Aortoiliac disease

Editors-In-Chief: Alexandra Almonacid M.D. [mailto:aalmonacid@partners.org]and Jeffrey J. Popma M.D. [mailto:jpopma@partners.org]

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

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