Aortoiliac disease
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
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
- Balloon expandable stent: Useful in Ostial Lesions
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].