What are the considerations for vascular intervention in common iliac artery (CIA) stenosis?

From the Guidelines

Vascular intervention is recommended for common iliac artery stenosis when the patient has lifestyle-limiting claudication, critical limb ischemia, or significant stenosis (>50-70%) with corresponding symptoms, with a preference for endovascular approaches such as angioplasty with stenting over open surgical bypass due to lower morbidity and mortality. The primary goal of intervention is to improve quality of life and prevent limb-threatening ischemia. According to the most recent guidelines, in iliac lesions, balloon angioplasty with or without stenting in external iliac arteries, or primary stenting in common iliac arteries, should be considered 1.

Key Considerations

• The decision for intervention should be based on symptom severity, anatomical considerations, and the patient's overall health status.
• Technical success rates exceed 95% with primary patency rates of 70-90% at 5 years.
• Patients undergoing intervention should receive antiplatelet therapy, typically aspirin 81-325mg daily indefinitely, plus clopidogrel 75mg daily for at least 1-3 months post-procedure.
• Risk factor modification including smoking cessation, diabetes management, and lipid control with high-intensity statins is essential for long-term success.
• Endovascular therapy is typically the first-line treatment due to its lower morbidity and mortality compared to open surgery, as supported by previous guidelines 1.

Interventional Options

• Endovascular approaches such as angioplasty with stenting
• Open surgical bypass
• Balloon-expandable stents are preferred over self-expanding stents in the common iliac arteries due to their precise deployment and resistance to external compression.

Patient Management

• Patients with severe intermittent claudication or critical limb ischemia should be considered for intervention.
• Translesional pressure gradients should be obtained to evaluate the significance of angiographic iliac arterial stenoses of 50% to 75% diameter before intervention 1.
• Provisional stent placement is indicated for use in the iliac arteries as salvage therapy for a suboptimal or failed result from balloon dilation 1.

From the Research

Vascular Intervention Considerations

• The decision to intervene in common iliac artery stenosis depends on various factors, including the severity of symptoms, the presence of other vascular diseases, and the patient's overall health 2.
• Endovascular revascularization is now considered first-line therapy for patients with claudication and critical limb ischemia, as well as asymptomatic patients who require large-bore access 2.
• The choice of treatment modality, such as angioplasty or stenting, depends on the specific characteristics of the lesion and the patient's condition 3, 4.

Treatment Options

• Covered stents have been shown to offer better outcomes than angioplasty alone for common iliac artery in-stent restenosis, with higher freedom from re-stenosis and target lesion revascularization rates 3.
• Unilateral iliac artery stenting can improve perfusion and symptoms in both limbs in patients with bilateral iliac lesions, even if only one limb is treated 4.
• Endovascular revascularization strategies may vary depending on the presence of intermittent claudication or critical limb ischemia, with patients with critical limb ischemia more likely to require multilevel interventions and have higher adverse limb event rates 5.

Patient Selection and Outcomes

• Patients with intermittent claudication and critical limb ischemia have significant differences in anatomic features, treatment strategies, and clinical outcomes, with patients with critical limb ischemia generally having poorer outcomes 5.
• The choice of treatment modality and patient selection should be individualized based on the specific characteristics of the patient and the lesion, as well as the presence of other vascular diseases 6, 2.