Strategies for managing aortoiliac occlusions: access, treatment and outcomes

Abstract

Treatment of severe aortoiliac disease has dramatically evolved from a dependence on open aortobifemoral grafting to hybrid and endovascular only approaches. Open surgery has been the gold standard treatment of severe aortoiliac disease with excellent patency rates, but with increased length of stay and major complications. In contrast, endovascular interventions can successfully treat almost any lesion with decreased risk, compared to open surgery. Although primary patency rates remain inferior, secondary endovascular interventions are often minor procedures resulting in comparable long-term outcomes. The risks of renal insufficiency, embolization and access complications are not insignificant; however, most can be prevented or managed without significant clinical consequence. Endovascular therapies should be considered a first-line treatment option for all patients with aortoiliac disease, especially those with high-risk cardiovascular comorbidities.

Keywords:

• access
• aortic occlusion
• aortoiliac occlusion
• atherosclerosis
• endovascular
• iliac occlusion
• iliac stenosis
• stent

Financial & competing interests disclosure

DG Clair is a consultant for Arsenal Medical, Confluent, Endologix, Vessix Vascular and Volcano Corp. DG Clair is on the advisory board for Boston Scientific and Medtronic and is a DSMB member for Bard. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Endovascular therapies should be considered as first-line therapy for all patients with aortoiliac occlusive disease over open surgical approaches.

• The large majority of patients with severe aortoiliac occlusive disease have significant cardiovascular comorbidities, many of whom also have a long history of smoking, COPD and often renal insufficiency. These risk factors need to be included in decision making regarding selection of treatment.

• A thorough preoperative exam and axial imaging is strongly recommended to assess the extent and character of the aortoiliac disease, as well as to identify lesions that may alter plans for access.

• Open aortobifemoral or biiliac bypass is viewed as the ‘gold standard’ for treatment of advanced aortoiliac disease, with primary patency rates higher than endovascular interventions. However, secondary patency rates between the two techniques are comparable and endovascular procedures are associated with significantly decreased operative mortality and morbidity and shorter length of stay.

• Endovascular interventions for aortoiliac disease often require brachial and bifemoral access. Hybrid procedures with femoral endarterectomies and patch angioplasty are recommended if the common femoral or profunda artery stenosis is >50%.

• Stenting is recommended over angioplasty for the treatment of significant lesions, with balloon expandable stents deployed at the bifurcation in a ‘kissing’ configuration and the self-expanding stent through the external iliac arteries.

• Access site complications are the most common for aortoiliac interventions. Iliac rupture, dissection, embolization and renal insufficiency are serious, potential complications and understanding of causes and techniques to minimize their risk is imperative. Interventionalists should be prepared to manage or have available backup from a vascular surgeon if necessary.

• Postoperatively, patients should be maintained on antiplatelet therapy and a statin. An outpatient follow-up visit should be scheduled within 4–6 weeks with duplex ultrasound, segmental pressures and PVRs, as well as possibly computed tomography angiography if an aortic intervention was performed.

Notes