Is significant stenosis greater than 70% in the left common iliac artery stent an indication for angioplasty with two balloons and vascular stenting?

From the Guidelines

Significant stenosis greater than 70% in the left common iliac artery stent is an indication for angioplasty with vascular stenting, as it represents a critical narrowing that significantly impairs blood flow to the lower extremity and carries a high risk of progression to complete occlusion. The management of peripheral arterial disease, including iliac artery stenosis, is guided by the ACC/AHA 2005 practice guidelines, which suggest that endovascular treatment, including angioplasty and stenting, is a viable option for patients with significant stenosis 1.

Key Considerations

• The use of two balloons for angioplasty is not explicitly recommended in the guidelines, but the procedure typically involves pre-dilation with a smaller balloon to initially open the stenosis, followed by a larger balloon to fully expand the vessel before stent placement.
• The placement of a new stent within the previously stented segment (in-stent restenosis) is appropriate when the narrowing is severe and symptomatic, as supported by evidence showing improved walking distance, reduced claudication symptoms, and prevention of critical limb ischemia in patients with high-grade iliac stenosis.
• Patients undergoing this procedure should receive antiplatelet therapy (typically aspirin 81mg daily indefinitely plus clopidogrel 75mg daily for at least 1-3 months post-procedure) to prevent stent thrombosis, as recommended by the guidelines 1.

Evidence-Based Decision

The decision to perform angioplasty with vascular stenting for significant stenosis greater than 70% in the left common iliac artery stent is based on the highest quality evidence available, which suggests that endovascular treatment is a viable option for patients with significant stenosis 1. The guidelines emphasize the importance of patient selection and the need for individualized treatment plans, taking into account the severity of the stenosis, the presence of symptoms, and the patient's overall health status.

Clinical Implications

• The procedure should be performed by an experienced interventionalist, with careful attention to technique and patient selection.
• Patients should be closely monitored for complications, including stent thrombosis, restenosis, and vascular injury.
• The use of antiplatelet therapy and other medications should be tailored to the individual patient's needs and risk factors.

From the Research

Iliac Artery Stenosis Treatment

• Significant stenosis greater than 70% in the left common iliac artery stent is a serious condition that requires proper treatment.
• According to the study by 2, iliac angioplasty with selective stenting is a viable treatment option for iliac artery occlusive disease.
• The study found that primary patency rates were not high, but assisted primary and secondary patency rates were excellent without primary stenting.
• However, the study also noted that patients with TASC type C/type D iliac lesions, a stenotic ipsilateral superficial femoral artery, ulcer/gangrene, smoking history, and chronic renal failure with hemodialysis should be considered for primary stenting.

Angioplasty and Stenting

• The study by 3 compared primary stent placement versus primary angioplasty followed by selective stent placement in patients with iliac-artery occlusive disease.
• The results showed that there were no substantial differences in technical results and clinical outcomes of the two treatment strategies both at short-term and long-term follow-up.
• The study by 4 evaluated the safety and performance of the Dynamic stainless-steel balloon-expanding stent system in treating iliac atherosclerotic lesions.
• The results showed that the Dynamic stent system was safe and effective, with a primary endpoint of freedom from major adverse limb events (MALE) at 12 months reached in 96.2% of cases.

Treatment Outcomes

• The study by 5 evaluated the outcomes of venography-guided treatment of patients with May-Thurner syndrome.
• The results showed that clinical improvement and decrease in CEAP score occurred in 95% and 77% of stented patients, respectively.
• The study by 6 investigated the factors influencing migration of the iliac limb and methods of treatment after endovascular abdominal aortic aneurysm repair (EVAR).
• The results showed that migration of the iliac limb was influenced by a complex combination of several factors, including a large aneurysm, dilated or aneurysmal CIA, short length of fixation, and lower degree of iliac limb oversizing.