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
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
