What is the treatment for severe atherosclerosis of the abdominal aorta and bilateral iliac arteries with mild to moderate stenosis?

Treatment of Severe Atherosclerosis of the Abdominal Aorta and Bilateral Iliac Arteries

Endovascular intervention is the recommended first-line treatment for severe atherosclerosis of the abdominal aorta and bilateral iliac arteries with mild to moderate stenosis, due to high technical success rates (>90%) and favorable long-term outcomes. 1

Initial Assessment and Classification

• Diagnostic evaluation should include duplex ultrasound imaging of the aortoiliac segment and lower extremities to determine the extent of disease 1, 2
• Cross-sectional imaging with CT angiography (CTA) or MR angiography (MRA) is recommended to reveal the exact nature and level of stenosis for treatment planning 1, 2
• The Trans-Atlantic Inter-Society Consensus (TASC) classification should be used to guide treatment selection based on lesion complexity 1
• Ankle-brachial index (ABI) measurement is essential to determine the severity of ischemia and guide treatment decisions 1, 2

Medical Management

• All patients should receive comprehensive cardiovascular risk factor modification regardless of intervention strategy 1, 2
• High-dose statin therapy is indicated for all patients to improve walking distance and reduce cardiovascular events 1, 2
• Single antiplatelet therapy is recommended to reduce the risk of major adverse cardiovascular events 1, 2
• Antihypertensive therapy should be administered to all patients with hypertension 2
• Supervised exercise therapy should be initiated in all patients with non-limb-threatening disease to improve maximum walking distance 1, 2

Endovascular Intervention

For aortoiliac atherosclerotic disease, the treatment approach should be based on TASC classification:

TASC A and B Lesions (Short Stenoses/Occlusions)

• Endovascular therapy is the treatment of choice with high technical success rates and excellent long-term patency 1
• Primary percutaneous transluminal angioplasty (PTA) with selective stenting is highly effective 1
• For common iliac artery lesions, primary stenting can be considered with patency rates comparing favorably to surgical revascularization 1

TASC C Lesions (Bilateral Common Iliac Artery Occlusions)

• Endovascular-first approach is recommended due to low morbidity and mortality with >90% technical success rate 1
• Primary stenting has demonstrated significantly higher 12-month primary patency rates (92.1%) compared to selective stenting (82.9%) 1

TASC D Lesions (Diffuse Disease)

• In experienced centers, endovascular therapy can still be considered as first-line treatment 1
• For diffuse disease involving the distal aorta and both iliac vessels, a comprehensive approach including catheter-directed stent placement for aortoiliac disease plus femoral angioplasty may be appropriate 1
• Covered balloon-expandable stents have demonstrated higher patency rates than bare metal stents at long-term follow-up 2

Surgical Revascularization

• Surgical revascularization should be considered when endovascular therapy fails or is not technically feasible 1
• Aorto-bifemoral bypass surgery is indicated for extensive disease involving the infrarenal aorta and iliac arteries in suitable surgical candidates 1
• Aorto-iliac endarterectomy can be considered as an alternative technique in selected patients when other methods are inappropriate 3

Hybrid Procedures

• For ilio-femoral lesions, a hybrid procedure combining endarterectomy or bypass at the femoral level with endovascular therapy of iliac arteries is indicated 1
• In cases of extensive disease, covered endovascular reconstruction of the aortic bifurcation can be considered with reported 1- and 2-year primary patency rates of 87% and 82%, respectively 1

Post-Intervention Management

• All patients should receive antiplatelet therapy following intervention 1, 2
• Regular follow-up with vascular studies is essential to monitor patency 2, 4
• Patients should be enrolled in a clinical surveillance program after endovascular revascularization 1

Important Considerations and Pitfalls

• Concomitant superficial femoral artery (SFA) stenosis (>50%) should be addressed at the time of iliac intervention, as it is a predictor of iliac intervention failure 2
• The placement of stents should generally be avoided in bending areas (hip and knee joints) 1
• Stent implantation should be avoided in segments suitable as landing zones for potential bypass procedures 1
• The choice between balloon-expandable and self-expandable stents depends on lesion location and characteristics - balloon-expandable stents provide higher radial stiffness and more accurate placement for bifurcation lesions 1