What is the initial management approach for a patient with stenosis of the iliac artery?

Initial Management of Iliac Artery Stenosis

The initial management approach for a patient with stenosis of the iliac artery should include antiplatelet therapy, risk factor modification, and a supervised exercise program, with endovascular intervention reserved for patients who fail conservative management or have severe symptoms. 1, 2

Diagnostic Evaluation

• Initial evaluation should include measurement of ankle-brachial index (ABI) and pulse volume recording (PVR) to confirm the diagnosis and assess severity 2
• Duplex ultrasound imaging of the aortoiliac segment and lower extremity is recommended to determine concordance between clinical symptoms and peripheral arterial disease (PAD) 1
• Cross-sectional imaging with computed tomography angiography (CTA) or magnetic resonance angiography (MRA) is recommended to reveal the exact nature and level of stenosis and underlying atherosclerotic plaque to plan treatment strategy 1, 2

Medical Management

• Antiplatelet therapy (single-agent) should be initiated in all symptomatic patients to reduce the risk of major adverse cardiovascular events (MACE) and cardiovascular mortality 1, 2
• High-dose statin therapy is indicated for all patients with PAD if tolerated (class IA recommendation) 1, 2
• Antihypertensive therapy should be administered to all patients with hypertension and PAD to reduce the risk of MACE including stroke, myocardial infarction, heart failure, or cardiovascular death 1
• Cilostazol is recommended to improve symptoms and walking distance in patients with intermittent claudication 1, 2
• Optimal control of diabetes and hyperlipidemia is essential 1, 2
• Tobacco cessation should be strongly encouraged in all patients with PAD 1, 2

Supervised Exercise Therapy (SET)

• A supervised exercise program should be initiated in all patients with non-limb-threatening PAD to improve maximum walking distance 1
• Several randomized controlled trials (CLEVER, ERASE, IRONIC) have demonstrated significant improvement in disease-specific quality of life measurements, walking distance, and treadmill walking performance following SET 1
• SET can reduce overall mortality and the need for secondary revascularization procedures 1
• A combination of endovascular revascularization and SET is associated with significant improvement in total walking distance, ABI, and reduced risk of future revascularization or amputation compared to SET alone 1

Endovascular Intervention

• Endovascular intervention should be considered when optimal medical therapy and supervised exercise programs fail to control symptoms or in cases of critical limb ischemia 2
• For TASC A and B lesions, percutaneous transluminal angioplasty (PTA) alone or in combination with stent placement in patients with suboptimal results after PTA is usually appropriate 1
• For TASC C lesions, primary stenting combined with antiplatelet therapy is usually the first choice, followed by open surgery if endovascular therapy fails 1
• For TASC D lesions, catheter-directed aortoiliac stent or stent-graft placement combined with antiplatelet therapy is usually the first choice, followed by open surgery if endovascular therapy fails 1
• The TASC authors have noted that when choosing between endovascular and open-surgical or bypass therapies with equivalent short-term and long-term outcomes, endovascular techniques should be used first 1

Surgical Revascularization

• Surgical revascularization is typically reserved for patients who fail endovascular therapy or have extensive disease not amenable to endovascular treatment 1
• Recent studies have demonstrated no significant differences in short- and long-term secondary patency comparing endovascular revascularization and open surgery for treatment of aortoiliac occlusive disease 1
• Endovascular approaches are associated with increased secondary interventions but decreased length of hospital stay and fewer postoperative complications 1

Important Considerations and Pitfalls

• Stenotic (>50%) superficial femoral artery (SFA) should be addressed at the time of iliac intervention, as it is a predictor of iliac intervention failure 1
• Independent predictors for iliac intervention failure include hypertension, hypercholesterolemia, chronic renal insufficiency, poor tibial runoff, external iliac artery disease, female gender, smoking, gangrene, ulcer, diabetes mellitus, and presence of a distal bypass 1
• Covered balloon-expandable stents have demonstrated significantly higher patency rates than bare metal stents at 18,24,48, and 60 months in the COBEST trial 1
• When treating TASC C and D lesions with primary stenting, be aware of significantly higher complication rates compared to TASC A and B lesions, despite similar long-term patency rates 1