What is the management of severe stenosis of the proximal common iliac artery (Common Iliac Artery)?

From the Guidelines

Management of severe stenosis of the proximal common iliac artery typically involves endovascular intervention as the first-line treatment, with primary stenting in common iliac arteries being a recommended approach 1.

Key Considerations

• Endovascular stenting is the preferred approach, using balloon-expandable stents or self-expanding stents depending on lesion characteristics.
• The procedure involves accessing the artery, crossing the stenosis with a guidewire, pre-dilating with an appropriate-sized balloon, and deploying a stent.
• Patients require antiplatelet therapy with aspirin and clopidogrel to prevent stent thrombosis and restenosis.
• For patients unsuitable for endovascular treatment, surgical options include aortobifemoral bypass, iliofemoral bypass, or endarterectomy.
• Risk factor modification is essential, including smoking cessation, lipid management, blood pressure control, diabetes management, and exercise therapy.

Procedure Details

• Accessing the artery is usually done via the femoral artery.
• Crossing the stenosis with a guidewire and pre-dilating with an appropriate-sized balloon are crucial steps.
• Deploying a stent, typically 7-10mm in diameter, is the final step in the procedure.
• Antiplatelet therapy with aspirin (81-325mg daily indefinitely) and clopidogrel (75mg daily for at least 1-3 months post-procedure) is necessary.

Evidence-Based Recommendations

• The 2024 ESC guidelines for the management of peripheral arterial and aortic diseases recommend primary stenting in common iliac arteries 1.
• The ACR Appropriateness Criteria for iliac artery occlusive disease also support endovascular intervention as the first-line treatment 1.
• The use of covered stents has shown promising results in terms of patency rates and clinical improvement 1.

Conclusion Not Allowed, so the answer ends here.

From the Research

Management of Severe Stenosis of the Proximal Common Iliac Artery

The management of severe stenosis of the proximal common iliac artery involves several endovascular treatment options, including:

• Percutaneous transluminal angioplasty (PTA) alone
• Primary stenting (PS)
• Covered stents The choice of treatment depends on various factors, including the severity of the stenosis, the presence of occlusions, and the patient's overall health.

Treatment Options

• Percutaneous Transluminal Angioplasty (PTA): PTA is a minimally invasive procedure that involves inflating a balloon to widen the narrowed artery 2, 3.
• Primary Stenting (PS): PS involves placing a stent in the narrowed artery to keep it open 2, 3.
• Covered Stents: Covered stents are used to treat in-stent restenosis and have been shown to have better outcomes than angioplasty alone 4.

Outcomes and Durability

The outcomes and durability of endovascular treatment for iliac artery occlusions have been studied, with results showing:

• High technical success rates (91%) 5
• Improved ankle-brachial index (mean increase from 0.45 to 0.83) 5
• Good mid-term durability, with 3-year primary patency, secondary patency, and limb salvage rates of 76%, 90%, and 97%, respectively 5
• Diabetes and critical ischemia at presentation are associated with decreased patency rates 5

Considerations

• The TransAtlantic Inter-Society Consensus (TASC) classification system is used to stratify patients with iliac artery occlusions, with TASC-C and -D lesions being more complex and challenging to treat 5.
• Endovascular treatment of iliac artery occlusions can be safely extended to TASC-C and -D patients, with good outcomes and low morbidity 5.
• Internal iliac artery angioplasty and stenting is a technically feasible and safe procedure, with a high success rate and low morbidity 6.