What is the recommended treatment for common iliac artery stenosis?

Treatment of Common Iliac Artery Stenosis

Endovascular revascularization with primary stenting combined with antiplatelet therapy is the first-line treatment for common iliac artery stenosis, with open surgery reserved for endovascular failure. 1

Treatment Algorithm Based on TASC Classification

The approach to common iliac artery stenosis is stratified by lesion complexity using the TASC II classification system:

TASC A Lesions (Short Stenoses)

• Percutaneous transluminal angioplasty (PTA) alone is usually appropriate, with selective stent placement only if PTA results are suboptimal 1
• Antiplatelet therapy should be initiated as adjunctive treatment 1
• Surgical revascularization is not appropriate for initial therapy (rating 4/9) 1

TASC B Lesions (Short Occlusions)

• Primary PTA or primary stenting are both usually appropriate (rating 8/9) 1
• Antiplatelet therapy is essential as adjunctive treatment 1
• Best medical management alone is usually not appropriate (rating 2/9) 1

TASC C Lesions (Bilateral Stenoses/Occlusions)

• Primary stenting combined with antiplatelet therapy is the first choice (rating 8/9) 1, 2
• Open surgery is appropriate (rating 7/9) but should be reserved for endovascular failure 1
• Recent data support an endovascular-first approach even for these complex lesions, with 5- to 6-year patency rates similar to open surgery 1, 2

TASC D Lesions (Diffuse Aortoiliac Disease)

• Catheter-directed aortoiliac stent or stent-graft placement with or without femoral angioplasty combined with antiplatelet therapy is the first choice 1
• Open surgery should be performed if endovascular therapy fails 1
• Multiple societal guidelines now recommend an endovascular-first approach for all TASC lesions, including D lesions 1

Critical Technical Considerations

Concomitant Superficial Femoral Artery Disease

Any stenotic (>50%) superficial femoral artery (SFA) must be addressed at the time of iliac intervention, as untreated SFA stenosis is a strong predictor of iliac intervention failure with only 36% 3-year primary patency 1, 3, 2

In contrast, occluded SFAs can be observed, demonstrating 84% 3-year primary patency 1

Stent Selection

• Covered balloon-expandable stents demonstrate superior outcomes compared to bare metal stents, particularly for TASC C and D lesions 1
• At 18-month follow-up, covered stents show significantly better binary restenosis rates (95.4% vs 82.2%), lower amputation rates (1.2% vs 3.6%), and improved clinical outcomes (94.2% vs 76.7%) 1
• Five-year primary patency rates are significantly higher with covered stents (87% vs 53%) in patients undergoing simultaneous common femoral artery endarterectomy and iliac revascularization 1

Essential Adjunctive Medical Therapy

Antiplatelet Therapy

• Single-agent antiplatelet therapy is mandatory for all symptomatic patients to reduce major adverse cardiovascular events and cardiovascular mortality 3, 2
• Antiplatelet therapy receives the highest appropriateness rating (8/9) across all TASC classifications 1

Lipid Management

• High-dose statin therapy is indicated for all patients with peripheral arterial disease if tolerated (class IA recommendation) 3, 2

Supervised Exercise Therapy

• A supervised exercise program should be initiated in conjunction with iliac intervention, along with risk factor modification including smoking cessation and control of hyperlipidemia, diabetes, and hypertension 1, 3

Acute Thromboembolism: Different Approach

For isolated acute embolic events involving the common iliac artery, the treatment paradigm differs:

• Surgical revascularization is the best treatment for acute embolic events 1
• Catheter-directed mechanical thrombectomy is usually appropriate 1
• Anticoagulation is usually indicated except in situations such as recent surgery 1
• CTA is the preferred diagnostic modality, revealing the exact nature and level of both thrombosis and underlying atherosclerotic plaque 1

Comparative Outcomes: Endovascular vs Open Surgery

Recent evidence demonstrates that endovascular and open surgical approaches have equivalent outcomes:

• Similar 2-year survival, limb salvage (100% vs 92.3%), and primary/primary-assisted patency (85% vs 85%) 1
• Endovascular revascularization is associated with increased secondary interventions but decreased hospital length of stay and fewer postoperative complications 1, 2
• Open surgery maintains a stable 30-day mortality of 3.6% and major complication rate of 20% 1
• When short-term and long-term outcomes are equivalent, endovascular techniques should be used first 1

Predictors of Failure to Avoid

Multiple independent predictors of iliac intervention failure have been identified: hypertension, hypercholesterolemia, chronic renal insufficiency, poor tibial runoff, external iliac artery disease, female gender, smoking, gangrene, ulcer, diabetes mellitus, presence of a distal bypass, and hormone replacement therapy in female patients 1, 2

The most critical modifiable factor is addressing concomitant SFA stenosis at the time of intervention, which can improve 3-year primary patency from 36% to 75% 1