What is the next step in management for an ulcerated plaque with adjacent stranding of the common iliac artery seen on computed tomography (CT)?

Management of Ulcerated Plaque with Adjacent Stranding of the Common Iliac Artery

The next step in management for an ulcerated plaque with adjacent stranding of the common iliac artery seen on CT should be a CTA pelvis with runoff to fully characterize the lesion, followed by initiation of antiplatelet therapy and consultation with a vascular specialist for potential endovascular intervention. 1

Initial Evaluation

• CTA pelvis with runoff is rated "usually appropriate" (8/9) by the American College of Radiology for comprehensive evaluation of iliac artery disease to assess:

  • Extent of the penetrating ulcer
  • Presence of associated aneurysmal changes
  • Degree of surrounding inflammation
  • Other vascular lesions 1, 2

• CT is superior to other imaging modalities for evaluating:

  • Plaque morphology
  • Vessel wall characteristics
  • Extent of calcification
  • Adjacent soft tissue changes/stranding 3, 4

Risk Assessment

• Adjacent stranding of the common iliac artery suggests inflammatory changes that may indicate:

  • Plaque instability
  • Potential for rupture or thrombosis
  • Higher risk for acute complications 1, 2

• Ulcerated plaque with stranding represents a high-risk finding that requires prompt evaluation and management to prevent:

  • Thromboembolism
  • Vessel occlusion
  • Acute limb ischemia 2

Management Algorithm

1. Immediate antiplatelet therapy:

   • Initiate ASA 75-325 mg daily to reduce risk of thromboembolism 2, 5
   • Consider dual antiplatelet therapy if high-risk features are present 2

2. Vascular specialist consultation:

   • Urgent referral for assessment of need for intervention 2, 1
   • Evaluation of pulses, capillary refill, and signs of tissue compromise 2

3. Endovascular intervention planning:

   • Primary stenting is the preferred approach for common iliac artery lesions 2, 5
   • Vessel diameter assessment is critical for procedural planning and outcomes 6

Intervention Considerations

• Endovascular repair with stent placement is recommended for:

  • Symptomatic lesions
  • High-risk morphological features (deep ulceration, significant stranding)
  • Hemodynamically significant stenosis 1, 5

• Factors affecting intervention success:

  • Minimum vessel diameter (smaller vessels have higher complication rates) 6
  • Extent of calcification (heavily calcified vessels are more challenging) 7, 6
  • Lesion location (common iliac arteries generally have better outcomes than external iliac) 6

Post-Intervention Management

• Long-term antiplatelet therapy:

  • ASA 75-325 mg daily for all patients 2
  • Consider clopidogrel for higher-risk patients (superior to ASA alone in reducing cardiovascular mortality) 2

• Risk factor modification:

  • High-dose statin therapy (if tolerated) 2
  • Hypertension management 2
  • Diabetes control 2
  • Smoking cessation 2

Important Caveats

• CT findings must be correlated with clinical symptoms to determine urgency of intervention 2
• Small vessel diameter, particularly of the external iliac artery, is associated with higher rates of procedural complications and need for target lesion revascularization 6
• Fatty plaques are more likely to develop ulcerations and may require more aggressive management 4
• Ulcerations more commonly occur proximal to the point of maximum stenosis 4