Specialist for Infrarenal Aortic Atherosclerosis
Vascular surgeons are the primary specialists who treat atherosclerosis of the infrarenal aorta, with interventional radiologists and interventional cardiologists serving as alternative specialists for endovascular approaches. 1, 2
Primary Specialist: Vascular Surgery
Vascular surgeons manage the full spectrum of infrarenal aortic atherosclerotic disease, from medical management through complex surgical reconstruction. 1
The Society for Vascular Surgery specifically recommends aortobifemoral bypass for symptomatic, hemodynamically significant aorto-bi-iliac disease (Class I, Level of Evidence A), which is the gold standard surgical procedure performed by vascular surgeons. 2
Vascular surgeons achieve excellent outcomes with aortobifemoral bypass, with 87.5% limb-based 5-year patency and 80.4% patient-based 5-year patency, and an operative mortality of 3.3%. 2
Alternative Specialists for Endovascular Treatment
Interventional radiologists perform minimally invasive endovascular procedures for infrarenal aortic occlusive disease, including percutaneous angioplasty with primary aortic stent implantation. 3, 4
Interventional cardiologists also perform catheter-based interventions for aortic atherosclerotic disease using imaging and catheterization techniques. 3
Endovascular stent implantation demonstrates long-term effectiveness with mean estimated primary patency of 185.6 months for infrarenal aortic occlusive disease. 4
Multidisciplinary Collaboration
The European Society of Cardiology recommends hybrid procedures combining surgical and endovascular techniques when iliac disease coexists with infrarenal aortic pathology, requiring collaboration between vascular surgeons and interventionalists. 1, 5
For patients with combined inflow (aortic/iliac) and outflow (femoral-popliteal) disease, address inflow lesions first (Class I, Level of Evidence B), which may involve both vascular surgeons and interventionalists working sequentially. 2, 5
Clinical Decision Algorithm
For symptomatic infrarenal aortic atherosclerosis:
If patient is a good surgical candidate with extensive disease: Refer to vascular surgeon for aortobifemoral bypass 2
If patient has focal stenosis (<5 cm) or is high surgical risk: Consider interventional radiology or interventional cardiology for endovascular stenting 1, 4
If patient has severe comorbidities precluding aortic surgery: Vascular surgeon can perform axillofemoral-femoral bypass as alternative (operative mortality 4.9-6%) 2, 5
Important Caveats
Simultaneous renal artery involvement requires additional expertise, as aortorenal bypass or alternative renal revascularization may be needed to preserve renal function. 2
Nonoperative management of infrarenal aortic occlusion carries increased mortality and high limb loss rates, making specialist referral critical for symptomatic patients. 6
All three interventional specialties (vascular surgery, interventional radiology, interventional cardiology) can treat this condition, and cooperation between specialties delivers optimal patient care rather than competition. 3