From the Guidelines
The patient with a 90% stenosis in the left internal iliac artery due to atherosclerotic changes should undergo bilateral percutaneous transluminal angioplasty only, with selective stenting for suboptimal results, as this procedure has a high rating of 8, indicating it is usually appropriate 1. The patient's history of heavy smoking and severe claudication without symptoms at rest, along with the angiogram demonstrating significant stenosis, necessitates an intervention that can effectively manage the condition and improve quality of life.
- Key considerations in managing this patient include:
- The use of antiplatelet adjunctive therapy, which has a high rating of 8, indicating it is usually appropriate 1.
- The potential benefits of supervised exercise programs as part of best medical management, although this approach alone may not be sufficient for a patient with such severe stenosis 1.
- The importance of considering the morphology and length of the lesions when deciding between percutaneous transluminal angioplasty and stent placement 1. The patient's condition, characterized by severe claudication and significant stenosis, suggests that a more invasive approach like surgical revascularization may be considered if endovascular procedures fail, but this should not be the first line of treatment given its lower rating of 4 1.
- Lifestyle modifications and medical management, including smoking cessation, control of blood pressure and diabetes if applicable, and the use of statins for lipid management, are crucial in the overall management plan to reduce the risk of further vascular events and improve quality of life.
From the Research
Atherosclerotic Changes in the Left Internal Iliac Artery
- The patient has heterogeneous plaque within the left internal iliac artery causing at least 90% stenosis, which is a common finding in patients undergoing angiography 2.
- Internal iliac artery (IIA) stenosis can cause hip pain, erectile dysfunction, and buttock claudication, and endovascular repair has been well documented for patients with significant stenosis 3.
Treatment Options for Internal Iliac Artery Stenosis
- Percutaneous angioplasty and stenting of the IIA is technically feasible and safe, with a high success rate and low morbidity 2.
- Endovascular intervention, including percutaneous transluminal angioplasty, bare metal stents, atherectomy, drug-coated balloon, and drug-eluting stents, can be used to treat internal iliac artery stenosis 4.
- Surgical therapies, such as distal bypass surgery, thromboendartectomy, and amputation, may also be considered in some cases 4.
Differences in Treatment Approaches for Intermittent Claudication and Critical Limb Ischemia
- Patients with intermittent claudication (IC) and critical limb ischemia (CLI) have significant anatomic, lesion, and treatment differences, with higher mortality and adverse limb outcomes in CLI 5.
- Patients with IC are more likely to receive optimal medical therapy and have higher femoropopliteal artery interventions, while patients with CLI are more likely to have multilevel peripheral artery disease and require below-the-knee interventions 5.
Management of Internal Iliac Artery Stenosis
- Internal iliac artery stenosis management is not well reported in guidelines, but it is essential to consider this diagnosis in patients with proximal walking pain 6.
- Risk factor modification, including tobacco cessation, and treatment of underlying conditions like diabetes mellitus, hyperlipidemia, and hypertension, is crucial in managing internal iliac artery stenosis 4.