Aortoiliac Disease - Pearls

  • Intermittent claudication predominant symptom, exercise-induced pain in buttock, thigh, or calf muscles
  • Atheroemboli arises from ulcerative stenotic plaques causing digital ischemia “blue toe syndrome”
  • Collaterals prevent critical ischemia (lumbar, inferior epigastric arteries, mesenteric circulation)
  • Leriche Syndrome- occlusion of infrarenal aorta (short-distance claudication, impotence)
  • Limb-threatening ischemia/tissue loss rare
  • Younger patients, lower prevalence of HTN and DM
  • Absent or disappearing femoral pulse with exercise is specific for dx

Procedure5-year Patency

Angioplasty56%

Primary stenting72%

Aortobifemoral bypass85-95%

Aortoiliac endarterectomy85-90%

Fem-Fem bypass65-85%

Axillofemoral bypass63%

  1. Diagosis/Initial Management:
  2. H&P, BP, DM, smoking cessation, cholesterol management
  3. Physical Exam
  4. Exercise-induced ischemia
  5. ABI may be >0.85 at rest but <0.4 with exercise
  6. Mild claudication symptoms:
  7. walking program, lifestyle modification, antiplatelet therapy, control of comorbidities
  8. Severe, lifestyle-limiting claudication:
  9. Arterial imaging
  10. Duplex, aortogram, MRA
  1. General Endovascular Management:
  2. “Simple iliac lesions” may benefit from angioplasty/stent
  3. Duplex:
  4. peak systolic velocity (PSV) >300cm/sec
  5. Velocity ratio (VR) >2.0
  6. Lesion length <5cm
  7. Complex lesions- vessel occlusion, anerysmal changes, >5cm stenosis, bilateral diffuse disease, femoral occlusive disease
  8. May be better in OR
  1. Iliac Angioplasty
  2. Initial success is 78-100% after PTA
  3. Patency rates for angioplasty 94%, 85%, and 56% at 1, 3, and 5 years
  4. Extensive disease (TASC C) inferior patency rates and may elect for bypass surgey
  1. Primary iliac stenting
  2. Initial success is 95%
  3. Patency rates for stent 95%, 95%, and 72% 1,3,5 years
  4. Complication rates 3.1-10.6% for PTA, 0-10.8% for stent (comparable)
  5. Pseudoaneurysm/hematoma/thrombosis 1-2%
  6. Major morbidity 3-10% (artery dissection/rupture, thrombosis, restenosis)
  7. Mortality 0.3-1.2% usually associated with post-procedure coronary events
  1. Surgical Intervention
  2. Pre-op workup/medical clearance essential
  3. Aortobifemoral Bypass
  4. Complete aortic occlusion, or extensive bilateral or unilateral iliac disease
  5. Mortality 2-3%, patency 85-95% at 5yrs, 75-85% at 10yrs
  6. Transabdominal vs. retroperitoneal approach
  7. PTFE graft
  8. Aortoiliac Endarterectomy
  9. Useful in select patients- younger patients with short-distance claudication, disease involving distal aorta and CIA
  10. Fem-fem bypass
  11. Reserved for patients at high risk for aortic reconstruction
  12. May be performed under regional or local anesthesia
  13. Patency rates similar to aortic reconstruction when outflow is acceptable (65-85% at 5yrs, limb salvage 85% at 5yrs)
  14. Operative mortality 0-6.2%
  15. Angioplasty/stenting of unilateral iliac with fem-fem crossover can be considered if aortobifem not an option (96%, 85%, and 85% patency at 1, 3, and 5 years)
  16. Axillofemoral bypass
  17. Generally reserved for the highest risk patients
  18. 86%, 72%, and 63% 1, 3, and 5yr patency rates
  19. Long term patency depends on outflow
  20. Mortality <5%
  21. May be done under local/regional, avoids abdominal procedure
  22. Higher risk for infection
  23. Procedure of choice for secondary reconstruction after aortic graft infection
  24. Complications
  25. Majority= cardiovascular. MI, CHF, arrhythmia
  26. Preoperative eval essential
  27. Renal dysfunction up to 10% after aortobifem
  28. Adequate hydration, avoid hypotension
  29. Acute graft thrombosis
  30. Usually technical error
  31. Urgent reop essential to correct error
  32. Late graft thrombosis
  33. Usually advanced atherosclerotic disease involving proximal or distal anastamosis
  34. Pseudoaneurysm
  35. May occur at anastamosis from infection/degeneration graft/suture material
  36. Minimize graft tension, use monofilament suture
  37. Hematoma/Lymph leak
  38. Leads to wound infection
  39. Careful closure, ligation of lymphatics
  40. Perioperative antibiotics 24 hrs
  41. Graft infection
  42. Significant morbidity/mortality
  43. Aortoenteric fistula can occur
  44. Proper retroperitoneal closure essential
  45. Colonic ischemia
  46. More common with AAA repair
  47. Pre-op eval of IMA and internal iliac artery can identify patients at risk
  48. Internal iliac important to maintain IMA collaterals