What is the initial management for a patient with more than 50% stenosis of bilateral iliac arteries?

Management of Bilateral Iliac Artery Stenosis >50%

For patients with bilateral iliac artery stenosis >50%, primary stenting is the recommended initial management approach, particularly for TASC C lesions such as bilateral common iliac artery occlusions. 1

Diagnostic Evaluation

• Cross-sectional imaging with CT angiography (CTA) or MR angiography (MRA) is essential to determine the exact nature and level of stenosis, extent of atherosclerotic plaque, and to plan the treatment strategy 1, 2
• Translesional pressure gradients (with and without vasodilation) should be obtained to evaluate the significance of angiographic iliac arterial stenoses of 50% to 75% diameter before intervention 1
• Assessment of ankle-brachial index (ABI) is necessary to determine the severity of ischemia and guide treatment selection 3

Treatment Algorithm Based on TASC Classification

For bilateral iliac artery stenosis >50% (TASC C lesion):

• Primary stenting is the first-line treatment with a high appropriateness rating (8/9) 1
• Percutaneous transluminal angioplasty (PTA) alone may be appropriate (6/9 rating) but is generally less effective than primary stenting for complex lesions 1
• Surgical revascularization is also appropriate (7/9 rating) but typically reserved for cases where endovascular therapy fails 1

Endovascular Approach

• Primary stenting is effective for common iliac artery stenoses and occlusions (Level of Evidence: B) 1
• Primary stenting is also effective for external iliac artery stenoses and occlusions (Level of Evidence: C) 1
• Covered balloon-expandable stents have demonstrated significantly higher patency rates than bare metal stents at 18,24,48, and 60 months (95.1%, 82.1%, 79.9%, 74.7% for covered stents versus 73.9%, 70.9%, 63% and 62.5% for bare metal stents) 1
• Recent studies support an endovascular-first approach even for TASC C and D lesions, with similar 5- to 6-year patency rates to open surgery 1

Adjunctive Therapy

• Single-agent antiplatelet therapy is recommended for 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 peripheral arterial disease if tolerated 1, 2
• A supervised exercise program should be initiated to improve walking distance and reduce the need for secondary revascularization procedures 1
• Antihypertensive therapy should be administered to all patients with hypertension and PAD 1, 2

Important Considerations and Potential Pitfalls

• Any 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, 2
• Multivariate analysis has identified several independent predictors of iliac intervention failure: hypertension, hypercholesterolemia, chronic renal insufficiency, poor tibial runoff, external iliac artery disease, female gender, smoking, diabetes mellitus, and presence of a distal bypass 1
• Patients with diabetes have been shown to have decreased primary patency rates (57% vs 83%) after iliac artery interventions 4
• Critical ischemia at presentation is associated with decreased patency rates 4

Comparative Outcomes

• Endovascular revascularization (EVR) is associated with increased secondary interventions but decreased length of hospital stay and fewer postoperative complications compared to open surgery 1
• A meta-analysis comparing EVR, covered endovascular reconstruction of aortic bifurcation, and open surgery showed that open surgery has improved 3- and 5-year primary patency but similar secondary patency to endovascular approaches 1
• Open surgery has increased 30-day morbidity and mortality compared with endovascular approaches 1

By following this evidence-based approach to managing bilateral iliac artery stenosis >50%, clinicians can optimize outcomes while minimizing procedural risks and complications.