Concomitant Venous Disease in Patients with Advanced Peripheral Arterial Disease: A Patient- and Limb-Level Analysis

Background: Advanced stages of peripheral arterial disease, particularly chronic limb-threatening ischemia, are characterized by unfavorable limb outcomes and a substantial risk of major amputation. Clinical evaluation traditionally focuses on arterial obstruction; however, venous dysfunction may coexist and contribute to local limb pathophysiology in advanced PAD, remaining insufficiently recognized in routine practice. Methods: We performed a retrospective cohort analysis of consecutive patients with advanced peripheral arterial disease managed at the First Surgical Clinic of the Emergency County Clinical Hospital of Craiova over a five-year period (January 2020 to December 2024). Venous disease was defined using a clinically oriented composite definition incorporating imaging-confirmed venous pathology, prior deep venous thrombosis, and persistent lower-limb edema attributable to venous dysfunction. Arterial disease severity was assessed using multimodal imaging. Analyses were performed at both patient and limb levels to evaluate associations between venous disease, arterial severity markers, and clinical outcomes. Results: Among 241 patients (482 limbs), concomitant venous disease was identified in 68.9% at the patient level and was predominantly unilateral. At the limb level, venous disease was significantly associated with markers of severe arterial involvement, including inflow disease, higher segment occlusion scores, impaired tibial runoff, and absence of a patent pedal arch. Despite greater arterial severity, patients with venous disease exhibited a lower unadjusted rate of major amputation compared with those without venous involvement. Conclusions: Concomitant venous disease is highly prevalent in patients with advanced PAD and is closely linked to arterial disease severity. These findings suggest that venous dysfunction represents an integral component of advanced limb-threatening ischemia rather than an isolated comorbidity. Incorporating clinically oriented venous assessment may improve understanding of limb pathophysiology and support a more integrated arterio-venous approach to advanced PAD management.