Peripheral arterial disease (PAD) in women is an under-recognized, understudied, and undertreated disorder. The magnitude of this problem can be realized from the fact that 21% to 67% of documented symptoms or diagnoses upon admission in nursing home residents are consistent with PAD.1 Nearly 75% to 90% of nursing home residents are women, aged 65 years or older. PAD may therefore be a large contributor to disability in this population. Adding to the problem is the fact that 48% of women aged 65 to 75 years live alone, without readily available, adequate support at home, potentially resulting in the need for an extended care facility. Therefore, it seems it would be in society's best interest, in terms of costs and disability, to prevent, identify, treat, and better study PAD in women.
Women are obviously different from men in terms of anatomy and physiology, but may also differ in terms of clinical presentation of disease states and response to treatment. In general, women tend to have smaller, less-compliant arteries, which may translate into the need for different devices and techniques to treat PAD. Even though less is known about the natural history of PAD in women, none can argue about the disability that it can cause across the genders. Cardiovascular disease is the number 1 cause of death in women and a recent survey showed only 50% of respondents understood this to be true.2
Women tend to be underrepresented in clinical studies, but it is unclear if lower prevalence of some subtypes of PAD contributes to this or if there is a true bias against including women. There are few studies aimed at PAD in women alone and fewer that perform significant subgroup analyses of PAD in women. We have yet to elicit whether there is a difference in vascular biology between the genders and whether women react differently to various treatments for vascular disease than men. There may be questions raised if physicians treat women with vascular disease differently than men. Herein, we will review the 3 major subtypes of PAD: carotid atherosclerotic disease (Figure 11-1), lower extremity arterial disease, and aneurysmal disease, specifically in women, with respect to biology, treatment, and outcome.
Carotid angiogram demonstrating severe, focal stenosis (arrow).
It may prove important to determine the difference between the genders in regards to carotid artery anatomy and physiology. In general, there are differences in carotid artery diameter between women and men from the age 25 years and onward.3 Both genders, however, experience an increase in diameter as well as a decrease in compliance with age, which most likely contributes to the increased formation of atherosclerotic lesions later in life. In fact, a reduced compliance in women aged 45 to 60 years ...