Aortoiliac disease

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

Overview

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

Surgical

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


Historical Perspective

  • [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
  • In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
  • In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

Classification

  • [Disease name] may be classified according to [classification method] into [number] subtypes/groups:
  • [group1]
  • [group2]
  • [group3]
  • Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].

Pathophysiology

  • The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
  • The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
  • On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
  • On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Clinical Features

Differentiating [disease name] from other Diseases

  • [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
  • [Differential dx1]
  • [Differential dx2]
  • [Differential dx3]

Epidemiology and Demographics

  • The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
  • In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

  • Patients of all age groups may develop [disease name].
  • [Disease name] is more commonly observed among patients aged [age range] years old.
  • [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

  • [Disease name] affects men and women equally.
  • [Gender 1] are more commonly affected with [disease name] than [gender 2].
  • The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

  • There is no racial predilection for [disease name].
  • [Disease name] usually affects individuals of the [race 1] race.
  • [Race 2] individuals are less likely to develop [disease name].

Risk Factors

  • Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Natural History, Complications and Prognosis

  • The majority of patients with [disease name] remain asymptomatic for [duration/years].
  • Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
  • If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
  • Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
  • Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

  • The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
  • [criterion 1]
  • [criterion 2]
  • [criterion 3]
  • [criterion 4]

Symptoms

  • [Disease name] is usually asymptomatic.
  • Symptoms of [disease name] may include the following:
  • [symptom 1]
  • [symptom 2]
  • [symptom 3]
  • [symptom 4]
  • [symptom 5]
  • [symptom 6]

Physical Examination

  • Patients with [disease name] usually appear [general appearance].
  • Physical examination may be remarkable for:
  • [finding 1]
  • [finding 2]
  • [finding 3]
  • [finding 4]
  • [finding 5]
  • [finding 6]

Laboratory Findings

  • There are no specific laboratory findings associated with [disease name].
  • A [positive/negative] [test name] is diagnostic of [disease name].
  • An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
  • Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Imaging Findings

  • There are no [imaging study] findings associated with [disease name].
  • [Imaging study 1] is the imaging modality of choice for [disease name].
  • On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
  • [Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

  • [Disease name] may also be diagnosed using [diagnostic study name].
  • Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

  • There is no treatment for [disease name]; the mainstay of therapy is supportive care.
  • The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
  • [Medical therapy 1] acts by [mechanism of action 1].
  • Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

  • Surgery is the mainstay of therapy for [disease name].
  • [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
  • [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

  • There are no primary preventive measures available for [disease name].
  • Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
  • Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

References


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