What is the workup for suspected stenosis of the right common iliac artery?

From the Guidelines

The workup for suspected stenosis of the right common iliac artery should begin with a thorough clinical assessment, including a detailed history and physical examination, followed by non-invasive testing with ankle-brachial index (ABI) measurement and duplex ultrasonography, and then CT angiography (CTA) or MR angiography (MRA) for more detailed anatomical assessment, as recommended by the 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease 1.

The clinical assessment should focus on symptoms like claudication, diminished femoral pulses, and bruits over the iliac arteries. Initial non-invasive testing should include ABI measurement, which compares blood pressure in the ankle to that in the arm, with a value below 0.9 suggesting arterial disease. Duplex ultrasonography is often the first imaging study, providing information about blood flow velocity and the degree of stenosis.

For more detailed anatomical assessment, CTA or MRA is recommended, with CTA offering excellent spatial resolution and the ability to visualize calcifications, as noted in the acr appropriateness criteria for iliac artery occlusive disease 1. In cases where these studies are inconclusive or when intervention is planned, digital subtraction angiography remains the gold standard, allowing for both diagnosis and potential therapeutic intervention.

Additional laboratory tests should include lipid profile, blood glucose, and renal function tests to assess cardiovascular risk factors and guide treatment decisions, as suggested by the acr appropriateness criteria for iliac artery occlusive disease 1. This comprehensive approach enables accurate diagnosis of iliac artery stenosis and helps determine the most appropriate management strategy, whether medical therapy, endovascular intervention, or surgical bypass.

Some key points to consider in the workup include:

• The use of duplex US for initial imaging, with a sensitivity and specificity for diagnosing stenoses >50% in diameter of approximately 90% to 95% 1
• The advantages of CTA, including excellent spatial resolution and the ability to visualize calcifications, making it a useful tool for preoperative planning and diagnosis 1
• The importance of assessing cardiovascular risk factors and guiding treatment decisions with laboratory tests, such as lipid profile, blood glucose, and renal function tests 1

From the Research

Workup for Suspected Stenosis of the Right Common Iliac Artery

The workup for suspected stenosis of the right common iliac artery involves several diagnostic tests to confirm the presence and severity of the stenosis. The following are some of the key tests used:

• Color Doppler sonography: This test uses sound waves to create images of the blood vessels and can help identify areas of stenosis or blockage 2.
• Computed Tomography (CT) angiogram: This test uses X-rays and contrast dye to create detailed images of the blood vessels and can help identify areas of stenosis or blockage 2.
• Ankle-brachial index (ABI): This test compares the blood pressure in the ankles to the blood pressure in the arms and can help identify areas of poor blood flow 2, 3, 4.
• Intravascular ultrasound (IVUS): This test uses a small ultrasound probe to create images of the blood vessels from the inside and can help identify areas of stenosis or blockage 5, 6.
• Arteriography: This test uses X-rays and contrast dye to create images of the blood vessels and can help identify areas of stenosis or blockage 5.
• Duplex scanning: This test uses a combination of ultrasound and Doppler technology to create images of the blood vessels and can help identify areas of stenosis or blockage 5, 4.

Diagnostic Criteria

The diagnostic criteria for stenosis of the right common iliac artery vary depending on the test used. For example:

• A caliber diameter of <16 mm for the common iliac vein (CIV) or <14 mm for the external iliac vein (EIV) on CT venography is considered stenotic 6.
• An ABI of <0.9 is considered abnormal and may indicate the presence of stenosis or blockage 3, 4.
• A stenosis of >50% on arteriography or IVUS is considered significant and may require treatment 5.

Treatment Options

The treatment options for stenosis of the right common iliac artery depend on the severity of the stenosis and the presence of symptoms. Treatment options may include:

• Endovascular stenting: This involves placing a small metal stent in the affected blood vessel to keep it open and improve blood flow 2, 3.
• Angioplasty: This involves using a small balloon to widen the affected blood vessel and improve blood flow 3.
• Surgery: This may be necessary in some cases to bypass the affected blood vessel or to remove the blockage 3, 4.