What are the treatment options for aortoiliac (Aortoiliac Occlusive Disease) syndrome?

From the Guidelines

Treatment for aortoiliac syndrome should prioritize a combination of medical management and revascularization procedures, with a focus on cardiovascular risk factor modification, antiplatelet therapy, and supervised exercise therapy, as well as endovascular or surgical interventions for symptomatic patients with significant aortoiliac occlusive disease, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1.

Medical Management

Medical management is a crucial component of treatment for aortoiliac syndrome, and should include:

• Cardiovascular risk factor modification, such as smoking cessation, blood pressure control, diabetes management, and cholesterol reduction with statins like atorvastatin 40-80mg daily
• Antiplatelet therapy with aspirin 81-325mg daily to prevent thrombotic complications
• Supervised exercise therapy, involving structured walking programs 3-5 times weekly for 30-60 minutes to improve claudication symptoms and functional capacity

Revascularization Procedures

Revascularization procedures are necessary for symptomatic patients with significant aortoiliac occlusive disease, and can be achieved through:

• Endovascular approaches, such as angioplasty with stenting, which is less invasive and preferred for focal lesions
• Surgical interventions, such as aortobifemoral bypass, for extensive disease
• Hybrid procedures, combining both endovascular and surgical approaches, for complex cases

Post-Intervention Care

Post-intervention, patients require:

• Lifelong antiplatelet therapy
• Regular follow-up with vascular ultrasound to monitor for restenosis

The 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease recommends endovascular procedures as a revascularization option for patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac occlusive disease 1. The CLEVER study demonstrated superior treadmill walking performance at 6-month follow-up in the supervised exercise cohort versus the primary stenting cohort for patients with claudication resulting from aortoiliac peripheral artery disease 1. The ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease provide a comprehensive overview of vascular surgical procedures for inflow improvement, including aortobifemoral bypass and iliac endarterectomy 1.

From the Research

Treatment Options for Aortoiliac Occlusive Disease

The treatment options for aortoiliac occlusive disease (AIOD) include:

• Medical therapy and supervised exercise programs for mild to moderate intermittent claudication 2
• Endovascular approach for patients with debilitating claudication or critical limb ischemia, with patency rates comparable to open surgery 2, 3
• Surgical revascularization for selected patients 2
• Stent-graft placement as an option for treatment of diffuse aortoiliac occlusive disease, with technical, clinical, and hemodynamic success 3
• Robot-assisted laparoscopic (RAL) surgery for AIOD revascularization, with excellent patency rates and low complication rates 4
• Hybrid pelvic revascularization for complex aortoiliac aneurysm repair, focusing on optimizing revascularization while limiting pelvic surgical dissection 5

Medical Management

Medical management of AIOD includes:

• Risk factor modification 2
• Statins, ACE inhibitors, and ARBs to reduce cardiovascular disease 6

Interventional Procedures

Interventional procedures for AIOD include:

• Endovascular interventions, such as stent-graft placement 3
• Surgical revascularization, including open surgery and RAL surgery 2, 4
• Hybrid pelvic revascularization for complex aortoiliac aneurysm repair 5