Peripheral Arterial Disease (PAD) affects more than 200 million people[1]. With an estimated prevalence of 3 to 29% in women[2]. Asymptomatic PAD is more common in women than in men[3]. However, when symptomatic, women have a more complex and severe disease, affecting several arterial sectors (with chronic limb threatening ischemia-CLTI) and with worse outcomes[3-6]. Women present with symptoms, on average, 10 to 20 years later than men[4]. There has been a low representation of women in PAD studies and clinical trials[7]. This study aims to characterize PAD in hospitalized women. It is an objective to compare the cardiovascular risk factors, clinical presentation, therapeutic strategies and outcomes between women and men.

An observational, analytical, retrospective and longitudinal study was conducted at the Vascular Surgery Department of an University Hospital. The patients admitted with a clinical diagnosis of PAD, confirmed by ankle-brachial index, between January 2018 and December 2019, were consecutively included in the study. The clinical data was retrieved from the hospital information system. Recorded data comprised: clinical presentation, comorbidities, chronic medication, length of stay, type of admission, type of treatment (medical; surgical revascularization; endovascular treatment; major amputation; minor amputation), outcomes: discharge destination, revascularization success, 30-day mortality and amputation-free survival. The sample was divided into two groups according to gender. For the analysis of both therapeutic strategies and outcomes, the main groups were further subdivided according to the clinical presentation (CLTI or intermittent claudication). Regarding the comparison of categorical variables, the chi-square test (χ2) or Fisher's exact test was used. In quantitative variables, the comparison between groups was performed using the t test for independent samples or the Mann-Whitney U test. The association of gender with the probability of major amputation was evaluated using binary logistic regressions (both univariate and multivariate analysis). In the outcome amputation-free survival, Kaplan-Meier survival analysis was performed and the Log-Rank Test was used to assess the differences between the male and female groups. For all tests, p<0.05 was considered a statistically significant value, with a confidence interval (CI) of 95%.

Of 162 potentially eligible patients, four were excluded (under the age of 40- n=2; admitted for diagnostic imaging procedures - n=2). We analysed 158 patients (51 females). Women had a higher mean age (76.5±10.4 years versus 69.5±10.6 years; p<0.001). In the age group ≥80 years there was a higher prevalence of PAD in females. Women also had lower smoking habits (4.0% versus 58.9%, p<0.001), higher prevalence of arterial hypertension (90.2% versus 73.8%, p=0.021), diabetes mellitus (74.5% versus 57.0%, p=0.036) and depression (7.0% versus 0.9%, p=0.002). There was a greater number of women medicated with insulin (42.0% versus 24.3%, p=0.027) and antihypertensive therapy (88.0% versus 71.0%, p=0.026). Females had more CLTI (98.0% versus 87.9% p=0.038), particularly Fontaine stage IV (p=0.021), and dependency at admission (28.0% versus 4.3%, p<0.001). Females had less interventions on the aortoiliac sector (18.0% versus 50.0% p=0.012). No significant differences were found for infra-inguinal revascularization between genders. In patients with CLTI, men were more often revascularized by conventional surgery (18.0% versus 41.5%, p=0.005). On the other hand, the major amputation rate was higher in women (40.0% versus 21.3%, p=0.020), particularly above-knee (p<0.024). There are no significant differences regarding endovascular revascularization, minor amputation and medical treatment (Table 1). Through univariate analysis, it was found that women with CLTI had a 2.47 times higher risk of major amputation than men with CLTI (p=0.018). However, in multivariate analysis, gender was not considered an independent predictor of major amputation, age being the main factor (Table 2). In patients revascularized for CLTI (21 females and 54 males), the success of revascularization was similar between genders (90.5% in females and 90.7% in males, p>0 .99). Regarding 30-day mortality for CLTI, we found that 6 women (12.0%) and 5 men (5.3%) died. No statistically significant differences were found (p=0.191). No significant differences were found between genders in the outcomes: length of stay, discharge destination, and amputation-free survival.

Females were older, more dependent and more frequent admitted with CLTI, with a consequently higher major amputation rate. Besides prompt diagnosis, and intervention, public and social health measures are needed to improve functional state in elderly women in order to reduce female amputation rates.