From the Guidelines
Aortoiliac disease is typically managed with a combination of revascularization and supervised exercise or pharmacotherapy to improve walking performance and quality of life (QOL). The disease involves atherosclerotic narrowing or occlusion of the distal aorta and iliac arteries, reducing blood flow to the lower extremities 1. Symptoms of aortoiliac disease include lower extremity claudication, particularly in the buttocks, thighs, and calves during exertion, which resolves with rest. Patients may also experience erectile dysfunction in males (Leriche syndrome), diminished or absent femoral pulses, and bruits over the femoral arteries.
Key factors to consider in the management of aortoiliac disease include:
- Risk factors such as smoking, hypertension, diabetes, hyperlipidemia, and advanced age
- Diagnosis using non-invasive vascular studies like ankle-brachial index (ABI) measurements, duplex ultrasound, CT angiography, or MR angiography to visualize the extent of disease
- Management strategies including risk factor modification, exercise therapy, antiplatelet medications, and revascularization procedures for severe symptoms or critical limb ischemia
- The importance of vessel patency in determining symptom improvement after endovascular treatment, with long-term patency being greater in the aortoiliac than in the femoropopliteal segment 1
According to the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline, revascularization procedures, such as endovascular stenting or surgical bypass, are effective in improving walking performance and QOL in patients with aortoiliac disease and claudication 1. The selection of a revascularization approach is individualized based on the patient's goals, anatomic findings, perioperative risk, and anticipated benefit. Surgical procedures are usually reserved for patients who do not derive adequate benefit from nonsurgical therapy, have favorable arterial anatomy, and acceptable risk of perioperative adverse events. Combining revascularization with supervised exercise or pharmacotherapy results in greater improvements in walking performance and QOL than exercise or medical therapy alone 1.
From the Research
Definition and Classification of Aortoiliac Disease
- Aortoiliac occlusive disease is a common condition that may cause a spectrum of chronic symptoms from intermittent claudication to critical limb ischemia 2.
- The TransAtlantic Inter-Society Consensus (TASC) guidelines classify aortoiliac atherosclerotic disease based on morphology and level of lesions 3.
Treatment Options for Aortoiliac Disease
- Treatment is indicated for symptoms that have failed lifestyle and medical therapies or occasionally to facilitate other interventional procedures such as TAVR and/or placement of hemodynamic assist devices 2.
- TASC A, B, and C lesions are best managed with endovascular intervention, while TASC D lesions may be treated by endovascular methods or open surgery 2, 3.
- Aortobifemoral bypass (ABF) has been considered the gold standard in the treatment of aortoiliac occlusive disease (AIOD), with a long-term patency rate of 85%-90% at 5 years and 75%-80% at 10 years 3.
- Endovascular therapies, such as stenting and angioplasty, have led to a paradigm change in the treatment of aortoiliac disease, offering a less invasive approach with acceptable short- and long-term outcomes 3, 4.
Factors Affecting Outcome in Aortoiliac Disease Treatment
- Residual pressure gradient (> 10 mmHg) and no treatment with aspirin are adverse factors affecting outcome in aortoiliac stenting 4.
- Statin use has been associated with a 32% reduction in 30-day mortality after aortobifemoral bypass for aortoiliac occlusive disease 5.
- Patient characteristics, such as age, diabetes, hypertension, and history of chronic obstructive pulmonary disease, can affect treatment outcomes 5.
Current Trends and Recommendations in Aortoiliac Disease Management
- An endovascular-first approach is increasingly being used in the treatment of aortoiliac disease, with open surgery as a secondary option 2.
- The choice of treatment should be based on the individual patient's characteristics, disease severity, and comorbidities 6.
- Further research is needed to determine the optimal treatment strategies for aortoiliac disease and to improve patient outcomes 3, 6.