Aortoiliac disease

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Editors-In-Chief: Alexandra Almonacid M.D. [1]and Jeffrey J. Popma M.D. [2]

Classification

Morphological Stratification of Iliac Lesions-ACC/AHA Guidelines

• TASC Type A iliac lesions
  • Single stenosis less than 3 cm of the CIA or EIA (unilateral/bilateral)
• TASC Type B iliac lesions
  • Single stenosis 3 to 10 cm in length, not extending into the CFA
  • Total of 2 stenosis less than 5 cm long in the CIA and/or EIA and not extending into the CFA
  • Unilateral CIA occlusion
• TASC Type C iliac lesions
  • Bilateral 5 to 10 cm long stenosis of the CIA and/or EIA, note extending into the CFA
  • Unilateral EIA occlusion not extending into the CFA
  • Unilateral EIA stenosis extending into the CFA
  • Bilateral CIA occlusion
• TASC Type D iliac lesions
  • Diffuse, multiple unilateral stenosis involving the CIA, EIA and CFA (usually more than 10 cm long)
  • Unilateral occlusion involving both the CIA and EIA
  • Bilateral EIA occlusions
  • Diffuse disease involving the aorta and both iliac arteries
  • Iliac stenosis in a patient with an abdominal aortic anuerysm or other lesion requiring aortic or iliac surgery

Diagnosis

• MR angiography
  • Gadofosveset-enhanced MR angiography showed significant improvement (P < .001) compared with unenhanced MR angiography for diagnosis of clinically significant aortoiliac occlusive disease ( 50% stenosis) .
  • The improvement in diagnostic efficacy compared with unenhanced MR angiography was clearly demonstrated. There was an improvement in overall accuracy, sensitivity, and specificity.
• CT Angiography
  • CT angiographic examination is less invasive and less expensive than conventional angiography
  • Improves resolution with decreased contrast load and acquisition time without increasing radiation exposure

Indications for Revascularization

• Relief of symptomatic lower extremity ischemia, including claudication, rest pain, ulceration or gangrene, or embolization causing blue toe syndrome
• Restoration y/o preservation of inflow to the lower extremity in the setting of pre-existing or anticipated distal bypass
• Procurement of access to more proximal vascular beds for anticipated invasive procedures. Occasionally revascularization is indicated to rescue flow-limiting dissection complicating access for other invasive procedures

Technical Issues

• Endovascular Access
  • Ipsilateral femoral artery
  • Contralateral femoral artery
  • Brachial artery: In patients with flush occlusions at the aortic bifurcation
• Multiple access sites may be required for successful treatment:
  • Bilateral femoral
  • Femoral/brachial

Treatment Options

Interventional Management of Iliac Lesions

PTA

• Endovascular treatment of iliac stenoses
  • High technical success rates
  • Low morbidity.
• Iliac PTA/stenting
  • High rates of patency
  • Improvement in functional outcome for the individual patient
• Stent placement
  • Balloon expandable stent: Useful in Ostial Lesions
    • Greater radial force
    • Allow greater precision for placement
  • Self-expandable stent
    • Longer lesions in which the proximal vessel maybe several millimeters larger than the distal vessel
    • Used predominantly in common iliac artery orificial occlusions

Complications

• Intraoperative complications
• Dissection
• Extravasation
• Arterial rupture
• Postoperative complications
• Pseudoaneurysm formation at the access site
• Distal embolization
• Hematoma

Prognosis

• Ideal Iliac PTA Lesions
  • Stenotic lesion
  • Non-calcified
  • Discrete (< 3cm)
  • Patent run – off vessels (> 2)
  • Non- diabetic patients
• Predictors of long-term failure
  • Clinical status: CLI vs claudicant
  • Smoking
  • Women?
  • Vessel diameter < 8mm
  • Outflow status
  • Lack of antiplatelet regimen
  • Number of stents
  • Occlusion vs. stenosis