stenosis (red arrow) with calcified morphology (white arrows). (D) The image displays massively calcified plaque excised from the RICA during carotid endarterectomy.