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